Inspection on 26/06/06 for 43, Florence Avenue

This inspection was carried out on 26th June 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

43, Florence Avenue 15/05/08

43, Florence Avenue 11/09/07

43, Florence Avenue 28/11/05

43, Florence Avenue 24/05/05

43, Florence Avenue 22/11/04

43, Florence Avenue 27/04/04

43, Florence Avenue 21/10/03

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 43, Florence Avenue Morden Surrey SM4 6EX Lead Inspector Jon Fry Unannounced Inspection 26th June 2006 10:30 43, Florence Avenue DS0000027216.V302029.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 43, Florence Avenue DS0000027216.V302029.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. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 43, Florence Avenue Address Morden Surrey SM4 6EX 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 646 5921 www.caremanagementgroup.com Care Management Group Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Eight Adults (M/F) with Learning Disabilities Date of last inspection Brief Description of the Service: 43 Florence Avenue is a registered care home for eight adults with learning disabilities. The home is owned and managed by Care Management Group (CMG) and is situated in a quiet residential road in Morden. Public transport, churches, leisure facilities, local shops and the shopping centres of Morden, Sutton and Mitcham are close by. The home is set over two floors with a self-contained flat for one resident within the grounds. The home is staffed twenty-four hours a day. Information about the home is provided to residents and their representatives in a written guide. The current range of fees are £1183.00 to £1509.00 per week. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 26th June 2006. The inspection took place over five hours. The inspector spoke with four residents, the manager and three members of staff. A number of records were examined, as well as a tour of the communal areas of the home. Completed survey forms were received from four residents and three staff members. What the service does well: What has improved since the last inspection? What they could do better: Staffing levels must be reviewed to ensure that residents get the support they require at all times. Any future admissions need to be carefully considered to make sure that the service is fully able to meet the individual needs of all residents living there. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 6 The registered provider must make sure that all staff working at, or involved with, the service have a clear understanding of their roles and responsibilities around the Protection of Vulnerable Adults (POVA). Residents care plans must be fully reviewed at least every six months. The homes laundry facilities must be improved. A new permanent manager needs to be put in post and an application for them to be registered with the CSCI entered. 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. 43, Florence Avenue DS0000027216.V302029.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 43, Florence Avenue DS0000027216.V302029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are appropriately assessed prior to admission, however careful consideration must be given to any future admissions to make sure that the service will be able to meet individual needs. EVIDENCE: No new residents have been admitted to the home since the December 2005 inspection. Documentation seen for two residents included initial assessments by the home and information from the placing Local Authority. The acting manager reported that one resident was due to move out of the service within the next week. Any new admissions must be carefully considered given the high and sometimes very complex needs of the residents currently living at the home. The organisation must make sure that the individual needs and aspirations of all residents accommodated can be fully addressed. Staffing levels and the communal space available should be looked at closely as part of the admission process. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected 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. Care plans contain good information about the strengths and needs of each resident. Being reviewed more often and being made even more person centred could further improve these documents. Good individual risk assessments are in place for each resident. EVIDENCE: Care plans were looked at for two residents. The main ‘working’ information is contained within the review files put together annually. These give good information about the individual support required and include specific guidelines around daily routines and behaviour. A Requirement has been made for the home to make sure that each resident’s care plan is reviewed at least six monthly. Key workers currently complete a written monthly report about each resident although these were not being done consistently at the time of this inspection. These reports could be adapted to make sure that the key worker reviews the goals for each resident 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 10 with them on a monthly basis. This will help to help to make sure that the care planning process is ‘live’ at all times. The format of the care plans could be looked at to make sure that they are person centred and reflect all important information in one place. Individual risk assessments are in place that assist in ensuring the safety of residents. These documents are kept under review. Care staff on duty were observed to help residents in making choices for lunch. Individual residents spoken to all said that they liked the staff and enjoyed living at the home. Residents meetings are held at the home but these have not been happening on a monthly basis this year. The most recent meeting was in June 2006 and this showed that residents were asked for their views about the food and activities being planned. As stated previously it is important that any new admissions to the home are carefully considered. The high needs of the current resident group was seen to make considerable demands on the staff at times and this must impact on the ability to support real choice for each individual. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities and to be part of the local community as required. This support could be improved by making sure that there are sufficient numbers of staff on duty to meet the needs of residents at all times. Residents are supported to maintain relationships with their families and friends. EVIDENCE: One resident said that the support from staff ‘had improved recently’ and another said that ‘they enjoyed going to the pub with staff’. Another resident said that they went to a day centre twice a week and liked going out to the park. Two residents said that they regularly attend a local college. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 12 All three staff spoken to all felt that the staffing levels needed to be reviewed to make sure that there were enough staff on duty to provide adequate 1-1 time and activities with residents. One resident requires two staff to be with them while out of the house. Care documentation seen for two other residents stated that one individual also required two staff to escort them out and that the other individual would require high levels of 1-1 support to initiate and follow through with activities. It is important that the organisation reviews the staffing levels in place to make sure that they are sufficient to meet the needs of residents. It is strongly recommended that there are at least four staff on both the morning and afternoon shift. Residents receive good support to maintain relationships with their families and friends. Most residents have regular contact with family members and some take holidays with their families. One resident was being supported to travel home on the day of the inspection and another person said that they had just come back from a weekend at home. One resident showed the inspector photographs of their family who they see regularly. Comments from residents about the food provided included ‘alright’ and ‘I like the food’. A full record of the food provided to each resident is kept and recent main meals provided included roast pork, pizza, Cornish pasties and sausages. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of residents are met. Satisfactory medication systems are in place for the protection of clients. EVIDENCE: All residents are registered with local GP practices. Arrangements are in place for residents to receive regular health check ups including optical and dental care. Care files included records of appointments and other health checks. Each resident has a health action plan in place but these documents needed updating for two residents whose files were examined. It is important that the actions plans are working documents and kept under regular review. Residents spoken to said that they were treated respectfully by care staff. One resident said ‘they treat me well’ and another said the support had ‘improved’ in recent weeks. Medication administration records are maintained satisfactorily. Good information is recorded for each resident as part of a medication profile. This 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 14 says what each medication is for and gives guidance on when ‘as needed’ medicines should be used. All items of medication are securely stored and an organisational procedure for medication is available for reference by staff. The acting manager reported that senior staff have had medication training but other care staff still needed to do this course. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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. A satisfactory complaints procedure is in place. Further work needs to take place around roles and responsibilities within the service to ensure the protection of vulnerable adults. EVIDENCE: Serious allegations were made by one resident following the November 2005 inspection. Protection of Vulnerable Adults (POVA) procedures were started by the organisation following discussion with the CSCI. Some allegations made by the resident were upheld and these then led to further concerns being investigated. Disciplinary procedures were followed by the organisation as required to respond to issues around staff conduct. A Requirement has been made for the organisation to look at the roles and responsibilities for POVA of all staff involved with the service. It is very important that all staff have a clear understanding around POVA and whistle blowing to make sure that residents are protected at all times. Further work should also take place to try to make sure that relatives and friends of residents feel able to come forward with any issues or concerns they have. The home does have a satisfactory complaints procedure in place and residents are provided with information in an accessible format about how to make a complaint. Two residents said that they would speak to the manager or their key worker if they had a complaint. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 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, 25 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are generally well maintained. New laundry facilities must be provided as a priority for hygiene reasons. The home is kept clean and tidy. EVIDENCE: The home provides homely accommodation to residents although communal areas can seem a little cramped when everyone is at home. This is due in part to the complex needs of some residents living there. All residents spoken to were satisfied with their bedrooms and these were seen to be personalised to the individual. A new laundry area has not yet been provided for resident’s use and the quiet room still houses a tumble dryer. The current facility is inadequate and needs to be replaced as a priority. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 17 The premises are generally well maintained and kept to a satisfactory state. New flooring has been fitted in the kitchen and the call bell system has been repaired since the November 2005 inspection. The following issues however need to be addressed: dining room – the hole in the ceiling requires repair ground floor bedroom hallway – this area needs some re-decoration lightshade in first floor hallway – requires cleaning or replacement kitchen – a larger oven should be provided. One member of staff spoke about the difficulties of cooking for residents in such a small oven. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 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, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Provider must review the staffing levels to make sure that sufficient numbers of staff are available in the home to meet the needs of residents. Staff are provided with good opportunities for training, however the basic training for some care staff now requires updating. Residents are protected by the recruitment procedures in place. EVIDENCE: The staffing levels must be reviewed to make sure that sufficient staff are on duty to meet the needs of residents at all times. The acting manager and staff spoken to reported that there were usually three care staff on in the morning and four in the afternoon. One staff member said the current levels did not allow for ‘proper attention’ to residents. Care documentation looked at stated that two residents individually required two staff when out in the community. Other resident’s assessments referred to the high levels of support needed to effectively engage with them. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 19 Residents spoken to were positive about the staff. Comments included ‘they’re ok’, ‘nice’ and ‘much better’. An organisational training programme is available to staff and courses include key working, values, abuse awareness and Makaton. Training records are kept for each staff member. Basic training in Food Hygiene and First Aid needs to be refreshed for one member of staff whose records were looked at. Medication training must be provided to all care staff working at the home. NVQ training is being provided but individual staff spoken to said that availability was limited. Two staff said that this training had only just restarted after having been stopped for a period. It is strongly recommended that the organisation make this training available to all care staff at Levels Two and Three. The home carries out the required checks on new staff and these include necessary Criminal Records Bureau (CRB) checks before they start work in the home. This helps to ensure the safety of residents. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 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, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New management arrangements need to be put in place at the home. Further work needs to be carried out to make sure that the organisational system for quality assurance is fully implemented. Improvements could be made to make sure that resident’s views are listened to. The Health and Safety of residents is protected by regular checks on the building and equipment. EVIDENCE: The registered manager is no longer employed by the organisation. An acting manager is in post and she reported that a full time manager has been appointed for the service. A Requirement has been made for a new manager to be registered with the CSCI. It is essential that the new managers hours are supernumerary to ensure sufficient time to effectively manage the service. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 21 An organisational quality assurance system is in place but the acting manager said that this had not yet been fully carried out. Surveys had been sent out to representatives of residents in June 2006 but their responses had not yet been looked at to inform any development plan for the home. Residents meetings are held but not consistently on a monthly basis. Minutes of these meeting showed that residents are asked about issues such as activities and food. It is recommended that the minutes be regularly discussed at staff meetings to make sure that actions are taken in response to resident’s views and suggestions. A senior manager from the organisation visits the home each month to carry out a Regulation 26 visit as required by law. The next visit was written in the diary and the home was reminded that these visits must be unannounced. Good systems are in place to make sure that regular Health and safety checks are carried out. Good records are kept for checks of hot water temperatures, First Aid boxes, fridge temperatures and fire equipment. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 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 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 2 X 3 X 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 23 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 YA3 Regulation 12 (1) (2) (5) Requirement The Registered Persons must ensure that any new admissions to the service are carefully considered. This is with regard to the ability of the service to meet the individual needs and aspirations of all those accommodated at the home. 2. YA6 15 (2) The Registered Persons must ensure that care plans are fully reviewed on at least a six monthly basis. The Registered Persons must ensure that health action plans are fully completed for each resident and are kept under review. The Registered Persons must ensure that all staff who work at or are involved with the home are fully aware of their roles and responsibilities around the Protection of Vulnerable Adults. Representatives of residents must be reassured by the organisation that any concerns 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 24 Timescale for action 01/08/06 01/09/06 3. YA19 12 (1) 01/09/06 4. YA23 13 (6) 01/08/06 will be listened to and treated seriously. 5. YA24 16 (2) (f) The Registered Persons must ensure that new laundry facilities are provided for the home. These must be adequate in size and suitable to meet the needs of residents. The Registered Persons must ensure that: the hole in the dining room ceiling is repaired, the ground floor bedroom hallway is re-decorated, the light shade in the first floor hallway is cleaned or replaced, 7. YA33 18 (1) (a) The Registered Persons must ensure that the staffing levels in place at the home are reviewed immediately. Suitable numbers of staff must be available at all times to meet the needs of residents. 8. YA35 18 (1) (c) The Registered Persons must ensure that all care staff receive up to date training in First Aid, Food Hygiene and Medication. The Registered Persons must ensure that an application to register a manager for the home is submitted to the CSCI. The Registered Persons must ensure that a quality assurance system is fully implemented at the home. This system must provide for consultation with residents and their representatives. 43, Florence Avenue DS0000027216.V302029.R01.S.doc Version 5.2 Page 25 01/11/06 6. YA24 23 (2) (b) 01/10/06 01/08/06 01/10/06 9. YA37 8 (1) 01/10/06 10. YA39 24 (1) (2) (3) (4) (5) 01/09/06 11. YA39 26 (3) The Registered Persons must ensure that the Regulation 26 monthly visits are unannounced. 01/08/06 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 YA6 YA6 Good Practice Recommendations It is recommended that the key workers monthly report format be adapted to include a review of the goals currently in place for each resident. The Registered Persons should look at the format of the care plans to make sure they are person centred and reflect all important information about the individual in one place. It is recommended that a larger oven be provided for use at the home. It is strongly recommended that four members of care staff be on duty at all times during daytime shifts. It is strongly recommended that all care staff have access to NVQ training at Level Two or Three as appropriate. Residents meetings should be held at least once a month. The minutes of these meeting should be discussed and actioned at the staff meeting. 3. 4. 5. 6. 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