Care Home: Briarwood Drive, 69

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What the care home does well The people spoken with appeared generally satisfied with life at the home. The staff at the home provide meals for people that meet their very individual needs. One person likes to go out in the morning on a daily basis and staff are able to escort him. The recording of people`s health care needs is good. Assessments and care plans are up to date. What has improved since the last inspection? A Local Authority Protection of Vulnerable Adults Procedure is now in place. COSHH products are locked away in a cleaning cupboard under the stairs. What the care home could do better: The People at the home need to be more involved in planning their own care. Information needs to be recorded in a way in which people who live at the home can understand. People need more opportunities and support to improve their social life.There needs to be some improvements in the home, particularly making a homely environment. The Registered Manager needs to evidence that Quality Assurance has led to improvements in the service. CARE HOME ADULTS 18-65 Briarwood Drive, 69 Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW Lead Inspector Susan Woolnough-Singh Key Unannounced Inspection 7 /19 December 2007 11.30 th th Briarwood Drive, 69 DS0000027085.V348894.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 Briarwood Drive, 69 DS0000027085.V348894.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. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarwood Drive, 69 Address Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW 01923 450 851 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) info@santacarehomes.co.uk Santa Bapoo Santa Bapoo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user who is visually impaired can be accommodated, as agreed by the Commission for Social Care Inspection, on 27th June 2005. The Condition of registration will only apply for as long as the service user’s assessed needs can be met. The home must advise CSCI when the service user no longer resides at the home. 30th November 2006 Date of last inspection Brief Description of the Service: 69 Briarwood Drive is registered as a care home for three people who have a learning disability. The home is privately owned by Santa Care Homes, a small organisation who own and manage two other care homes locally. All the people who live at the home have their own bedroom. They share communal facilities including a well maintained garden. The home is situated close to local shops and public transport. There is 24 hour staffing and they provide support and care as needed. The Registered Person has produced a Service User Guide, which outlines the Aims and Objectives of the service. Local authority funding supports the people who live at the home and the current fees range from £850 to £1,250 per week. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on 7th December 2007 and 19th December 2007. The total time spent at the home was approximately eight hours over both dates. The Inspector met with two of the people who live at the home and the staff on duty at the time. The Deputy Manager was on duty at the time of the inspection and the Registered Manager came in to meet with the Inspector on the first date. The Inspector spoke with two people who live at the home and the staff, examined records and looked at the environment. What the service does well: What has improved since the last inspection? What they could do better: The People at the home need to be more involved in planning their own care. Information needs to be recorded in a way in which people who live at the home can understand. People need more opportunities and support to improve their social life. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 6 There needs to be some improvements in the home, particularly making a homely environment. The Registered Manager needs to evidence that Quality Assurance has led to improvements in the service. 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. Briarwood Drive, 69 DS0000027085.V348894.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 Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who are moving into the home are provided with a range of information. This needs to be updated and consideration be given to creating a format that will be more easily accessible for people who use the service. An assessment of people’s care needs takes place prior to them moving in to the home. EVIDENCE: The Registered Manager has developed a Statement of Purpose and Service Users Guide. These include information on staff, the admission criteria, fees and how to male a complaint. The Service Users Guide and Statement of Purpose need to be updated and presented in a format suitable for people who use the service. All of the people who live at Briarwood had moved in prior to the last inspection in November 2006. A Needs Led Assessment is carried out prior to people moving in, this covers a range of information, which is usually provided by the funding Local Authority. Briarwood Drive, 69 DS0000027085.V348894.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual needs are recorded in care plans. Care plans must be person centred and include the wishes and goals of people who use the service. Risk assessments are in place and some of these are necessary. The staff need to look at how they can enable all of the people who reside at Briarwood to participate in the daily routines of the home. EVIDENCE: The care plans of all three people who use the service were examined. These included information on the care to be provided such as personal care, mobility, diet, activities and any religious observance. One person has a communication book whereby staff are able to write down what they need to ask or say. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 10 A requirement of the last key inspection, which took place on 30th November 2006 was that, the home introduces person centred planning. Person centred plans would demonstrate that people have been consulted with regard to planning their own care and identifying their own needs. The Inspector discussed with the Registered Manager and Deputy Manager Person Centred Plans and how the information would differ from some of the information on a care plan. Care plans that are person centred also needed to be presented in a format that can be understood by people who use the service. The Inspector spoke with two people about their experience of Briarwood Drive. The inspector spoke with one person by writing down questions. Answers given were either a yes or a no. One of the people spoken with said he would like to be able to talk with people more and go out to the Salvation Army. Generally, from the limited information given, it appeared that people were satisfied with the service. One person does not speak English. The Inspector was informed that one member of staff is employed who can speak his language. The home must look at ways in which this can be addressed as there will be times when this person will not be able to communicate with care staff in the home and be understood. Risk assessments have been carried out. These had been carried out in the areas of travelling independently, daily chores and assessments relating to any behaviour that may be a risk to the person or others. The risk assessment for the person who leaves the building for periods of time without staff supervision must be reviewed and updated. The risk assessment is also prevalent to standard 24 (Environment). At the last inspection a requirement was made for people to be encouraged to participate more particularly in the kitchen. The inspector was informed that this person was welcome in the kitchen. There was no evidence of this person being encouraged to participate in the kitchen. This should be covered in the care plan. Briarwood Drive, 69 DS0000027085.V348894.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,27 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records seen and discussion that took place with people living at the home highlighted the need for people to be offered the opportunity to develop selfhelp skills in the home. One person in the home needs assistance to develop a social and educational schedule. The daily routines for two people involve them in the local community. People have contact with their family. The cultural and religious needs of people are met in menu planning. All of the people who use the service should be encouraged to participate in shopping and food preparation. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 12 EVIDENCE: The people who live at the home are not involved in many household tasks or cooking. The staff should consider how they could support individuals to learn new skills and to be involved in these areas where appropriate. One person attends a day service. Two people stay at the home during day. Information on the reason for this was contained in the Annual Quality Assurance Assessment; staff also spoke to the Inspector about this. One person did confirm that he goes out most mornings but would like to have more contact with people. One person stays in for most of the day. People have their daily routines. However, the home must demonstrate how they will enable people to participate in education/training or fulfilling activities. The information presented in the Annual Quality Assessment states that activities are offered on a daily basis. The care plan of one person stated that local outings for shopping talking books and visits to the part formed part of the activity schedule. The staff must look at ways to engage people in some activities, particularly those who do not attend a day service during the week. Activities and a schedule must be clearly defined as part of the care plan and/or the person centred plan. This must be done on an individual basis as all three people have very different needs. People at the home have contact with family. Throughout the two days of the inspections the Inspector saw staff working in a calm and respectful manner with people who use the service. A record is made of the meals taken this was seen by the Inspector. All three people who use the service have a different main meal of the day, which is usually in the evening. Menus are planned on a daily basis; the tastes of people are different, English and Asian food is cooked and one person is a vegetarian. The Inspector confirmed with staff that a daily budget is available for food. A shopping list is prepared every Wednesday and this is given to the Registered Manager who does the weekly shop. The Inspector observed one person being involved in his own food preparation. People do not food shop with staff unless they go out for individual items. The staff must, if possible, encourage people to participate in shopping and cooking as part of their personal development. Briarwood Drive, 69 DS0000027085.V348894.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,18 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care needs are recorded and met. Medication is appropriately managed. EVIDENCE: The personal care needs of people who use the service are recorded in the care plans. People are registered with a General Practitioner and other health care professionals as required. There was evidence of liaison and appointments with health care professionals in the care files that were examined. A record of all health care appointments is kept within care plans. There is a suitable medication procedure. A local Pharmacy delivers medication in a blister pack weekly. This system was viewed along with the Medication Administration Records. The Pharmacy does not carry out a regular audit. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 14 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure and protection of vulnerable adults procedure are in place. The complaints procedure is not in a format that is accessible to the people currently living at Briarwood Drive. EVIDENCE: There is a complaints procedure, which details timescales and how to contact the Commission for Social Care Inspection. This is not recorded in a format that would be easy for people in the home to access or understand. Local Authority Protection of Vulnerable Adults procedures are in place. The Inspector was informed that staff had attended Protection of Vulnerable Adults training with the London Borough of Hillingdon, but that certificates had not been issued. These must be available for examination by the next inspection. The Inspector was able to view the policies and procedures file. This contained information on adult abuse dated 2004, which forms part of in house training. A Whistle Blowing Policy for staff is also in place. It is to be recommended that all staff sign when they have read and understood documents on the protection of vulnerable adults. The Inspector spoke with the Deputy Manager about the management of people’s finances. The family manage the finances of one person. Two people have a bank account and staff help them to manage their money. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean and generally well maintained home. Improvements should be made to personalise the home and make it more attractive and homely. EVIDENCE: The home is a four-bedroom property in a residential road close to local shops and public transport. There is off road parking for two vehicles to the front of the home. One bedroom is on the ground floor and three are on the first floor. One bedroom is used for staff that sleep in. Everybody has their own bedroom. There is a large lounge/diner area a bathroom, two separate WCs and a wellequipped kitchen. There is a garden to the rear of the home mainly laid to lawn. In general the house is well maintained, although some area need to be improved. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 16 One person in the home finds it hard to allow pictures and ornaments to be displayed. Therefore the communal living areas are quite bland and there is a lack of homely warmth. The rooms are functional with little to identify who is living in the home. In the lounge a patio door and two windows to the side of this patio door are covered with wide spaced bars. The reason for this was given; one person likes to leave the home without staff knowing, and is prone to do this on a regular basis if preventative measures are not put in place. This person likes to travel on public transport some distance. Measures to prevent behaviour that may put this person at risk are necessary. However, this preventative measure detracts from the ambiance of lounge area and in the opinion of the Inspector gives a stark appearance to the lounge. Bedrooms belonging to the three people were seen by the Inspector. These also were quite bland. The Inspector spoke with staff about this. The explanation given was that person being blind likes to know where everything is and one person will allow only the most basic items to be put in his room and will remove or break anything that is not wanted. One room had no bedside table and a material headboard that needed cleaning or replacing. At the last inspection ideas were recommended on how to create a more homely atmosphere. These included using murals and a variety of textures and colours. Also that people should be consulted about how they can make bedrooms more attractive and appealing. The home was being kept to a high standard of cleanliness particularly in the kitchen and bathrooms. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at the home are supported by staff who have received NVQ training in care. People in the home are supported by the homes recruitment procedures. Induction training is in place, this needs to be further improved by the introduction of skills for car training. EVIDENCE: Adequate staff were on duty at the time of the inspection. On the first day of the inspection two staff were on duty in the morning, one member of staff went out with a person living at the home as part of his daily routine. On the second day of the inspection one member of staff was on the afternoon/evening shift. The information given in the Annual Quality Assurance Assessment indicated that five staff are employed at the home one Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 18 full time and four part time. The Registered Manager also works shifts in the home. Two staff have achieved NVQ Level 2. and two staff are working towards NVQ Level 2. There is internal induction process, this is a checklist of good practice and procedures and the Deputy or Registered Manager complete this with new staff. The home does not operate a Skills for Care Induction and Foundation programme. The Manager agreed to forward updated information on training staff had undertaken since the last inspection. The personnel files of two staff were examined, these staff had commenced employment since the last inspection. These contained the required recruitment documents to ensure good recruitment practice. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced Registered Manager. There are suitable procedures to maintain good health and safety. A Quality Assurance that reflects the views of people in the home and can evidence monitoring planning needs to be put in place. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Owner is the Registered Manager. She has worked with people with learning disabilities for over twenty years and has managed homes for approximately seventeen years. She is qualified to NVQ Level 4. A health and safety manual is available for the guidance of staff. The Registered Manager undertakes health and safety audits. A fire risk assessment was in place. Records indicated that regular fire drills had taken place. Gas Safety service had taken place in November 2007 and emergency lighting in June 2007. A COSHH assessment was in place but needed updating as this was dated 2004. The Registered Manager had completed the Annual Quality Assurance Assessment. When the requirements of the last inspection were discussed with the Registered Manager and Deputy Manager it became apparent that these had only been reviewed recently. An annual development plan highlighting the how standards are monitored and a system of planning, action and review must be in place. There was no evidence of this at the time of the inspection. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 26 x 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 x LIFESTYLES Standard No Score 11 3 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4&5 Timescale for action The Registered Person must 01/04/08 review the Statement of Purpose and Service Users Guide and look at providing a more accessible format for people who use the service. The Registered Person must 01/03/08 introduce person centred planning where each person is involved in developing and reviewing their own care plans. Care plans must include information on likes, dislikes and social needs. Care plans must be available in a format, which can be understood by the person they are written about. Timescale of 31/03/07 not met. 3. YA7 12(5)(b)18(1)(c) The Registered Person must arrange for all the staff to Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 23 Requirement 2. YA6 12(2)&(3) 1516(2)(m) 01/03/08 learn Makaton and some basic words in the language one person speaks so that they can communicate with the people who live at the home. Time scale of 31/03/07 not met 4. YA7 5 (2) Care plans, the Service User Guide, contracts, the complaints procedure and other key documents should be recorded in formats, which the people who live at the home can understand. Timescale of 31/01/07 not met 5. YA8 YA6 12 (b) & 15 (1) The Registered Person must 01/03/08 set out in the care plan how people will be enabled to participate in the day-today running of the home. The risk assessment for one 01/03/08 person must be reviewed and updated to reflect behaviour management strategies. In particular, the need to have a restrictive grill fitted to the door and window in the lounge. The Registered Person must 31/03/08 make sure the social and educational needs of people who live at the home are met and that they have full and active lives which meet their needs. The Registered Person must 01/03/08 review the leisure activities in the home and individual DS0000027085.V348894.R01.S.doc Version 5.2 Page 24 01/03/08 6. YA9 YA24 1216(2)(h) 7. YA12 12 (1) (b) 8. YA14 16 (2) (m) Briarwood Drive, 69 9. YA22 22 (2) 10. YA24 23 (1) (a) choices must be recorded in the care plan. The complaints procedure 01/03/08 must be presented in a format suitable for people who use the service. The Registered Person must 01/06/08 improve the environment for people. This must be reviewed and an action plan forwarded to the Inspector by the date given. The Registered Person must 01/06/08 offer new staff the Skills for Care Induction and Foundation Course. The Registered Person must 01/06/08 ensure that all people have the furniture required under standard 26 and that care is taken to personalise bedrooms. The Registered Person must 01/06/08 ensure that there is an annual development plan based on a system of planning action and review. 11. YA35 18 (1) (a) 12. YA25 YA26 23 (1) & 23 (2) (f) 13. YA39 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. 1 Refer to Standard YA23 Good Practice Recommendations A front sheet should be added to protection of vulnerable adults policies to evidence that staff have read them this can then be signed. Briarwood Drive, 69 DS0000027085.V348894.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Briarwood Drive, 69 DS0000027085.V348894.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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