Inspection on 25/06/07 for 61 Somerset Road

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

61 Somerset Road 08/04/08

61 Somerset Road 12/06/06

61 Somerset Road 27/02/06

61 Somerset Road 11/07/05

61 Somerset Road 28/02/05

61 Somerset Road 22/09/04

Similar services:

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Edenvale

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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 61 Somerset Road Barnet Hertfordshire EN5 1RF Lead Inspector James Pitts Key Unannounced Inspection 25th June 2007 11:20 61 Somerset Road DS0000010530.V341513.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 61 Somerset Road DS0000010530.V341513.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. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 61 Somerset Road Address Barnet Hertfordshire EN5 1RF 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) 020 8364 8222 F/P 020 8364 8222 www.pentahact.org.uk Adepta Ms Rachel Gabriella Parker Ms Cheryl Adele Kearns Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Specific Service Users Two specific service users who are currently resident in the home and are over 65 years of age can reside in this home. This condition will need to be reviewed when one such service user vacates the home. 12th June 2006 Date of last inspection Brief Description of the Service: 61 Somerset Road is a care home for five adults who have a learning disability. The home was opened in February 1991. The building is owned and maintained by Sanctuary Housing and PentaHact provides the care, a Barnet based organisation, which manages several projects specialising in the provision of care for people who have special needs. The home is a detached two-storey building in a quiet residential area with shops and amenities close by. There is a gradient driveway leading up to the front door, and an area for off street parking to the front of the building. There is a large attractive garden at the rear of the premises. One bedroom is located on the ground floor, with the remaining bedrooms upstairs. There is no lift available, so the home is not suitable for people who have problems with mobility. There is a shower and toilet on the ground floor and two bathrooms and toilet facilities on the first floor. On the second floor there are two bedrooms, a bathroom/toilet and a sleep-in room for staff. There is a kitchen/diner, a large lounge and an activities room, a laundry room and an office located on the ground floor. Two managers, Ms Rachel Gabriella Parker and Ms Cheryl Adele Kearns, on a job-sharing basis, manage the home. The range of fees for people living in the home is £62.35 to £94.45 depending on the level of their disability. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Most of the people who live here are not able to hold lengthy vocal conversations but all can make at least some of their needs known in other ways. It is encouraging to note that staff demonstrate a significant knowledge of the individual communication techniques that person employs and the specific ways in which each makes their needs known. All of the people who live here and four members of the permanent staff team were present during this visit. As already mentioned, most of the people who live here have very limited vocal communication abilities or are able to respond to questions other than to a limited degree. Therefore observation of interactions was used. This showed that staff were aware of each of these person’s needs and thought about what each person might want to be doing at different points during the day. One person did talk about how they were settling into the home and about what they were doing during the day. In addition to these interactions and observations a number of records were seen and a conversation was also had with the home’s registered manager. What the service does well: What has improved since the last inspection? The preferences for meals that reflect individual’s tastes have improved and consultation is evidently occurring with the people who live here. The views of 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 6 the people who live here, and other stakeholders, are currently being sought as a part of the quality assurance review. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 61 Somerset Road DS0000010530.V341513.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 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 1 & 2 were assessed at this inspection visit. The people who use the service can feel confidant that the home will only accept new service for admission in the proper way, and give due consideration to their needs. EVIDENCE: The service users’ guide and statement of purpose contain the necessary written information about the home. Although pictures are used these are not in any recognised format, such as Makaton, that at least some of the people who use the service may be more familiar with and therefore find more accessible. Both of these documents must be reviewed in order to examine if these can be presented in a more service user friendly way. All but one of the people who use the service who live here has done so for a number of years. A new service user was admitted in March of this year. A completed assessment, although brief, was made by the home. In conjunction with the information that was provided by the placing authority it does, 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 9 however, appear that sufficient information was provided in order to make an appropriate placement decision. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 6, 7 & 9 were assessed at this inspection visit. The people who use the service can feel confident that all of the staff, whether permanent or temporary, know enough about what they need. There is, however, a need to ensure that risk assessments properly reflect both common risks, and those that are unique to individual service user’s support needs. EVIDENCE: The sample of care plans that were viewed, three in very great detail, show that a person centred care planning approach is used. The care plans are detailed, written from the service users point of view (using words like “I Like” etc) and are regularly reviewed. Again, as with the statement of purpose and service user guide, pictures are used but these are not in a recognised format. Where presentation of the individual care plan may be summarised in a different way to assist a service user to understand it this must be done. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 11 Physical care support, activities of daily living, social and leisure activities and the right to adhere to personally held values and beliefs are reflected in each care plan. However, the home’s manager recognises that it would be timely for updated diversity awareness training to happen for the staff team. Most of the people who use the service have difficulty in making their wishes known through spoken communication, although all appear to understand what is said so long as any conversation is kept clear and is not too complicated. This requires that the staff team be minutely aware of the individual methods that each person employs to express their thoughts and needs. It should be noted that four permanent staff, and one regular agency worker, with which discussions were held during the course of this visit, demonstrated a detailed knowledge of person’s unique personality, needs and preferences. The case records of the people who use the service include risk assessments that tell staff and other people about anything that may harm a service user related specifically to their individual needs. The home must, however, ensure that risks common for each service user are also considered in addition to the specific risks. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16 & 17 were assessed at this inspection visit. The people who use the service can feel confident that the staff of the home try to provide opportunities for everyone to develop their personal and social skills. The opportunity for each person to maintain family relations is actively encouraged and supported. EVIDENCE: The people who use the service are supported to make use of a wide range of community based facilities. These can be anything from shopping trips, to attendance at local clubs run by particular organisations or daytime activities. The staff that were present during this visit demonstrated a clear understanding of the cultural and religious practise preference that each person who uses this service chooses to adhere to. They were also able to describe how respect for these is maintained and how service users who wish 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 13 to attend places of religious worship are enabled to do so. Details of the social, leisure and culturally appropriate activities in which each person participates are written in their records. The home benefits from having a vehicle that the people who use the service may use (Staff drive this). The home recently purchased a new car, which one service user in particular was excited about, very keenly pointing this out a number of times during this visit. The home’s staff group continue to encourage the people who use the service to maintain relationships with their family members, although unfortunately most have very little if any contact with their families. Two service users currently have advocates and the home should seek to secure advocates for the other three people who live here. There is an open visitors policy. The home has a key worker system and it is part of the key worker role to keep family members / advocates informed of progress made, where appropriate. Visitors can be seen in the communal areas, of which the home has a range, or people’s own bedroom if it is thought to be appropriate and safe to do so. Staff were seen to interact with the people who use the service in a totally appropriate and respectful way. The home has all appropriate policies and practices on maintaining dignity and rights. Individual preferences for the food that each person likes to eat are now given due consideration, as was required at the previous key standards inspection last year. The menus show that appropriately varied and nutritious meals are available. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20 were assessed at this inspection. The people who use the service can feel confident that they will get the right support to take care of their personal and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will usually get the proper support from staff to make sure that this happens. EVIDENCE: The people who use the service each have a care plan that outlines the ways in which each person wants to be cared for and supported and about what each likes or does not like. All of the people who live at the home usually go to see a local GP if they are not feeling well. The staff write down anything that happens if some one 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 15 becomes unwell and the dates that each person visits a GP or any other healthcare professionals. If anyone needs to take medicine then the staff help him or her to do this. None of the people who live here can do this without help and the staff have written down why this is so on each of the care plans. The staff are usually good at making sure that people take their medicines so that they can stay well. There was one medication error recently, which resulted in service users missing a day’s dosage of their medication. Fortunately this did not result in anyone suffering ill effects. As a result of this two members of staff were given additional supervision to re-affirm the importance of administering medication as it is prescribed. Evidence of the way in which the manager of the home dealt with this issue was also seen. The staff make sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away. The home used a blister pack monitored dosage system that is obtained through a local “Boots” pharmacy. A Pharmacist also visits the home regularly to review the handling of medicines and to provide advice as and when it may be necessary. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 22 & 23 were assessed at this inspection. The people who use the service can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The complaints procedure is not compiled in an easily accessible format that is necessary to maximise ease of understanding for the people who live here. The pictorial version that exists has not been compiled using any recognise symbol associated with increasing the understanding of it by people with a learning disability. However, it should be noted that staff have actively supported two of the people who live here that wished to complain about repairs that were needed to the house in the last few months. (Please see “Environment “ section of this report for further comment). These complaints were responded to by the managing organisation that passed these on to the owners of the property. The policy of the geographical authority in which the home is located, namely London Borough of Barnet Protection of Vulnerable Adults Procedure, is available for the staff to see at the home. No concerns have been raised about anyone at the home coming to harm. In conversation with members of the staff team it was noted that there is a good degree of awareness and 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 17 understanding about keeping people safe from harm and what to do if any concerns were to arise. 61 Somerset Road DS0000010530.V341513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 24 & 30 were assessed at this inspection. The people who use the service can feel increasingly confident that the redecoration and refurbishment that has been awaited is now about to commence. However they cannot feel the same way about the maintenance of the home, as there are significant delays in addressing repairs when these are identified. EVIDENCE: An extensive tour of the home was conducted with members of the staff team. There are a number of areas of improvement to the fabric of the home that have been required for quite some time. The delay to commencing this work was, it is said, due to the service possibly being moved to another building. It 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 19 has recently been decided that this will not now occur and a programme of redecoration and refurbishment was due to start the day following the date of this inspection. There is clearly significant difficulty in liaison between Adepta, as the managing organisation, and Sanctuary Housing Association who own the property. These issues must be addressed and the managing organisation must not allow repairs to be delayed without taking the necessary action to remedy them. The home is kept clean and tidy, which will show even more obviously once the redecoration and refurbishment have been completed. 61 Somerset Road DS0000010530.V341513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 32, 33, 34, 35 & 36 were assessed at this inspection. The people who use the service can feel confident that there is a committed staff team to meet their needs and that these staff are safe people to support them. However, the quality of the support that is offered by the staff team could be compromised if an appropriate number of staff are not qualified and the appraisal and development plans are not monitored adequately to ensure that the objectives of these are achieved. EVIDENCE: It is necessary by law for half of the staff team to have a proper qualification to work with adults who need support in a care home. The name of this qualification is NVQ 2. There is a system in place to ensure that staff are provided with the opportunity to obtain this qualification. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 21 The home currently has 6 staff, excluding the manager’s post, 3 x 37 hours (or 37.5) 2 x 33 hr and 1 x 18.5 hour per week posts. From these positions there are two staff will soon be taking maternity leave. The home also uses agency staff to cover for any vacancies on shift but does usually manage to use temporary workers who are familiar with the needs of the people who live here. In the morning of this inspection the home’s manager had been interviewing for new staff to cover one permanent staff vacancy that currently exists. Adepta, as the managing company that owns the home, has been reported at previous inspections, as properly carrying out checks to make sure that those who work here are safe people to work with the service users. These checks include things like checking if a new member of staff has ever been found guilty of a crime (known as a CRB check), and asking people who used to employ them if their work was good and if they are the right sort of person to work with the service users and to support them. One recent recruit has yet to have a copy of relevant pre employment documentation on their personnel record at the home, the manager explained that the checks had literally only just been fully completed and that this documentation will be obtained shortly. The home keeps records that say what training courses staff have done, and when they did them. These records show that staff training occurs at fairly regular intervals and covers the necessary standard training as well as more specific areas relating to the needs of the people who live here. Additionally there is an appraisals system in place that also includes training and development plans. The sample of staff records that were seen show that appraisals have happened in the last year, however, there is little indication of how development plans are monitored to ensure that the objectives are being achieved. This must be rectified in order to ensure that the appraisal and development system operates effectively. The previous Key standards and random inspections identified that although most staff were receiving regular supervision, there was no evidence to show how many supervisions that particular members of staff had received that year. Supervision records were looked at and there are now indications of significant improvements and the manager was able to explain why gaps had occurred for a particular member of staff. The manager also stated that the aim is for each member of staff to meet for supervision once per month. This should mean that even if there are occasions when a meeting cannot happen in a particular month, the home should be able to ensure that the minimum standard of at least six supervision meetings each year is still achieved. 61 Somerset Road DS0000010530.V341513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 37, 39 & 42 were assessed at this inspection. The people who use the service can feel confident that they are living in a home that has good internal management, is run with their best interests at heart and that their views are sought. EVIDENCE: Previous inspection reports have noted that the home’s registered manager is more than suitably qualified and experienced to run the home. The home is in the process of undertaking Adepta’s quality audit system; this system now involves service user questionnaires and is said to be geared to being lead by the views of the people who use the service and other 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 23 stakeholders. A copy of the quality assurance audit and resulting annual development plan must be sent to the local Commission office once these are completed. A representative of the managing organisation carries out monthly visits to the home; reports are then written. These reports are now being kept electronically on computer as they are sent to the home via e-mail. The managing organisation should note that the monthly visits reports are now no longer required to be submitted to the Commission unless these are specifically requested. The following health and safety checks have been carried out within the last year: Fire Alarm System / emergency lighting: 24/04/07 Fire extinguishers: 15/05/07 Gas Safety Check: 09/08/ 06 Portable electrical appliances: 02/10/06 Legionellosis: no evidence of this check was available. A copy must be obtained and sent to the local Commission office. The home is generally good at making sure that the people who live and work here are kept safe from fire and other hazards. Fire alarms are tested regularly and fire drills also occur. 61 Somerset Road DS0000010530.V341513.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 2 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 3 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 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 3 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 25 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 YA1 4 (2) & 6 (a) Regulation Requirement Both the statement of purpose and service user guide must be reviewed in order to examine if these can be presented in a more service user friendly way. Where presentation of the individual care plan may be summarised in a different way to assist a service user to understand it this must be done. The home must ensure that risks common for each service user are also considered in addition to the specific risks. These issues regarding effective repairs and maintenance of the home must be addressed and the managing organisation must not allow repairs to be delayed without taking the necessary action to remedy them. There is little indication of how development plans are monitored to ensure that the objectives are being achieved. This must be rectified in order to DS0000010530.V341513.R01.S.doc Timescale for action 25/10/07 2. YA6 15 (1) & (2) (a) 23/12/07 3. YA9 13 (4) ( c ) 31/10/07 4. YA24 23 (2) (b) 25/08/07 6. YA35 18 (1) ( c ) (i) 25/08/07 61 Somerset Road Version 5.2 Page 26 ensure that the appraisal and development system operates effectively. 7. YA39 24 (2) A copy of the quality assurance audit and resulting annual development plan must be sent to the local Commission office once these are completed. A copy of the Legionellosis test confirmation must be obtained and sent to the local Commission office. 20/09/07 8. YA42 23 (2) ( c ) 25/08/07 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 YA15 Good Practice Recommendations It would be timely for updated diversity awareness training to happen for the whole staff team. Two service users currently have advocates and the home should seek to secure advocates for the other three people who live here. 61 Somerset Road DS0000010530.V341513.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 61 Somerset Road DS0000010530.V341513.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. 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