Inspection on 04/05/06 for 267 Hersham Road

This inspection was carried out on 4th May 2006.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

267 Hersham Road 25/07/07

267 Hersham Road 30/11/05

267 Hersham Road 01/08/05

267 Hersham Road 29/11/04

267 Hersham Road 15/06/04

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33 St John`s Church Road

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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 Hersham Road (267) 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ Lead Inspector Denise Debieux Key Inspection 4th May 2006 10:00 Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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 Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hersham Road (267) Address 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ 01932 226125 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) The Regard Partnership Limited Miss Suzan Namusoke Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 20-65 years Services users shall all be in the category LD (Adults with learning disabilities). Two named persons may also have a physical disability. 30th November 2005 Date of last inspection Brief Description of the Service: 267 Hersham Road is a care home providing residential care for up to six residents with mild to moderate learning disabilities, two of whom may also have a physical disability. The home is detached and is situated in a residential area a short distance from Walton on Thames town centre and its facilities. The bedrooms are situated on two floors, two bedrooms are on the ground floor and four bedrooms are on the first floor. The bedrooms are personalised and homely. The garden is well maintained and safe for the service users to enjoy. Currently there are three male and three female service users living in the home. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 6.25 hours and was carried out by Denise Débieux, Regulation Inspector. Mr Nero Andrews (Acting Manager) was present as the representative for the home. A tour of the premises took place. Two of the service users were spoken with at some length with a further two service users and three members of staff being spoken with during the visit. Some of the comments made to the inspector during the visit are quoted in this report. The service user care plans and individual risk assessments were sampled, as were the home’s policies and procedures, staff training and recruitment records, incident records, fire safety log, medication records and storage and activity records. The home provided a pre-inspection questionnaire and comments cards were received from five service users. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? Regard Partnership have now reviewed their Protection of Vulnerable Adults policy in line with the local, Surrey, multi-agency procedure. The ongoing maintenance and redecoration of the home and gardens provide the service users with homely and comfortable surroundings in which to live. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 6 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. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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 Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs and aspirations are fully assessed and documented prior to admission and on an ongoing basis in monthly reviews. EVIDENCE: There have been no new admissions to the home since the last inspection. However, the company policy is that all service users are fully assessed prior to being invited to visit the home as part of the home’s pre-admission procedure. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ individual plans are clear and comprehensive and include details of needs and goals. They also incorporate known or indicated preferences and in depth risk assessments. EVIDENCE: Service users spoken with were complimentary regarding the care they receive at the home and confirmed that the staff always help them when needed. During this visit, and on several occasions, service users were seen to go to staff and request assistance with a task or personal care. Each time this occurred the staff were seen to respond promptly and with a clear understanding of the assistance requested. Care plans inspected were comprehensive and set out actions which need to be taken by care staff to ensure that all aspects of the health and personal care needs of the service users are met. Daily recording showed that staff provide care and support to the service users in the way they prefer. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 10 The care plans also fully evidenced that staff enable service users to take responsible risks. These risks are assessed and included in each care plan with appropriate actions/training identified to reduce the level of risk. A recommendation has been made that care plans are signed by the service users or their representatives and that daily recording relates more specifically to the care plans and demonstrates staff action taken to meet the service users’ identified goals. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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): 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. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected. Meals are well-balanced and varied. EVIDENCE: All service users have individual plans that detail their stated likes and dislikes. Staff enable and work with service users to plan and follow activities and pursuits based on this information. Service users are also offered the opportunity to try activities that they have not tried before. The daily routines at the home reflect the requirement to promote independence, individual choice and freedom of movement with service users observed to be making choices of what to do and when. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 12 On the day of this visit, service users were all involved in planning and preparing for a birthday party the following week. The service user concerned discussed these plans with the inspector and said how much she was looking forward to her party. Service users are all offered the option of a minimum seven days annual holiday, which they help choose and plan. At present, the service users are exploring options for this year’s holiday, with help and support from staff. Staff support service users to maintain family links and friendships inside and outside the home, this may involve family members or friends being invited to participate in planned activities or being invited for meals. There are no restrictions to visiting and service users can see visitors in the privacy of their own rooms if they wish. The menu for the week of this visit was seen to be varied and well-balanced. The inspector was advised that service users plan their own meals, usually on a Sunday, with assistance and guidance from the staff where needed. The main, hot meal is in the evening. Staff monitor what the service users eat and alternatives are available if the service user wants something different to the planned meal. The inspector was advised that service users are weighed monthly and any unexplained loss of weight or appetite would result in a referral to the GP. Lunch on the day of this visit was pizza, which the service users had helped to prepare and serve. All interactions observed between the staff and service users were seen to be respectful and caring. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Sound policies and practices are in place for the administration and management of medications. EVIDENCE: Service users spoken with confirmed that staff provide personal care and assistance, where needed, in the way they have indicated they prefer. This was seen to be clearly set out in their individual plans. The care plans sampled also provided evidence that service users’ healthcare needs are being met. Service users are all registered with a local GP and referrals to other health care professionals are obtained, as necessary, from the GP surgery. Staff were observed to always knock and ask permission to enter service users’ private rooms and all personal care was carried out behind closed doors. Service users spoken with confirmed that staff do not enter their personal rooms without permission. Assistance is provided to promote and maintain independence where appropriate. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 14 Medication administration record (MAR) sheets, medication storage and some medication administration were all observed during this visit and were seen to be in line with the home’s policies and procedures. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that service users feel their views will be listened to. Policies are in place to protect service users from abuse but lack of robust staff recruitment procedures are placing them at possible risk of harm or abuse. EVIDENCE: The home has a complaints procedure in place that is accessible to all service users in picture format. Service users spoken with were aware of who to talk to if they were not happy. All service users have an allocated key worker and meet with their key worker at least once a month. Regard Partnership have now reviewed their policy and procedure on the protection of vulnerable adults, in line with the Surrey local procedure. A copy of this new policy was available in the home and local contact numbers were clearly posted on the notice board for staff to refer to. During this visit it was discussed and clarified that, should one service user hit another service user, the incident should be referred to the local vulnerable adult team and to CSCI. Service users told the inspector that they felt safe at the home and were comfortable and at ease with the staff that were on duty. Staff recruitment is addressed in the ‘Staffing’ section of this report. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: During this visit one service user proudly showed the inspector around her home. The service user showed the inspector her bedroom and said how much she liked her own room, which was highly individualised and contained many personal mementos and possessions. The garden was observed to be well maintained and easily accessible to all service users. The home has a conservatory, a communal sitting room and a separate dining area, which is also used for activities. At the last inspection it was stated that a decision had been made to remove the existing conservatory and replace it with a new one. This work was due to begin in January 2006 but has not been carried out. A representative of Regard Partnership then visited the home in March and noted that the conservatory roof had leaks and identified that they should be repaired by the maintenance department by the 21st April 06. On the day of this visit the work had not been carried out and the roof still leaks Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 17 when it rains. The provider must ensure that work is carried out to make good the conservatory roof and without further delay. A requirement has been made. During the tour of the home, all areas were found to be tidy and well organised, with a homely atmosphere. On the whole, the home was well maintained but the following issues were also identified as needing attention: • The freezer in the kitchen needs de-frosting. • The salad drawer in the kitchen fridge is broken and needs replacing. • The first floor bathroom has mould around the window. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 18 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, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a staff training programme which is designed to ensure that service users are supported by competent and qualified staff. Arrangements for staff recruitment are not satisfactory and are placing service users at possible risk of harm or abuse. EVIDENCE: At present one of the twelve care workers holds an NVQ in care and the inspector was advised that all other care workers are enrolled on a course but do not yet have definite start dates. A requirement has been made for the company to provide CSCI, Eashing office with a training plan showing how they plan to achieve 50 of care workers with an NVQ qualification in care. Staff files sampled showed that new staff had received comprehensive induction, which meets with the Skills for Care guidelines. Other staff training is provided by the Regard Partnership training department who have recently visited the home to assess all individual and team training requirements to ensure that mandatory updates and ongoing training is arranged as needed. During the visit two staff files were sampled. On their application forms there were large unexplained gaps in employment and the members of staff had not given a full employment history. In both cases, previous places of Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 19 employment had not been checked, reasons for leaving were not explored and references had not been verified. Both files had proof of identity and current photographs and the home had obtained enhanced Criminal Records Bureau certificates for both members of staff. The specific requirements of the amended Schedule 2 of the Care Homes Regulations 2001 were discussed with the acting manager. This area was of concern at the last inspection in November last year and a requirement was made that staff files be reviewed and all missing information obtained. An action plan, received from the home in December 05, stated that staff files had been reviewed and contained the required information. However, this requirement has not been met, has been carried forward with a limited timescale and must now be addressed in full and without delay. Additional requirements have also been made and the registered person must ensure that the home’s recruitment practices do not continue to place service users at risk. All service users surveyed answered that the staff treat them well and all felt that the staff listen and act on what they say. On more than one occasion during this visit, the service users commented on or demonstrated their liking for and trust in the staff. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 20 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. All policies and procedures are in place to ensure, so far as is reasonably practicable, the health and safety of service users and staff. EVIDENCE: In February of this year the registered manager left the home. Since that time the management of the home has been carried out by the previous deputy, who is now the acting manager. Mr Andrews has six years experience working in care, has worked at the home for the past four years and has been the deputy manager at 267 Hersham Road since October 2004. The acting manager and the staff team are congratulated for their success in ensuring that there has been minimal disruption for the service users at this Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 21 time of change, and for the maintenance of the relaxed, happy and homely atmosphere at the home. The company’s quality assurance department has carried out a survey with service users and relatives. A recommendation has been made that the home also includes GPs, Care Managers and other health and social care professionals in their quality assurance surveys. Once the results of the surveys are all received the home will need to correlate the results and draw up an action plan to address any issues raised. A copy of these results and the action plan needs to be given and explained to all service users and a copy placed in the service users’ guide and sent to CSCI, Eashing office. During the tour of the home it was noted that some of the window opening restrictors on the upper floor were broken or had been disconnected. The home must ensure that all window restrictors are in place and in good working order. Window restrictors should only be disconnected in service users’ personal rooms following a thorough and documented risk assessment based on that individual service user. Window restrictors in any communal areas can only be disconnected if the risk assessments for all service users indicate it is safe to do so. The file on recorded incidents/accidents was sampled. The records were well kept and included actions taken to prevent a recurrence if possible. However, it was noted that some incidents should have been reported to CSCI but had not been. A copy of the CSCI guidance for providers was left at the home for future reference. All necessary health and safety checks are carried out by the staff at the home with documentary evidence inspected of routine fire practices and evacuations, fire equipment checks, daily checks of fridge and freezer temperatures. All records were up to date and well maintained. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 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 3 X 2 X 3 X X 2 X Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 23 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 YA24 Regulation 23(2)(b) Requirement Timescale for action 05/06/06 2 YA24YA30 3 YA32 4 YA34 The registered person must ensure that the conservatory roof is repaired and made watertight. 05/06/06 23(2)(c)(d) The registered person must address the following issues: • The freezer in the kitchen to be de-frosted. • The salad drawer in the kitchen fridge to be replaced. • The mould around the window in the first floor bathroom to be removed/treated. 18(1)(c)(i) The registered person must 05/06/06 compile a training plan showing how the home is to achieve 50 of care workers qualified to NVQ level 2 in care. The plan to include definite start dates and expected completion dates. A copy to be sent to CSCI, Eashing office. 19(1)(b) The registered person must not 04/05/06 Schedule 2 employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of DS0000013470.V292651.R01.S.doc Version 5.1 Hersham Road (267) Page 24 5 YA34 19(1)(b) Schedule 2 6 YA34 18(1)(a) 19(1)(a-c) Schedule2 7 YA34 18(1)(c)(i) 19(1)(a-c) Schedule2 8 YA39 24(2) The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must ensure that staff files for all persons employed since 26th July 2004 contain all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) and be satisfied as to the appropriateness of the references obtained. (Timescale of 11/01/06 not met) The registered person must ensure that any staff that do not have all the required checks and documentation in place, are not left in charge of the home and are closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. The registered person must ensure that all staff responsible for staff recruitment are aware of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. The registered person must ensure that the results of the DS0000013470.V292651.R01.S.doc 02/06/06 04/05/06 04/05/06 04/08/06 Hersham Road (267) Version 5.1 Page 25 9 YA42 13(4)(a-c) 23(2)(c) 10 YA42 37(1)(a-g) 37(2) 11 YA39 10(1) service user and their relatives or representatives surveys (specific to Hersham Road) are correlated, an action plan drawn up to address any issues and the results published and made available for service users and their representatives. A copy to be placed in the home’s service user guide and a copy sent to the CSCI, Eashing office. The registered person must 04/05/06 ensure that all window opening restrictors are in place, are in good working order and are only disconnected where individual risk assessments indicate it is safe to do so. The registered person must give 04/05/06 notice to the CSCI, Eashing office, of any occurrence detailed in Regulation 37 of the Care Homes Regulations 2001. The registered person must 19/05/06 submit, to the CSCI, Eashing office, an improvement (action) plan, setting out exactly how requirements 1-10 will be met in full. The plan must include specific timescales for completion of each requirement. 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 YA6 Good Practice Recommendations It is recommended that care plans are signed by the service users or their representatives and that daily recording relates more specifically to the care plans and demonstrates staff action taken to meet the service users’ identified goals. DS0000013470.V292651.R01.S.doc Version 5.1 Page 26 Hersham Road (267) 2 YA39 It is recommended that the home includes GPs, Care Managers and other health and social care professionals in their quality assurance surveys. Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Hersham Road (267) DS0000013470.V292651.R01.S.doc Version 5.1 Page 28 - 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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