Inspection on 06/05/05 for The Old Rectory (Trowbridge)

This inspection was carried out on 6th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Rectory (Trowbridge) 04/01/10

The Old Rectory (Trowbridge) 12/09/07

The Old Rectory (Trowbridge) 29/06/06

The Old Rectory (Trowbridge) 05/10/05

The Old Rectory (Trowbridge) 24/09/04

The Old Rectory (Trowbridge) 28/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Old Rectory (The) 27 Stallard Street Trowbridge Wiltshire BA14 9AA Lead Inspector Tim Goadby Unannounced 6th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Old Rectory (The) Address 27 Stallard Street Trowbridge Wiltshire BA14 9AA 01225 77778 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkcare Homes (No 2) Limited Mr Ean Rayton True Care Home 8 Category(ies) of 8 LD Learning Disability registration, with number of places Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th September 2004 Brief Description of the Service: The Old Rectory provides care and accommodation for up to 8 adults with a learning disability. There is a particular focus on autism. The home is operated by a subsidiary of Craegmoor Healthcare, a private sector organisation with 4 registered care homes for this client group within Wiltshire. The property is situated in a residential area of Trowbridge. A range of amenities are available in the town itself. Larger centres, such as Bath and Bristol, are within reasonable travelling distance. The service has been open for around 8 years, initially under different ownership. A number of service users have lived there from the beginning. The current group is well established. They are all males. All service users have single bedrooms. This includes some on the ground floor. 2 bedrooms have en-suite facilities. The others have bathrooms and toilets nearby. Communal areas are situated on the ground floor. There is access to a large enclosed garden. There is also an adjacent building, which is used for daytime activities. Another plot is used to grow vegetables. The home is staffed at all times. There are high ratios of support throughout the day. Night time cover consists of one waking and one sleeping in staff. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in May 2005. A total of 6.75 hours was spent in the home. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; sampling a meal; meeting 7 service users; discussion with management, and other staff on duty; tour of the premises. What the service does well: What has improved since the last inspection? The home has enjoyed a period of staff stability, with all shifts being covered by its own permanent or relief employees. This contributes to continuity and consistency in service delivery. A new registered manager has been confirmed in post, following his promotion from within the existing staff team. This development appears to have been welcomed by people. The manager is now making good progress towards achieving all the required qualifications. A focus on training has also continued to develop for other staff. Many support workers have now achieved NVQ awards in care, whilst others are working towards this. Recent courses have also addressed topics specifically relevant to this home and its service user group. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 6 Changes at a senior level within Craegmoor have brought a renewed focus on issues of service development. There were encouraging signs that significant improvements are planned over the forthcoming period. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5 Information for prospective service users is in place, but needs reviewing and updating. Standards relating to admissions to the home were not applicable at this inspection. The home is able to meet the needs of its service users. Service users do not yet have completed statements of terms and conditions. EVIDENCE: The Old Rectory has a Statement of Purpose, and Service User Guide. These were seen to be readily available. The Guide has been produced in accessible formats. There was an existing unmet requirement to update the Statement. The version on display in the home continued to show the name of the previous registered manager. The current manager, Mr Ean True, completed registration with the CSCI in October 2004. The home has not had any new admissions for over 2 years. The current service user group is well established. Information is available to describe their needs, and the strategies to support these. Staff support was seen to be in place for all service users throughout the day. This enabled them to be offered a variety of opportunities. Records also showed that a range of Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 9 professionals and resources are accessed, to assist the home in meeting its service users’ needs. A sampled file showed that the individual had recently been the subject of a multi-disciplinary review. Another existing unmet requirement related to completed statements of terms and conditions for service users. The example seen had been signed and dated by the resident. But it had not been signed by any other relevant persons. Some gaps had also been left unfilled, such as the room to be occupied, and the fees to be paid. The manager reported that other service users’ records would be similar. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 Service users’ needs and goals are reflected in their individual care plans. Their own input to these could be developed further. Service users have opportunities to exercise independence and choice, and to be consulted on the conduct of the home. Systems for risk management support the undertaking of social opportunities. The format used could be clarified, to provide better evidence of the approaches in place. EVIDENCE: A care plan format has been devised in-house. This addresses all required areas. Systems are built in to show monthly review. Plans are produced on computer, enabling speedier updating when changes are required. A sampled file showed an instance of two care plans on the same topic. One dated from March 2004, and the second from January 2005. They gave differing guidance. Duplication of material should be avoided, to minimise any risk of confusion and inconsistency. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 11 The same file showed that the service user had contributed to his daily notes. But there was less evidence of his input into the planning of care. A person centred planning booklet had been completed. But this format was reported by the manager to have been abandoned. The issue was due to be looked at again. Issues of choice and autonomy are addressed in service user records. There is a focus on promoting independence. If restrictions are imposed as part of overall care, there are clearly documented reasons. Service users participate in the day to day running of the home. They were observed to contribute to all practical tasks during this inspection. Craegmoor also has residents’ conferences. This gives some people an opportunity to comment more widely on the organisation’s conduct. Risk assessments show consideration of positive reasons to take risks, as well as potential negative outcomes. Where possible, they place emphasis on the support that can be given to enable an opportunity to be undertaken. But some deficits were identified from the sample viewed. The format was not entirely clear. It was not apparent whether the risk level judgement was made before or after putting relevant measures in place. The definition of a risk as low, medium or high did not appear to be linked to any objective criteria. On one document, the judgement of risk level had not been shown. The same assessment mentioned an action in need of addressing. The document had been drawn up in March 2003, and reviewed in January 2004. No details could be seen about any follow up on the identified action, or reasons why circumstances had changed. Another risk assessment for the same person concerned whether or not they could retain their own room key. From the document alone, it was not possible to conclude what decision had been reached. The same assessment form had also been used to address a separate issue, regarding access to the kitchen. Linking these two topics had contributed to the confusion. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 & 17 Service users have frequent opportunities to undertake a range of activities, both at home, and within their local community. Service users are supported to maintain personal and family relationships. Daily lives for service users have an appropriate balance between necessary routine, and individual choice. Arrangements for the provision of meals promote independence, choice and social inclusion. EVIDENCE: The Old Rectory has an adjacent building which offers a range of daytime opportunities. Some service users also attend the local college, supported by staff from the home. Courses undertaken include independent living, money management, and sport. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 13 Service users are regularly supported to get out and access a range of opportunities. Staffing levels support this. The home also has 2 vehicles. On the day of this inspection groups went out in both the morning and afternoon. Activities undertaken were swimming, shopping, and a country walk. Service users spoke about other recent trips, including meals out, attending a Bristol City football match, and a bank holiday outing to a steam railway. Conversations with service users and staff, and some photos on display, also showed the range of holidays that have been provided. Records showed that good links are maintained with service users’ families. Key information is shared, where appropriate. Visitors can come to the Old Rectory. Residents are also enabled to go and stay with family or friends. One service user talked about a recent occasion when he had spent some time with friends of his late parents, who he had known for many years. Each service user has a weekly timetable on display. These are produced in pictorial form, to promote understanding. A number of service users drew attention to these, to show what they were doing that day. It was clear that they are regularly referred to. The tables showed that each individual had a range of planned activities to fill the week, both at home and elsewhere. Staff explained that flexibility is built in, especially where needed to reflect an individual’s needs. An example was seen in a sampled record of clear instructions about how to support an individual who is very reliant on routines, and may become distressed if these are unduly disrupted. Lunch on the day of the inspection was sandwiches. A choice of fillings was available, reflecting individual preferences. Staff and service users ate together, in a pleasant social atmosphere. Support needed by one individual was given sensitively. Various service users assisted with relevant tasks, such as clearing tables. One resident is more independent, usually buying and preparing his own meals. This person talked about the regular Friday evening takeaways which he enjoys, and was looking forward to doing so again later that day. The individual was also aware that the home’s kitchen was due to be out of action the following week, whilst being refurbished. The temporary alternative arrangements had been fully discussed with him. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users’ health needs are met. EVIDENCE: The manager was able to discuss the various health needs of individual service users. It was clear that a number of appropriate steps were being taken to respond to these. A sampled record showed evidence of regular input from health professionals on key topics. The service user had seen their GP within the previous month, and had had an eye test earlier in the week of the inspection. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Suitable arrangements are in place to ensure the welfare and protection of vulnerable service users. EVIDENCE: The complaints procedure is prominently displayed within a public area of the home. Recording systems are in place. These showed that only one complaint issue had arisen since the previous inspection. This had been notified to the CSCI at the time of receipt, as required by regulations. Suitable steps were being taken, in line with all other relevant agencies, to respond to the issues raised. The Old Rectory has made referrals to local vulnerable adults procedures when required. The home supports people who may present with challenging behaviour. Records showed that all staff are given suitable training, to assist in the effective management of such issues. A 2 day course is provided, and an annual refresher is held. Information about the content of training showed that there is a focus on defusing and de-escalating potentially difficult situations. Some instruction in physical interventions is also given. There are clear parameters around the level to which this may be practised. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 & 30 Significant improvements are required to the quality of the living environment for service users. EVIDENCE: Previous inspections have highlighted the need for significant improvements to the fabric of the building. It is recognised and acknowledged by Craegmoor as an issue requiring major investment. The manager reported that a large scale programme of works has now been authorised. This will mean that the whole property is to be refurbished, over a period of time. A project manager is to be appointed to oversee this. No documented action plan was available as yet. This meant that a requirement of the previous inspection report remained unmet. Each service user has a single bedroom. One person has an individual flat, with separate access internally. He took pleasure in showing this, and clearly appreciates the space available. This resident, and one other, have keys to their own rooms. 6 bedrooms were seen during this visit, with the permission Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 17 of their occupants. They are furnished and decorated to reflect the personal taste of the service user. Redecoration of one ground floor room was taking place on the day of the inspection. A first floor room was due to be addressed the following week, and had been cleared out in readiness. The kitchen remained in need of refurbishment, as at previous inspections. The work was scheduled to take place in the week after this visit. Staff and service users confirmed how much they were looking forward to having improved facilities. The home appeared clean and hygienic to a reasonable standard in all areas seen. The utility room was checked, and found to be in good condition. The home employs a cleaner, who has an NVQ qualification. Some areas of the home are difficult to keep clean, due to the need for refurbishment. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 35 Effective arrangements are in place to ensure suitable staffing cover to meet the needs and preferences of service users. Service users are supported by appropriately trained staff. EVIDENCE: The home was suitably staffed on the day of the inspection, and rotas provided evidence that cover is maintained at high levels of staff to service users. It was observed that some residents need one-to-one support for much of the time. This responsibility was shared amongst the staff on duty. The team in place consisted of the manager, a deputy, 3 senior carers, 15 support workers, and 3 relief staff. The home had not needed to make use of agency cover for over a year. Training records showed that 11 care staff had achieved NVQ Level 2. Another person had done Level 3. This represented 60 of carers. 5 other staff were working towards Level 2; and 2 were now studying for Level 3. Records also showed that a range of other relevant courses are provided to staff, from induction onwards. Craegmoor has its own training department. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 19 External providers are also accessed as necessary. For instance, the majority of the team had recently had autism specific training, given by a specialist instructor. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 & 43 The home is well managed, and the service receives good organisational support. Systems are in place to monitor quality, and to promote steps to ensure further developments and improvements. Recording systems contain appropriate levels of detail regarding service users. Fire safety measures need attention, to ensure that the welfare of service users is promoted and protected. EVIDENCE: The home’s registered manager is Mr Ean True. He has worked at the Old Rectory for a number of years, and was previously the deputy manager. His registration with the CSCI was completed in October 2004. He has recently Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 21 obtained his Level 4 NVQ in management, and has now enrolled for the Registered Manager Award. Craegmoor’s services are extensively audited by the organisation. The manager provided evidence of the various weekly and monthly reports that he is required to submit. There are also visits to the home by senior managers. The purpose of these is to ensure that all establishments achieve a minimum standard of performance, and to promote them to move beyond this to reach a level of excellence. Records are stored securely. Clear guidance is in place about confidentiality, and the boundaries around sharing of information. Sampled service user records showed that entries are made 4 times a day, including for the overnight period. There is a clear division between objective and subjective comments. This provides a detailed ongoing record of care. One service user is supported by staff to make his own daily records. The person was keen to mention this, and clearly valued having this input. Fire alarm systems should be tested once a week. The log book showed a gap of 19 days between tests in February and March 2005; and another of 20 days, again in March. Records of staff instruction in fire safety did not provide clear evidence of the training reported to have taken place. Only 5 staff out of 24 were shown to have received instruction in the first 3 months of 2005. 8 of the other 19 staff had no record of instruction in the final quarter of 2004 either. An employee who began working at the home in April 2004 had no recorded fire safety instruction until 28th March 2005. Craegmoor had had recent changes at a senior level in the organisation. The manager and staff reported feeling positive about these developments. A major commitment of investment to the home was now proposed. Staff felt that there were clear benefits to being part of a national organisation. Arrangements for financial operation of the home were discussed. Systems are in place which enable access to funds, both for individual service users, and from the home’s budget. An insurance certificate on display in the home indicated that appropriate current cover was in place. An issue arising from a delay in payment of the home’s annual registration fee was being pursued with the company around the time of this inspection. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 N/A 3 N/A 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Rectory (The) Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 2 3 D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(c); 6(a); Schedule 1 Requirement The persons registered must review the Statement of Purpose and ensure that all elements required by Schedule 1 of the Care Homes Regulations 2001 are included. (Timescale of 30/11/04 not met) COMMENT: The Statement needs updating, principally to reflect the change of registered manager. The persons registered must ensure that each service user has a completed statement of terms and conditions, which is signed by or on behalf of the service user. (Timescale of 30/11/04 not met) COMMENT: This was unmet on the sampled record, and the manager stated that it would also need attention on others. The persons registered must produce a maintenance plan for the building. (Timescale of 31/01/05 not met) COMMENT: There had been extensive consultation about the building, and a major programme of works was being scheduled. But there was no Version 1.30 Timescale for action Not later than 30/06/05. 2. YA5 5(1)(b) & (c) Not later than 31/07/05. 3. YA24 23(2)(b) Not later than 31/07/05. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Page 24 4. YA30 13(3); 16(2)(g); 23(2)(b) 5. YA42 23(4)(c), (d) & (e) documented plan available as yet. The persons registered must ensure that the kitchen is refurbished, so that all surfaces may be kept clean to infection control standards. (Timescale of 31/01/05 not met) COMMENT: This work was due to take place in the week following the inspection. There must be evidence that all required checks and instruction relating to fire safety are carried out at the prescribed intervals. Not later than 31/05/05. From 06/05/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA9 Good Practice Recommendations Care plan formats should be reviewed to remove any duplication, and to show the input of service users. The homes risk assessment format should be reviewed and clarified. Old Rectory (The) D51_S28608_OLDRECTORY_v194572_060505Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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