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Inspection on 14/11/05 for Welbeck House

Also see our care home review for Welbeck House for more information

This inspection was carried out on 14th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 people accommodated at Welbeck house are cared for by a very committed staff team who have a clear understanding of the individual needs of the service users accommodated. Positive relationships have been developed between the service users and staff members. Feedback received from healthcare professionals in preparation for this announced inspection was positive with all professionals stating that they are happy with the overall care provided at the home.

What has improved since the last inspection?

Since the last inspection the proprietors, manager and staff have demonstrated a clear commitment towards meeting the National Minimum Standards and this was evident in the findings of this inspection. Service users have benefited from the recent investment into their home. Following consultation with the service users the home has been redecorated and new carpets and floor coverings provided in all rooms with the exception of the hall, stairs and landing which does not currently require replacement. New curtains have also been purchased for numerous rooms, the lounge suite has been replaced, new furniture in one bedroom has been purchased, a new shower and a new washing machine has been installed and the kitchen refurbished. The home is now much more welcoming, bright and homely. All service users have been on a five-day holiday to Blackpool accompanied by three staff and the service user present at the inspection was keen to share his photographs of the holiday with the inspector. Staffing arrangements have been reviewed and a new staff member employed. The manager has completed an NVQ award, developed and implemented a new Statement of Purpose and Service User Guide and completely reviewed all of the homes records. The placing authority has formally reviewed two service users and the person most recently admitted now accesses day service provision two days per week. Training opportunities have also been reviewed and staff have undertaken a number of training courses and future training events have been identified which are service specific to working with people with learning disabilities.

What the care home could do better:

The manager has reviewed and developed a number of generic and individual risk assessments however further assessments should be developed for community activities and safe working practices. An annual development plan based on the homes quality assurance systems should be developed in addition to a staff training and development plan.

CARE HOME ADULTS 18-65 Welbeck House 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS Lead Inspector Rebecca Harrison Announced Inspection 14th November 2005 10:00 Welbeck House DS0000030055.V252700.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 Welbeck House DS0000030055.V252700.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. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Welbeck House Address 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS 01902 681909 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) Arcare (West Midlands) Limited Mrs Balvir Sahota Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Welbeck House is a traditional semi-detached house and is situated in an urban area of Bushbury. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of three adults who have a learning disability. The accommodation provided is on two floors comprising: Two single bedrooms, a bathroom and a staff sleeping-in room on the first floor and one single bedroom with en-suite on the ground floor. Communal space includes a kitchen, lounge and dining room. The home has a small garden to the rear of the property; which is well maintained. The proprietor of the home is Dr Sharma and the Registered Manager is Ms Balvir Sahota. The homes philosophy is to Maintain a high standard of care, respecting individuality, privacy, residents dignity and independence at all times. First and foremost a happy and secure environment within the home. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and commenced at 10.00 am and lasted 3.5 hours. On arrival to the home, two people were out accessing day services and one person was at home and played an active role in the inspection process. The inspection included talking with the service user present at the inspection, the senior care officer, managers, examination of a number of records and a full tour of the environment. The service user, staff member and managers were most welcoming and cooperated fully throughout the inspection. The purpose of this announced inspection was to review the progress made by the home since the unannounced inspection undertaken on the 5th May 2005 when eight requirements were made. No additional inspections have been undertaken by CSCI and no complaints or referrals to adult protection have been made in relation to this service. The inspector would like to acknowledge the significant improvements made in relation to the environment following the last inspection, which has had a very positive outcome for the people living at Welbeck House. This announced inspection was positive and the staff and managers are to be commended for the significant work undertaken since the last inspection and the commitment shown towards meeting the standards and improving the quality of the service provided to the people in residence. What the service does well: What has improved since the last inspection? Since the last inspection the proprietors, manager and staff have demonstrated a clear commitment towards meeting the National Minimum Standards and this was evident in the findings of this inspection. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 6 Service users have benefited from the recent investment into their home. Following consultation with the service users the home has been redecorated and new carpets and floor coverings provided in all rooms with the exception of the hall, stairs and landing which does not currently require replacement. New curtains have also been purchased for numerous rooms, the lounge suite has been replaced, new furniture in one bedroom has been purchased, a new shower and a new washing machine has been installed and the kitchen refurbished. The home is now much more welcoming, bright and homely. All service users have been on a five-day holiday to Blackpool accompanied by three staff and the service user present at the inspection was keen to share his photographs of the holiday with the inspector. Staffing arrangements have been reviewed and a new staff member employed. The manager has completed an NVQ award, developed and implemented a new Statement of Purpose and Service User Guide and completely reviewed all of the homes records. The placing authority has formally reviewed two service users and the person most recently admitted now accesses day service provision two days per week. Training opportunities have also been reviewed and staff have undertaken a number of training courses and future training events have been identified which are service specific to working with people with learning disabilities. 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. Welbeck House DS0000030055.V252700.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 Welbeck House DS0000030055.V252700.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): 1 and 5 The Statement of Purpose and Service User Guide is good providing people with information of the service the home aims to provide. Service Users are provided with a written contract of the terms and conditions of residence. EVIDENCE: The intended outcome for key standard 2 was assessed and met at the previous inspection and was not reviewed on this occasion. There have been no new admissions or discharges since the home was last inspected. The manager has revised the Statement of Purpose and Service User Guide. Both documents were found well presented and meet the requirements of Schedule 1, Regulations 4 and 5 of The Care Homes Regulations 2001. A requirement was made at the previous inspection that the manager develop and agree with each service user a written contract as specified in standard 5.2. The findings of this inspection evidence that this requirement has now been met. Welbeck House DS0000030055.V252700.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): 9 Service users are enabled to take responsible risks within a risk-assessed framework, which is regularly reviewed and updated. EVIDENCE: The intended outcomes for key standards 6 and 7 were assessed and met at the previous inspection and were not reviewed on this occasion. It was reported that the placing authority has formally assessed two service users since the last inspection. A requirement was made at the previous inspection for risk assessments to be reviewed and new ones developed. The finding of this inspection evidence that the manager has reviewed and developed a number of risk assessments and is working towards developing a range of new assessments in relation to community presence and participation and safe working practices. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 10 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): 12,16 and 17 Service users are provided with educational opportunities, flexible routines and a choice of meals, which take into account individual preferences and dietary requirements. EVIDENCE: The intended outcomes for key standards 13 and 15 were assessed and met at the previous inspection in addition to standard 14 (Leisure) and were therefore not reviewed on this occasion. Two people living at the home access local authority day service provision five days per week. The person most recently admitted to the home accesses day services two days per week, although following a review this will increase. Two people access Wolverhampton Adult Education Service via day services and access a range of educational courses. None of the people currently living at the home access paid or voluntary employment. Discussions held with the service user present at the inspection indicated that he enjoys attending day services and college. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 11 Observations made and discussions held evidence that service users have unrestricted access to the home and their privacy and dignity is upheld. Bedrooms and bathrooms are lockable and service users may choose when to be alone or in the company of others. People living at the home are expected to maintain a safe and clean environment. The senior care officer and the managers interacted positively with the service user present at the home during the inspection. It was reported that the home has policies in place in relation to smoking and drinking. None of the people living at the home smoke. The menu seen at the inspection appeared to be well balanced. It was reported that people take their main meal whilst in day services and that the menu provided by the home is flexible. Individual records of meals eaten are well documented and is evident that staff are aware of personal preferences. It was reported that one person has special dietary needs as identified by a healthcare professional. Service users are supported to prepare meals under staff supervision and assist with laying the table and washing up. It was reported that a relative did have concerns in relation to the quality of food provided however discussions held and a letter seen on file from the relative indicate that the matter has been satisfactorily addressed. The service user spoken with during the inspection commented that he likes the food however examination of food stocks indicated that shop brand basic foods are purchased and it is therefore recommended that service users be offered a greater variety of brand foods. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 12 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 Service users are safeguarded by the homes system of handling, storing and managing medication. EVIDENCE: The intended outcomes for key standards 18 and 19 were assessed and met at the previous inspection and were not reviewed on this occasion. Feedback received from healthcare professionals in preparation for this announced inspection was positive with all professionals stating that they are happy with the overall care provided at the home. Since the last inspection the home has changed pharmacists and Boots Chemists now supply the home with prescribed medicines for two service users. The Monitored Dosage System (MDS) is now used and staff have received the appropriate training in the new system and two staff have undertaken accredited training the in the safe handling of medicines. The medication cupboard was found well organised and medication administration records (MAR) appeared satisfactory at the time of the inspection. It was reported that none of the current service users are prescribed controlled drugs. The homes medication policy was not reviewed on this occasion. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints procedure in place and systems to safeguard service users from potential abuse. EVIDENCE: A requirement was made at the previous inspection for a record of all complaints be kept, detailing the investigation, action taken and the outcome. Findings of this inspection evidence that this requirment has now been met. In preparation for this inspection the CSCI received two comment cards from relatives/visitors who indicated that they were not familiar with the homes complaints procedure or the CSCI inspection report. This was discussed during the inspection and managers committed to providing relatives with a copy of the complaints procedure and details of how to access the homes inspection report. The home has not received any complaints since the last inspection. No formal complaints have been referred to the Commission for Social Care Inspection and there have been no referrals made under adult protection procedures. Since the last inspection the manager has attended a ‘Train the Trainers’ course in Adult protection through Wolverhampton Adult protection Committee. All staff are due to attend training in Protection of Vulnerable Adults (PoVA) – Recognising and Reporting. A copy of the Inter-Agency Adult Protection policy and procedure were also seen at the inspection. Financial records were checked against monies held on behalf of two service users and were an accurate reflection. Records and receipts of expenditure are retained and copies regularly forwarded to Wolverhampton Civic Offices. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 14 A relative manages the financial affairs of one service user. Discussions held indicate that managers are happy with this arrangement and the individual receives his finances direct from his relative. No service user is subject to restraint. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The standard of the environment is much improved providing service users with a comfortable and homely place to live. EVIDENCE: Two requirements were made at the previous inspection in relation to the environment for a planned maintenance and renewal programme for the fabric and decoration of the premises to be developed and that furnishings and fittings must be of a good quality, fulfil their purpose and be appropriate to the needs of the service users. Through a full tour of the environment and records seen it is evident that these requirements have now been met. Following consultation with the service users the home has been redecorated and new carpets and floor coverings provided in all rooms with the exception of the hall, stairs and landing, which does not require replacement. New curtains have also been purchased for numerous rooms, the lounge suite replaced, new furniture in one bedroom, a shower, the kitchen refurbished and a new washing machine purchased. The home is now much more welcoming, bright and homely. The service user present at the inspection gave the inspector a tour of his home and his choice of décor for his room; which was Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 16 also very personalised. It was evident that he and his peers have benefited from the improvements made to their home. The manager committed to including the bathroom on the programme of maintenance and renewal. The home was found extremely clean and tidy during this announced inspection. It was reported that service users assist staff with maintaining a clean home. The home has an infection control policy in place however is working to develop an appropriate policy specifically for this home. The manager reported that she and one other staff member have completed a distance-learning course on infection control. A new COSHH file has been developed and includes guidelines for staff and service users. A new washing machine has recently been purchased. The home does not provide a separate laundry therefore the manager agreed to develop and implement a risk assessment for soiled clothing being carried through a room where food is prepared and cooked. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 17 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): 34 and 35 Service users are protected and supported by a committed and well-trained staff team. EVIDENCE: The intended outcomes for standards 31,32 and 36 were assessed and met at the previous inspection and were not reviewed on this occasion. Since the last inspection one member of staff has been employed. The personnel file was seen and was well presented. All pre-employment checks had been undertaken including the PoVA First check. The home has been waiting over eight weeks for the CRB disclosure therefore in the interim the staff member has commenced her induction and is working under close supervision of the senior care officer. Following the last inspection opportunities for staff to access training has much improved. The manager sought a copy of the Independent Sector Training Programme arranged through Wolverhampton City Council. Staff have started to access a number of courses and through staff appraisals further courses have been identified. A Consultant Psychologist has also provided staff with training and guidelines to support one service user and it was reported a social care professional from Pond Lane Social Services team is also to provide staff with training in person centred planning and challenging behaviours. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 18 An individual training record was seen on the personnel file reviewed and the manager agreed to develop a staff training and development plan for the team. It was reported that two staff have obtained a NVQ level 2 and 3, one is currently working towards the award and the senior care office is to register in January 2006. An induction workbook was seen for the newly recruited member of staff. The workbook is based on TOPSS and not LDAF. The manager committed to looking into induction for staff employed in learning disability services and was advised of the new NVQ awards and the CWPLD (Certificate in Working with People with Learning Disability) framework. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 19 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): 37,38,39,41 and 42 The manager is committed to improving the service for the people in residence. The home has made progress towards raising the standard of record keeping and safe working practices are promoted. EVIDENCE: The registered manager of the home is Ms Balvir Sahota. Since the last inspection Ms Sahota has completed NVQ level 2 and is nearing completion of NVQ level 3. She is to commence NVQ 4 in December 2005, followed by the Registered Managers Award. The findings of this inspection evidence that the manager has worked extremely hard in meeting previous requirements and developing and implementing new records. Her enthusiasm and commitment to change and the development of the service is commendable. Ms Sahota has undertaken a number of training courses appropriate to her role since the last inspection and has identified her future training needs; which were shared with the inspector. The manager was complementary of the support of the proprietors and of her staff in achieving the work undertaken. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 20 The home has a quality assurance system in place and a file has been developed with numerous letters and positive views about the service. The manager agreed to develop an annual development plan for the home in the near future. Unannounced monthly visits required by regulation 26 are being undertaken by Dr Sharma, Registered Provider, however reports of the findings are not currently being undertaken. During the inspection Dr Sharma agreed to produce a report based on his visits and forward a copy to CSCI and the home. As previously stated the manager has worked considerably hard in developing and implementing numerous records with the support of the proprietors and her team members. Sufficient information was available to evidence that the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. Since the last inspection the manager has undertaken the ‘Aset’ Health and Safety in the Workplace training course. The contents of this distance-learning course were shared with the inspector and the information found comprehensive. All staff have received basic training in safe working practices however accredited courses have been identified. Inspection of health and safety records indicated that regular checks and tests are being undertaken. The proprietor agreed to forward a copy of the certificate for electrical hardwiring that is required to be tested a minimum of once every five years. The manager has started to develop risk assessments for safe working practices and COSHH data sheets have been reviewed. The fire arrangements were found to be satisfactory at the Fire Officers inspection of the home on 12.10.05. The one recommendation made has been complied with. The Environmental Health Department last visited the home in July 2002. The CSCI have been formally notified that the home currently falls under the division’s alternative enforcement strategy due to the very low number of service users at the home who only consume meals of a night and over the weekend in a ‘family’ type environment. The homes health and safety policy was not reviewed on this occasion. Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 21 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 3 x x x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Welbeck House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 4 2 x 3 3 x DS0000030055.V252700.R01.S.doc Version 5.0 Page 22 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 2 Standard YA35 YA39 Regulation 18(1)(c) Requirement Timescale for action 28/02/06 31/12/05 3 YA39 A staff training and development plan must be developed. 26 (4)(5) A report must be produced on the findings of unannounced monthly visits and be forwarded to CSCI and a copy retained at the home. 24(1)(a&b)(2)(3) An annual development plan based on the homes quality assurance systems must be developed. 31/03/06 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 YA17 YA20 Good Practice Recommendations It is recommended that service users be offered a greater variety of brand foods. It is recommended that incoming prescribed drugs be checked, recorded and signed off by the staff member receiving service user medication. DS0000030055.V252700.R01.S.doc Version 5.0 Page 23 Welbeck House 3 YA20 It is recommended that individual service user MAR charts be sectioned and a photograph of the service user be provided. It is recommended that the refurbishment of the bathroom be included in the homes planned maintenance and renewal programme. It is recommended that an index be developed for the COSHH data sheets for easier reference. 4 YA24 5 YA30 Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Welbeck House DS0000030055.V252700.R01.S.doc Version 5.0 Page 25 - 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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