Care Home: 224 Glenfrome Road

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What the care home does well Glenfrome Road currently provides individual support to two people in a small, homely environment. People make decisions about their lifestyle, accessing both the community and other meaningful activities. The home has good processes for finding out peoples views. They are involved in the planning and review of their care and are able to express their needs. The new manager has made information more accessible for people living at the home. People said they were happy living at Glenfrome and got on well with each other. What has improved since the last inspection? The home has developed information for people through a statement of purpose and service user guide so that they are well informed about the home. Prospective people wishing to move to the home can make a decision through information provided. Up to date contracts are now in place telling people about the services and facilities offered and the terms and conditions of their stay. Assessments and care plans show peoples` needs and how these are to be met. Peoples` care, general wellbeing and lifestyle is monitored through daily records being kept. Care planning show people are consenting to be supported with their medication needs. Risk assessments in place help to ensure that people are supported safely in taking risks. The damp on the staircase has been rectified, as has the blackened grouting in the bathroom. Fencing has been removed from the garden so as to ensure peoples safe access to the garden area. The fire procedures have improved helping to ensure the health and safety of people. CARE HOME ADULTS 18-65 224 Glenfrome Road Eastville Bristol BS5 6TR Lead Inspector Sarah Webb Unannounced Inspection 2 September 2008 08:15 nd 224 Glenfrome Road DS0000026638.V365747.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 224 Glenfrome Road DS0000026638.V365747.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. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 224 Glenfrome Road Address Eastville Bristol BS5 6TR 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) 0117 9392192 Freeways Trust Ltd Mrs Sharon Prowse Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 3 persons aged 18 - 64 years of age Date of last inspection 31st August 2007 Brief Description of the Service: 224 Glenfrome Road is registered to provide accommodation and personal care for up to three people with a learning disability. The home is operated by Freeways Trust Limited, a charitable trust. The home is a semi-detached house based over two floors in a residential area of Bristol. It is close to local shops and facilities. The home aims to provide support for people who are working towards living independently and is not staffed for a whole twenty-four hour period. Glenfrome has strong links with a sister home, Underhay House, which is in walkable distance. Both are staffed by the same team and people are able to get help from Underhay in an emergency. The range of fees is from £558 94 to £571 60. Items such as hairdressing, activities, clothing and personal items are not included in this fee. The home has two cats. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection that was carried out over a morning. We looked at information received since the last inspection. This included an Annual Quality Assurance Assessment (AQAA) and monthly reports of the home’s management. We met with the two people using living at the home who told us about their experiences of living at Glenfrome. The deputy manager visited the home briefly to show where records were kept. One of the people using the service helped with the inspection process showing us where to find written information and showing us around most of the house. We case tracked their care and support by looking at various records and documents. These included assessments, care plans, and how people are supported in taking risks safely. Staff training records were also looked at. The previous manager was transferred to another of Freeways homes in March 2008 due to re-structuring within the organisation. Ms Sharon Prowse was registered as Manager in April 2008. Eleven requirements, with four of them that were outstanding, have been met. Two requirements and three recommendations have been made through this visit. What the service does well: What has improved since the last inspection? 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 6 The home has developed information for people through a statement of purpose and service user guide so that they are well informed about the home. Prospective people wishing to move to the home can make a decision through information provided. Up to date contracts are now in place telling people about the services and facilities offered and the terms and conditions of their stay. Assessments and care plans show peoples’ needs and how these are to be met. Peoples’ care, general wellbeing and lifestyle is monitored through daily records being kept. Care planning show people are consenting to be supported with their medication needs. Risk assessments in place help to ensure that people are supported safely in taking risks. The damp on the staircase has been rectified, as has the blackened grouting in the bathroom. Fencing has been removed from the garden so as to ensure peoples safe access to the garden area. The fire procedures have improved helping to ensure the health and safety of people. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 224 Glenfrome Road DS0000026638.V365747.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 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 5. Quality in this outcome area is good. People who use the service have the information needed to choose a home that will meet their needs. Peoples’ needs are assessed before moving to the home to help ensure that they will be met. People benefit from knowing what they can expect of their stay. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new people admitted to Glenfrome since the last inspection. One person has moved leaving two people who have lived at the home for several years. They both told us they were very happy living at the home. A requirement has been met for an updated Statement of Purpose to be developed. This had been signed and dated April 2008 and had information about Freeways organisation, the home, staff team and the homes procedures. A requirement has also been met for a service user guide to be available for prospective people wanting to move to the home telling them about living at the home. Local authority assessments were seen in care files as were assessments completed by the home for one person. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 9 A requirement has been met to update service user agreements. These were seen showing the terms and conditions of peoples stay, the amount of fees paid and any contributions made by people. The manager was advised for these to be signed and dated by people living at the home to help show these had been explained to them and their involvement in their care. Since the last inspection the new manager has improved the accessibilty of care files for the people living at the home. Previously, the majority of information had been kept at Underhay House. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, & 9 Quality in this outcome area is good. Care planning has improved showing how people are involved in the planning of their care and how they want to be supported with their needs. Some areas need to be developed further providing more detailed information. People are involved in making decisions about their lives and in all aspects of living at the home. Risk assessments support people to take risks as part of their lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has started individual personal plans for people and these are in the process of being completed. An external facilitator has helped people to plan their care by asking them what their wishes are and how these can be met by the home. However the manager is aware that care plans are in the early stages and need to be further developed. Monthly keyworker packs showed that peoples care and support is being reviewed and monitored monthly. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 11 Care files showed that one person has had a yearly formal review of their care. There was comprehensive information recorded while another has been booked for the other person. A recommendation has been met for for daily records to be kept of peoples’ activities and support offered by staff. People said they are involved in making decisions about their lifestyle. They gave examples of making choices about their leisure time, holidays, and food they wanted to cook. The organisation operates safe financial systems for supporting people with their finances that helps protect them from financial abuse. Financial risk assessments seen included peoples’ understanding of money and financial management. A recommendation has been met to review the current practice of keeping monies at Underhay House so that people can be better supported in being independent. We saw that financial records are now kept at Glenfrome and people can access their finances better. A requirement to update and expand on current risk assessments has been met. A folder with risk assessments has been set up with an index showing future review dates. Risk assessments showed people are being supported to take risks safely. Actions to be taken showed how risks are reduced. Individual risk assessments included how people are supported safely with their medication, being at home alone, accessing the community and travelling independently. People said they felt safe as they can contact staff at Underhay at any time. A recommendation is made for risk assessments to be signed and dated by people showing they are involved in the planning of their care. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17. Quality in this outcome area is good. People are involved in leading an independent lifestyle through their involvement in the routines of the home. They make choices about taking part in meaningful activities both in the home and in the local community. People are supported with their relationships and in having a healthy and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both people living at the home told us they are involved in activities during the week and have different independent lifestyles such as work, college courses, and attend day services. This was also seen through records of activities. They said they had a front door key and access the community both independently and with staff support. During the visit, one person left to go to a work placement while another person had a day at home. They said they were planning their birthday celebration. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 13 Day trips are offered during weekends and holiday periods with transport available through a mini bus that is based at Underhay House. We were told they go swimming once a week, and the trips had included ten pin bowling, and visits to the seaside. We were told people had been on holiday to Spain supported by two staff and that they had a good time. One person explained that they shared watching different programmes on the television in the lounge, and that they could go to their own rooms for privacy and some space. People said they visited their families and were helped to maintain their personal friendships. We were told household tasks and routines of the home are discussed at house meetings. A rota showed how these are shared and minutes from a house meeting showed these had been discussed. Staff assist in the planning, budgeting and cooking of meals. We were told staff also support people with food shopping. One of the key times that staff are at the home is during the late afternoon and early evening to support in the cooking of the main meal. An individual explained that people take turns with cooking and if something on the menu chosen was not wanted then an alternative was had. Menus seen showed that meals were both varied and healthy. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good. People are supported to lead healthy lifestyles with their healthcare needs being monitored well. People are happy to be supported with the administration of medication if needed with safe systems in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: None of the people living at Glenfrome currently need support with their personal care and are independent in these areas and in making decisions about their choice of clothes and hair styles. Records are kept of peoples’ personal details, and healthcare appointments such as optician, dentist, and chiropodist. We were told by people that they make their own appointments to see the doctor and make choices about whether they go on their own or need staff support. Healthcare is monitored monthly through monthly keyworker meetings with the individual and any changes to peoples health is recorded. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 15 Correspondence also seen in care files showed when referrals to appropriate specialist services had been made. Health Action Plans showed how people are supported with all areas of their health. We were told by people about their involvement in their health action plans. We saw the arrangements for supporting people with their medication. This is minimal as one person self medicates. An assessment had been carried out to show if they are able to take their own medication. They are helped to be kept safe as they let staff know when they have taken their medication and a record is kept. These records show that people are consenting to be supported with medication. The home has appropriate arrangments to keep a record of any medication going out of the home such as when people may go away for a weekend. A record is kept if any ‘home remedies’ are given to people. Stock control records showed the balances held. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Although people feel their views are listened to and they know how to complain, they would benefit from being reminded about the process. People can expect to be protected from abuse and benefit from staff trained in abuse awareness. Staff would further benefit from being updated in safeguarding training to further ensure people are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one complaint since the last inspection. This has been dealt with by appriopriate action taken. An individual said they had no complaints and that they feel they are listened to by staff and knew how to complain. However they also told us but that generally they did not like making complaints as this may get staff into trouble. The deputy manager who was present at the time said it was important for people to be able to make a complaint as this helped to improve things for people. There was evidence of one person making a complaint and they had been supported with this. A copy of the complaints procedure was in the hall and in the office. However there was no contact details about how to contact us if needed. It was evident that some people needed some reassurance if needing to make a complaint. We fed back to the manager that people would benefit from this being raised at house meetings to help them feel more confident in making a complaint if needed. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 17 The organisation has a policy and procedure for the protection and safeguarding of people. Staff receive training in understanding abuse through their initial induction. However not all staff have received updating in this area. This was also shown as an area for improvement in the AQAA. The manager has contacted a senior staff member who is able to train staff in safeguarding to organise updates. A recommendation is made for staff to attend training in safeguarding to keep staff informed and updated with current practice. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The home is clean, comfortable and homely and provides a suitable environment for people to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glenfrome Road is a semi-detached house based over two floors. There is a large garden to the rear of the property. The house is situated on a busy main road in a residential suburb. It is well in keeping with the local community, and the people living at the home have access to local shops and bus routes. We were shown around by people living at the home. The home has a small kitchen and lounge. It was evident that since the last inspection some areas of the home have been decorated and refurbished. There is new seating in the lounge and the hallway has new laminate flooring. There is one bedroom on the ground floor and two others on the first floor. A bathroom is also on the first floor. Only one person’s bedroom was seen and 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 19 this had been decorated and recarpeted. They said they had been involved in choices as to how they wanted their bedroom decorated. A requirement has been met for damp area on the stairway to be rectified as has a recommendation for areas in the bathroom to be repaired. A requirement has also been met to clear old fencing from garden so that people are safe to use this area. People are responsible for cleaning their own rooms and help with general household tasks. A cleaner is employed in the home once a week to ensure the overall cleanliness of the home. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, & 35. Quality in this outcome area is good. People benefit from a staff team who have a good understanding of their role and responsibilities and who are trained and competent to meet the individual needs of people. People are supported by sufficient staff to meet peoples’ needs, but their working hours must be recorded. People benefit from recruitment policies and procedures that help to keep them safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has undergone a lot of changes during the past eighteen months and it was evident that the home has begun a period of stability with minimal staff change. The staff team of thirteen staff are based at Underhay House. A recommendation is met for staffing hours to be reviewed as we were told by people of the times staff supported them. Individual staff come over from Underhay House usually at five oclock to help with the shopping and cooking. Staff may spend part of the evening at the home with people depending on their wishes. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 21 Staff are also available if needed during the day and sometimes a more flexible approach is needed. However there was no rota to show the support hours offered by staff. A requirement is made for the home to keep a written record of the time staff are rostered to be on duty and any additional hours provided. This will inform people being supported and for the the home to monitor staffing hours. New staff have an induction period that includes completing the Learning Disability Award Framework (LDAF) and are then encouraged to complete a National Vocational Qualification (NVQ). Currently there are six staff with a National Vocational Qualification level 2 or above and six staff working towards this. The manager has begun to set up new staffing files that contain recruitment documentation including Criminal Record checks, application, and references. Three staffing files were seen. Improvements have been made with staffing files now in place at the home. Some of the information contained in these was sporadic, not all training was recorded. However the manager has completed a training summary showing when staff have completed training and when updates have been booked. There are no staff who sleep in. There are arrangements for people to contact staff who sleep in at Underhay House in an emergency. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is good. People using the service and staff benefit from a well run home with good outcomes for people. The views of the people who live in the home are sought and acted upon with their rights and best interests kept safe through clear record keeping. People and staff benefit from systems that help to promote and protect their health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Sharon Prowse was registered as manager during April 2008. She is competent and experienced to run the home. The Freeways Trust has employed her for five years, and most of this employment has been in senior roles. She has a National Vocational Qualification level 3 and plans to start the Registered Managers Award (RMA) later in the year. Other training she has 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 23 attended includes mandatory training, working with people who present behaviours that challenge and Aspergers Syndrome Awareness. A new deputy manager has also been employed who has worked with Ms Prowse prior to this post. It is evident that both the staff and the people using the service benefit from both the manager and deputy’s leadership and management approach to the running of the home. It was seen to be ‘open’ and proactive. People said they can talk about their views at house meetings, when their care is reviewed and on a regular basis when staff are supporting them. This was also evidenced through written records. People have completed a questionnaire earlier in the year asking them about the service and if they are happy. Families have also been consulted about their views. The manager has completed an action plan in response to peoples’ views to help focus on areas that need improving. This is good practice. As previously recorded, there have been improvements in the keeping of records of peoples’ care and support at Glenfrome. Ms Prowse has now developed systems in supporting people with their care records and finances being accessible to them. Staff are responsible for monitoring different areas of the home such as health and safety, fire and medication. Fire documents showed staff had been inducted in the fire procedures of the home. The fire drill record showed a requirement has been met for staff to be involved in regular fire drills. A recent fire risk assessment was also seen. The home receives monthly visits from other managers who monitor people’s care, and health and safety meeting a recommendation for this to be done separately from Underhay House. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 25 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. Standard YA22 Regulation 22(7)(a) Requirement Give people a copy of the complaints procedure and include the contact details of the Commission. Keep a record of hours staff are rostered to work. Timescale for action 03/09/08 1.. YA33 Schedule 4 (7) 03/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA9 YA22 YA23 Good Practice Recommendations Risk assessments to be dated and signed by people living at the home. Reinforce the complaints process with those people who do not feel confident in using this. Update staff in safeguarding procedures. 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 224 Glenfrome Road DS0000026638.V365747.R01.S.doc Version 5.2 Page 27 - 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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