Inspection on 10/10/06 for The Old Vicarage [Blakeney]

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Vicarage [Blakeney] 17/05/07

The Old Vicarage [Blakeney] 06/12/05

The Old Vicarage [Blakeney] 02/08/05

The Old Vicarage [Blakeney] 15/03/05

The Old Vicarage [Blakeney] 10/12/04

The Old Vicarage [Blakeney] 23/03/04

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 The Old Vicarage The Old Vicarage Church Square Blakeney Nr Lydney Gloucestershire GL15 4DS Lead Inspector Suzanne Collins Key Unannounced Inspection 10th October 2006 11:00 The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 1 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 The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 2 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 Stationery 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. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Old Vicarage Church Square Blakeney Nr Lydney Gloucestershire GL15 4DS 01594 517098 Stepping Stones Resettlement Unit Limited To be appointed Care Home 13 Category(ies) of Learning disability (13) registration, with number of places The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: The Old Vicarage is owned by Stepping Stones Resettlement Unit Ltd, which owns four other homes in the area. The organisation has been awarded the ISO 9002 award and has retained the award in subsequent years. The Old Vicarage is a Grade 2 listed building and provides residential care for 13 people with a learning disability and a history of challenging behaviour. The accommodation is provided in the main house, the nearby Coach House and in a self contained flat. The main house accommodates eight people over three floors. All have single rooms with en suite facilities. Four people live in the Coach House across the courtyard. They have single rooms with the use of a bathroom and a shower room. One person lives in the flat. To the rear of the properties are well maintained gardens. At the front of the main house there is a garden overlooking the village. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six and half hours. A tour of the property was undertaken. Three service users were case tracked, which involved looking at their care plans daily records, medication, and risk assessments. Four service users and three staff were spoken to. Time was spent with the acting manager who was very helpful and keen to take on board points raised by the inspector. The acting manager has only been in post for a few months and is in the process of developing a more person centred approach within the home. Copies of the statement of purpose/service user guide are kept on service users files. The current fees for the home range from £967.86 to £1,186.44 What the service does well: What has improved since the last inspection? What they could do better: The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 6 The day-to-day care plan files do not have enough detail recorded on them. Service users files seen had varying types of forms. It was unclear as to when files had been reviewed, as they were not dated. Fire doors need to be checked to ensure the service users are protected and safe. 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. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 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 the following standard(s): 2 The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. A new pre-admission procedure and assessment are being developed. The work that had been started showed good practice. The paperwork needs to be completed to ensure that it takes into account all the aspects of the persons needs and aspirations as mentioned in standard two. EVIDENCE: The acting manager is working on developing and new pre-admission assessment that is person centred. It included what is important to the service user as well as the care, support and health needs of the person. The acting manager meets with new service users before they move in and these meetings are also recorded on the file. One assessment that is currently being completed was seen during the inspection. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 6,7 and 9 The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The introduction of working with a person centred approach to care planning shows good practice. These plans need to be completed and become part of their main file to ensure that a person centred culture continues within the home. The service users comment cards are a useful way of seeking the views of the individuals using the service. There needs to be evidence on how these views are being addressed and then fed back to the service users. Consideration should be given to changing the questions each time the cards are filled out so that different aspects of the service could be looked at each time. As the person centred plans are developed additional risk assessments will need to be in place. EVIDENCE: The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 10 Service users files were case tracked. The acting manager is currently introducing person centred plans for service users. These are not all complete and as yet are not kept in the person’s main file. The main care plan files being used were seen. There was limited detail in the care plans and it was not clear when they were last reviewed. Daily records are completed and at the end of the month the key worker writes a report based on the daily records. In one file this had been completed for September. You could clearly see any appointments that the person had had with G.P’s etc. Another file seen had not had the monthly reports filled in. One file also contained records of dental and chiropody appointments. The last appointment recorded for the dentist was 18 months ago and chiropodist 15 months ago. One service user showed me their current file and their new person centred plan. The new plans have details of all the health and support needs. They also include details of the service user’s dreams and aspirations. There was also a greater emphasise on their cultural needs. The service user was very proud of their file. They had been involved in all aspects of the plan and chose all the pictures used on the plan. Although these person centred plans are not on the main files as yet some aspects of them are being introduced for example someone who likes playing bingo has started attending a bingo session in the local village. Service users are able to made decisions regarding attending the day service at Stepping Stones. On the day of the inspection one person had chosen to stay at home for the day. Other service users were either at the day service, at college, working with horses on a farm, or in town shopping. One service user spoken to said that they had chosen to go to Stepping Stones once a week. Service users have recently completed service users comment cards. These included questions like, Do you like living here? Do you choose the things you do? Do the staff treat you well? Etc. Service users have filled these in. The acting manager said that the intention is that these are looked at every six weeks or so and acted upon. We discussed service user meetings. These have not worked in the past due partly to the group dynamics. The acting manager said that they are introducing group discussions with the individuals that live in the coach house. They have had one discussion group and at this meeting discussed the possibility of a new service user moving in. These discussions need to be recorded so that ideas brought up in the discussions can be followed through. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 11 Some of the service users that smoke are being supported to give up. If they choose to have the support an agreement is written up with then saying how often they will have a cigarette. The service users sign these agreements. Detailed risk assessments are on file. As the new person centred plans are developed service users may be taking more and/or new risks. Current risk assessments will need to be reviewed. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16 and 17 The quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Service users are encouraged to use the local community and enjoy a variety of experiences and interests. They take part in holidays some of which link to a particular hobby or interest. Some people have chosen to go abroad to the same destination for the last few years. A healthy diet is provided and service users are encouraged to plan the menu and suggest new meals to try. Service users are encouraged to have friends outside of the home and are supported with maintaining relationships with family members. EVIDENCE: The staffing levels have been increased. There are 4 and sometimes 5 staff on duty. On the day of the inspection most of the service users were either at the resource centre or at college. The staff from the Old Vicarage support the The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 13 service users at college. Two service users had been shopping during the day. When service users returned home at the end of the day staff interact well with them asking about their day and taking time to talk about anything they wanted to discuss. One service users showed me some of the artwork they had completed at college. These paintings have been framed and are up on the walls around the house. Another service user talked about the NVQ they are doing while working on a farm. Service users are encouraged to take part in activities outside of the home. They visit the local pub and restaurants and have started taking part in other local events like the bingo sessions. They have also been to local discos. A group of service users are going on holiday this weekend. They were looking forward to this. There have been several holidays for service users these included a cowboy convention and a holiday to Greece. Service users are supported to keep in contact with family and friends. Staff support service users to make phone calls and write letters to family members. Contact with family and friendships were discussed during the handover meeting. On occasions some service users go and stay with family members. All service users who want a key to their room have one. Some service users spend more time than others in their rooms. The service users who live in the coach house have their own dining /living room. This is where they choose to eat and spend time watching TV. With the introduction of healthy eating the acting manager encourages staff and service users to cook food from scratch rather than use pre-prepared or readymade meals. Fresh fruit was available for service users. They are offered alternatives to ensure their cultural needs are met and are encouraged to say what foods they like and dislike. A menu is then written up. The layout for the menu is new and very colourful. It has lots of pictures on it, and there is a reminder to service users encouraging them to inform staff of new dishes they would like to try. Mealtimes can often be trigger points for service users. The dining area has two tables one of which is large. It is difficult to access the table during meal times as the room is quite narrow and there is a sideboard against one wall. The acting manager plans to move the sideboard to make access to the table easier. Some of the décor in the dining room is quite dark. It is a recommendation that the décor and layout of this room is looked at to try and create a more calm atmosphere. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 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 the following standard(s): 18, 19 and 20 The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Service users are protected by the medication system in place. They receive the support with personal care in the way they prefer and require. There may at time be gaps in meeting the health needs of individuals. EVIDENCE: A handover meeting was observed. Details of support given to service users were reported as well as their emotional wellbeing. Personal support is received in varying ways depending on the service users needs and wishes. Service users have regular access to the GP. Two of the service users had seen the GP on the day of the inspection while at the Stepping Stones day resource. Details of these visits were discussed at the handover. The nurse at stepping stones phoned through the outcomes of the appointments to the acting manager. It was not always clear on the file when someone had seen the dentist or chiropodist. In one file the last recorded visit to the dentist was 18 months ago. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 15 The medication was seen. The requirements from the pharmacist’s inspection had been completed. Staff responsible for medication showed the inspector the improvements made to the medication records including details of the stock received and stock control. Staff spoken to confirmed that they have to attend training on the administering of medication before being given the responsibility. One staff whom had been on the training said that she would be shadowed until she is confident to administer alone. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 22 and 23 The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. It is a requirement that a complaints, concerns, comments file is set up. This is to ensure a clear record of complaints and concerns are kept, as well as the recording the investigation and conclusion of each case. Service users are able to make comments, complaints about the support they receive. This needs to be further developed to ensure they have a greater say in all aspects of the running of the home. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The acting manager has produced a new easy read complaints procedure. This is displayed on the notice board in the kitchen. Staff spoken to had a clear understanding of what to do if someone wishes to make a complaint or raise a concern. Letters of response were seen when complaints or concerns had been investigated. However the initial complaint or concern was not with the response so it is unclear as to whether the complaint concern was fully investigated. One service user had made a complaint about a member of staff. This was fully investigated and details of the investigation were seen. The service user was fully aware of the outcome of the investigation. Service users have service user comment cards, which they are encouraged to fill out. These were seen on service users files. The comment cards have only The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 17 just been introduced and so there is not yet evidence to see if their views have impacted on the way the service is run. Staff files were inspected. CRB’S and POVA first’s were on the files. Staff spoken to had received training in abuse of vulnerable adults. Physical intervention is only used as a last resort and to protect the individual. Staff spoken to had received training in dealing with behaviour that could be challenging. They have not had to use any intervention techniques since working at the home. The acting manager supports both staff and service users to develop positive relationships with each other. This includes having discussions with staff and service users, writing to service users regarding their behaviour, and developing positive interaction with staff and service users. Service users spoken to said that they could speak to the staff and acting manager if they were not happy about something. Service users are protected. Evidence was seen regarding a concern staff had raised. The social worker had worked with the staff team to put guidelines in place and a risk assessment to ensure the safety and wellbeing of the individual. Staff were also reminded of the guidelines at the handover. This evidence showed good practice The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 24 and 30 The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The Old Vicarage has a homely and comfortable feel to it. The service users have been encouraged to personalise their bedrooms. In two of the bedrooms the service users had broken furniture. They need to be consulted as to whether they want this furniture replaced. There are some environmental issues that need to be addressed to ensure the safety of the service users. EVIDENCE: A work place risk assessment was seen and is complete. The smoking area was seen during the inspection. There is insufficient ventilation in the smoking area when the external door is closed. This is an outstanding requirement from the last inspection 6th Dec 05. Service users need to be encouraged to keep the inner door closed while in the smoking area as the smell of smoke travels into the living room and dining room. The ground floor shower/WC room requires refurbishment. The acting manager informed the inspector that this is on a list of works to be completed The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 19 but could not say when it will be completed. All electrical equipment had been tested within the last year. The kitchen in the coach house has a strong odour. The service users who live in the coach house are using the kitchen to make drinks. They also want to use the kitchen to cook meals. The kitchen has a musty smell and is in need of refurbishing. This needs to be carried out before they start to use the kitchen to cook or prepare food as the washing machine and tumble dryer are currently in the kitchen and will need to be relocated. The lighting in the corridors is very dull. This may be due to the light shades that need cleaning or replacing. Bedroom 6 needs to be redecorated. Some of the paper has been pulled off the wall. Under the paper the wall is very crumbly especially around the window. The paint on the window frame is also flaking off and the window surround is very dirty. The skirting board is also coming away under the window. The communal areas were all clean. The service users are supported to clean their own bedroom and bathrooms. The grounds of the property are extensive. Staff are working hard to maintain these and encourage the service users to get involved. There are plans to extend the use of the garden. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Staffing levels enable the service users needs to be met. Staff receive an induction when they start work at the Old Vicarage. Staff have regular supervision and undertake appropriate training. The acting manager has introduced person centred planning and is working with individuals to make the care plans and files more person centred. EVIDENCE: The staffing level has been raised to ensure that service users needs are met. On the day of the inspection the acting manager was meeting with one of the staff to discuss person centred planning and develop a support plan for one of the service users. Staff spoken to say that they had supervision every 6 weeks. Supervision records were looked at and were up to date. A number of the staff are working toward their NVQ’S at level 2 and 3. The acting manager is the work-based assessor. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The acting manager is in the process of completing the paper work to apply to become the registered manager. The acting manager has only been in post for a few months. With the introduction of person centred planning there is a clear focus on the way staff are working. Service users are encouraged to come and talk about any issues, ideas they have, and any concerns etc or just talk about how their day has been. Service users may not always be protected by health and safety of the home. EVIDENCE: During the inspection several of the service users sat with the acting manager and/or staff to discuss how there day had been. They also talked about any issues they had. All the staff seen took time to patiently listen to what they were saying. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 22 Several of bedroom doors, which are fire doors, do not fully close unless pulled. This is also the case for the door leading to the stairs next to the living room. There is a requirement that all fire doors are fitted correctly and are regularly checked to ensure they are in working order. Service users talked about the comment cards that they filled out. One person in particular wanted to show the inspector the one they filled out but could not find it on their file. These cards need to be developed so that the service users can see that their views underpin the development and running of the home. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 24 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. 2. 3. 4. Standard YA2 YA42 YA19 YA24 Regulation 14 37 12 13,23 Requirement Ensure comprehensive pre admission assessment (Previous timescale 31/01/06) Train staff in the reporting and administration of incidents. (Previous timescale 31/03/06) Ensure individual have access to the healthcare facilities when needed. Ensure the home is safe concerning: ventilation in smoking area. The wall in bedroom 6 and skirting board is repaired, the room is then redecorated. A record is kept of all complaints including details of the investigations and outcomes. The Kitchen in the Coach House is refurbished and the washing machine and tumble dryer are re located. Provide a system for regular consultation and decision making with service users and quality assurance survey. Ensure that all fire doors shut fully and are check regularly Provide a comprehensive care planning system, which is person DS0000016626.V312113.R01.S.doc Timescale for action 30/12/06 31/12/06 31/12/06 31/12/06 5. 6. YA22 YA30 22 13 31/12/06 31/12/06 7. YA39 12 (2) (3) 24 (3) 23(4) 15 31/03/07 8. 10. YA42 YA6 31/12/06 31/01/07 The Old Vicarage Version 5.2 Page 25 centred and of best practice. (Previous timescales of 30/4/05 & 30/6/05 & 30/10/05 & 31/03/06 not met) This work has begun and needs to be in place for all individuals. 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 YA17 YA24 Good Practice Recommendations Consideration is given to the layout and décor of the dining room. Place the refurbishment of the ground floor shower/WC on a list of works to be completed. The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI The Old Vicarage DS0000016626.V312113.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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