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Inspection on 05/01/06 for The Watery Lane Project

Also see our care home review for The Watery Lane Project for more information

This inspection was carried out on 5th January 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Manager and the care team have a good knowledge of the support needs of service users and encourage them to lead fulfilling lives. They advocate appropriately for service users with higher levels of support needs. Staff receive specialist training to enable them to support the service users who do require a specialised service particularly in the area of communication. The service works actively with external agencies and Health Care Professionals to develop and improve the support provided to service users. The views of service users are sought and the manager has been innovative in arranging adapted methods of communication to enable these views to be expressed and acted upon.

What has improved since the last inspection?

All staff now receive regular training relating to fire procedures. There are regular fire drills, which include evacuation of the home. The long-term health care needs of service users and any restrictions to choice are now discussed as part of the review process and the outcomes reflected within care plans.Three staff have been recruited to the home`s staff team, including a new deputy manager. This will ensure greater consistency in the support of the service users and provide valuable support for the Registered Manager.

What the care home could do better:

Equal opportunities training for all staff to be considered. This will provide staff with relevant information to support the service users. All staff are to be supervised regularly and a clear record kept within their personnel file. This will ensure all staff are supported to provide a quality service. Risk Assessments should be reviewed regularly and form part of the care plan for each service user. This will promote and maintain the safety of all service users. The home should review the development and its progress in adapting information into accessible formats for service users. This will provide opportunities for all service users to make informed choices.

CARE HOME ADULTS 18-65 The Watery Lane Project RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN Lead Inspector David Smith Unannounced Inspection 5th January 2006 09.45 The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Watery Lane Project 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) RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN 0207 296 8000 RNID Mr Nicholas Foskett Care Home 3 Category(ies) of Sensory impairment (3) registration, with number of places The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 3 people of either gender with dual sensory impairment aged 18-64 who require personal care only. 20th July 2005 Date of last inspection Brief Description of the Service: Watery Lane Cottage accommodates three people with dual sensory impairment, aged 18- 64, who require personal care and intensive stafing support. The building, which is situated on the main RNID Poolmead site, is on one level with en-suite bathrooms with specialist baths and showers, which enables service users to maintain and maximize their independence. There is a large spacious open plan room, which is designed for easy access and movement into the living area, dining area and kitchen. The hallway has support rails, which enable service users to access different sections of the home independently. Externally there is a ramp with support rails on both sides, which lead to a spacious, enclosed garden and patio area, which has been raised to enable service users to grow their own vegetables and flowers. There are many features around the home of a therapeutic and tactile nature, which offer stimulation and a positive environment for service users. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day. The inspector gathered information for this report from discussions with the Registered Care Manager, three staff members, one service user, observations of communication and interaction between staff and all three service users, inspection of care plans and other records and a tour of the home. What the service does well: What has improved since the last inspection? All staff now receive regular training relating to fire procedures. There are regular fire drills, which include evacuation of the home. The long-term health care needs of service users and any restrictions to choice are now discussed as part of the review process and the outcomes reflected within care plans. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 6 Three staff have been recruited to the home’s staff team, including a new deputy manager. This will ensure greater consistency in the support of the service users and provide valuable support for the Registered Manager. 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 Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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): 1, 3, 5 The home has a Statement of Purpose. This is supplemented by various assessments carried out for all prospective service users prior to entry to the service. There are contracts in place between the service users and RNID but not between the RNID and Funding Authorities, as there need to be. This remains an outstanding requirement from previous inspections but because compliance with this requirement is outside the control of the manager it is being raised with the Commission for Social Care Inspection’s Provider Relationship Manager as a national issue. EVIDENCE: The home’s Statement of Purpose contains all information as outlined in the National Minimum Standards. The document is well presented, including photographs of the home, garden, and communal areas. The document has also been developed in Braille. Contracts are exchanged by the RNID with service users or their relatives, but this does not apply to the contract between the funding authority and the RNID. These are required to enable the Registered Manager to ensure he is providing the correct level of service contracted by the Funding Authority. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 9 The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 and 9. The care plans examined provided good information in how to support each service user. There was a clear review process evident. The home has an experienced and skilled staff team who provide appropriate levels of support to service users. Staff also advocate appropriately for service users. There are Risk Assessments in place. These must be reviewed on a regular basis and form part of each care plan to promote the safety of each service user. EVIDENCE: Two service user care plans were examined and these provided comprehensive information on the areas of support each person required. Regular reviews are held, which include service users, their families, Social Workers and Keyworkers. These are clearly recorded and the outcomes used to update individual care plans. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 11 Interactions between staff and all three service users were observed at various times during the inspection. These demonstrated the staff had a good knowledge of the support needs of service users and how to communicate and guide them effectively. Discussion between the inspector and four staff members also confirmed this. One service user was observed discussing personal issues with a member of staff who dealt with these discussions in a sensitive and professional way. The staff member provided the service user with relevant information but let them make decisions. British Sign Language was used as the mode of communication. Another service user had chosen an activity of using tactile bricks to build various shapes to explore, using touch. Staff were communicating with him effectively using the Deaf Blind Manual Alphabet. There are regular house meetings where the service users can discuss the general running of the home, things they would like to do, discuss holidays. Daily records confirmed attendance of these meetings and the agreed outcomes. There are both generic and person centred Risk Assessments in place. However, the inspector found some of these to be out of date as there was no evidence of review. All Risk Assessments must be subject to regular review to ensure the welfare of service users. These should also form part of each care plan. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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, 14, 15 and 17. Service users are well supported by staff to use facilities both within the Poole mead site and in the wider community. They are also well supported to enjoy holidays, visits to family and friends. Visitors to the home are welcomed. One service user is currently being supported by the staff team to gain a greater understanding and the opportunity for personal development in personal relationships and sexuality. A clear plan needs to be developed to support this service user in this area. A healthy, balanced and varied diet is promoted. EVIDENCE: All service users have the opportunity to attend daily Educational Development Studies. Facilities available in the wider community are also used, including swimming, going for walks, going on holiday, trips to local pubs and going out for meals. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 13 One service user explained to the inspector that he liked going swimming, going out and attending music sessions. He confirmed that his music session was that afternoon and he had arranged to go swimming the next morning. Staff always support him with these activities and “helped him”. He also spoke about his family and that both his mother and brother had come to his review just before Christmas. One service user has demonstrated both through discussions with staff members and his own actions that he requires support with personal relationships and the expression of his sexuality. This issue was discussed at his recent review. Following this, the Registered Manager has been asked to approach an appropriate agency to support this work, obtain details of the support which can be offered, the approximate time scales and cost implications. The inspector concurs that this is an important area of support for this service user which needs to be addressed as soon as possible. The menus are planned in advance and are displayed in the kitchen area. These show a wide range of food, which provide both a healthy and balanced diet. The inspector observed one service user choosing and preparing his own breakfast. He was supported by a member of staff who encouraged him to make use of Braille symbols in the kitchen area and also used a ‘hand over hand’ method of support when appropriate. The staff member provided sufficient time and space for the service user to make the best use of his own skills and abilities and only provided assistance when necessary. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 care plans clearly explain the support each service users requires in relation to their personal and health care. Longer-term needs are now discussed as part of the review process. Experienced staff have a good knowledge of each service user and how to provide appropriate levels of support. A monitored dosage system of medication for service users is in operation and this is well managed. EVIDENCE: Each service user is registered with a local GP, Dentist and other relevant professionals such as a chiropodist. Each care plan explains the support needs for each service user in this area. These are reviewed regularly and the records of the most recent reviews describe discussion regarding the longer-term health needs of each service user. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 15 There are varying levels of support from other health care professionals such as Occupational Therapist, Psychiatrist, and Community Psychiatric Nurse. Contact with these professionals was clearly recorded in each service users file and the outcomes acted upon. The inspector observed staff interacting and guiding service users within the home. Staff spoken with displayed a good knowledge of the personal care they need to provide to service users and this was in accordance with the care plans examined. One service user is currently being supported in the review of his epilepsy medication. The records confirmed that the service user, his family, staff, his GP and Funding Authority are all actively involved in this review process. The home uses the Boots Monitored Dosage System of medicine administration. Staff records examined show that staff have received training by Boots on this system and they also have in house instruction and a medication assessment prior to dispensing medication to service users. One staff member told the inspector that the medication procedure was explained to her as part of her induction process but she was not yet able to administer medication, as she had not completed her assessment. The medication records show profiles of each service user, recent photograph, details of their medication, times of administration and manufactures notes on each of the prescribed medications administered within the home. Two staff are required to check the medication administered to service users and sign the appropriate records. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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 Service users are enabled to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. EVIDENCE: The home has a complaints procedure, which all service users have explained to them. This is also available in Braille. There have been no complaints recorded since the last inspection. One service user who spoke to the inspector explained that he would feel able to talk to staff if he had a problem or felt unhappy. He explained that he would prefer to speak to either one of his Keyworkers or the manager of the home. He was sure they would be able to help him. The home has clear guidelines and risk assessments in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. Staff receive regular training in responding to these using the NAAPI system, which is accredited by the British Institute of Learning Disabilities. Clear records of accidents and incidents are maintained. Staff spoken with explained that they also use daily observation when supporting service users. This would help alert them to any changes in behaviour, which may cause them concern. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 17 The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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, 29 and 30 The home is well maintained and has several adaptations which complement both the skills and abilities of the service users and help to promote their independence. The home was clean and tidy. EVIDENCE: The home is well maintained and provides a homely environment. The open plan kitchen/lounge/dining area promotes the service users independence. The inspector observed service users using these areas at various times during the day. This particular lay out allows staff the opportunity to observe service users without the need to guide unnecessarily or restrict their movement around the home. This helps the homely feel and promotes service users independence. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 19 This is supported by the specialist equipment in place. Flashing fire alarm system, a buzzer call system, lower light switches, tactile symbols and textile surfaces, and support rails both within the home and outside the front and rear of the house. A number of pieces of service user artwork are displayed throughout the home, together with several photographs of recent holidays. New furniture has been purchased for the lounge area. Outdoor space is ample, and the surrounding garden contains a patio and vegetable plot. There is also a raised area, which provides tactile stimulation for service users with higher levels of support needs or mobility problems. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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, 35 and 36. Service users are supported by an experienced staff team who have a good knowledge of their support needs. The home’s recruitment policy and training of staff promote both service users rights and their safety. Staff are provided with training both by the organisation and external agencies. There needs to be a clear action plan in relation to supporting staff to obtain a National Vocational Qualification. All staff need to be supervised on a regular basis and a clear record maintained in their personnel files. EVIDENCE: There is a low turnover of staff, which provides a consistent approach in supporting each service user. The home is usually staffed to provide 1:1 support for service users during the day. However, on the day of inspection, there were only two staff on duty on the morning shift. Staff sickness had led to this situation and the manager The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 21 confirmed that cover could not be provided by either relief staff or agency cover. This did not appear to put service users at risk, although it did affect the level of support and interaction available to them. The Service Manager had been informed and a manager from another service on the Poolemead site had agreed to provide additional support if required. The staffing rotas confirmed that this situation is not common practice and the inspector could find no evidence from the records examined of the home being understaffed on any other occasion. Staff are inducted into the service and the initial instruction is recorded on an induction checklist. One staff member had recently been recruited to the home’s relief staff bank. She explained to the inspector that following her appointment she had visited the service and then spent two days in the home undergoing her induction. Areas covered included a tour of the home, fire procedures, health and safety, medication, care plans, job role and ethos of the service. This member of staff commented that she felt the induction was thorough and did prepare her to form part of the shift team. The home operates a robust recruitment policy. The personnel files examined show records of staff application forms, references and enhanced Criminal Record Bureau Disclosures. Staff also receive training in the Protection of Vulnerable Adults. There are a number of training opportunities for staff. This includes general health and safety training and more specialised training in relation to service users support needs. Staff records examined contained records of fire training, food hygiene, Risk Assessments, Protection of Vulnerable Adults, Boots MDS, NAAPI, Manual Handling, as well as British Sign Language Stage1 and 2, CACDP Level 3 in Communication with Deaf Blind people, Epilepsy and Deaf Awareness. The home does not have 50 of the staff team trained to at least NVQ Level 2. There needs to be a clear plan developed to show how the home intends to meet this standard. Following the last inspection recommendation, consideration should still be given to providing Equal Opportunities training for all staff. Staff are supervised and annually appraised on a 1:1 basis. Records showed that some staff are not being supervised regularly as described in their The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 22 supervision contract. All staff must be supervised regularly and a clear record of the meeting, together with the agreed outcomes, maintained. Three staff have recently been recruited, including a Deputy Manager, and will commence employment once a satisfactory Enhanced Criminal Records Bureau check is received. This will help to both maintain the consistency and the quality of the support for service users and the general management of the home. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 23 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): 37, 38 and 39 The home is well run and has effective procedures in place to provide service users with the support they require to lead fulfilling lives. The manager is qualified and competent to run Watery Lane, and meet its statement of purpose, aims & objectives. The progress made in providing information in formats accessible for service users should be reviewed by the home. EVIDENCE: The Registered Manager has completed NVQ Level 4 in Care and is currently working towards the Registered Managers Award. He is a qualified NVQ Assessor and has attained both CACDP Level 1 and 2 in British Sign Language. He also undertakes periodic training to maintain his knowledge and update his skills and level of competence. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 24 The management approach is open and positive, with a clear sense of direction and leadership. Staff spoken with said their views are listened to, and that they are well supported by the manager. There are regular staff meetings, where staff can agenda topics for discussion regarding the general running of the home and other issues relevant to the team. Staff spoken with feel theses meetings are important and valued. A staff Team Away Day is also currently being planned. Service users have regular house meetings, which involved them in discussions regarding their home and the support provided by the staff team. Records show that their views are listened to and acted upon. The manager has also developed questionnaires, seeking the views of service users, relatives and other professionals. There are other systems in place to measure the success in achieving the aims, objectives and statement of purpose of the home. The home has information transcribed into Braille to support one service user. Other service users would require individually adapted methods to enable them to access information. Staff support service users at present by explaining information to them either by using British Sign Language or Deaf Blind Manual Alphabet. The development of other appropriate accessible formats for service users should be reviewed and a record of this process form part of each care plan. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 25 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 3 2 X 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 2 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X X X The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES 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. Standard YA8 YA36 YA35 Regulation 13.4 18.2 18.1 Requirement Risk Assessments must be regularly reviewed and form part of each care plan. All staff must be supervised regularly and a clear record maintained. The home to provide a clear action plan to enable staff to obtain a National Vocational Qualification to Level 2/3. Timescale for action 05/01/06 05/01/06 05/04/06 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. Refer to Standard 35 6 Good Practice Recommendations Equal opportunities training for staff to be considered. The development of accessible formats for service users should be reviewed by the home and a record kept as part of each care plan. The Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Watery Lane Project DS0000049993.V274318.R01.S.doc Version 5.1 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. 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