Inspection on 20/10/05 for 2 Mundania Road

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Mundania Road 25/11/08

2 Mundania Road 29/11/06

2 Mundania Road 14/07/05

2 Mundania Road 01/02/05

2 Mundania Road 02/11/04

2 Mundania Road 13/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Mundania Road 2 Mundania Road London SE22 0NG Lead Inspector Lisa Wilde Unannounced Inspection 20th October 2005 10:00 Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mundania Road Address 2 Mundania Road London SE22 0NG 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) 0208 693 1983 0208 693 9276 Saffronland Homes Ms Teresa Carter Care Home 6 Category(ies) of Learning disability (6), Physical disability (0) registration, with number of places Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: Mundania Road is registered to provide accommodation and care to 6 service users with learning disabilities. At the time of this inspection there were 5 male service users living at the home, with no vacancies. The house is a large Victorian style 3 storey-detached building located in a side street close to many local shops, community services and transport links. There is a large communal dining area and lounge with a communal kitchen on the lower ground floor. There is a garden with patio at the back of the house. There is no lift and the house is not wheelchair accessible. The homes mission statement is that it aims to assist its residents with appropriate support to achieve greater independence and living skills with a view to moving back into the community. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in October 2005. The inspector spoke with the Registered Manager and staff and looked through files and documents. Given the limited communication abilities of these service users it was more difficult to gather their views but the inspector saw all five service users and contacted family members by phone following the inspection. The inspector also spoke with social workers and professionals involved with the home. As at the previous inspection, opinions of relatives differ about this home and there is evidence of some areas of good practice but also concerns about the management of ongoing issues within the home that affect all service users. There has been an increase in significant incidents that have been reported to the Commission over the past few months, possibly as a result of these issues. These problems make the requirements made previously about consultation and action planning all the more important. The inspector found that several of the requirements made previously had not been met by this inspection and work must be undertaken to ensure that they are met by the next inspection. (Some of the timescales for previous requirements had not elapsed by the day of this inspection.) What the service does well: Of the standards assessed at this inspection the home showed that: • service users’ needs and wishes are assessed by suitable staff prior to them coming to the home. • prospective service users have the opportunity to visit the home and undergo a series of trial stays prior to them permanently moving to the home. • Care plans are in place and reviewed often enough for service users to know that as their needs change they will continue to be met by the staff at the home. • service users are offered an individual programme of activities that allows them to access the local community as they choose. • generally the home ensures that service users physical and emotional needs are met by accessing external professionals when needs cannot be met by staff. • generally the service users are protected by the home’s policies and procedures around medication. • the registered manager has the experience and skills necessary to manage the home well. • the home’s policies, procedures and practice ensure that as far as possible service users are protected from abuse. • the spacious, shared areas in the home are clean, attractive and comfortable providing a space that supports the service users lifestyles. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 6 • the home is protecting service users by the effective and consistent operation of health and safety procedures and systems. 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. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Service users’ needs and wishes are assessed by suitable staff prior to them coming to the home and staff and management discuss whether they can meet the needs of someone before they are offered a place at the home. This means that prospective service users and their families can know that their needs and wishes are going to be met by the home before they move there. Prospective service users have the opportunity to visit the home and undergo a series of trial stays prior to them permanently moving to the home. This programme of trial stays varies according to their individual needs and abilities. EVIDENCE: The inspector saw thorough needs and risk assessments of all service users on file that had been carried out prior to them moving to the home. The manager stated that she would attend and conduct the assessments of potential service users with her manager. One service user has moved to the home since the last inspection and a full needs and risk assessment was carried out prior to them undergoing a series of trial stays at the home. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans are in place and reviewed often enough for service users to know that as their needs change they will continue to be met by the staff at the home. Generally service users are consulted about all aspects of their life at the home but given the limited communication of some of the service users the home is not doing enough to consult formally with families and other stakeholders which means that they cannot be sure that they are running the service in the best interests of the people who use it. EVIDENCE: The care plans in place were reviewed at six monthly intervals as required. Guidelines and programmes are in place along with ‘Wishes and Aspirations’ forms. There was evidence in the files that families are consulted and kept informed of ongoing issues at the home. Some of the family members who spoke with the inspector were very happy with the home and felt that they were able to sort out any difficulties with the staff and manager. Some of the family members did not feel this was the case. Given the nature of this service user group and the limited communication of some of the people at the home, consultation with the family members is very important and a requirement had been made under this standard and Standards 22 & 39. (See Requirement 1) Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 10 There was a previous requirement that the Registered Manager must ensure that all staff are aware of and follow the latest action or support plans devised in the most recent reviews or by external professionals. The Registered Manager stated that staff have been made aware of the current guidelines from the most recent reviews, although staff were still seen working in a way that had been deemed unuseful in their care file. The visiting professional stated that there was a good level of service provided at this home but that staf would benefit from training specific to each service users’ needs. They are planning to deliver a programme of training following completion of their assessment. This requirement has ben absorbed by the training requirement under Standard 35. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 & 17 Service users are offered an individual programme of activities that allows them to access the local community as they choose. The home is not doing enough to ensure that there is a varied programme of activities within the home for those service users who, for whatever reason, cannot access the community at any particular time which means that service users may not be stimulated enough on a day-to-day basis. Service users are supported on a one-to-one basis to shop, cook and eat as they choose. EVIDENCE: Independent advocates are brought into service user reviews in an attempt to ensure their rights are being observed. Family are involved in the care of service users in different ways dependent on the service user. Although service users have limited communication abilities they are able to assert themselves and make clear what they do and do not want to do. There was a previous requirement that the Registered Manager must ensure that additional activities take place in the home so that the service user who is Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 12 currently not able to engage with his external activities has the option to take part should he wish. It is not enough in this instance for staff to merely ask him if he wants to do something, further effort must go into providing a varied and stimulating environment around him. During the inspection the inspector observed the practice with regard to this service user and spoke to the Registered Manager and visiting professional about their activities. Although it appears that the manager has attempted to encourage actvities to occur around this service user without them having to engage with it, this in practice is not occurring and the requirement is repeated. (See Requirement 2) There was a previous requirement that the Registered Manager must ensure that the practice of locking away all the food in the home stops and that alternative methods are found to ensure that the one service user who is at risk of eating inappropriate food is supported not to do this. The inspector discussed this issue again with the manager and it appears that all service users have some issues about eating food without stopping and would not be abel to cook food by themselves even if food were made available in the kitchen. The Registered Manager stated that there should always be biscuits, dry bread, fruit and juice available in the ktichen. On the day of the inspection there was no juice initially. Given that service users would not be able to cook independently the previous requirement was altered. (See Requirements 3 & 4) One service users’ relative stated that although the food was generally ok, too many sandwiches are offered. This had been fed back to the manager. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Generally the home ensures that service users physical and emotional needs are met by accessing external professionals when needs cannot be met by staff. Currently there is a significant and ongoing problem within the home, which is impacting negatively on all service users but the home is doing all it can to ascertain the causes of the problem and address them. Generally the service users are protected by the home’s policies and procedures around medication, with some slight problems with the recording of stock levels and administration. EVIDENCE: Given the limited communication abilities of the service users it was difficult for the inspector to establish if service users are being offered personal support in the way they prefer. The inspector spoke with staff and checked through the files and found that service users’ health needs are met and they receive regular checks from appropriate professionals. Specialists are brought into the home when required such as Speech and Language, psychologists and behavioural specialists. There are current problems in the home with increased levels of aggression that are impacting on all service users in negative but varying ways. Service Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 14 users families are concerned about the issue. The Registered Manager and staff are aware of the issue and are attempting to manager by offering virtual 1:1 support to all service users. The visiting professional (who has visited on several occasions recently) felt that there were enough staff on duty in the home an din fact more staff would be detrimental as too many people around would upset the service users. Although there were differing views from some family members as to the cause of the aggression, generally it is felt by involved professionals that one service user seems to be initiating most of the aggression currently and the specific issues are being addressed by their multidisciplinary care team. Their review is due in the few weeks following the inspection. (See Requirement 5) The inspector checked the stocks of medication held in the home and the administration records. The home uses the ‘blister pack’ system of medication administration for most medications. The inspector found that currently the medication stocks are not carried forward onto the next sheet so it not possible to check if the correct amounts of stock are held. There were some gaps in the administration of one service user’s ointments. (See Requirements 6 & 7). Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home’s policies, procedures and practice ensure that as far as possible service users are protected from abuse. Appropriate measures are taken when abuse is suspected or alleged. EVIDENCE: The inspector is now made aware of when vulnerable adults issues are raised at this home. The social workers involved communicate with the Commission with regard to any meetings that are called. Staff showed awareness of what to do if they suspected any abuse and the home has an appropriate policy around protection of vulnerable adults. Abuse training has been booked for December and April 2006. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 & 30 The spacious shared areas in the home are clean, attractive and comfortable providing a space that supports the service users’ lifestyles. EVIDENCE: The shared space in the home is spacious, comfortable and clean. On this inspection the inspector did not see any of the service users’ rooms but previous inspections have confirmed that all bedrooms meet the required size standards. The home has six toilets and three bathrooms, which meets the requirements of the standards. The current service users do not need any specialist equipment to assist with their mobility. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 35 The current management and staff vacancies along with the gaps in the training and NVQ programme mean that service users are not being offered support by an as effective staff team as possible. EVIDENCE: Five of the current staff hold or are undertaking the NVQ Level 2 in Care or equivalent. As there are eleven staff excluding the manager the home is not as yet quite achieving the target of 50 of care being delivered by staff holding this qualification or equivalent. (See Requirement 8) There was a previous requirement that the Registered Individuals must ensure that a suitably experienced and skilled individual is recruited to the deputy post at the home. The Registered Manager stated that they are currently short listing but have not as yet recruited. (See Requirement 9) In addition they have two staff vacancies amounting to a significant number of agency and bank staff being used at the home. Given the need for almost constant 1:1 staffing for these service users the need for consistent, permanent staff is considerable. (See Requirement 10) There had been reports made of one service user being seen recently on their own in the street. The Registered Manager and staff were not aware of this and an investigation into how this could have happened must take place as this Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 18 service user is deemed at risk and needs to have escorts at all times when outside of the home. (See Requirement 11) There was a previous requirement that the Registered Manager must ensure that training appropriate to the individual needs of the service users is offered to staff to enable them to feel secure in working with the service users more challenging behaviours. The Registered Manager stated that the multidisciplinary team are preparing a programme of service user specific training for the team that is due to be delivered shortly. The inspector spoke with a behavioural specialist who was visiting on the day who will be planning specialist training following their assessment of one of the service users. (See Requirement 12) There was a previous requirement that the Registered Manager must ensure that she checks whether the current induction and foundation programme for staff is based on the Learning Disabilities Award Framework and Skills for Care requirements and if it is not ensures that the programme is redevised so that it is in line with those requirement. This was checked on the day of the inspection and found to be in line with the requirements. There was a previous recommendation that the Registered Individuals should consider changing the on-call rota so that other service managers are on-call for this home on certain weeks to allow the registered manager to have time off from being on-call for the home. The Service Manager takes the on-call every other week from the Registered Manager who stated that this practice is acceptable for them. The inspector wil be assessing the home’s recruitment records at their head office at a later date this year. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 As far as currently possible, the home is well run as the manager has the experience and skills necessary to show that she understands the needs of the service users and how staff, practice and procedures at the home should meet those needs. However the lack of deputy manager for a considerable period means that there is not enough management input into the home. The home is not currently showing that service users’ (and their families’ and other stakeholders’) views are being taken into account and are being used to develop the home in ways that are in the best interests of the service users. The home is protecting service users by the effective and consistent operation of health and safety procedures and systems. EVIDENCE: The current manager has now been registered with the Commission and is working on the NVQ Level 4 Registered Managers Award. She has a social work qualification and has been at this home since June 2004. She has worked in Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 20 the social care field since 1976. The home has still not recruited a deputy manager as discussed under Standard 33. There was a previous requirement that the Registered Manager must ensure that service users, their families and other stakeholders are formally consulted about their views of the service. The outcomes of these consultations must be recorded and action plans to address concerns drawn up. The Registered Manager stated that given previous experience they find that working individually with families at this home is more effective than meetings and they are continuing to do this. They had sent out a survey to families two weeks prior to the inspection but did not have any copies returned as yet. The timescales for all the quality assurance requirements had not elapsed by the time of this inspection. The previous requirement is repeated given that as yet there are no results of consultations that have been drawn up with action plans devised , this requirement is already noted under Standards 6 and 22. There was a previous requirement that the Registered Individuals must ensure that a comprehensive quality assurance system is in operation in the home that is based on the views of service users and other stakeholders. As stated above this is not yet in place and the requirement is repeated. (See Requirement 13) There was a previous requirement that the Registered Individuals must ensure that an annual development plan is drawn up for the home that is based on the views of service users and other stakeholders and which is published and made available to service users, stakeholders and the Commission. This requirement links into the other requirements around quality assurance and the home has not as yet drawn up such a plan (See Requirement 14) There was a previous recommednation that the Registered Individuals should consider using an externally recognised, professional quality assurance tool within the home. This has not been introduced yet and the recommednation is repeated (See Recommendation 1) On the tour of the building the inspector found no cause for concern with regard to health and safety. All the fire checks and records were in place and maintained appropriately as were the gas and other maintenance records. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mundania Road Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000007091.V258532.R01.S.doc Version 5.0 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 YA22YA39 Regulation 12 (3) 22 (2) 24 (3) Requirement Timescale for action 30/11/05 2 YA13 16 (2) (m) & (n) 3 YA17 16 (2) (i) The Registered Manager must ensure that service users, their families and other stakeholders are formally consulted about their views of the service. The outcomes of these meetings must be recorded and action plans to address concerns drawn up. Previous requirement but the timescale for completion had not elapsed by this inspection. The Registered Manager must 30/11/05 ensure that additional activities take place in the home so that the service user who is currently not able to engage with his external activities has the option to take part should he wish. It is not enough in this instance for staff to merely ask him if he wants to do something, further effort must go into providing a varied and stimulating environment around him. Previous requirement: Unmet timescale 31/08/05 The Registered Manager must 30/11/05 ensure that a wider variety if DS0000007091.V258532.R01.S.doc Version 5.0 Mundania Road Page 23 4 YA17 16(2)(i)&15 5 YA19 12 (1) (a) 6 YA20 13 (2) 7 YA20 13 (2) 8 YA32 18 (1) (c) (i) 9 YA33 18 (1) (a) 10 YA33 18 (1) (a) 11 YA33 13 (4) (c) interesting, healthy snacks are made available in the kitchen. The Registered Manager must ensure that the limitations on food access must be recorded in the service users care plans and the practice of locking away food reviewed on an ongoing, individual basis. The Registered Manager must inform the Commission of the results of the upcoming placement review. The Registered Manager must ensure that all medication stock numbers are carried forward onto the new medication administration charts and effective stock checking takes place. The Registered Manager must ensure that all prescribed topical medications are signed for at point of administration. The Registered Individuals must ensure that at least 50 of care is provided by staff holding the NVQ Level 2 in Care or equivalent. The Registered Individuals must ensure that a suitably experienced and skilled individual is recruited to the deputy post at the home. Previous requirement: Unmet timescale 31/10/05 The Registered Individuals must ensure that appropriate permanent staff are recruited to all staff vacancies. The Registered Manager must conduct an investigation into incidents of one service user being alone outside of the home. The Commission must be informed of the outcome of this investigation. DS0000007091.V258532.R01.S.doc 07/12/05 30/11/05 30/11/05 30/11/05 31/12/05 31/12/05 28/02/06 07/12/05 Mundania Road Version 5.0 Page 24 12 YA35 13 YA39 14 YA39 The Registered Manager must ensure that training appropriate to the individual needs of the service users is offered to staff to enable them to feel secure in working with the service users more challenging behaviours. Previous requirement: Unmet timescale 30/09/05 24(1)(2)&(3) The Registered Individuals must ensure that a comprehensive quality assurance system is in operation in the home that is based on the views of service users and other stakeholders. Previous requirement but the timescale for completion had not elapsed by this inspection. 24(1)(2)&(3) The Registered Individuals must ensure that an annual development plan is drawn up for the home that is based on the views of service users and other stakeholders and which is published and made available to service users, stakeholders and the Commission. Previous requirement but the timescale for completion had not elapsed by this inspection. 18 (1) (c) (i) 31/12/05 31/12/05 31/12/05 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 YA39 Good Practice Recommendations The Registered Individuals should consider using an externally recognised, professional quality assurance tool within the home. Mundania Road DS0000007091.V258532.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 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. 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