Care Home: Derwent Road (14)

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What the care home does well This home provides a good service for those in its care. The care each person needs is written down and regularly updated. The staff listen to what health care professionals advise and put this into practice. One health care professional said: `I`ve found the home makes a good response to our suggestions.` Service users are protected from risks and helped to live as full and stimulating life as possible. Because the manager and staff have taken the time and effort to get to know each person well, all service users are understood and can make choices about the way they live their lives. There is opportunity to get involved in different activities both in and out of the home. Relatives and friends are welcomed and there is good communication between all the people who are involved in care. One relative said: `They consult me and they invite me have a say if there are any changes to care.` The home provides good food and service users are asked what they prefer. The home is well decorated and provides a comfortable living space. There are interesting pictures and objects to look at which are provided after consultation with service users about their preferences. The manager and the staff are well trained and enthusiastic. The views of service users and others are surveyed and the results are used to plan improvements to the care offered. Health and safety is a priority. This protects service users welfare. What has improved since the last inspection? The way in which staff files are stored has improved to allow for CSCI to check recruitment and training records. Staff have all now received training in the safe handling of medicines. Records are now well maintained. The environment has improved with many areas having been redecorated since the last inspection and service users rooms made more personalised with pictures, music and TV equipment, furniture and bedding, all to service users taste. What the care home could do better: The home should find a way to make the improvements needed to the kitchen and bathroom, as this would improve the quality of life for the service users. The manager has only been in post for a short time and has plans for improvements across the range of standards, specifically: Improving the accessibility of care plans for service users, facilitating service users meetings, improving the recruitment of staff with the involvement of service users, increasing outings and one to one time with service users, developing family links, quality assurance and improvements in the storage of medicines. The manager has shown she has been responsive to the requirements and recommendations of the last inspection report and has identified new areas for improvement through her own quality assurance system. CARE HOME ADULTS 18-65 Derwent Road (14) 14 Derwent Road Fulford York YO10 4HQ Lead Inspector Karen Ritson Key Unannounced Inspection 31st October 2007 10:00 Derwent Road (14) DS0000015811.V349913.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 Derwent Road (14) DS0000015811.V349913.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. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Road (14) Address 14 Derwent Road Fulford York YO10 4HQ 01904 640551 T/F 01904 640551 Derwent.road@unitedresponse.org.uk None United Response 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) ****Post Vacant**** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for a maximum of 5 persons with a learning disability who may also have a physical disability. 15/11/2007 Date of last inspection Brief Description of the Service: Derwent Road is registered to provide residential, personal and social care for five people under 65 years of age who have learning disabilities and may also have physical disabilities. The home is a detached two-storey house in the residential area of Fulford within easy reach of local shops. It is about two miles from the centre of York and has good access to the Citys services and amenities. The home is part of the United Response organisation and benefits from the support of the companys training and management structure. The current scale of charges at Derwent Rd is £1,291:62 gross - per person per week. This information was provided to the Commission on 02/10/2007. The home has a statement of purpose and service user guide; these, with the CSCI report are available on request. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection for this service took twelve hours. This includes time spent gathering information, examining documentation and a visit to the site. The site visit took place on 31/10/2007 between 10:20am and 2:00pm Information for the inspection was also gathered from the following: • • • • • • • • • • Speaking with two members of staff. Speaking with one service user. Speaking with relatives and visitors to the home by telephone. Speaking with Health care professionals. Case tracking two service users on the day of the site visit. Looking at information provided by the manager prior to the site visit. Notifications sent to the commission from the home since the last inspection. Examining policies, procedures and records kept at the home. Examining information regarding the home on the file kept by CSCI. A tour of the premises All key standards were looked at during this inspection. The manager was available throughout the day of the site visit. Her application to be registered with CSCI has been received and is being processed. What the service does well: This home provides a good service for those in its care. The care each person needs is written down and regularly updated. The staff listen to what health care professionals advise and put this into practice. One health care professional said: ‘I’ve found the home makes a good response to our suggestions.’ Service users are protected from risks and helped to live as full and stimulating life as possible. Because the manager and staff have taken the time and effort to get to know each person well, all service users are understood and can make choices about the way they live their lives. There is opportunity to get involved in different activities both in and out of the home. Relatives and friends are welcomed and there is good communication between all the people who are involved in care. One relative said: ‘They consult me and they invite me have a say if there are any changes to care.’ Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 6 The home provides good food and service users are asked what they prefer. The home is well decorated and provides a comfortable living space. There are interesting pictures and objects to look at which are provided after consultation with service users about their preferences. The manager and the staff are well trained and enthusiastic. The views of service users and others are surveyed and the results are used to plan improvements to the care offered. Health and safety is a priority. This protects service users welfare. What has improved since the last inspection? 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. Derwent Road (14) DS0000015811.V349913.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 Derwent Road (14) DS0000015811.V349913.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): 2 People who use the service experience good quality outcomes in this area. Prospective service users and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and they and their representatives are clearly told about the service the will receive. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: No new admissions have been made since the last inspection. The manager however is fully aware of the requirements if a new service user was to be admitted and has the assessment tools available. Derwent Road (14) DS0000015811.V349913.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 People who use the service experience good quality outcomes in this area. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The care plans for two of the service users were examined. These showed detailed instructions for appropriate care, covering all areas including specific conditions. Each plan focuses upon the individual and is written with a holistic approach. Strengths and personal preferences are incorporated and future care needs and goals have been taken into consideration. Service users and relatives are involved in the development of the care plan and are consulted at review. Choices and the way in which individuals are able to indicate choice are recorded. Staff have thorough training in relevant areas of care. This ensures that care is focused and appropriate for each individual. A relative said: Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 10 ‘They’ve learnt her likes and dislikes which is important as (my relative) can’t speak.’ ‘They always ring if there’s been a visit to the GP or if they want to discuss anything about (my relative’s) care.’ Risk assessments were available for each service user. These were tailored to meet specific needs, such as personal care, going out, meal times, traffic, outings etc. Care needs are anticipated and service users are consulted about their aspirations with families or advocates where relevant. Changes in care planning are introduced in a measured and well thought out manner. All limitations on a service users freedom are explained and only in place when necessary. A relative explained that the risk assessments were developed as knowledge of the individual increased and were often being amended. Staff said they were involved in drawing up care plans, and had carried out risk assessments. A key worker system is in operation and staff said this works well. Each service user has highly individualised needs and a detailed knowledge is crucial to providing good person centred care. As all the service users at the home are non-verbal, detailed instructions for specific cares are very important and following them closely is important to avoid distress or discomfort. Staff, family members and health care professionals felt that the staff were able to offer such care. One health care professional said: ‘Despite staff changes I am confident that the home provides a good service which is responsive to individual needs.’ This person centred approach to individual needs and choices ensures service users receive an individual, tailored service. Derwent Road (14) DS0000015811.V349913.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): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet which they enjoy. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Each service user has an individual programme aimed at developing skills, and staff are available to support service users in this. Activities are on offer each day. Activities include going shopping, visiting teashops and going out for days. Others include, drawing, art and craft and baking. Most of the service users have complex care needs and their days are planned to take full account of each individual and what will help stimulate and entertain that person. Some service users attend day care. Responses to activities are recorded in diary Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 12 entries. Staff said they were given plenty of time to spend with service users on a one to one basis as key workers. A relative said: ‘There is always something going on at day care, (my relative) gets to go in the sensory room, swimming has been arranged, there are concerts, baking. There are also activities available at Derwent Road.’ The manager stated that more time was allowed for one to one time with service users and staff had received person centred planning training. Observations were made from time to time throughout the day and service users were obviously contented and engaged in activities that were stimulating and meaningful to them. Menus were seen and showed a variety of nutritious options. Residents are helped to choose what they would like to eat through the use of pictorial prompts if needed and assisted at meal times. Service users favourite foods are recorded on file and these preferences are taken into consideration when planning menus. Service users are regularly given the opportunity to go out to do the shopping. Some become involved in serving meals and in tidying away. One relative said: ‘The meals are good. (My relative) has particular preferences and these are taken into consideration. She also goes out food shopping with staff, which she enjoys’ The dietician is involved where necessary and all recommendations recorded and followed. Derwent Road (14) DS0000015811.V349913.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, 19 and 20 People who use the service experience good quality outcomes in this area. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: All personal care needs including the way in which care is to be offered are recorded in care plans. All service users have a key worker who will assist with personal shopping or visit the hairdressers for example. Staff ensure that care is person led. All staff have received manual handling training. Staff are alert to changes in mood and close observations are recorded each day. They are also aware of the particular needs of those service users who remain immobile for long periods of time. This is written into care plans. On the day of the site visit, care was offered with consideration, involving the service users by speaking to them throughout, consulting with them and explaining what was to be done. This ensures that service users receive personalised and appropriate health care. a relative said: Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 14 ’Although there has been a change in key worker, I think my relative is well cared for. Each member of staff has got to know her well.’ All access to health care professionals is recorded separately and detailed notes are kept on medical conditions. A health care professional said: ‘The home always contact us if there are any queries and act on our advice.’ Medication is stored, recorded and administered appropriately and all staff who handle medication have completed training. The home has a medication policy and procedure. Comments from health care professionals indicated that staff listened to and acted on their advice, and that they were always able to see their patients in private. This ensures that service users needs regarding medication are met. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. Residents and those who act on their behalf have access to a robust, effective complaints procedure; their complaints are listened to and acted on. Service users are protected from abuse and have their legal rights protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home has an effective complaints procedure and policy. Feedback from health care professionals indicated that there was always a senior person in charge who could be approached if there were any concerns, however, none were aware of any complaints made about the service. The home keeps a book for the purpose of recording complaints. The way in which complaints are recorded has improved and staff have received training to encourage them to record all areas of dissatisfaction from service users and representatives. The challenges inherent in encouraging service users to express a complaint were discussed. The manager said she was developing this through service users feedback in reviews of care. One complaint with outcomes had been received since the last inspection. Service user care plans clearly showed the way in which care was to be offered and daily diary sheets recorded service users responses to care offered and adjustments made where necessary. Staff said they met regularly to discuss care needs, make certain that the care offered was appropriate and to discuss any niggles. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 16 All staff have now received adult protection and abuse awareness training and were able to demonstrate this awareness in discussion. Service users are protected regarding the management of their finances. Personal allowances were checked against records and all were correct. Policies are in place. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. Service users live in a safe, well-maintained, stimulating and comfortable environment, which encourages independence. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home is clean, well decorated and furnished appropriately for the needs of the residents. Several rooms have been redecorated since the last inspection, and the result is a light modern home. Service users have been involved in choosing colours and soft furnishings, and one resident had been to choose new bedroom furniture. The garden is tidy and sufficiently large for service users to sit out in the warmer months. There is a summerhouse and the manager is planning better use of this outdoor space for next summer to include barbeques and other social events. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 18 Aids and equipment encourage service users to have maximum independence, however, the kitchen needs to be adapted as a matter of urgency, as the layout it not suitable for promoting independence. The staff work well to try and overcome this, through involving service users as much as possible in meal preparation, however, units and facilities at the correct height would improve this. This has been an outstanding issue for some time, but the landlords have not agreed for work to go ahead. The bath is not suitable for one service user as it is too narrow to sit in for very long. The landlords appear to be considering a request to adapt the bathroom to provide a walk in shower. This would benefit the service user in question. The home has a good infection control policy and staff had all received training in this. The laundry is situated away form the kitchen and is well run. Service users assist in whatever way they prefer. Some enjoy bringing their clothes to the laundry, others enjoy being involved when clothes are being washed and folded. A new system for organising clothes has been introduced to keep colours separate. This seems to be working well. Relatives said there was no problem with the laundry and all indicated they thought the home was homely and pleasant. One said: ‘They make a big effort to include (the service users) in choosing what they want. (My relatives) room reflects her interests and is all about her.’ Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Staff files were examined. There are sufficient staff on duty at all times, however, agency staff are used occasionally at times of sickness or holidays, and this sometimes can have a disrupting effect on the smooth running of the service as service users do not always know the workers. It is particularly important for staff to know the service users well in this home and the use of agency staff has at times meant that service users needs have not been fully appreciated. A relative said: ’On the whole they manage very well. When they use agency staff it is sometimes difficult because my relative does not speak and the agency staff do not understand her so well as the permanent staff.’ Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 20 Staff are well recruited with all documentation in place. Staff are also well trained. They all receive induction and foundation training with certificates on file and all have a training profile. Sufficient staff are on duty to allow service users to receive one to one attention when needed and for the key-worker system to work effectively. Staff were observed speaking with service users and offering care in a kind and thoughtful way. They were approachable and obviously understood each service users care needs well. Comments received from health care professionals indicated that they had a good working relationship with care staff, that they communicated effectively and that advice was acted upon. Staff said they received good support from the home’s management and had regular supervision. This ensures that service users needs are met by well trained and supported staff. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. The management and administration of the home are based on openness and respect. Service users changing needs are met through an effective and developing quality assurance system. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager, Diane Dawson has been working at the home for about six months. She has submitted her application to CSCI for registration as the manager. She has a background in caring for service users with a learning disability and has the Registered Managers Award and the equivalent of NVQ in care at Level 3 and could also demonstrate comprehensive training since taking up post, through United Response. Staff said she was supportive and kept them informed through staff meetings. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 22 The home carries out thorough internal health and safety checks. Quality checks are also carried out on the building and on systems within the home. Regular regulation 26 visits are carried out. Quality assurance is also pursued through review meetings with service users and their representatives, where constructive feedback is encouraged. The manager is working on ways to assist service users to make their views known. This is particularly important when all the service users at the home are non-verbal and feedback relies heavily upon observation of service users and their reactions. A member of the staff team is to attend quality assurance training soon and new quality assurance forms for representatives and others involved in care are to be used to improve the quality of information gathered. The home works to a clear health and safety policy, all staff said they were fully aware of the policy and are trained to put theory into practice. Safeguarding is given high priority and the home provides a range of policies and guidance to support good practice. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. The manager ensures risk assessments are completed and taken into account in planning the care and routines of the home. This ensures the safety of service users. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23 Requirement Timescale for action 31/03/08 2. YA24 23 The Manager must ensure that the kitchen facilities are upgraded and made accessible to people in wheelchairs. Previous timescales of 30/11/05 add 31/03/06 not met. The registered manager must 31/03/08 ensure the bathroom facilities meet the needs of all service users at the home. 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 YA37 YA39 YA32 Good Practice Recommendations The Manager should be registered with CSCI The manager should continue with her plans to improve quality assurance systems. The manager should consider ways to reduce the use of agency staff at the home. Derwent Road (14) DS0000015811.V349913.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Derwent Road (14) DS0000015811.V349913.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. 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