Inspection on 04/08/06 for 49 Almond Close

This inspection was carried out on 4th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

49 Almond Close 23/02/09

49 Almond Close 25/03/08

49 Almond Close 20/03/07

49 Almond Close 23/08/05

49 Almond Close 07/04/05

49 Almond Close 03/11/04

49 Almond Close 02/08/04

49 Almond Close 03/02/04

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

CARE HOME ADULTS 18-65 Almond Close (49) 49 Almond Close Bellfields Estate Guildford Surrey GU1 1NW Lead Inspector Vera Bulbeck Unannounced Inspection 4th August 2006 12:45 Almond Close (49) DS0000013506.V307048.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 Almond Close (49) DS0000013506.V307048.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. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Almond Close (49) Address 49 Almond Close Bellfields Estate Guildford Surrey GU1 1NW 01483 575806 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) www.mencap.org.uk Royal Mencap Society Ms Alison Jelley Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 19 - 65 YEARS OF AGE One named person may be over the age of 65 Date of last inspection 23rd August 2005 Brief Description of the Service: 49 Almond Close, Guildford is a detached property developed to provide accommodation for eight adults with learning disabilities. The home is set in a road close of similar properties. All rooms are for single occupancy, none with en-suite facilities. The home offers a sitting room equipped with television and music systems, a dining area, kitchen, and utility room for laundry and toilet and washing facilities. There is a garden to the rear of the property and some off road parking to the front. The registered providers are the MENCAP organisation and the Local Authority owns the premises. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mrs Vera Bulbeck Regulation Inspector carried out the site visit. Miss Stephanie Kogler, Shift Leader for the home was present. The site visit was undertaken over 3 hours and 15 minutes. Another visit to the home was undertaken on 07/08/06 to inspect staff files and recruitment process; this visit was over a 1 hour 15 minute period and included a discussion with the registered manager. There are currently eight service users living in the home, and the majority have lived in the home for some considerable time. The majority of service users were at various day centres and two were working on the day of the site visit; the inspector was able to speak with two service users during the time spent in the home. Two members of staff were spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Two care plans and two staff files were inspected. The inspector received positive comments from the staff team. The service users some were able to express themselves and observation made was that service users and staff have a good rapport and service users were relaxed and comfortable with staff on duty. As a matter of priority the home needs to update the homes fire risk assessment to include all rooms and communal areas of the home, as well as introducing a contingency plan in the event of an emergency. The fees range from £463.45 per week to £676.98 per week. The inspector would like to thank the service users, registered manager and staff members for their time, assistance and hospitality during the inspection. What the service does well: Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 6 The registered manager and staff team are committed to providing a safe and homely environment for service users. Service users are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of listening, and regular meetings with service users. The inspector advised the home to contact Age Concern for an Advocate to be involved with service users who do not have any family or friends. 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. Almond Close (49) DS0000013506.V307048.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 Almond Close (49) DS0000013506.V307048.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a detailed and informative statement of purpose and service users’ guide, both documents need up dating. It was noted in the service users guide, which, had not been updated since 28/09/04, and referred to a cat, the cat died in December 2005. The inspector was informed a full assessment had not been undertaken on the last service user entering the home, because of management problems. EVIDENCE: The inspector informed the member of staff in charge of the home that the statement of purpose, which details the service provided to service users, needs to be updated. The service user guide needs to be updated and each service user and their relative should be provided with a copy. Please send an updated version of the statement of purpose and service users guide to Commission for Social Care Inspection (CSCI) to be held on file. Care plans were well documented. Service users need to be involved with their care planning where possible, if not their relatives need to be involved. All service users entering the home need to have a full needs assessment undertaken. The service user was admitted to the home in 2004 and this process had not been completed. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 9 Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected 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. An individual plan is drawn up for each service user, and service users need to be involved with their care plan. EVIDENCE: The individual plans for two service users were seen. Care plans were well documented and a number of risk assessments had been undertaken. The inspector observed that one of the risk assessments documented, was seen to be followed on the day of the site visit by a service user who likes to undertake ironing. Staff was seen to knock before entering service user’s bedrooms. Service users are able to communicate and were observed that they are supported to make decisions, such as how they spend their free time, choosing holidays and days out. The registered manager stated that areas of risk to the health and welfare of service users are identified, assessed and recorded. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 11 The registered manager and key workers carry out risk assessments, all staff need training to undertake risk assessments, the registered manager oversees all risk assessments. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 to take part in appropriate activities both within the home and in the local community. EVIDENCE: Service users attend various day centres, and many are involved in the local community. Some service users attend Church on Sundays. Two-service users work, one on a voluntary basis and the other service user works part time. Service users enjoy various activities, going out for meals, visits to the pub, and trips to the seaside, including a picnic on the beach or sometimes fish and chips. Many other outings take place, mostly at weekends and the service users are taken out to different places. Several of the service users are involved with jobs around the house these include keeping their bedrooms clean and tidy, cooking, emptying the bins, putting their clothes away and gardening. Most of the service users like to go shopping; this is undertaken with their key worker. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 13 It was pleasing to note that the daily menu is in picture form to enable the service users to choose the food they like. However, on the day of the site visit it was not clear if the menu is followed, as several days had not been completed with the pictures, therefore the service users were unable to see what they were having for their main meal of the day, also it was difficult to establish if the meals were nutritionally balanced. The inspector was advised that the food budget has been reduced by £25.00 per week and if this had a bearing on the food provided in the home. The menu planning and nutritional content needs to be reviewed. The inspector would advise the management of the home to review the system in place for supporting service users with the cleanliness of their bedrooms, one service user’s bedroom needs a good clean, and there was no bulb or shade in the centre light. This could be dangerous if the service user should place a finger or object in the light fitting. The majority of service users have contact with family and friends. Any service users who does not have any contact with relatives, the inspector advised the staff member in charge of the home to contact an agency for an advocate for those service users who do not have any relatives or friends. The home’s transport is a people carrier, which seats six people and at times it would appear that the vehicle is not big enough to take service users out. The inspector was advised recently service users went to the theatre in Woking, and on these occasions when all the service users go out, they are able to use public transport. Three service users went to Cornwall for the weekend recently. Two service users go on holiday with their parents on a regular basis. One service user spends every weekend with her parents at home and a considerable amount of time during the week at her parent’s home. There are no planned holidays arranged at the moment. One-service user is on a one to one with a member of staff two days a week. All the service users spoken to were able to communicate and stated they like living in the home. There were positive comments about staff and it was very clear that service users have a good rapport with the staff. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 support is provided appropriately and service user’s healthcare needs are well met. Medication procedures are followed. EVIDENCE: It was evident from observation, that service users are supported with their personal care in a manner that promotes their choice, privacy and dignity. Individual wishes regarding the gender of staff giving personal support is recorded in individual plans. A key-worker system is in place to ensure continuity and consistency of support and service users were able to name their key-worker. Healthcare needs are met by a number of healthcare professionals, including general practitioners (G.P.’s), district nurses, community psychiatric nurses (CPN’s), speech and language therapists and psychologists. Contact with these professionals is recorded in individual plans. The medication procedures are being followed there are currently no service users who are able to self medicate. Staff training was seen to be undertaken on a regular basis, the registered manager undertakes the task of updating Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 15 staff of any changes and makes staff aware of the need to follow the medication procedures. The policies and procedures need to be updated, all staff should read the policies and procedures and should sign to indicate these have been read and understood. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 Good. This judgement has been made using available evidence including a visit to this service. Policies are in place to protect service users from abuse and neglect but policies and procedures need updating, to ensure service users are protected from possible risk of harm and abuse. EVIDENCE: Complaints records, or the complaints procedure was not available. It was noted in the handover book any concerns raised by service users or staff had been documented in this book. However, there was no indication of the action taken or any outcome. The two members of staff spoken to were aware of the protection of adult’s procedure, but were unable to inform the inspector when they had received training. Records for training were not available on the day of the site visit. However, the inspector returned to the home two days later and training records were observed and seen to be up to date apart from Protection of Adults training, which is in the process of being undertaken. Service users should be provided with a copy of how to make a complaint in picture format, and a copy should be provided to relatives. The home holds a copy of the Surrey Multi Agency Procedure for the Protection Of Vulnerable Adults. Staff commented they are aware of their responsibility to report any concerns they have and stated that they would report any concerns to the registered manager. It is recommended that training for all staff in the protection of vulnerable adults be carried out as a priority and on a regular basis. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 17 A service user made an allegation regarding a member of staff; this is in the process of being investigated. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected 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 poor. 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. It is accessible and safe. The home was looking very tired and needs redecorating throughout. EVIDENCE: The premises were found to be generally clean and hygienic and staff to be congratulated on the cleanliness of the home. However, The bedrooms and the whole house need decorating. Work needs to be undertaken in the downstairs bathroom where the tiles are off the wall and black mould is growing and going through the wall into the hallway. The lights in the bathrooms need to be checked by an electrician as the lighting in the shower room and bathroom was seen to be a bare hanging light bulb. A toilet seat was broken and the washbasin was without a plug. Both bathrooms had a star lock, which needs to be removed, as these can be dangerous as when locked from the outside the person inside is unable to get out. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 19 There is a store cupboard under the stairs, which needs to be checked with the fire officer to ensure in the event of a fire the service users are safe. A mattress needs replacing in one of the service users bedrooms. It was badly stained and had been used for drawing on. A kitchen drawer front, and a cupboard door were missing this need to be replaced. The handle was missing from the freezer, and the spice rack needs fixing to the wall, it is currently standing on top of the fridge. The broom, mops and bucket is currently stored in the garden, these need to be moved to a more suitable place. The drain in the garden needs a cover. The lounge has a new large screen T.V that, the service users clearly enjoy. However, the carpet is badly stained and a protection cover for the joining of the carpet and floor covering was broken and missing. The garden has been cleared and the registered manager informed the inspector this process has been undertaken recently, however, the garden requires considerable attention and a patio area needs to be created to enable the service users to enjoy the garden particuarly during the summer months. Each service user has their own bedroom and these had been made personal with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size. A service user was happy to show the inspector his bedroom, and informed the inspector it was very clean and tidy, of which he was justifiably proud. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and service users evidenced a high degree of respect and skill in working with the individual service users at the home. EVIDENCE: It was observed on the day of the visit there were two members of staff on duty with eight service users. Staff undertake the cleaning and cooking in the home, as well as care for the service users. Recruitment records were not available on the day of the visit, as the registered manager was not on duty. However, the inspector went back to the home two days later to check the staff files. Staff files were in order including a criminal record bureau (CRB) check was undertaken and all new staff complete an induction programme. All staff should be provided with a copy of General Social Council code of conduct document. Staff have undertaken a number of training courses and some certificates were seen, the management of the home has implemented a training plan to enable Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 21 view at a glance where there are shortfalls in training. Staff supervision is undertaken on a regular basis every two months. All staff require training for equality and diversity and the protection of vulnerable adults. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected 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 Poor. This judgement has been made using available evidence including a visit to this service. The atmosphere in the home was warm and friendly, service user’s benefit, from an open, positive and inclusive management style. The systems for service users consultation are varied and have been devised specifically to enable the service users to make their views known. EVIDENCE: The registered manager is in the process of completing the Registered Managers Award, and should be completed by early January 2007. Service users meetings are held on a regular basis, areas discussed include meals, holidays, days out, local events as well as a number of other areas. Service users finances were not inspected on this occasion, as the manager was not on duty at the time of the inspection. Staff has access to service users money. The registered manager manages the finances. It was discussed with the person in charge on the day of the site visit that service Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 23 users have some meals out and money is allocated from the homes budget for this purpose. However, if the money goes over the allocated amount service users are expected to pay the difference. The records for visits undertaken by a responsible person were not available on the day of the site visit, these reports need to undertaken on a monthly basis and be available in the home at all times, and a copy to be sent to the (CSCI). The Employers Liability Insurance certificate on the notice board had expired in June 2006. The Gas Safety record held on file had expired in May 2006. The record certificate for the testing of portable appliances had expired in April 2004. A number of records were not available and some records need to be reviewed. Particularly, where staff should be familiar with the Care Homes for Younger Adults, National Minimum Standards and be responsible for ensuring the home is meeting all the standards. All Records must be available for inspection purposes at all times. Fire records were not available on the day of the site visit. A risk assessment needs to be undertaken on the whole house, and an emergency contingency plan needs to be in place. The inspector would advise the home to identify all bedroom doors with a number, in the event of a fire the fire service would be able to locate a bedroom easily. A copy of the layout of the room numbers should be located next to the fire panel. The management of the home needs to provide, an accident book for service users as well as staff. In the laundry on the day of the site visit the COSHH cupboard was found unlocked in the utility room. The member of staff locked the cupboard immediately. All hazardous substances must be stored in a locked cupboard at all times. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 24 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 2 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 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 X X 2 X X 2 X Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 Page 25 No 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 2 3 4 5 6 7 8 Standard YA2 YA24 YA24 YA24 YA24 YA24 YA24 YA24 Regulation 14 23 23 23 23 23 23 23 Requirement All service users entering the home must have a full needs assessment undertaken. The premises need redecorating. Repairs to kitchen drawer and cupboard must be undertaken. The carpet in the lounge needs cleaning. A service users mattress needs replacing. Carpets need to be secure at areas where joining has been undertaken. Brooms, mops and buckets need to be stored appropriately. The home needs to implement a maintenance book to ensure all work required in the home is logged to include dates and a signature when completed. The Employers Liability Insurance Must be renewed. The Gas Safety record must to be undertaken. The testing of portable appliances must be undertaken. Visits undertaken by a responsible person to be available in the home at all times. DS0000013506.V307048.R01.S.doc Timescale for action 25/08/06 27/10/06 25/08/06 25/08/06 25/08/06 11/08/06 25/08/06 25/08/06 9 10 11 12 YA37 YA37 YA37 YA39 13 13 13 26 25/08/06 25/08/06 25/08/06 11/08/06 Almond Close (49) Version 5.2 Page 26 13 14 YA42 YA42 13 17 All cleaning materials must be stored appropriately at all times. Records must be available for inspection purposes at all times. 04/08/06 04/08/06 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 3 4 5 6 Refer to Standard YA1 YA16 YA17 A35 YA37 YA42 Good Practice Recommendations The homes Statement of Purpose and Service Users Guide need to be updated. To review key workers involvement with service users and the cleaning of bedrooms. Menu planning to be reviewed and to include a nutritional balance. All staff to receive training in equality and diversity and vulnerable adults procedure. All policies and procedures to be updated and staff to read and sign to indicate they have been read and understood. All bedroom doors to be numbered. Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 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 Almond Close (49) DS0000013506.V307048.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!