Care Home: First Care Lodge Limited

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What the care home does well The service provides solid support to service users within a secure structured environment. The home supports independence and empowers service users to take control of their lives. The emotional support provided at the project encourages service users to make positive choices to support their mental health. The home is comfortable with a cheerful, friendly atmosphere and good role models. There is a broad ethnic mix across the service users and staff at the home. Everyone gets on well and the cultural diversity is seen as a strength. One service user said the stability, structure and the company, had enabled him to turn his life around. He said that even when he moves on to more independence he will return to visit his friends at the home. The stakeholder consulted said that as a professional she found the home "excellent". She said they had a very good track record of preventing relapse with some quite complex people. The home provides "boundaries" and keeps a "good eye" on people. The stakeholder said the home was "spot on". What has improved since the last inspection? Window restrictors have been fitted to the first floor windows. A plumbing issue in the ground floor shower room has been attended to. What the care home could do better: The inspection resulted in ten legal requirements and one good practice recommendation. The service user guide needs amendment as was noted at the previous inspection. A number of requirements have been made to tighten up the administration of medication. The adult protection policy needs some expansion and the home needs to have a copy of the local social services policy to refer to. Recruitment procedure is robust but staff files and records must evidence this. There is a need for more staff training. The manager should plan future training for staff to ensure that they keep their core training up to date. The manager needs to ensure that all his practices reflect the excellent work which is being done at the home. CARE HOME ADULTS 18-65 First Care Lodge Limited 9 Beryl Avenue Beckton London E6 5JT Lead Inspector Anne Chamberlain Unannounced Inspection 23rd October 2007 10:00 First Care Lodge Limited DS0000067805.V353578.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 First Care Lodge Limited DS0000067805.V353578.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. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service First Care Lodge Limited Address 9 Beryl Avenue Beckton London E6 5JT 0207 474 9330 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) srumnah@aol.com First Care Lodge Limited Mr Satyatah Rumnah Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Sleep-in staff must not sleep in any communal area of the home. There must be separate private sleeping facilities for any sleep-in staff. The home`s documents must clearly indicate to any Commissioning Agent and prospective service users the period of the Tenancy before admittance or placement. 19th February 2007 Date of last inspection Brief Description of the Service: First Care Lodge Limited is a small residential care home registered to provide support to three service users aged 18 to 65 years who have enduring mental health needs. The home provides short, long term or permanent placements, providing one to one support and twenty-four hour care with waking night staff. First Care Lodge is not able to offer a service to people who present an active serious risk to themselves or others. The service is in a modern house located in Beckton, close to buses, trains and local amenities. It was registered in September 2006 and is managed by the proprietor, who also runs another similar three-bedded residential home in East Ham. Currently fees start from £700 per week and are variable depending on level of needs. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of key standards. The inspector spent nearly five hours at the service. During this time she viewed the files of the yhe three service users living there, as well as three staff personnel records. She viewed various other key documentation, also the arrangements for the administration of medication. The inspector made a tour of the premises and spoke with service users. Later she spoke with a stakeholder on the telephone. The inspector would like to take this opportunity to thank all contributors including the manager for their co-operation and assistance with the inspection. What the service does well: The service provides solid support to service users within a secure structured environment. The home supports independence and empowers service users to take control of their lives. The emotional support provided at the project encourages service users to make positive choices to support their mental health. The home is comfortable with a cheerful, friendly atmosphere and good role models. There is a broad ethnic mix across the service users and staff at the home. Everyone gets on well and the cultural diversity is seen as a strength. One service user said the stability, structure and the company, had enabled him to turn his life around. He said that even when he moves on to more independence he will return to visit his friends at the home. The stakeholder consulted said that as a professional she found the home excellent. She said they had a very good track record of preventing relapse with some quite complex people. The home provides boundaries and keeps a good eye on people. The stakeholder said the home was spot on. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 6 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. First Care Lodge Limited DS0000067805.V353578.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 First Care Lodge Limited DS0000067805.V353578.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 good. This judgement has been made using available evidence including a visit to this service. The home had produced information to help prospective service users decide if they would like to move in. Proper assessment is undertaken before a placement at the home is offered. EVIDENCE: The home has produced a service user guide. The guide states that there are two staff of duty at the home during the day. This is not quite correct and the staffing level fluctuates between one and two at any time of the day. The manager has been asked to amend the guide to state this more clearly (see requirements). The home currently has no vacancies. The manager explained how he would assess a prospective service user. He is somewhat dependent on the information supplied by professionals who have been working with the service user. But is helped by his own experience in the field. The manager said that assessment is ongoing after the person has moved into the home as their previous history is not always a guide their behaviour there. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 9 The inspector was impressed that the manager has a very open mind and weighs all the information coming to him carefully. Prospective service users are encouraged to visit the home before they decide to move in. First Care Lodge Limited DS0000067805.V353578.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans focus on meeting service users priority needs. They are based on risk assessments undertaken. Service users are encouraged to make decisions and have plenty of scope in their lives to do this. EVIDENCE: The previous inspection carried a requirement that care plans be expanded to include all the support which the home offers. The manager and the inspector discussed this. The inspector understands that the service users are very able and independent, and do not routinely need assistance with everyday tasks. The manager stated that service users might present a particular need (for example help to join a club) only once. The staff are generally supportive whatever the requests are. The inspector understands that the care plans focus specifically on the monitoring and supporting of mental health and the establishment of a stable lifestyle. She viewed the three care plans and was First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 11 satisfied that these and a generally helpful attitude from staff would meet the needs of the client group adequately. The manager was able to give many examples of service users taking decisions for themselves. The come and go largely as they please, visiting family and friends and accessing a variety of resources in the community. Service users manage their own money, benefits and time. The inspector viewed risk assessments on the files of the service users. The risks were generally associated with their previous lifestyles. One might expect to see these risks return if the mental health of the service users were to deteriorate. The risks are related to the care plans which are designed to reduce them. The manager spoke very knowledgeably about the risks identified and the monitoring and observation which are part of the service offered. The manager spoke of his close working relationship with community mental health (CMHT) professionals. First Care Lodge Limited DS0000067805.V353578.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): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to access a range of appropriate activities in the community. Relationships with families and friends are encouraged and rights are recognized. A healthy and varied diet is offered and meals are a shared pleasure. EVIDENCE: CMHT care co-ordinators share the responsibility for ensuring that service users have access to a range of positive leisure, recreation and community experiences. There are mental health support groups and groups which support withdrawal from alcohol and drugs, and these are made accessible to service users. Day opportunities is another programme which they can use. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 13 The manager stated that two of the service users enjoy undertaking the big household shop and they largely decide what is bought. The supermarket food is supplemented by fresh greengrocery and fruit bought locally. Meals are very much determined by service users choice, and they cook themselves, contributing from their own ethnicity and culture The service users generally eat dinner together. The kitchen has an attractive table and chairs for dining. Service users have a lot of family contact, spending overnights at home and with friends. One service user has a strong relationship with his brother they spend a lot of quality time together. First Care Lodge Limited DS0000067805.V353578.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encourages independent personal hygiene and grooming. Emotional needs are met and service users are supported to self-medicate. EVIDENCE: The manager stated that service users need very little support with their personal care. In the stability of the home they have fallen into routines for personal care, grooming, the laundering of clothes, and keeping their rooms tidy. The inspector saw all three service users and they looked well turned out and cared for. The manager stated that none of the service users has health problems with the exception of one being a little overweight. This is a side effect of a medication he takes. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 15 The service users have a medication review every six months and a Care Plan Approach (CPA) review every six months. The appointments alternate. The inspector felt that the key to the service users achieving and maintaining mental stability, lay with the emotional support they receive at the home. The manager said he believes that loneliness and isolation have been detrimental to their mental health in the past and they thrive in the family environment of the home. The staff who work in the evening make sure that they hang out with the service users, watching TV with them and joining in generally. The manager said you would not know who was staff and who service user. The service users are able to administer their own medication. Staff hand them the medication and they self-medicate. They also initial the MAR sheet themselves. One service user sometimes chooses not to initial the MAR sheet. On these occasions the staff member should put their initials in the box, provided they have seen the service user take the medication. Ticks must not be used. The inspector viewed the arrangements for the administration of medication. The medication is stored in a locked safe. The medication administration record (MAR) sheets were viewed and the manager and inspector balanced a medication for each of the service users. There were no discrepancies, but the manager agreed that if the MAR sheets were marked with when supply a medication had been started, it would be a great deal easier to audit the medication. The manager agreed to undertake an audit of the medication once a month (see requirements). Service users buy their own homely remedies. These are stored with the other medications and an entry is made on a MAR sheet when they are used. First Care Lodge Limited DS0000067805.V353578.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a sound complaints procedure. The adult protection policy needs some expansion. EVIDENCE: The inspector viewed the information regarding the complaints process. This information was satisfactory. It is also included in the service user guide. A good form for recording and investigating complaints has been devised. So far there have been no complaints to record. The manager remarked that the group at the home are compatible and rarely argue about anything. He was clear that any serious verbal or written complaint would be taken seriously and dealt with till resolution. All the service users work with a range of professionals. They are all able to communicate verbally and express their views. The inspector viewed the adult protection policy. The policy must be expanded to state that should there be a suspicion or allegation of abuse a referral must be made to social services in the first instance. The policy must also state that it is followed in conjunction with social services policy. The home must try to acquire a copy of the local authority adult protection policy (see requirements). First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 17 First Care Lodge Limited DS0000067805.V353578.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, bright environment with comfortable communal spaces. EVIDENCE: The inspector made a tour of the home. It has three bedrooms, two upstairs and one downstairs. She was impressed with the facilities the home has to offer. The kitchen is of a good size and very well fitted, with a nice table and chairs for service users to eat together. The sitting room is upstairs with a huge arched window, through which the sun streams. Sky TV is provided. There is a small garden where an awning has been provided to give shade close to the house. Bathroom and shower facilities are adequate and one bedroom which the inspector, with the permission of the service user, viewed, was pleasant and comfortable. The service user said it met his needs well. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 19 The inspector feels that the cheerful home environment, with plenty of sunlight and fresh air, is beneficial to the service users. There are no hygiene issues at the home. There were no unpleasant odours. Service users do their own laundry with minimal help. The washing machine is situated in the kitchen and the floor is impermeable. First Care Lodge Limited DS0000067805.V353578.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): 32,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment process is sound but there needs to be evidence available that it has been followed in every case. Staff have had some relevant training and this needs to be built on to ensure that all training is up to date and can be evidenced. EVIDENCE: The proprietor manages the home and spends plenty of time there. He has substantial experience with the client group, and provides a good role model to staff and service users. The inspector met one other member of staff who was helpful and interacted well with the service users. The staff personnel files are not kept in the home but the manager provided some basic staff information with a record sheet for each person. The inspector noted that recruitment included two professional references, identity checks and confirmation of the persons right to work in this country. There was a space for the Criminal Records Bureau (CRB) serial number, but in two First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 21 cases this had been completed with CRB in Process. The manager stated that both staff had been checked against the Protection of Vulnerable Adults (POVA) list, before they started work, and both now have clear CRB disclosures. The numbers should have been entered on the sheets as soon as they were obtained (see requirements). The inspector noted from the staff record sheets that training had been undertaken by them. Staff had undertaken training in Food Hygiene, Manual Handling, Abuse Awareness and Protection of Vulnerable Adults and First Aid. However the dates of the training had not been given, and the certificates were not available for inspection. The manager and inspector agreed that the following topics are care basics, to be renewed every year: First Aid Fire Health and Safety Food Hygiene Adult Protection The inspector told the manager that he needs to develop a matrix so that he can plan training for staff. The manager said that he undertakes the fire training himself with staff. The house is small and domestic and the inspector accepted this, providing the manager completes a record sheet. The sheet must detail the staff name, date when the training has been done, details of what has been covered and be signed by the trainer e.g. the manager (see requirements). First Care Lodge Limited DS0000067805.V353578.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 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 is well run by a competent manager but there some are shortfalls in complying with all regulations of the Care Standards Act 2000. EVIDENCE: There is a wealth of evidence that service users are benefiting from living at the home. The current level of competent management can be further improved by the manager ensuring compliance with all the necessary regulations. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 23 The manager stated that he is currently completing an Annual Quality Assessment Audit. This will give him a good opportunity to assess the effectiveness of his service, and identify any barriers to improvement. The manager told the inspector that he is also developing a tick box style survey for service users and stakeholders to complete. The manager stated that he has a five-year business plan and forecast, which were viewed by CSCI when they registered the service. The inspector viewed the contents of the refrigerator and noted that a jar of mayonnaise which was over half used, had no opened on date label to it. All opened food stored in the refrigerator must have the date of opening on it (see requirements). The home has a purpose made accident book. No accidents had been recorded in it. The inspector noted two First Aid kits, one in the office and another in the kitchen. The Control of Substances Hazardous to Health (COSHH) substances were all stored under lock and key. There was a risk assessment on COSHH substances and a data sheet for one particular substance. The manager needs to obtain data sheets for all the products stored (see requirements). The inspector viewed the landlords gas safety record which was dated 2/7/07 and was good for twelve months. She also viewed the electrical installation certificate which was dated 10th July 2006 and which is good for three years. The London Fire Brigade carried out a fire safety audit and risk assessment on 12/6/06. They recommended that the two smoke alarms be linked, a fire blanket and Co2 extinguisher be obtained. The manager stated that all these recommendations had been complied with. There was a certificate of maintenance for both extinguishers dated 24/7/06. An outside contractor had tested the portable electrical appliances on 6/2/07. The inspector viewed evidence that the fridge and freezer temperatures are recorded daily. The inspector tested the water out of a hot tap on a basin, just by running it over her hand. The water was warm but not hot. The manager explained that the home has a combination boiler, but the hot taps are all temperature controlled at 43 degrees Celsius. With a combination boiler system there is no storage of hot water so the risk of Legionella is low. However the manager is advised to ensure that shower heads are cleaned and de-scaled regularly (see recommendations). First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 24 The inspector was pleased to see that health and safety are taken very seriously at the home, and there is plenty of evidence of proper examination of systems by outside contractors. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 25 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 x 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 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 2 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 2 x x x 3 x x 3 2 First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 5 Requirement The Service User Guide needs to be amended to accurately reflect the number of staff on duty(previous timescale of 15/04/07 not met). The MAR sheet must be marked when a new supply of medication is begun, to facilitate audit. If a service user declines to initial the MAR sheet the staff must put their initials in the box provided they have seen the service user take the medication. Ticks must not be used. The manager must undertake an audit of the medication once a month and record this somewhere. The adult protection policy must be expanded to state that should there be a suspicion or allegation of abuse a referral must be made to social services, in the first instance. The policy must also state that it is followed in conjunction with social services policy. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 27 Timescale for action 01/12/07 2. YA20 13(2) 01/12/07 3. YA20 13(2) 01/12/07 4. YA20 13(2) 01/12/07 5. YA23 13(6) 01/12/07 6. YA34 19 The manager must try to acquire a copy of the local authority social services policy. Staff should start work without CRB check, only in exceptional circumstances and with the agreement of the CSCI. If information sheets are to be submitted as evidence instead of staff files, then the CRB serial number must be entered on the sheet as soon as it is received. The manager must ensure that the following core training is undertaken by staff and refreshed once a year: Fire Health and Safety Food Hygiene Adult Protection First Aid If the manager undertakes the fire training himself he must ensure that he records the staff members name, the date of the training and what is covered. The manager must ensure that all opened foods in the fridge are labelled with the date of opening (previous timescale of 15/04/07 not met). The manager needs to obtain data sheets for all COSHH substances used in the home. 01/12/07 7. YA35 18 (1)(c)(i) 01/04/08 8. YA35 18 (1)(c)(i) 01/12/07 9. YA42 13 (4) 01/12/07 10. YA42 13(4) 01/12/07 First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 28 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 YA42 Good Practice Recommendations The manager should ensure that shower heads are descaled and cleaned regularly, to control the risk of Legionella. First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 First Care Lodge Limited DS0000067805.V353578.R01.S.doc Version 5.2 Page 30 - 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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