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Inspection on 07/08/06 for Yaxley House Residential Home

Also see our care home review for Yaxley House Residential Home for more information

This inspection was carried out on 7th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 home has a friendly and homely feel, which has been commented on in previous reports. Residents moving into the home have their needs thoroughly assessed and are provided with information such as contracts. Health issues of the individual resident are acted on promptly, by contacting the necessary professional support required, such as the district nurse. Residents can follow individual lifestyles. The home is adequately staffed and there is good training available to staff.

What has improved since the last inspection?

Since the last inspection the new owners have been planning and indeed have started to build an extension to the home. This is planned to be integrated, but separately operating accommodation for older people who have dementia. The new manager has been developing a system of collating policies and procedures and these were in the office for staff to access. Care plans are being revised and updated in a new more comprehensive format with a small minority of them yet to do.

What the care home could do better:

This report has seven requirements that need actioning. The main theme is that of protection of the residents in terms of more robust recruitment that must ensure CRB`s (criminal records bureau) and references are obtained, ensuring staff are trained with regard to POVA (protection of vulnerable adults) and obtaining the locally agreed policy and procedure on POVA. The practice of keeping medication secure must be reviewed and staff must have a policy and procedure to follow when administering medication. A plan of refurbishment with timescales needs to be developed for the main house as its looking tired and areas in need of repair. There needs to be written confirmation that the home have implemented the recommendations of the fire officer visit from June 2006. An effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Information on display around the home needs reviewing and updating.

CARE HOMES FOR OLDER PEOPLE Yaxley House Residential Home Church Lane Yaxley Eye Suffolk IP23 8BU Lead Inspector Claire Hutton Key Unannounced Inspection 7th August 2006 03:30 X10015.doc Version 1.40 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 Yaxley House Residential Home DS0000066076.V305154.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 Older People. 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. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yaxley House Residential Home Address Church Lane Yaxley Eye Suffolk IP23 8BU 01379 783230 01379 783743 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) Providence Health Care Limited Mrs Carole Jeanette Wilson-Godber Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: The current owner purchased the home in December 2005. A new manager, Mrs Wilson-Godber was appointed at the same time and has been registered by the Commission for Social Care Inspection. The home is registered to provide care to up to 16 older people. The home has 12 single and 2 shared bedrooms, with bedroom accommodation on both the ground floor and the first floor. A shaft lift gives easy access to the upper floor for those unable to manage the stairs. The home is set in 4 acres of land close to the church in the village of Yaxley. The gardens are attractively planted. Ramps and handrails are provided at the front entrance, with level access from the lounge into the garden. There is parking to the front of the house. Fees for this home range from £331.00 to £425.00. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that focused upon the core standards relating to Older People. It took place on a weekday between the hours of 3.30pm and 9.00pm. The process included a tour of the building, discussions with several residents and staff from both the early, late and night shifts at the home. The manager briefly dropped in, but was on annual leave. Time was spent observing staff and service user interaction, examining of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The report has been written using accumulated evidence gathered before and during and after the fieldwork. One completed comment card was received back from a relative/visitor and one completed survey was received back from the current resident group. What the service does well: What has improved since the last inspection? What they could do better: Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 6 This report has seven requirements that need actioning. The main theme is that of protection of the residents in terms of more robust recruitment that must ensure CRB’s (criminal records bureau) and references are obtained, ensuring staff are trained with regard to POVA (protection of vulnerable adults) and obtaining the locally agreed policy and procedure on POVA. The practice of keeping medication secure must be reviewed and staff must have a policy and procedure to follow when administering medication. A plan of refurbishment with timescales needs to be developed for the main house as its looking tired and areas in need of repair. There needs to be written confirmation that the home have implemented the recommendations of the fire officer visit from June 2006. An effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Information on display around the home needs reviewing and updating. 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. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Standard 6 does not apply. Quality in this outcome area is good. Residents can expect all their needs to be properly assessed before they move into the home, with information about the home available. EVIDENCE: The home does have a Statement of Purpose and Service Users Guide in place. These are located in the main hall and individuals bedrooms. On the day of inspection staff spoken to were not clear about their location, but since inspection the manager has confirmed that all staff have been made aware of information about the home and its whereabouts should anyone wish to access it. Records for two new residents at the home were examined. These showed that an assessment and relevant information form other professionals had been obtained before the person moved into the home; therefore the home could judge that they could meet the needs of the individual. Also in place was evidence of a written contract and terms and conditions of residence. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. Residents can expect their needs to be set out in a plan with health care needs to be regularly monitored and action taken as necessary. Residents can expect to maintain their privacy at all times. However residents cannot be assured that they will be protected by the homes procedures and policies on dealing with medication. EVIDENCE: Care plans at the home were in the process of being updated and revised in terms of the format and contents. Selection of both old style and new were examined. The new format is much more comprehensive in the way of assessment informed care planning. Once a resident moves into the home an in-depth assessment is completed in areas such as nutrition, manual handling, and ‘waterlow’ scoring to prevent pressure sores. A dependency analysis is also completed. A care plan examined was developed into sections such as continence, breakdown of skin, falling, anaemia, confusion, personal care, activity record, visits from health professionals, night care plan and bathing with a weight recording. Each of these sections gave instructions to care staff on the level of support they needed to give the individual resident. The final section was then Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 10 to record each day the support and care given. Other new care plans examined followed this format, but with slightly differing sections depending on the residents needs. Care plans and notes made by staff contained details of medical and health intervention. A resident spoken with confirmed that one particular health need was being dealt with by the appropriate health professional and staff at the home had supported to make that happen. The senior person on duty was completing the lunchtime medication round and therefore this could be observed as well as all records relating to medication being examined. The home has some residents who self-administer and those residents had a safe place to keep their medication. Whilst the medication round was undertaken staff concerned were respectful, observed privacy and dignity of residents. Choice was a key factor and was always gained from the resident before administering the medication. The home use a monitored dosage system and this was known and understood by staff as they had been trained by the chemist who provided it. Medication was secure in a suitable drugs trolley. However one key factor that came to light that must be improved was the practice of dispensing medication to residents and leaving it with them to take at a later time. Whilst observing the lunchtime drug round, medication dispensed that morning was found still with a resident and in a public area. Therefore the records showed that the resident had had medication administered that morning, but in practice this had not been taken. In addition this medication was unsecured and a potential risk to other residents who may have taken it. Upon discussion with the staff member this was common practice at the home for a few residents, who were not routinely observed to take their medication, but it was left with them. The administration of medication procedure was requested. However the policy found was one that was out of date and it did not contain the administration procedure. Another resident handed two boxes of chemist dispensed painkillers to the senior carer stating that she no longer needed them. This medication was not known about by the home who managed all their other medication and the resident had been there three months. This medication may have not been secure. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 and 15 Quality in this outcome area is good. Residents can lead a lifestyle that they determine. Contact with family and friends can be maintained, as is a degree of control over ones life. Catering at the home is of an acceptable standard. EVIDENCE: Several residents were met through out the day, two spoken with at length in private and one survey form received back from a resident. Also one comment card from on e relative was received. All of who commented positively on the home in terms of the lifestyle that they were able to lead. One resident stated that activities were usually provided and a relative was happy with the activities organised by the home. On the day no activities were seen to be provided and when staff were asked about activities they were not able to locate the plan for activities that had recently been developed as stated by the manager. Staff did say they played cards and dominos with residents and spent one to one time with individuals. Comment from the relative in relation to their visiting and relationship with the home was positive. One concern raised by a relative since that last inspection was promptly resolved and to the relatives satisfaction. Residents spoken with praised the quality and quantity of food and drinks available to them. Residents confirmed that they had a choice of food available and were provided with alternatives. In the kitchen was a record of Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 12 food eaten by residents. On the day lunch was minced beef in onion gravy with seasonal vegetables with mashed potatoes. For tea the residents had a poached egg on toast. In the kitchen were plenty of stocks of good quality food. The dining room is spacious and a pleasant setting for residents to eat. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. Residents can expect complaints to be taken seriously however not all that is possible is currently in place to protect residents from potential abuse or harm. EVIDENCE: The home has a complaints procedure in place and this is displayed at the home for any visitors to see. There is a log of complaints in place, however this is not quite up to date. The experience that the commission has of Yaxley House is that they take concerns seriously, investigate and then take subsequent action to prevent a further reoccurrence. In relation to POVA (protection of vulnerable adults) the manager explained that the staff team have been given leaflets on how to recognise possible abuse. The manager also plans to have a training session for staff as she had recently attended a training session on POVA. However the home did not have a copy of the local agreed procedure developed by Suffolk Social Services and the police. The manager agreed to obtain a copy. In relation to staff recruitment, records of CRB’s (criminal records bureau) were examined. For the three staff recently recruited the manager was only able to provide evidence of one enhanced CRB being undertaken. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. Until the home has implemented its planned programme of refurbishment and upgrading, residents will not be living in a completely safe and hygienic environment. EVIDENCE: All communal areas of the home were visited along with several bedrooms with the residents permission. There is sufficient communal space available with a large communal lounge a smaller quite lounge and a good-sized dining room that would accommodate all the residents if needed. There is a shaft lift that residents were seen to use independently throughout the day. Upstairs there is a slope that that is not the correct gradient and therefore can feel quite steep. Staff spoken with stated that residents were able to manage this without problems. At the last inspection the report stated: ‘Some of the bathrooms and toilets were in need of re-decoration. The downstairs bathroom floor and skirting board were damaged behind the WC. The shower tray in the upstairs bathroom was discoloured as was the mat. Pipes in one of the WCs were black with some peeling of the wallpaper. The other WC at the end of the corridor had a discoloured bowl. The owner stated that there were plans to Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 15 replace the call bell system, to upgrade the heating system and the fire precautions, and to remove the steps and ramp on the first floor to level it out’. This has yet to happen. Other aspects of the home were also beginning to look in need of maintenance and repair. Decoration within the home needs to be planned and implemented as coving was missing from the hall, wallpaper peeling and plaster exposed in two different areas. At the last inspection the kitchen was in need of upgrade, this has now become quite desperate in terms of the cooker not working, one oven was broken the other oven needed a chair next to the door to keep it closed. A small top oven had been purchased. The handles on two chest freezers were broken and posed a hazard to anyone opening it. Cupboard doors were missing or broken. The tile floor into the pantry was broken and posed a trip hazard. The laundry is well equipped, but the tumble drier was broken. Staff were using a rod to brace the door shut in order that it would work. All these aspects have now culminated in a feeling that the main home is being left at the expense of the new development next door. The main home requires a specific date for upgrade impendent to that that is being completed in the new extension. The home is clean and without any odour and generally feels comfortable for the residents. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The home provides adequate numbers of staff who are well trained and supervised, however residents are not currently safeguarded and protected by the recruitment practice in place. EVIDENCE: The home employs a total of thirteen staff. These include care staff, housekeeping and a cook. The roster was examined and this showed that the home provide sufficient staff to meet the needs of residents. There are currently fourteen residents at the home. Three care staff work and early, two care staff work a late and two care staff on nights. Residents spoken with felt staff worked hard, but that there was always someone there to help if they needed them. The housekeeper comes in the morning and cleans through. All areas seen were nice and clean. A cook comes in six days a week, but currently the manager tends to cook on a Sunday. This is not ideal as it removes the manager from her main tasks. Recruitment was said to be taking place for a Sunday cook. The manager was able to show the training plan that she has implemented at the home and she has concentrated upon ensuring that all staff have up to date training in manual handling and fire safety. The current position for staff in NVQ is that the home has over the 50 requirement to have staff trained to level 2 in NVQ in care. There was evidence of staff supervision as well as an individual training plan. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 17 The recruitment records for three staff who recently started at the home were examined. There were gaps in information available in terms of CRB/POVA 1st and references obtained. There was good evidence of induction, application, identification including photograph and interview records. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. An appropriately qualified and experienced person manages the home. Management do not yet monitor and review the running of the home. Health and safety matters for residents are generally promoted and protected. EVIDENCE: The registered manager is appropriately qualified with NVQ 4 in care and the manager award and has several years experience in working with older people in a management position. She has continued with her own professional development by attending several courses since January 2006. These include medicine management, fire marshal, POVA and health and safety courses all of which are relevant to her position of manager. Staff and residents spoken with say that they find the manager approachable and feel she does her job well. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 19 Residents finances were not examined at this inspection, but were previously found to be well managed. The manager did confirm that the same systems of double signatures and receipts for all purchases bought on behalf of residents were still in place and that any monies held could be audited with this process in place. The manager had purchased a safe and was awaiting this to be installed. In relation to quality assurance the manager stated that she had yet to implement the system that she had been observing in the homes sister home in Norfolk. This would involve surveying all those people who had an interest in the home as well as the resident group. There had been one relative meeting when the home had been purchased. There has been two residents meeting and there was evidence of regular staff meetings. The home also has regulation 26 reports regularly completed by the owners and a report of these is sent to the commission. These reports are of good quality and relevant detail. In relation to health and safety staff training as commented upon is relevant. There was evidence that hoists and lifts were regularly serviced. Hot water temperatures are regularly taken and recorded to ensure there is no risk to residents from scalding. Fire equipment is regularly serviced and there is a fire risk assessment in place. The fire service visited on 14th June 2006 and prepared a report that contained work that required completing. Therefore the home must confirm in writing to the commission and fire service that this work has been completed. This is of particular relevance as two fire door closures in the office were seen to be broken. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 13 (2) Requirement There must be an up to date policy and procedure relating to medication that is available and known by staff. This must include a section on the administration of medication. Medication must be kept safe and secure at all times and not pose a potential risk to any resident. Residents must be safeguarded from potential abuse therefore: • The local agreed policy and procedure on abuse must be obtained. • Staff must receive training on POVA. • Staff employed must have a CRB or POVA 1st check completed before they start work at the home. The home must kept in a good state of repair, equipment must be maintained in good working order and the home must be in reasonable good decorative order. Therefore a plan of DS0000066076.V305154.R01.S.doc Timescale for action 30/09/06 2. OP9 13(2) 30/09/06 3. OP18 13 (6) 30/09/06 4. OP19 23 (2) (b)(c)(d) 30/09/06 Yaxley House Residential Home Version 5.2 Page 22 5. OP29 19 6. OP33 24 7. OP38 23 (4) refurbishment must be developed setting out all matters to be addressed and sent to the commission. 30/09/06 The home must operate a thorough recruitment procedure to safeguard residents. This must include taking 2 references one from a previous employer and ensuring CRB’s/POVA 1st check is undertaken. Effective quality assurance and 30/09/06 quality monitoring systems, based on seeking the views of service users, must be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. The fire service visited on 14th 30/09/06 June 2006 and prepared a report that contained work that required completing. Therefore the home must confirm in writing to the commission and fire service that this work has been completed. This is of particular relevance as two fire door closures in the office were seen to be broken 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 OP19 Good Practice Recommendations The planned programme for the upgrading of the fabric of the building should be set out for residents to see as soon as possible. (This is a repeat recommendation) The manager should risk assess residents who are capable of administering their own medication and provide them DS0000066076.V305154.R01.S.doc Version 5.2 Page 23 2. OP9 Yaxley House Residential Home 3. OP16 with the mechanisms to make this happen thereby offering them the flexibility, choice and self determination where ever possible. The complaint log should be kept up to date. Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Yaxley House Residential Home DS0000066076.V305154.R01.S.doc Version 5.2 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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