Inspection on 28/03/08 for Valdigarth

This inspection was carried out on 28th March 2008.

CSCI found this care home to be providing an Adequate service.

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

Valdigarth 09/03/09

Valdigarth 28/11/06

Valdigarth 21/02/06

Valdigarth 09/11/05

Valdigarth 07/12/04

Valdigarth 20/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Valdigarth Valdigarth 20 Granville Terrace Wheatley Hill Co Durham DH6 3JQ Lead Inspector Carole McKay Key Unannounced Inspection 28th March 2008 11:30 Valdigarth DS0000055219.V362809.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 Valdigarth DS0000055219.V362809.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. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valdigarth Address Valdigarth 20 Granville Terrace Wheatley Hill Co Durham DH6 3JQ 01429 823403 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) lorraine@lorrainemarshall.oneadoo.co.uk Mr Brian Gibson t/a Valdigarth Residential Care Home Arthur Galloway t/a Valdigarth Residential Care Home Mrs Lorraine Marshall Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: 2. Learning Disability - Code LD, maximum number of places 10 The maximum number of service users who can be accommodated is: 10 28th November 2006 Date of last inspection Brief Description of the Service: Valdigarth is a care home catering to the needs of 10 adults. It is a large house set on the main street of Wheatley Hill. Sited in the north east of Durham county, the home provides easy access by public transport to Durham, Sunderland and local towns of Peterlee and Hartlepool. The home provides living support for adults with learning disability and ages ranging from 18 to 65 years. Accommodation is provided on the ground floor and first floor. All bedrooms are single and reflect residents’ individual tastes. There is a large separate lounge and dining room and a garden to the rear of the home. Major improvements to the premises have been completed since the last inspection. At the time of inspection fees ranged from £412.00 to £421.50. These being the levels set by the contract with the local authorities placing people at the service. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 28 November 2006 • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • Sent surveys to staff and service users. The Visit: An unannounced visit was made on 28 March 2008. During the visit we: • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. Unfortunately none of the surveys were received in time to be included in the inspection report. What the service does well: The home has stated good values underpinning the care delivered to service users. Service users have their basic needs clearly assessed. People living at the service will be consulted about how the home runs and their views will be taken into account. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 6 Staffing levels are adapted so that the people who live at the service have their needs and requests met. Staff have procedures and training that help them in meeting the needs of service users. 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 summary of this inspection report can be made available in other formats on request. Valdigarth DS0000055219.V362809.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 Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People considering living at the service will have information provided to them and their needs will be assessed with a degree of input from them. EVIDENCE: Copies of the Service User Guide and the home’s Statement of Purpose are both available in the home. The home’s fees are covered, but amounts are not completed. A space is left for these to be inserted. The complaints process is included. The service user guide is not in a ‘user friendly’ format. This matter was raised at the last inspection of the home. The manager, Lorraine said that she is working on this and is gathering photographs, pictures etc. A copy of the most recent inspection report is hanging on the wall in hallway. The home has an assessment process of its own devising. The assessment clearly states what service users’ needs are. Some of the people who live at Valdigarth have the ability to contribute to the assessment process, but there is no evidence that they do so. Preliminary visits to the home are arranged. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 9 One of these took place on the day of the inspection, but at short notice, so existing service users could not all be consulted beforehand. Service users files include the written contract. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are supported to deliver planned care to service users who are consulted but could take a more active role in the process. EVIDENCE: Each service users has a service user plan. These are designed in house and cover all areas of need as identified by the manager of the service. They do not clearly reflect the wishes and aspirations of the people who live at the service. The plans are not presented in a format that people with learning disabilities could easily understand. They are however detailed and clearly written and describe for the staff the action staff need to take to support service users. Regular meetings also take place between each service user and their key worker, when the plans are discussed and the views of service users are recorded. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 11 Each service users’ plan includes risk assessments and the plans for managing risk. Lorraine said that all of the staff have received training in risk assessment. The home has written policies to do with decision making and risk taking. Although not in an accessible format, the statement of purpose for the home includes a statement of citizenship and the rights of service users. Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyles of the people living at the service reflect their individual preferences and expectations. EVIDENCE: Service user plans show that the service is aware of the need to support residents to develop social skills but these focus on the tasks rather than the values of respect, dignity, equality etc. Activity meetings take place weekly with Tracy, a member of staff. Lorraine said that it can be difficult to ascertain choices and the use of varied media to prompt ideas and discussions was discussed. Individual diaries are an ongoing account of what people do. On the day of the inspection some people were attending day centres and work placement. One Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 13 person is retired and was at home on the day of the inspection visit. Availability of local post- retirement activities was discussed with the manager but Lorraine was of the view that this person would not like to be with other older people. Lorraine has identified that more could be done to encourage in house activity and a wider choice of activity generally. This something that is planned for over the next twelve months. In line with this the home has identified a member of staff to take responsibility for promoting social activity. There is evidence that service users are supported to maintain family links. One service user was looking forward to going to stay with relatives. The diaries show that people who live at the service are supported to use local transport and community facilities. Records are kept of service users’ food preferences and the manager said that these are taken into account when the menus are planned. Lorraine acknowledges that more could be done to encourage service users to take part in menu planning. Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the service will have their health care needs addressed. The way this is managed does not always reflect the preference and ensure the dignity of the service user. EVIDENCE: All service users have an ‘OK health check ‘apart from the person most recently admitted. This is a good practice method of assessing the health needs of people who have a learning disability and are living in the community. None of the service users require routine clinical care, however there is a note in one of the assessments that the chiropodist is happy for the staff to cut a person’s toenails. There is no plan of care for this or evidence that staff have been trained and have had their competence assessed. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 15 Service users’ care plans are developed from the in house assessment. These include very clear descriptions of each person’s personality and behaviour, but the actions staff are expected to take to support service users are not always clearly described. For example one person tends to hoard things and is identified as needing a lot of encouragement to throw out papers, and not liking to carry out general domestic tasks, becoming agitated and verbal. But there is no clear plan of how staff should respond to this. Similarly, there is reference to one person needing support with personal care such as shaving, but no description of how the person prefers this to be managed. Routine health checks are logged dated with outcomes There is evidence that care plans are reviewed monthly and this is good practice. Annual reviews of care are carried out at the home with service users and their representatives. Care managers provide minutes of these meetings. Lorraine has acknowledged in the written self- assessment that evidencing choice and control needs more work. Daily diaries are a brief account of the daily activities of each person who lives at the home. Some entries simply state ‘as per care plan’ and few are detailed unless incidents have occurred, such as a person’s reluctance to co-operate, bad moods or incidents with other service users. The home has a written medication policy. And a step- by- step procedure. No one living at the home is self- medicating. Lorraine said that a new medication system from Boots chemist is going to be introduced on the 2 may 08. This will address the shortfall in the medication administration record (mar), that the strength and form of the medication is not currently shown. Also currently, staff re- dispense medication into dosettes for taking away from home i.e. weekends away, but in future this will be done by the pharmacist. The amount of medications being stored is acceptable. They are securely stored, none being kept in bedrooms. Staff files have certificates for training in medications and Boots will be delivering more training prior to the new system being introduced. There is no system for Lorraine to assess the competence of staff in handling medications. Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home will address concerns and strives to protect service users EVIDENCE: Since the last inspection no complaints about the service have been received by the Commission for Social Care Inspection (CSCI). The manager has stated that the service has not received any complaints in the same period. The home has a complaints procedure and this is included in the Statement of Purpose. It is not user friendly,( and this is acknowledged by the manager as something that needs to be addressed ) for example, it is not accessible to people who have reading difficulty, but it covers the important points. It does not provide for reference to anyone above he manager. The policy file refers to the National Care Standards Commission as the contact for unresolved complaints. This information is now out of date. Regular meetings take place with all service users as a group and on a one to one with key workers. Some service users have communication difficulties. The manager has the idea of introducing a suggestion box but said that she struggles with the idea of how to make this useable for all service users. As with making choices, the manager has identified that working with speech and Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 17 language therapist would assist some service users. But this has not yet been followed through. The home has a policy and procedures file. There is a policy on abuse of vulnerable people. Local contact numbers are included. (police, social services, CSCI). Recognition and reporting abuse is covered as well as definitions. A step- by- step guide is also included in the file with a flow chart showing the relevant telephone contacts. Durham County Council has a training package for protecting vulnerable people that staff have received. No incidents have occurred to warrant invoking procedures. The training pack refers to the Social Services and police as contacts. All policies are regularly reviewed. Lorraine has had mental capacity act training and said that the staff will be doing this in the future but as yet this is not planned in. There is a copy of the Mental Capacity Act in the home for staff to access. The home has a policy on aggression towards staff and detailed guidance to do with managing these situations. There is a policy on bullying. Some service users are self sufficient with money and handling bank accounts. Where necessary service users interests have been protected through guardianship of the local authority. However, the manager acts as appointee for three of the persons living at the home. Individual lockable cash tins are used to securely store monies held for safekeeping. Monies are signed for and countersigned and transactions are fully documented. Service users do not have a lockable facility in their rooms. Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, spacious home. EVIDENCE: Since the last inspection the building has been considerably improved. A new extension has been added and the original building has been refurbished. Some of the bedrooms have en suite facilities and there are bathrooms and bedrooms on each floor. At the time of the visit the heating was off in some rooms and a new boiler was on order. Fan heaters were being used to keep communal areas warm. Shortly after the visit the manager reported that the fault with the boiler had been remedied and the heating was again functioning properly. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 19 There is evidence of some damp penetration in one of the bathrooms. Lorraine said that the cause had been repaired and was now due for repainting. A fire sprinkler system has been installed. The paintwork in new the new rooms is clean and fresh. Lorraine said that service users had chosen the colours for their rooms. Some rooms are quite bare and there is a lack of mirrors in the ground floor bathroom and communal areas, as well as some of the bedrooms. Mirrors are useful for promoting independence and dignity. The home was clean throughout. A new kitchen has been installed and separate laundry facilities. Valdigarth DS0000055219.V362809.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well-established, qualified and growing staff team supports service users. Staff training may not always match the needs of the people who live at the service. EVIDENCE: The staff rotas have recently been adjusted to meet the requests of service users. Lorraine said that she was planning to recruit new staff to meet additional needs of the people who live at the service. A staff record is available for each person employed at the home. In the files examined they held a training plan with dates of staff induction training, and mandatory training. One person holds a national vocational qualification (NVQ) in care at level 3 and three people hold NVQ in care at level 2. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 21 Records to do with recruitment are included. An application form is completed. The home uses another agency to carry out criminal record checks on their behalf. Letters are available to confirm that these have been carried out but not all of the necessary information is included. For example, it is not evident that they have checked the list of named persons who are unsuitable to work with vulnerable adults. Copies of contracts are held. Interview checklists and interview assessment forms are used. Two written references are taken up. Staff are employed on probation for three months. The first one to one supervision follows this and further supervisions and staff meetings are regular and are recorded. There is no evidence that service users are involved in staff selection at interview stage, but the manager said that service users would meet applicants and their opinions would be taken into account. There is evidence that longer serving staff have opportunities for additional training, but there is no evidence that a training needs assessment has been carried out for the staff team as a whole. No impact assessment of all staff development has been carried out to identify the training benefits for service users and to inform future planning. For example one of the service users has speech and language difficulty, outcomes for this service user may be enhanced if all staff understood the most effective way to communicate with this person. There is no evidence that staff have received training in equal opportunities or person centred care planning. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed soundly so that service users are safe and are consulted but their ability to influence and control their interests and running of the home is to be further developed. EVIDENCE: The manager was previously a learning disability nurse and has undertaken the registered manager’s award. Lorraine has recently undertaken Mental Capacity Act Training. Quality assurance processes are in place. Service users are asked to complete a survey annually and feedback is given to service users and the staff. This Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 23 helps to form an action plan for the manager. As yet the survey has not been used with other agencies or interested parties but the manager has stated that this is being considered. Policies and procedures for the home are available in files in the office for staff to use. These are regularly reviewed. The home is well maintained and a new electrical wiring certificate was issued in 08.06 for five years. The Gas certificate is dated June 07. Portable appliance testing is due on 19.04.08. All water outlets are thermostatically controlled. Opening restrictors are fitted on windows. The home is clean throughout but the five steps to infection control guidance is not available. A handyman is available for running repairs. Regular meetings take place with service users and surveys are used. The provider visits the home monthly. An auditing checklist is produced rather than really rather than a report and service users are not central to the reporting process. A monthly audit of the building is undertaken to include the fire risk assessment. A Fire Certificate of inspection was issued on 3 March 08. Fire instruction is given at supervision with staff. The home has a health and safety policy and written procedures in place. The accident book was examined. No significant accidents have occurred. Those recorded are minor and show a low frequency. Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 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 Standard No Score 1 2 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 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 2 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 2 3 2 x 3 x 2 x x 3 x Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6 Requirement The registered persons must review the statement of purpose and service user guide to make these documents as accessible as possible to the people who live and may come to live at the home. The registered manager must clearly demonstrate that the people who come to live at the service are consulted regarding the assessment of their needs The registered manager must make the service user plans available to service users in away that meets their needs and abilities. And make sure that they reflect service users’ decisions, wishes and aspirations. The registered manager must make sure that for those service users who require support with personal care, plans include the preferences of service users in how this care is delivered. And describe clearly the action staff will take to ensure these needs are met. The registered manager must DS0000055219.V362809.R01.S.doc Timescale for action 31/07/08 2 YA2 14(1) © 31/08/08 3 YA6 YA7 15(2) (a) 31/07/08 4 YA18 15(1) 31/07/08 5 Valdigarth YA20 13(2) 30/06/08 Page 26 Version 5.2 6 YA22 22(1) 7 YA23 22 20 8 YA39 24 26 ensure that medicines are only administered from the original containers in which they are supplied, and that records show the strength and the form of the medication. The registered manager must make the complaints procedure clear to service users by producing it in a format that is accessible to their needs and abilities. The adult protection procedure should be revised to ensure the contact details for CSCI are updated. The registered manager must relinquish acting as agent for service users wherever practicable. The registered person must produce a written report arising from the monthly visits to the service. 31/08/08 31/07/08 31/07/08 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 Refer to Standard YA39 Good Practice Recommendations The views of interested parties should be taken into account in the quality assurance survey. The results of the surveys should be shared with service users’ representatives and other interested parties. The manager should consider carrying out a training need assessment for the staff team as a whole. And an impact assessment of staff development experienced so far, so that the benefits for service users are identified and inform future planning. The manager should obtain the guidance ‘ The five steps to infection control.’ 2 YA35 3 YA42 Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Valdigarth DS0000055219.V362809.R01.S.doc Version 5.2 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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