Inspection on 11/01/08 for Sitwell Grove

This is the latest available inspection report for this service, carried out on 11th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sitwell Grove 3 Sitwell Grove Stanmore Middlesex HA7 3NB Lead Inspector Robert Bond Key Unannounced Inspection 11th January 2008 10:00 Sitwell Grove DS0000070612.V354456.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 Sitwell Grove DS0000070612.V354456.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. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sitwell Grove Address 3 Sitwell Grove Stanmore Middlesex HA7 3NB 020 8537 0632 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) Kevin Tyahooa Kevin Tyahooa Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 4 New service Date of last inspection Brief Description of the Service: This residential care home for four adults with learning disabilities is a converted private house located in a quiet residential area, close to a public park and within a short distance of shops and local transport links. The front garden contains a parking bay, and further parking is available on the street outside. There is a small secure rear garden. On the ground floor are a living room, small dining room, kitchen, shower room with toilet, and two bedrooms. On the first floor there are two more bedrooms, an office/sleeping in room, and a bathroom with toilet. There is no lift. The bedrooms are all of a reasonable size. The home has its own vehicle and driver. A range of activities are available within the home and in the local community. Fees for staying in the care home are by negotiation with the owner. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use the service experience good quality outcomes. As this was the first inspection of a new service, I inspected the home against the anticipated outcomes for not only the key standards National Minimum Standards (NMS) for care homes for younger adults but for almost all of the standards. I sent out in advance of the inspection an Annual Quality Assurance Assessment (AQAA), which was completed and returned by the Registered Manager. I also sent out questionnaires to residents, relatives, staff members and care professionals associated with the home. Ten responses were received back and a high level of satisfaction was expressed. On the day of the inspection I spent four hours on the premises, I interviewed the Registered Manager, met two members of staff, talked to the three residents, toured the premises including two bedrooms with the occupants’ permission, and examined a range of records. Three of the four residential places have been taken. All current residents are male, and a fourth male is being considered for the one remaining vacancy. The all male staff team is still being recruited to, but a deputy manager is in post to assist the Registered Manager, who is also the owner of the home and is also the registered manager and owner of a nearby care home. Issues of equality and diversity were considered throughout the inspection. No omissions or concerns came to light. Details on the culture, ethnicity and the special needs of the residents are contained in the ‘Lifestyle’ section of this report. Of the 37 outcomes of the NMS assessed, 28 were found to be fully met, 2 were exceeded, and 7 were only partially met. This led me to make 7 requirements and 2 recommendations. What the service does well: Prospective residents and their relatives are provided with good information about the home, the needs of prospective residents are fully assessed prior to introductory visits being arranged, and contracts are being issued. Residents are provided with good opportunities for personal development and leisure activities in the community. The company of friends and relations is promoted, and good and varied food is served. Personal care needs are well documented, and staff members have received additional training in British Sign Language to help meets the needs of a resident with a hearing impairment. The home has good complaints and good safeguarding procedures in place. Residents’ views are carefully taken into account, and residents are well protected from abuse. The home is generally homely, comfortable, clean and safe. It is Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 6 appropriately decorated, furnished and equipped. Residents are involved in the robust recruitment process for staff and the induction procedure is very thorough. Residents express satisfaction with a well run home where their best interests are safeguarded. The dedication of the Registered Manager is particularly praised. Record keeping is generally very good and health and safety are given a high priority. 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. Sitwell Grove DS0000070612.V354456.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 Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are provided with good information about the home, the needs of prospective residents are fully assessed prior to introductory visits being arranged, and contracts are being issued. EVIDENCE: The Registered Manager was unable to produce a copy of the home’s Statement of Purpose for me, but one was submitted to the CSCI as part of the home’s registration process. I did however see a Service Users’ Guide that met the required standard and was a user-friendly document containing pictures. I examined in detail (case-tracked) the care file documents for one resident who I selected randomly. The file did not contain a full assessment, but the Registered Manager was able to produce from his car a detailed and comprehensive assessment from the referring local authority (London Borough of Harrow), and a hand written assessment undertaken by the Registered Manager himself that confirmed that the prospective resident’s needs would be able to be met within the Sitwell Grove home. An individualised ‘service user plan’ had been devised that was based on these assessments. The file contained reports on two pre-moving in visits that the prospective resident had made to the home. One resident wrote in his questionnaire, “ I visited the home before moving in and I received a brochure.” An example of the home’s contract with residents was shown to me. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 9 Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. With the exception of mental health needs, ‘service user plans’ are very good at identifying how assessed needs, goals and aspirations will be met. Residents are fully consulted about and involved in most aspects of the home, an independent lifestyle is promoted, and confidential material is appropriately handled. EVIDENCE: The care file I case-tracked contained a ‘client profile’ that included ethnicity and religion, a photograph of the resident, a ‘pen portrait ‘ signed by the resident, a ‘day timetable’, a support plan, and a person-centred care plan that included guidelines for staff on how to meet the resident’s needs. The key worker system was seen to be in use, with the Registered Manager being the key worker in this instance. Residents’ own goals were identified on the record, and detailed care objectives and how they will be met were also recorded and signed by both the resident and the key worker. Privacy and dignity were referred to in the care plan, and the goals identified clearly related to promoting independence. The care objectives included sections on physical health, social activities, personal care, cultural and spiritual needs, and medication. What was missing Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 11 however, was a section on the resident’s mental health needs and how to meet them. This omission was indicated by a reference to psycho-sexual therapy within the care file. The Registered Manager agreed that a section on mental health needs was generally warranted as each resident saw a psychiatrist, and a community psychiatric nurse, and one resident was subject to the Care Programme Approach. In terms of decision making, all the residents are involved in drawing up their care plans, which are reviewed after six weeks, six months, and then annually. Residents, their relatives or advocates, sign agreement to the care plans. The Registered Manager said that collective residents’ meetings are held monthly, but food menu planning meetings are weekly, and activity planning meetings are daily. I observed one of the latter. A resident wrote in his questionnaire response, “I choose my activities and meals. I like it here.” The Registered Manager reported that residents are encouraged to wash up dishes, dust the furniture, or undertake gardening. I asked a resident what he liked to do and he replied ‘hoovering’. A risk assessment had been undertaken on five different aspects, had been signed by the resident, and a review date had been set. The Registered Manager reported the home’s staff have a positive attitude towards responsible risk taking by residents. In terms of confidentiality, I noted the home’s policy on access to client records, and noted that care files were kept in a locked office. Sitwell Grove DS0000070612.V354456.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): 11, 12, 13, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have good opportunities for personal development and leisure activities in the community, whilst also enjoying the company of friends and relations, and having good and varied food. EVIDENCE: The three current residents are all male and white, although one has an AngloIndian background. The residents have a range of needs that are additional to their learning disability. The group is deliberately all male, with an all male staff group, as at least one resident has been known to make inappropriate sexual advances to females. The care file I examined contained a ‘day timetable’ showing the resident’s planned visits to day centres and social clubs. Nothing was entered on the timetable for weekend days although the Registered Manager said that planned activities took place at weekends also. He added that the home has its own vehicle and designated driver, and attendance at day centres, social clubs, and college are all promoted. No resident has any employment at present. Independence is promoted in that Freedom Passes and Taxi Cards have been applied for. Activities within the community are encouraged, such as Friday Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 13 night visits to a local Public House. Visitors to the home are encouraged as the visitors’ book testifies. At least one resident has a girl friend. Two residents go to church, one regularly. I saw the food menu, which is in picture form to promote residents involvement in making choices. Residents are encouraged to assist in food preparation and are allowed to make their own snacks. A record is kept of food eaten. A relative wrote in their questionnaire, “The residents are taken out each day to the cinema, shopping etc. This is what my son needs, to learn to socialise in public”. Sitwell Grove DS0000070612.V354456.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive good personal support in ways that they choose, but further attention must be paid to recording health care needs, and how they are going to be met. Medication administration is satisfactory subject to a minor improvement. EVIDENCE: The support plan I examined in detail contained details of physical health issues, and how to meet the resident’s personal care needs, but as indicated in the ‘individual needs and choices’ outcome group section of this report did not cover mental health needs. A professional involved with the home wrote in their questionnaire, “The service has managed health care needs to a satisfactory level. I feel satisfied that the staff have the right skills and knowledge to support the service users (in terms of meeting their social and health care needs). One service user has a hearing impairment and the staff have attended British Sign Language training with the service user to develop their skills.” A relative wrote, “The home has a routine of get up, wash, breakfast, and tidy up. My brother’s personal hygiene is excellent”. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 15 The file examined contained details of GP, dentist, optician, use of hospital specialists, medication and a signed authority from the resident to administer medicines, but no weight chart. I noted that medication was appropriately stored, that medication records contained a photograph of the resident to aid identification, that staff had instructions on how to administer medication, that records showed medication being received and being administered and signed for by staff, but there was no list of sample staff signatures. A Medication Administration Record (MAR sheet) was only present in one case. Sitwell Grove DS0000070612.V354456.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has good complaints and good safeguarding procedures in place. Residents’ views are carefully taken into account, and residents are well protected from abuse. EVIDENCE: I examined the home’s complaints policy and procedure, which were displayed in the home and made available to relatives. No complaints had been recorded by the home, and none have been made to the CSCI. The feedback questionnaires received from service users, relatives, staff and care professionals were all positive in their tone. I examined the home’s ‘protection of vulnerable adults’ policy and procedure, which meets the standard. All staff members have been appropriately trained. I examined the cash held by the home on behalf of a resident, and the associated records. These were all in order. Sitwell Grove DS0000070612.V354456.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, 25, 26, 27, 28, 29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally homely, comfortable, clean and safe. It is appropriately decorated, furnished and equipped. EVIDENCE: I toured the premises and saw two residents’ bedrooms with their permission. The building and grounds are suitable for their purpose and the rooms are of sufficient size. The bedrooms are well decorated and equipped but only minimally furnished. The Registered Manager explained that additional chairs could be borrowed from elsewhere in the home if the resident had a visitor to entertain privately, and that a missing table ‘was on its way’. Communal areas are well furnished and equipped. A relative wrote in their questionnaire, “The home is comfortable and homely”. Whilst this is generally true, the skirting board and one door threshold in the kitchen have not been completed. Bathrooms and toilets are satisfactory. No specialist equipment is necessary. The window of the staff sleeping in room/office only has a net curtain. In line with NMS 28.3, a blind or heavy curtains are recommended as this room is overlooked by properties at the rear. The home was found to be clean, tidy and hygienic throughout. Cleaning materials were safely locked away. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 18 A resident told me, “ I am happy here. I am pleased with my room”. Sitwell Grove DS0000070612.V354456.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): 31, 32, 34, and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff members do not have sufficiently accurate job descriptions, and a higher proportion of the support staff must have a professional care qualification, in order to better support residents. However residents are involved in the robust recruitment process for staff. The induction procedure is very thorough. EVIDENCE: I asked to see job descriptions and found that the one for the deputy manager inappropriately made reference to domiciliary care, and the one for a support worker named the proprietor’s other home as opposed to the Sitwell Grove home. According to the AQAA supplied by the Registered Manager, only 20 of the existing support staff have an NVQ level 2 in care. The NMS require at least 50 . The Registered Manager said he is in contact with a local College in this regard. The staff team are still being recruited, hence formal staff meetings have not commenced but the Registered Manager said one was planned for later in the month. I checked the staff rota which was satisfactory. I examined the recruitment files of the two members of staff I met at the home. Both had transferred from the proprietor’s other home, and one was part-time. In both cases application forms had been completed, interview notes had been kept, Criminal Record Bureau disclosures were on file, as were all other required checks and references. Employment contracts were on file. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 20 There were in one instance notes of the prospective employee meeting the residents for the first time, as part of the interview assessment process. The residents’ comments on the applicant were also recorded. These practices are commended. The files seen contained evidence of a substantial and thorough induction process, which fulfilled the Skills for Care Common Induction Standard. The induction process, which lasts up to 12 weeks, is also commended. Training records are kept and training needs identified for the year ahead. Mandatory training needs are covered and additional specialist training needs are met, such as the BSL training previously reported. The care professional who completed a questionnaire said, “The owner is working with the local Learning Disability team for staff training to work with service users.” A member of staff said in their questionnaire, “Everything was covered in my induction when I started. I have already finished my training in POVA, food and hygiene, infection control, medication, and fire and safety.” As the staff team is not fully recruited, the staff supervision system is not yet fully established and hence has not been assessed at this inspection. Sitwell Grove DS0000070612.V354456.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, 40, 41,and 42. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents expressed satisfaction with a well run home where their best interests are safeguarded. Record keeping is generally very good and health and safety are given a high priority. EVIDENCE: The Registered Manager, who is also the owner of the home, is currently completing his NVQ level 4 in care, and Registered Managers Award. It is clear from the feedback received from residents, relatives, staff, and professionals in touch with the home that the Registered Manager is held in high esteem by all. A relative writes, “He has gone out of his way to make sure that (name of resident) settled in.” A staff member says, “Our manager always communicates with us regularly. He always helps us in our work.” As the home is only recently opened, an annual quality assurance system is not yet established, but one is planned. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 22 The home was seen to have a full set of relevant policies. As recorded above, one weight record was missing but in general records were very good. I checked fridge, freezer and hot water temperature records, and medication records. In terms of health and safety, I checked that cleaning materials were safely locked away, and that first aid kits were complete. Fire, electricity and gas safety certificates were all checked during the home’s registration process in July 2007 and hence were not rechecked at this inspection. A monthly health and safety audit to check for potential hazards within the property is recommended. Sitwell Grove DS0000070612.V354456.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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X X 3 3 3 X Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No, it’s a new service. 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 YA6 Regulation 15(1) Requirement ‘Service user plans’ must indicate how the resident’s assessed mental health needs are to be met. The advertised programme of activities for residents must include activities on Saturdays and Sundays. In order to ensure that health care needs of residents are being met, a weight chart must be completed monthly for each resident. A list must be maintained of sample signatures and initials of all staff members who administer medication. The skirting board and door threshold in the kitchen must be made good to enhance the safety of residents. All staff employed at the care home must have job descriptions that specifically relate to their work at Sitwell Grove. Staff must receive additional NVQ in care training so that at least 50 of the group are qualified. Timescale for action 01/03/08 2 YA14 16(2)(n) 01/03/08 3 YA19 12(1)(a) 01/02/08 4 YA20 13(2) 01/03/08 5 YA24 23(2)(b) 01/03/08 6 YA31 18(2) 01/03/08 7 YA32 18(1)© 01/03/09 Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 25 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 Refer to Standard YA28 YA42 Good Practice Recommendations A blind or heavy curtain should be fitted to the window in the staff sleeping in room. A monthly health and safety audit to check for potential hazards within the property. Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sitwell Grove DS0000070612.V354456.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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