Inspection on 17/05/06 for Wrekin Cottage

This inspection was carried out on 17th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wrekin Cottage 22/10/08

Wrekin Cottage 04/07/07

Wrekin Cottage 08/09/06

Wrekin Cottage 28/10/05

Wrekin Cottage 07/06/05

Wrekin Cottage 05/01/05

Wrekin Cottage 23/06/04

Wrekin Cottage 16/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Care Ironbridge Forbes Close Ironbridge Telford Shropshire TF7 5LE Lead Inspector Sue Woods Key Unannounced Inspection 17th May 2006 01:00 Care Ironbridge DS0000020540.V292547.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 Care Ironbridge DS0000020540.V292547.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. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Care Ironbridge Address Forbes Close Ironbridge Telford Shropshire TF7 5LE 01952 432065 01952 432209 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Care Home 30 Category(ies) of Learning disability (29), Learning disability over registration, with number 65 years of age (1) of places Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: Cottage And Rural Enterprises (Limited) is a registered charity established in 1966. The Company has communities nationwide and its headquarters are based in Leicester. Care Ironbridge is a residential development that occupies a small cul-de-sac in the Ironbridge area of Telford. The development was purpose built and is situated close to local amenities and is a short journey from Telford Town Centre. Severn and Wrekin Cottages are registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of thirty adults with learning disabilities below the age of 65 years. There is currently one service user living at Severn Cottage who is over 65 years and the homes registration category reflects this. The cottages are set in beautifully maintained and attractive gardens. In addition to the cottages, service users have access to workshops, a community centre, communal dining room and games area, which are all provided, on the main site of this development. Information is shared with service users in the service user guide and in house meetings and quality review sessions held on a regular basis. Fees range from £425.69 to £566.46 not including individual support packages. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Care Ironbridge was carried out by two inspectors from 1.00 pm until 6.30 pm on 17th May 2006. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the fieldwork activity inspectors spoke with service users and staff and reviewed records including care plans (four in detail), rotas and health and safety information. The manager of Wrekin cottage was on duty during the inspection and was supportive and fully cooperative. The lead inspector made an appointment to return on 23rd May 2006 to review staff files that are kept centrally on site. What the service does well: What has improved since the last inspection? Since the time of the last inspection increased staffing levels have been implemented at Wrekin Cottage. Feedback from service users and staff felt that as a result of this change, opportunities to access community resources has improved. Likewise the improvement in recording documentation has enable staff to demonstrate that service users wishes and aspirations are being noted and actioned, with some very positive results. The implementation of the person centred plans and assessments will, when fully operational, provide valuable information in relation to the needs, wishes and aspirations of service users. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 6 The recording of water temperatures for health and safety purposes has now been implemented effectively following immediate requirements left at the time of the last inspection of the home. 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. Care Ironbridge DS0000020540.V292547.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 Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An effective admissions process is in place to ensure that the home will be able to meet the assessed needs of service users admitted. EVIDENCE: Since the last inspection of the home there has been one new admission to Severn Cottage. The care file of this person was reviewed and found to contained essential information to allow the home to develop and implement an essential lifestyle and health action plan. Staff commented that the service user had settled in well to his new home. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are identified and met through a newly implemented person centred plans. Service users’ increasing needs can be effectively identified allowing for the home to request additional resources to meet those needs. Service users may be vulnerable because risk assessments are incomplete or not completed on all occasions. EVIDENCE: Care plans at Severn Cottage reflect a person centred approach and assessed needs are detailed in a way that is preferred by the service user. Staff have adapted some of the documents used to reflect the likes and preferences of individuals, for example by using different colours. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 10 Full assessments of needs were seen on two files reviewed and an additional assessment tool has been implemented to provide useful evidence to demonstrate at least two service users’ needs have increased. Care plans at Wrekin Cottage are not written in the same format however they still reflect a person centred assessment of need. Care files reviewed at Wrekin Cottage require reviewing and updating to ensure that information is current and up to date. Service users who spoke with the inspectors felt that they were able to make decisions about what they did during evenings and weekends. They also stated that they were involved in reviews and were supported to maintain contact with family and friends. At the time of the inspection staff demonstrated through discussions heard by the inspectors that they were aware of significant events relating to individuals and that they communicated well to ensure, for example, that birthday cards are sent on time. Some risk assessments were seen on care files however through discussions at both cottages it was identified that some activities are not risk assessed. Risk assessments were however seen to support holidays. It was positive to note that the manager of Wrekin Cottage had been to the holiday cottage to be used and completed an assessment of the environment and the surrounding area. The assessment identified that three staff would support the holiday however one of those staff would be doing waking nights and the impact of this had not been considered. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are increasingly enabled to participate in the community-based activities allowing them a good quality of life. Service users are supported to enjoy a healthy lifestyle by maintain a balanced diet. EVIDENCE: Opportunities for service users to participate in in-house and community-based activities have increased considerably at Wrekin Cottage and the improved recording of activities supported this improvement. Opportunities for service users at Severn Cottage are good. The Person Centred Planning process will further identify opportunities and the challenge Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 12 for staff at both homes will then be to accommodate these activities with resources available. It was stated that the majority of service users pursue goals and activities during the daytime when they are at day service uses or when additional staff support is available. Service users plans identify evening activities although a lot of service users enjoy spending their evenings at home enjoying the soaps on television or relaxing with their own interests and hobbies. This was confirmed in conversations with service users. There was evidence to support the hobby of one service user at Wrekin Cottage as model aeroplanes were seen in communal areas in various stages of creation. Bedrooms seen reflected the hobbies and interest of service users case tracked by the inspectors. One service users has aspirations of becoming an actress and the manager has been proactive in making connections for her to pursue this through drama workshops and trips to the theatre. The hobbies of one service user listed in his care plan were seen to have been acted upon in his activity record. Health action plan include essential information on diet. The Residential Services Manager stated the home has responsibility to promote healthy eating but to also reflect individual likes and choices. On the day of the inspection service users were looking forward to baked potatoes and prawns. The inspector reviewed the storage and recording of service user’s money. The cash tin reviewed contained more money than recorded. The manager reported that some cash tins are kept with the bursar at the site’s main office and money is requested if needed. The manager was prompted to ensure that this arrangement did not mean that service users could not participate in impromptu activities. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred and flexible support enables service users to access health care emergencies and routine appointments. The home has a safe system for storing, handling and recording medication. An individualised protocol would offer the service user reassurance that a consistent approach is adopted by all staff EVIDENCE: Health action plans are now being implemented in Severn Cottage and there are plans to do the same in Wrekin Cottage. These are user-focussed documents and contain valuable information relating to the health care needs of the individual. Both cottages keep good records to support health care appointments and outcomes. The manager of Wrekin Cottage has arranged specialist support for one service user to look deeper into his health care needs. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 14 There was written evidence to support that service users receive routine appointments for the dentist and optician and that the home works closely with other health care services. There was an agreement signed by the local GP that named service users could be given paracetamol as and when required. The arrangements for the storage and administration of medication were reviewed as part of the inspection. The administration was observed to be private and without interruption. Medication recording sheets were seen at Wrekin Cottage to be up to date and the storage cabinet was well organised. Records of medicines administered reflected the medication prescribed and detailed in the care plan. The protocol for the administration of a PRN medication was in place and had recently been updated for one service user. Allergies suffered by one service user were recorded on mediation records and on essential basic information sheets. There was no protocol to support the behaviours of one service user and although staff on duty were confident that they could safely de-escalate a situation the fact that agency staff are used at the home indicates that a consistent approach would benefit the service user and instil confidence in staff. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Effective adult protection procedure ensure that the agency operates in the best interests of service users however written records in relation to the logging and monitoring of complaints need to be reviewed to offer similar protection. An issue concerning the storage of confidential information needs to be reviewed to protect service users. EVIDENCE: The residential service manager has developed a procedure for recording complaints and is now in the process of implementing it. This will provide a valuable resource for the managers at each cottage. The manager at Wrekin cottage was unsure of her role within the complaints process and a complaint that had been made to a senior member of staff at the cottage had not been actioned to the complainant’s satisfaction. Without the complaints book in operation inspectors were not able to identify who was dealing with the complaint and at what stage the investigation was at. The residential service manager committed to follow this up and ensure that there are clear lines of accountability in relation to complaints recording and investigation and ensure that all staff are aware of them. The home has demonstrated appropriate use of the adult protection procedures to which they subscribe and it was positive to note that managers take an active and open role in the process. Documentation relating to such an investigation was seen on a file reviewed and it was agreed that it, as the issue Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 16 had been resolved the information should be removed from the main working file to ensure information is only seen on a ‘need to know basis’. (This requirement will affect the scoring for National minimum standard 10) Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Both cottages are being maintained to ensure that service users have a clean and homely place to live however the safety of two service users is being compromised by inappropriate locks fitted to their doors. EVIDENCE: Care have shared plans with CSCI in relation to separating the registration of Wrekin and Severn Cottage before a further refurbishment takes place. This was considered when reviewing the environmental standards where inspectors viewed the rooms of service users case tracked and communal areas while speaking with service users. It was found however that two of the flats were fitted with inappropriate locks. Areas seen were clean and bedrooms were well personalised to individual tastes. Rooms also reflected hobbies and interests of the service user. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have benefited from higher staffing levels within the home and others may do so following the second review. Service users benefit from staff receiving good training opportunities. Robust recruitment and selection procedures protect service users. EVIDENCE: It was encouraging to note that Wrekin Cottage has implemented increased staffing levels at key times throughout the day. Staff who spoke with the inspector all commented that this had improved the quality of life for service users by enabling them to participate in more and regular activities. There is currently two staff on each shift at Severn Cottage and the manager stated a similar review of staffing levels would now take place there. Additional funding has been implemented for one service user and further funding has been requested. Impact on the home of these additional staffing levels must be assessed in line with the homes statement of purpose. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 19 The majority of staff who spoke with the inspector stated that they received ongoing support and regular supervision. (Supervision records could not be viewed on 23/05/06 as the manager had the only key and was supporting a service user holiday). Staff at Severn Cottage reported that they had all received the mandatory training and in addition three out of four stated that they have achieved NVQ level 2 or 3. Staff training records were available for review at the time of the visit to the main office on 23rd May. They were up to date and demonstrated when training had taken place, who had facilitated the training and when refreshers were due. One member of staff spoke of the medication training received via a distance learning support package. The manager at Wrekin Cottage spoke knowledgeably about autism and the impact and challenges that it places on an individual. She had recently attended a conference on the subject and demonstrated how she was putting her learning into practice. Staff files were reviewed on 23rd May. All files reviewed contained all essential information and the administrator was well organised and in the process of updating staff CRB disclosures. A return to work interview seen on one file reviewed was comprehensive and identified areas of support for the staff member. Confidential information was stored securely and details of disciplinary investigations were available for review when requested. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 20 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, 39, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Person centred planning processes will enable and empower service users. Service users and staff would benefit from the manager receiving input, training and support to enable her to effectively carry out her various management roles. Inappropriate risk assessments in relation to the use of COSHH place staff and service users who use the products at risk. EVIDENCE: There is a manager for each cottage, both of whom are applying for registration with CSCI as the two cottages separate. The manger of Wrekin Cottage was on duty at the time of the inspection. There is a significant difference in the paperwork between the two cottages. Staff from both cottages who spoke with the inspector were positive about the Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 21 support that they receive from their prospective managers on a day to day basis. However given some of the shortfalls in Wrekin Cottage in particular it is evident that the manger would benefit from further input from her supervisor (or outside agency) in terms of developing strategies for managing and through training opportunities that are geared towards management roles and responsibilities. This said the manager was totally committed to her role and evidently placed service users first. She had the full support of the staff team on duty at the time of the inspection. Various tasks are delegated to key staff members and this is seen to be empowering however the manager must be aware of what staff are developing and ensure they work with the manager and not in isolation. The manager at Wrekin Cottage was not overly familiar with the newly implemented QA system and in order for the process to begin the manager must be able to share it with others. It was also evident that some key work related issues had not been recorded appropriately. The manager could not demonstrate that the service was service user led. Service users at Severn Cottage stated that they felt consulted in decisions made about their lives and the person centred planning processes that are being implemented will further enable and empower service users. The recording of health and safety checks have improved since the time of the last inspection of the home. The inspector was shown the cupboard containing the COSHH products and explained that the risk assessments were kept in the office. These were seen later by the inspector but were not adequate for the purpose. The manager of Wrekin cottage accepted that these assessments needed to be in place. This shortfall was found in both cottages. An accident book was seen available in both cottages and accident records were seen on individual files to ensure the confidentiality of the information. One service user has been diagnosed with dementia and staff have received training in order to better understand and meet her needs. The home is currently reviewing support arrangements in relation to staffing. The home must review its registration in light of new assessments and update the statement of purpose following this review. Visits carried out under regulation 26 requirements are sent to CSCI on a regular basis and have always reflected positively on the service even when there may be issues identified during CSCI inspections. Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 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 3 3 x 2 2 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 3 3 2 x 2 x x 2 x Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 23 NO 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 YA9 YA9 Regulation 13 (4) (b) (c) 13 (4) (b) (c) 18 (1) (a) 17 (1) (b) 12 Requirement Risk assessments must be carried out to support all activities The risk assessment completed for the forthcoming holiday must contain a review of safe staffing levels Confidential information relating to POVA investigations must be stored appropriately Individualised protocols must be developed and implemented to ensure behaviours are managed appropriately and consistently All staff must be aware of the complaints procedure and appropriate records must be kept to detail complaints and outcomes. Suitable locks must be fitted to both flat entrance doors. Managers must apply for registration with CSCI The managers must be trained in to carry out her management tasks and responsibilities effectively. Risk assessments must be in place to support the use of COSHH products. DS0000020540.V292547.R01.S.doc Timescale for action 05/06/06 29/05/06 3 4 YA10 YA18 29/05/06 05/06/06 5 YA22 22 (3) (4) (7) (8) 05/06/06 6 7 8 YA24 YA37 YA37 23 (20 8, 9 8,9 29/05/06 26/06/06 26/06/06 9 YA42 13 (4) (b) 05/06/06 Care Ironbridge Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 25 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 Care Ironbridge DS0000020540.V292547.R01.S.doc Version 5.2 Page 26 - 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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