Inspection on 27/02/06 for 61 Somerset Road

This inspection was carried out on 27th February 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 10 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 25/06/07

61 Somerset Road 12/06/06

61 Somerset Road 11/07/05

61 Somerset Road 28/02/05

61 Somerset Road 22/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 61 Somerset Road Barnet Hertfordshire EN5 1RF Lead Inspector Anthony Lewis Unannounced Inspection 09:00 27 February & 1st March 2006 th 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 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 020 8364 8222 PentaHact Ms Rachel Gabriella Parker Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 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. 11th July 2005 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. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 27th February 2006 at 9am and was completed at 1.30pm. A support worker was available and was very helpful and accommodating. Neither of the two registered managers, who job share, were available at the unannounced inspection, which presented problems in obtaining some confidential information. In light of this an announced visit took place on Wednesday 1st March 2006 to view further information and to provide feedback from the inspection. This visit commenced at 9am and was completed at 11.50am. One of the registered managers was available and was very helpful. At the unannounced inspection, evidence was gathered by speaking formally to three members of staff. Conversation with residents proved difficult due to their communication and comprehension difficulties. However, two residents were briefly spoken to informally. Information was also gathered by viewing various documents, residents’ and staff files and certificates. An internal and external tour of the home was conducted with a support worker. Overall, parts of the home are in need of repair to bring the home up to an acceptable standard. Progress with maintenance issues have been slow resulting in areas of the home looking neglected. In spite of this, the staff team are ensuring that residents live in a relatively homely environment. They have a good understanding of individual residents’ care needs and of their roles and responsibilities. Observations of residents in the home and the way that they interact with each other and with the staff, feed back from residents and staff and information recorded in residents’ care plans indicate that residents are comfortable and reasonably happy living in the home. The skills knowledge and experience of the two managers who job share complement each other and enhance the care that residents receive. What the service does well: Residents are well looked after by a competent staff team who ensure that the residents are an integral part of their community. The rapport between the staff and the staff and residents is professional and friendly. The home has two dedicated and sufficiently qualified registered managers who job share and work well together to ensure that the home is properly managed and the residents’ needs are met. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Ten requirements have been made at this inspection, five of which have been restated. Two recommendations were also made. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The requirements made cover four main themes, which are: menus not being planned according to residents’ likes and dislikes and are not varied. The general maintenance and cleanliness of the home, which is not to a satisfactory level. Staffing issues such as training and the level of staffing in the home, which can have an affect on the support provided to residents and an adequate quality monitoring method, which takes into account the views of residents. All of the core standards have been inspected over the two statutory inspections for the year. To ensure that meals are varied and that residents’ wishes and choices are included, there must be a review of the menu planning. It is recommended that the complaints procedure be reviewed to ensure that residents concerns are being taken seriously. Cracks in various parts of the home must be repaired to ensure that residents live in a well decorated environment. The knobs on the hob must be replaced to ensure that the hob can be used adequately and safely. The shower/toilet room must be upgraded to ensure that it can be used safely and comfortably. At all times the home must be free from offensive odours and clean and tidy to ensure that residents are comfortable and safe. Staff must receive training appropriate to the work that they perform to ensure that residents’ needs are being met and that residents are safe at all times. It is recommended that staff files be sorted into a logical sequence to enable easy access of information. Staffing levels must be reviewed to ensure staff numbers are enough to meet the needs of the residents at all times. To gauge the quality of service being provided to residents, a more appropriate quality assurance method must be adopted. In order to ensure that residents and staff are safe at all times, the contraventions identified by the London Fire and Emergency Planning Authority (LFEPA) must be met. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 7 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. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 8 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.V271227.R01.S.doc Version 5.0 Page 9 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. Robust assessments and regular reviews of needs ensure that residents are being supported by the staff team to be as independent as possible and improve their life skills. EVIDENCE: The home has a comprehensive assessment procedure, which is followed robustly. The most recent resident to the home has comprehensive information regarding her assessment, which according to the information in her file, was conducted over a period of a month. The assessment includes the initial contact, visits by the prospective resident to the home and what she did at each visit also details of her health and domestic and social needs. The staff team are ensuring that residents’ needs and aspirations are met by reviewing their needs monthly. The details of these reviews were seen in residents’ files. The staff are ensuring that residents have one-to-one meetings where they discuss and record information on what the resident achieved for the month. Residents’ care plans also contained information on appointments with health care professionals such as their GP, optician and dentist. One resident, with mobility difficulties, visits a surgical fitting clinic for treatment. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 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): 8 and 9. Staff support ensures that residents are able to express their views about how the home is run and that residents are supported to be more independent by taking assessed risks. EVIDENCE: Keyworker ensure that residents are able to express their views about the home and their care needs at the residents’ monthly one-to-one meetings. When viewed, the records of the meetings contained information on various aspects of the running of the home such as: how the resident feels about the staffing in the home, the environment and activities. One resident’s care plan stated that the resident would rather leave decision making in the home up to staff. Each resident has comprehensive PentaHact risk assessments, which cover a variety of risks to the individual resident such as: the resident being out and about in the community, personal care, cooking, mobility difficulties and how long a resident can be left alone, without staff support. The risk assessments contain a section on the identified risk, a summary of action to eliminate or reduce the risk and a date for the risk to be reviewed. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 and 17. The staff team are supporting residents to develop emotionally and enhance their personal and social skills. Staff are not ensuring that meals are varied and creative, with an emphases on residents likes and wishes. This means that residents are not being provided with a comprehensive diet according to their individual requirements. EVIDENCE: According to the registered manager, some residents attend college and undertake various courses. On looking through the files of all of the residents, one resident’s file contained certificates of college courses attended over the years such as sensory expression and sensory cooking. Staff spoken to say that residents have an active social life and engage in appropriate activities. When asked what he enjoyed doing, a resident abruptly said, “Out for walks”. Care plans contained individual activities that residents engage in such as: going out for drives, to the pub and out for meals. One resident’s care plan describes his religious denomination and that he enjoys going to church. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 12 At the previous inspection, a requirement was made that meals prepared in the home must be more varied and not predictable. When viewed the menus for the past ten weeks contained almost identical foods every week, just that the days were varied. Meals such as, sausage and lentil pie, beef casserole, shepherds pie and fish and chips are each prepared every week. The menus were contrasted with residents care plans. The care plans contained information stating that all of the residents like most meals but there was no clear information on what these meals are and there was no comprehensive information on what residents do not like to eat. A requirement is made that the registered persons ensure that a review of the menu planning takes place and that there is comprehensive information in residents’ care plans regarding their likes and dislikes. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. The staff are ensuring that personal care is provided according to residents’ needs and robust health care checks and professional intervention is offered to all residents. This means that residents are receiving good support in areas of their personal care and physical and mental health. EVIDENCE: The details of how staff should support residents with their personal care are contained in their care plans. On the day of the inspection, all of the residents were dressed appropriately taking into account their age and culture. Staff spoken to about supporting residents with their personal care were able to describe the support that they provide and how residents are included when being supported with their personal care. Such as asking residents what they wish to wear for the day and whether they would rather a bath or shower. All of the residents were indirectly observed throughout the inspection process and all seemed relatively healthy and content. Two residents were quite active and sociable and moved about the home freely, with staff support when required. Each of the residents has up to date and comprehensive information on their health care needs, with information on regular health care checks and professional intervention. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 14 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. Although the home has a comprehensive complaints policy and procedure, it is not clear whether all complaints are being recorded. This may lead to complaints being overlooked and residents not being confident that their concerns will be taken seriously. EVIDENCE: The home has PentaHact’s complaints policy and procedure, which contains comprehensive information on how to make a complaint and the procedures leading to resolution of the complaint. It was recommended at the previous inspection that a review of the complaints procedure take place to ensure that all complaints are being reported and recorded. The recommendation was made due to the fact that there have been no complaints made since April 2001. The registered persons have not reviewed the complaints procedure and this recommendation is therefore restated. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 15 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, 27, 28 and 30. Although the organisation is aware of most of the maintenance issues in the home progress in resolving them is slow, which leaves areas in the home looking worn and neglected. Staff are also not ensuring that all areas of the home are kept clean and tidy at all times. These issues mean that residents’ health, safety and comfort is being ignored and residents are being put at risk. EVIDENCE: A requirement made at the previous inspection that the cracks in the activity/lounge room, the front lounge and the front entrance hall be repaired has not been met. This requirement is restated. The registered manager stated that the maintenance department is aware of the issues and have assessed that work needs to be carried out but no progress has been made in resolving these issues. There was also an immediate requirement at the previous inspection that the cooker be repaired or replaced due to its poor condition. This requirement has been met. A new cooker was purchased and installed shortly after the inspection. However, whilst touring the kitchen the knobs on the hob were seen to be badly burnt and melted in places due to the spread of the heat from the fire. A requirement is made that the registered persons ensure that the knobs on the hob are replaced. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 16 Despite being made a requirement at the previous two inspections, the ground floor shower/toilet room has not been upgraded. The registered manager stated that although the maintenance department have assessed the shower/toilet room, there has been no progress regarding repairs. The registered manager went on to say that one of the consequences of the poor state of the room is that water accumulates near the toilet and an offensive odour sometimes lingers in parts of the home. The requirement regarding the shower/toilet room is restated. Work to replace the carpets in the activities room as per a requirement at the previous inspection has begun. The carpet has been delivered and the registered manager stated that they are waiting for the carpet fitter to lay the carpet. Whilst touring the home there was an offensive odour in some areas, this was due to one of the upstairs toilets having faeces in the toilet bowl. In addition, the downstairs toilet/shower room had an offensive odour due to the maintenance issues highlighted in this report. The lounge was untidy with pieces of cotton wool strewn on the floor. The cleaner dealt with the issues highlighted once she arrived at about 12:30pm. A requirement is made that the registered persons ensure that all areas of the home are kept clean, tidy and free of offensive odours at all times. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 36. Although the staff have a good understanding of the needs of the residents, they are not receiving sufficient training and supervision to enhance their skills and understanding. Staff numbers may also be insufficient at times to meet all of the residents’ needs. This means that residents may not being fully supported at all times EVIDENCE: Five staff files were viewed and all contained a copy of their job description. When spoken to, the staff had a good understanding of their roles and responsibilities towards the residents. They were able to describe in depth how their knowledge and skills helps them to support the residents more effectively. Finding information in staff files proved difficult due to there being no logical order to the files. A recommendation is made regarding this. Staff training certificates were limited. Some files contained adequate training certificates and information however, three of the files viewed did not contain all of the statutory training such as moving and handling and health and safety. Staff training profiles contained a list of training courses. The list indicated courses that staff had attended, did not attend, and booked. There was no information to show that courses that staff did not attend were rebooked. A requirement is made that the registered persons ensure that all staff receive training appropriate for the work that they perform in the home. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 18 Throughout the inspection there were only two staff on duty both were working quite hard. At one point a staff member left the home with a resident leaving just one staff with three residents. Two of the residents were wondering about the house frequently. The one member of staff had to support the residents, answering the telephone and preparing lunch. When this was discussed with the registered manager she stated that the staffing levels have always been the same and staff are able to cope. A requirement is made the registered persons ensure that staffing levels are reviewed to ensure that sufficient staff are on duty at all times to meet the needs of the residents. Although the registered managers have been ensuring that staff receive supervision, it has been quite infrequent for some staff. The files of five staff were viewed and their supervision records indicate that some have been without supervision since November 2005. There were also gaps of four and five months without recorded supervision. A requirement is made that all staff must receive regular supervision. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. Residents are not provided with an adequate objective method of relating their views as to the quality of service provided. Safety inspections by the relevant authorities ensure the safety of the residents and staff. However, any contraventions highlighted at inspections must be met to ensure that residents and staff are not put at risk. EVIDENCE: The registered persons have not, as yet, found a way of conducting an anonymous quality assurance system, as was a requirement at the previous inspection. The registered manager stated that the staff fill in the questionnaires for the residents due to the residents learning difficulties. Alternative ways of conducting an anonymous quality assurance system was discussed with the registered manager. This requirement is restated. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 20 The Portable Appliances Test (PAT) and water/legionella test certificates, which were not available at the previous inspection and were made a requirement, were sent to the Commission. The London Fire and Emergency Planning Authority (LFEPA) certificate, which was sent to the Commission, contained four contraventions, which need to be met. A requirement is made that the registered persons ensure that the contraventions identified by the (LFEPA) are met. 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X x Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X 1 3 X 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 X X 2 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 61 Somerset Road Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score X X 1 X X 2 x DS0000010530.V271227.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 16(2)(i) Requirement The registered persons must ensure that a review of the menu takes place and that there is comprehensive information in residents’ care plans regarding the foods they like and dislike. (Timescale of 19/08/05 not met). This requirement is revised and restated. The registered persons must ensure that the cracks in the walls identified in this report are repaired. (Timescale of 23/09/05 not met). This requirement is restated. The registered persons must ensure that the knobs on the hob are replaced. The registered persons must ensure that the ground floor shower/toilet room is upgraded to an acceptable level. (Timescale of 23/09/05 not met). This requirement is restated. The registered persons must ensure that all areas of the home are kept clean, tidy and free from offensive odours at all times. DS0000010530.V271227.R01.S.doc Timescale for action 31/03/06 2. YA24 23(2)(b) 05/05/06 3. 4. YA24 YA27 16 (g) (h) 23(2)(a) (b),(d) 31/03/06 05/05/06 5. YA30 16 (k), 23 (d) 31/03/06 61 Somerset Road Version 5.0 Page 23 6. YA32 7 YA33 8. YA36 9. YA39 10 YA42 The registered persons must ensure that all staff receive training appropriated to the work that they perform in the home. 18 (1) (a) The registered persons must ensure that the staffing levels are reviewed to ensure that sufficient staff are on duty at all times to meet the needs of the residents. 18 (2) The registered persons must ensure that all staff receive supervision at least six times a year and is recorded. (Timescale of 23/09/05 not met). This requirement is restated. 24(1),(b(2) The registered persons must (3) ensure that they find a way of conducting an anonymous quality assurance system in order to enhance the reliability of the findings. A summary of the findings must be produced and an action plan developed. (Timescale of 23/09/05 not met). This requirement is restated. 23 (4) (a) The registered persons must ensure that the contraventions identified by the (LFEPA) are met. 18 (1) (i) 05/05/06 05/05/06 31/03/06 05/05/06 31/03/06 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 YA22 YA32 Good Practice Recommendations It is recommended that a review of the recording of complaints takes place within the staff team and with residents. It is recommended that staff files are sorted into a logical and consistent sequence. DS0000010530.V271227.R01.S.doc Version 5.0 Page 24 61 Somerset Road Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 61 Somerset Road DS0000010530.V271227.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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