Inspection on 06/12/05 for The Old Vicarage [Blakeney]

This inspection was carried out on 6th December 2005.

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 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 12 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] 10/10/06

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 Mr Peter Still Unannounced Inspection 6th December 2005 11:15 The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 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.V271012.R01.S.doc Version 5.0 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.V271012.R01.S.doc Version 5.0 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.V271012.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02/08/05 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.V271012.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours. The acting manager and senior carer supported the inspection process. A tour of the properties was undertaken and five residents and four staff were spoken with. The care of two residents was case tracked, which involved looking at care plans, daily records, risk assessments and medication. The home had no vacancies and the atmosphere was welcoming with most residents fully content during the day. The acting manager was most helpful and keen to taken on board points that were raised. He also spoke of his job satisfaction in working at the home and of looking forward to providing whatever support he could to the new manager. This report identifies a number of matters requiring action, which may seem negative, however the inspector wishes to make clear that these should not detract from the good progress that has been made. What the service does well: Staff focus on the needs of residents and the acting manager was keen to make improvements to the service and to listen positively to the points identified. Residents live in an attractive environment within the centre of the community, they take advantage of this and also of the wide range of activities available away from the home. Residents value the day services at the nearby Stepping Stones, which includes a Day centre and gym. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 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.V271012.R01.S.doc Version 5.0 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 written documentation did not ensure that individual needs and aspirations were assessed prior to admission, which may put residents at risk. EVIDENCE: Two files were examined and both contained a statement of terms and conditions, which were signed but one was dated for admission to a previous home. The previous inspection noted this to be an issue and the requirement will be repeated. However the last report found none of the documents to be signed or dated and this had been complied with. It will be necessary for full documentation and assessment to be completed prior to future residents coming to the home. Limited documentation was available and this standard must be considered to ensure comprehensive assessment is undertaken and evidenced. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 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, 8, 9 Care planning needs further development to promote independence and choice and residents would benefit from more consultation on all aspects of life in the home. A good risk assessment record is maintained. EVIDENCE: Two care plans were seen. The last inspection found no evidence of who was compiling care plans, and they were also undated. The acting manager has dealt with this however an inconsistency remains in the completion of care plans. The way the care plans are constructed makes them difficult to follow. One had a list of four resident needs but the care plan only listed two, so the other objectives were missing. The objectives also had no written heading, making them difficult to understand. The care plan content was limited and needs to be developed. Key workers complete monthly reports and a daily report sheet supports this work. The daily report sheets include some good recording, which would be helpful to key workers, however the monthly reports were limited and work is needed to develop them as well as key worker involvement. The home has a current policy of staff working with only one aim for each resident and key issues could be missed or delayed. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 10 Risk assessments were completed and well recorded but should be reviewed within overall care planning. The last inspection raised further concerns about the use of sanctions, concerning cigarettes and that the care plan did not clearly state a reason. Since the last inspection, the care plan about it had been shredded. This is not permitted within regulation 17, which requires that records must be held for a minimum of three years. The acting manager said the matter was dealt with verbally on a daily basis with the resident and that there was not considered to be a restriction since the resident holds their cigarettes. Where a care plan identifies sanctions or matters of concern, then comprehensive information must be included. It is most important that care records about sanctions are maintained and a requirement will be made and repeated. The acting manager and senior carer should be praised for already identifying a need to review and improve the care planning system. Notes about this were seen in minutes of a well-recorded staff meeting on 15/11/05 and also, during the previous week three staff attended a care planning course. The previous inspection said that feedback from some comment cards indicated that people living at the home would like to have more involvement in the running of the home and that a quality assurance survey last completed in 2003 must be repeated with an emphasis on how people can be involved more in the running of the home, with staff recruitment and selection being one example given. The survey had not been repeated and the acting manager would find further guidance about this to be helpful. It is important to note that the acting manager was considered to be very keen to develop this aspect at the home but needs guidance. At this inspection, the inspector talked to a group of residents, who talked to each other about being involved more in the running of the home and said they would like this. The last house meeting was held on 18/08/05 and whilst a good start, needs to be developed. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 15, 16, 17 The lifestyle of residents is promoted and residents enjoy a variety of experience and interests. A healthy diet was provided. EVIDENCE: The last inspection found that residents were occasionally restricted in their activities by inappropriate staffing levels. The providers should be commended for addressing this and staffing now ensures residents are supported to maintain full lives. It was also noted that the manager post is supernumerary. One resident showed the inspector their record book about the way staff consider their progress. The resident was very happy with this and controls its use. This was considered to be an excellent initiative promoted by the resident and fully supported by staff. Concerning activity, another resident said “I like Stepping Stones and I love it here”, “ Nothing could be better”. The home is in the centre of the village and enables easy community contact. Stepping Stones has a day centre which residents attend and where a range of activity is offered. Some residents go swimming every week, college courses are available and one resident talked about looking forward to starting after The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 12 Christmas. The home has worked hard to ensure one resident was able to have a special one to one holiday at Euro Disney. The acting manager has specific interest and skills in cooking and specifically ensures residents favourite meals are included on the menu, talking to residents on a daily basis. Residents said they liked the food and that the acting manager consults them. One resident has specific food constantly available meeting a cultural need. Staff confirmed that alternatives are provided when requested. The evening meal being prepared by one of the care staff looked very appealing and was a fish pie. A bowl of fresh fruit was seen in the dining room and fresh vegetables in the kitchen. A local butcher supplies fresh meat. One resident said they enjoyed shopping for food. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 13 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): 20 Residents were protected by the medication systems in place. Storage should be reviewed and improved. EVIDENCE: The last inspection identified a number of issues, which have all been addressed. Storage of medication needs to be improved. The medication is locked in a cupboard under stairs along with other items. The lighting should be reviewed since the door to the drugs cupboard blocks light. The morning medication rack was too full and a better way of using the space needs to be considered. It will be recommended that the local pharmacist be asked to check the medication system and also to provide guidance on re-establishing the drugs area to ensure it complies with best practice for the storage and administration of medication. It would also be helpful to staff if the pharmacist would be prepared to provide staff with training on medication. The acting manager thought the pharmacist would be willing to provide this support. One resident said they had asked for their medication to be reviewed and were pleased with the outcome. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 14 One resident attends a day centre on a regular basis and mid day medication was put into a labelled pot to go with the resident. This is not regarded as best practice and a recommendation will be made that the manager asks the pharmacist to provided the mid day medication in its own blister pack to ensure no mistakes are made. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 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 the following standard(s): 22, 23 The standards require further work to ensure residents feel they are listened to and that steps are taken concerning the way complaints are responded to. POVA must be activated regarding a recent incident. EVIDENCE: The last inspection required easier access to information with a separate complaints log for storing complaints and this was responded to. The name of the Commission had also been changed correctly. Two residents said they did not feel staff had listened to them. Residents gave two examples. One concerned the lack of lighting and another about a difficulty with another resident and violence towards a member of staff. The incident dated 02/12/05, was briefly recorded on the green daily report sheet but a regulation 37 report had not been completed and the acting manager was only aware that a resident had “Played up over the weekend”. Staff training is needed to ensure good communication and the protection of residents and staff. Development of care plans and the role of the key worker, with comprehensive recordings of communication with residents would be helpful. This would also enable likes and dislikes and discussion about how difficulties could be resolved, to be heard and recorded in a structured way. Three residents said staff listened them. Three residents felt that more frequent house meetings would help them to make their views known. The community learning disability team may be able to help look at ways of working with residents, where specific difficulties are found. A complaint from a resident had been responded to verbally and the lack of documentation may have put the resident and home at risk. Any complaint must be reported fully and documented. The particular matter must be The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 16 pursued by the acting manager and the POVA process activated. It must also be forwarded to the CSCI under regulation 37. A requirement will be made for staff to have training on the handling and process of complaints. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 17 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, 30 The standard of the environment was good, providing residents with an attractive and homely place to live in. However some environmental issues were identified and require action to ensure resident safety. EVIDENCE: On the day of inspection, full redecoration of the Coach House sitting room had just been completed and looked very good. The first floor bathroom had been upgraded since the last inspection and was in a pleasant condition. Air fresheners had been put into all resident’s bedrooms. Portable electrical appliance equipment testing, was being undertaken on the day of inspection. The lounge in the main part of the building was homely and comfortable. Resident’s artwork was very attractive. A number of issues from the last inspection had all been carefully attended to by the acting manager, who demonstrated commitment to swift action on any points raised. It is unfortunate that on this inspection, a number of new matters were found and it may be useful for a maintenance person or member of staff to make a regular check of the home to try to ensure maintenance is kept up to date. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 18 A format for work place risk assessments had been provided but was not completed and a requirement will be made for this to be undertaken. The window restrictor in bedroom 6 needs improvement and in bedroom 8, it must be reviewed since the window was considered to be open too high and a resident may fall from it, especially considering the height of the window from the floor. The window restrictor of bedroom 7 had a flimsy fixing and may come away. The window also needed decoration. All windows must be reviewed to ensure window restrictors are all safe. The front entrance hall, which has a door to close it off from the home, was used for smoking and since the outside door was closed, the amount of smoke in the room was significant. A requirement for adequate ventilation will be made. The ground floor rear bedroom had a lot of mould on the window and needs cleaning and the reason found so that the problem can be resolved permanently. The bathroom window in bedroom 6a needs the same work. The ground floor shower/WC room requires refurbishment. A large plastic storage container for a resident in bedroom 6 was broken with a number of sharp bits of plastic. A resident said she/he had fallen on steps leading from the patio of the main home to the coach house and was in pain and using a stick on the day of inspection. She/he said they had previously asked for a light to be replaced and the lack of it had caused the fall and the resident was unhappy that no action had been taken. The resident also said that a member of staff had fallen too. The member of staff was spoken with and said they had caught hold of the railing and had not had any injury. Other staff said that the area was well lit and not a hazard. However on leaving, the inspector came from the lights of the inside of the home and did agree with the resident that the steps were not so easy to distinguish. It was noted that whilst the incident was reported in the accident book and a regulation 37 was submitted, there was no mention of the external lighting for the step. Recordings must contain all the facts. The maintenance team must act swiftly concerning health and safety issues or seek external support. The resident came out with the inspector and reinforced the point. A requirement will be made that good lighting is always maintained and that residents are consulted to ensure they are fully happy with it. A recommendation will be made that staff receive training on the completion of documentation about accidents. A member of staff was working hard during the inspection to ensure a good standard of hygiene and should be commended for her valuable work. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 19 The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 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): 33, 35, 36 Staffing levels enable resident’s needs to be met. Staff have access to training, which supports their work and this report indicates further training is needed. Structured and well-recorded staff supervision must be provided a minimum of six times a year. EVIDENCE: Staffing levels had been improved since the last inspection and their deployment should meet resident’s needs. Residents praised the care given by staff. One resident said “I love it here and I love the staff”. Staff training has improved since the last inspection. An external moderator has completed work for four staff and verification is currently awaited. Two staff have resumed NVQ level 2 training and three staff have just started. This falls short of the requirement for 50 of staff to have the award but it is progress. A range of training opportunities are undertaken by staff. The last inspection noted that a training matrix for staff, identifying training was out of date. The acting manager had tried to resolve this and requested an up to date one but unfortunately the one provided was dated 2003; the acting manager had made entries on it to up date it. The matrix is considered to be a valuable management tool and it will be recommended that an up to date one be produced. No new staff had been appointed since the last inspection. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 21 Staff supervision was in place using format though it will be difficult for the senior staff team to ensure the minimum sessions are provided this year. Supervision skills training had been provided. The supervision notes read, were limited in content and will need developing as supervision is progressed. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 22 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): 40 Staff have a focus on ensuring the well being of residents. Evidence shows that the responsible individual and acting manager are committed to the resolution of issues, which will ensure the home moves towards current best practice. EVIDENCE: The responsible individual supports the acting manager and this will continue during the transition of management. The acting manager was very positive about the home and of supporting the new manager. Residents gave good praise to him during the inspection. The acting manager will need help to produce a priority list of tasks to be undertaken, with an aim of reducing the number of issues prior to a new manager starting. A key priority will be to ensure quality assurance standard 39 is carefully considered and developed. Policies and procedures at the home could benefit from reorganising so that all staff can immediately identify them. A central easy to read index may help with this. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 23 The responsible individual should support the acting manager to ensure work place risk assessments are completed. A number of issues were identified within this section at the last inspection and the acting manager has worked hard to ensure they were all responded to. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 24 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 X 2 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Old Vicarage Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X X 2 X X X DS0000016626.V271012.R01.S.doc Version 5.0 Page 25 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 YA23 Regulation 22 Requirement Investigate complaint by a resident and activate POVA and send regulation 37 report to CSCI Train staff in the reporting and administration of incidents. Ensure external lighting is maintained to provided safety and that residents also feel content with the lighting. Ensure the home is safe concerning: window restrictors; ventilation in smoking area; mould; a broken plastic storage unit. Complete work place risk assessments Staff to receive training concerning complaints and recording requirements Provide a system for regular consultation and decision making with residents and quality assurance survey. (Previous timescale of 30/10/05 not met) Retain records at the home for a minimum of 3 years. Provided detail about a sanction, recording evidence of consultation with individuals and DS0000016626.V271012.R01.S.doc Timescale for action 22/12/06 2 3 YA42 YA24 37 23 31/03/06 22/12/06 4 YA24 23 31/01/06 5 6 7 YA42 YA22 YA8 23 22 12 (2) (3) 24 (3) 31/03/06 31/03/06 31/03/06 8 9 YA41 YA7 17 Sch 3 12-2/3 17-1a S3(3q) 22/12/05 31/01/06 The Old Vicarage Version 5.0 Page 26 10 YA6 15 11 12 YA2 YA5 14 5(1) (c) other significant people involved in their care as to whether best interests are being served. (Previous timescale of 2/10/05 not met) Provide a comprehensive care planning system, which is person centred and of best practice. (Previous timescales of 30/4/05 & 30/6/05 & 30/10/05 not met) Ensue comprehensive pre admission assessment Service users must have a statement of terms and conditions. 31/03/06 31/01/06 28/02/06 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 3 4 Refer to Standard YA20 YA43 YA24 YA20 Good Practice Recommendations Residents requiring medication away from the home should have a specific blister pack for the medication. The staff training matrix is a good management tool and should be brought up to date. Place the refurbishment of the ground floor shower/WC on a list of works to be completed. Medication storage be reviewed following professional guidance and training given to staff concerning administration of medication. The Old Vicarage DS0000016626.V271012.R01.S.doc Version 5.0 Page 27 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.V271012.R01.S.doc Version 5.0 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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