Inspection on 22/07/08 for 89 Grosvenor Avenue

This inspection was carried out on 22nd July 2008.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

89 Grosvenor Avenue 04/12/07

89 Grosvenor Avenue 30/05/06

89 Grosvenor Avenue 30/01/06

89 Grosvenor Avenue 25/11/05

89 Grosvenor Avenue 03/02/05

89 Grosvenor Avenue 04/10/04

Similar services:

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 89 Grosvenor Avenue Carshalton Surrey SM5 3EN Lead Inspector Emma Dove Unannounced Inspection 22nd and 29th July 2008 5:30 89 Grosvenor Avenue DS0000007134.V367290.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 89 Grosvenor Avenue DS0000007134.V367290.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. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 89 Grosvenor Avenue Address Carshalton Surrey SM5 3EN 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 8647 3912 020 8647 3912 manager.grosvenoravenue@careuk.com Care Solutions Limited vacant Care Home 5 Category(ies) of Learning disability (0) registration, with number of places 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 5. Date of last inspection 4th December 2007 Brief Description of the Service: 89 Grosvenor Avenue provides residential care for up to five people with learning disabilities. Five people are currently living there. The home is located in a residential road in Carshalton, close to local shops and amenities with good transport links. The home is not identifiable as a care home and is in keeping with neighbouring houses. Information about the service is available in the Statement of Purpose and Service User Guide. The fees vary depending on peoples assessed need. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate quality outcomes. This unannounced inspection took place over one hour on the 22nd July and five hours on the 29th July 2008. One regulation inspector visited, looked at records, spoke with people who use the service and their representatives, staff and the manager. Questionnaires were sent to placing social workers, health professionals and staff. We have received two completed questionnaires. We received a completed Annual Quality Assurance Assessment (AQAA), which contained brief information which has been used in this report. What the service does well: What has improved since the last inspection? What they could do better: Update the Statement of Purpose to include details of the new manager to ensure people who use the service and their representatives have up to date information about the services. The Service Users Guide should be made accessible to people who use the service to ensure they can understand the services provided. Pre admission assessments to be completed to ensure the service is appropriate to meet individuals needs. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 6 Care plans could be more person centred and include the support the individual needs and how they prefer to be assisted. Annual reviews of care should take place to ensure the service is still appropriate to meet individuals needs. Risk assessments must be reviewed and updated as required to ensure people who use the service are safe and staff have up to date information to ensure individuals safety is maintained. Risk assessments should include the actions staff need to take to protect people from harm. People who use the service could be more involved in community activities and this should be explored with individuals. More could be done to involve people who use the service in the day to day running of the home by being involved in meal preparation, shopping and house hold tasks. Any health appointments made by professionals must be attended to ensure that people’s health needs are fully met. The complaints procedure should be developed in more accessible formats to ensure the people who live there understand how to complain and who they can speak with. The staff rota must available and up to date with the staff on duty at all times. All staff must complete training in safeguarding and be aware of local practices to protect people who use the service from harm. The induction training for new staff should include privacy, dignity, equalities and diversity and safeguarding to ensure new staff can meet the needs of the people who use the service. Staff recruitment must include receiving two written references and completing a Criminal Records Bureau check before new staff start work. The application form must be updated to include a full employment history. The organisation needs to develop more robust systems to check the quality of the services provided to ensure the needs of people who use the service are met. Inform the CSCI of any issues which affect the health and well being of people who use the service, to comply with the Care Homes Regulations 2002. 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. 89 Grosvenor Avenue DS0000007134.V367290.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 89 Grosvenor Avenue DS0000007134.V367290.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): 1 and 2 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose, which sets out its aims and objectives. The Service Users Guide should be developed in an accessible format to ensure it can be understood by people who use the service. Preadmission assessments were not seen. EVIDENCE: The Statement of Purpose and Service Users Guide give people information about the services provided, the organisation, staff, the aims of the service, consultation and some relevant policies. These documents require updating to include details of the new manager. We did not see any progress in producing the Service Users Guide in an accessible format. This means people who use the service may not have full information and understanding of the services provided including how they can make a complaint. We did not see assessments in case files and are unable to check if these documents are being kept up to date as required in the last inspection in December 2007. For peoples needs to be met, they must be assessed and kept under review, to ensure that the service is still appropriate. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Care plans contain basic information about individuals needs, although they could be more detailed and person centred. It is not clear how people who use the service are involved in developing and reviewing their care plans. Annual reviews have not been routinely carried out. Risk assessments are in place but have not been reviewed. EVIDENCE: We saw care plans contain information about individuals needs, however, these could be more person centred to include the care and support individuals need and how they prefer to be supported. We saw monthly reviews completed for one person until January 2008, the records noted ‘no change’ for the previous seven months, this may indicate that staff are just writing the review without including improvements or deterioration in individuals abilities and behaviours. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 10 We saw a Person Centred Plan in one case file which had not been completed in full and did not include people who are important to the individual. We saw an annual review of care provided for one person in February 2007, with no evidence available of more recent reviews. Annual reviews should be held every year, to ensure that the home is still the most appropriate place for individuals and to offer people who use the service and their representatives the opportunity to comment about the care provided. The manager is aware of the areas that need to improve and is developing a plan to ensure the work is completed. We saw a communication ‘dictionary’ in one person’s file. We feel this could be developed further with more detail of the words, gestures and signs the individual uses and what they mean, to help staff provide more appropriate care. One person said the home ‘always’ meets the needs of their relative. One person said the home ‘always’ gives the care and support needed. We saw a whole life risk assessment completed in November 2005, reviewed monthly until January 2008. We feel these risk assessments should include details of the actions staff should take, to minimise the risk and protect the person from harm. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service take part in a few regular activities. People who use the service have the opportunity to maintain important family relationships. People receive a varied diet. EVIDENCE: The manager said that they are planning to provide more home based activities for people. We saw that people go out to a day centre, attend a ‘Friday’ club and spend time with their relatives. People also have regular aromatherapy and music sessions. There is more scope for people who use the service to be involved in community activities and this should be explored with individuals. One person told us that their friend or relative does what they want during the day and at weekends, although added a comment that ‘most activities have to be supervised and are linked with staff availability’. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 12 The manager told us that all people who use the service had recently been on holiday, which was paid for by the organisation. One person told us that they had ‘a good time on holiday’ and said they ‘enjoyed going away’. The manager and staff said that people are supported to maintain contact with their family. This was confirmed by one person who uses the service and two relatives. People receive a balanced diet with any religious and medical dietary needs catered for. Peoples comments about the food included ‘I like the food here’ and ‘I enjoyed dinner’. We didn’t see people who use the service involved in the meal preparation. This is an area that could be developed to involve people more in the day to day running of the home and to support people to develop to their full potential. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People have access to health care professionals, although there have been delays in receiving health screening. The views of people who use the service have not been sought about the way personal care is delivered. Medication is well managed with records up to date and signed by staff. EVIDENCE: The manager told us that he has implemented same gender support with personal care for people who use the service and that this has been well received by relatives. The practice of male staff supporting females who use the service is considered old fashioned and does not ensure individuals privacy, dignity and wishes are taken into account when care is being given. When people are unable to request a preference, this should be discussed with relatives and representatives to ensure individuals privacy and dignity is maintained. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 14 Case files could contain more detailed information about the support and assistance required and what individuals can do, to maintain their independence and develop self help skills to improve people’s quality of life. We saw letters from the health protection agency inviting people who use the service to health screening. The manager reported that this had not taken place as originally planned and had taken two months to be completed. This delay in health screening did not ensure peoples health needs are fully met. We should have been notified of the need for people who use the service to have this health screening. Medication is generally well managed with records up to date and signed by staff. One person has one ‘as required’ medication which must have clear guidelines for staff to follow to ensure the individual’s health needs are met. It was not clear on two separate dates the reason for this medication being administered. The manager said that this would be discussed with the GP and the medication would probably be discontinued. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is available and on display, however it is not available in different formats to ensure it is accessible to everyone who uses the service. Policies are in place regarding safeguarding. Not all staff have completed training in safeguarding and may not fully understand their role and responsibilities. EVIDENCE: The complaints procedure is included in the Statement of Purpose and is made available to representatives of people who use the service. It is not clear if people who use the service are aware of how to make a complaint and who they can speak with. Relatives and friends of people who use the service are aware of who to speak to and how to make a complaint. One person indicated that they have little to complain about but that any comments they make ‘are always followed up’. The manager said they have not received any complaints since the last inspection. We have received one anonymous concern regarding care practices, which were not found to be issues. Appropriate policies are in place for safeguarding. New staff must complete the local authorities training to ensure they are familiar with local practices and complete the organisations training in safeguarding as a part of their induction to the service. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 16 The service holds some money for people. We saw the balance to be correct and records up to date for two people who use the service. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 17 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): 24, 25, 27 and 30 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The environment is generally well maintained. The home is a pleasant and safe place to live. Bedrooms are single. All areas are well lit, clean and tidy. EVIDENCE: People who use the service can access a lounge with doors to the garden and a kitchen/dining room on the ground floor. One person told us they enjoy sitting in the garden. Another person told us they ‘like watching television in the comfy chair’. We saw that bedrooms have been personalised to individuals taste with pictures, photographs and belongings. One person said they like their room and have everything they need. One person told us that they spend time in their room and are ‘comfy’ in it. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 18 An adapted bathroom with toilet is available on the ground and first floor. The manager said that the redecoration schedule will continue to bring all areas of the home to a good standard. The manager said they have improved the cleaning schedule to ensure the home is maintained to a good standard. One person said there has been ‘a big improvement to the hygiene and cleanliness of the home, with more attention to detail particularly in individuals bedrooms’. Two people said the home is ‘always’ clean and fresh. All areas of the home were seen to be clean and tidy. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 19 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): 32, 34 and 35 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There are enough staff to meet the needs of the people who live there. The organisation has a training and development programme which is available to all staff, although new staff need to complete their core training. Staff recruitment practices and records need to improve to ensure people are protected from harm. EVIDENCE: There was no written staff rota for the week of our visit, previous rota sheets did not always include the manager’s hours, it was not always possible to check who was on duty. The staff rota must be written and up to date at all times to comply with the Care Homes Regulations 2002. The manager said there had been one full time member of staff leave in the last twelve months, although old staff rotas indicated that four staff had left since March 2008. Three new members of staff have been employed since April 2008, all with no experience in social care settings. The organisation must ensure that new staff complete a detailed induction to social care, 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 20 including dignity, privacy, equalities and diversity and safeguarding. This will ensure that peoples individual needs will be understood and met by staff. We saw some positive interactions between staff and people who use the service. People said they ‘like the staff’ saying they ‘like talking to one particular member of staff’. Two people said the staff ‘always’ treat them well. Two people said staff ‘always’ listen and act on what is said. Staff training records showed us that three members of staff have completed training in medication administration and one person has completed training in infection control, first aid, food hygiene and values in social care. Staff files did not contain all the necessary checks. We saw one written reference in one staff file, no references in one staff file and two references in another staff file. The manager said that the outstanding references had been received and were probably at another of the organisation’s homes. We saw a Criminal Records Bureau (CRB) check in one staff file, but not in two other staff files. The manager said that CRB checks had been completed and the details would be at the organisations head office. The organisation must ensure that the application form is updated to include a full employment history from candidates. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 21 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): 37, 39 and 42 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There is no registered manager, the organisation has put appropriate systems in place to cover the management of the service. We did not see the quality assurance systems in place and were unable to measure how involved people who use the service and their representatives are in the monitoring and reviewing of the services provided and any plans for development. Health and safety is generally well managed with records of checks up to date, with the exception of the weekly test of the fire alarm system. EVIDENCE: The home has been without a registered manager for a few years this is apparent with the issues found during this inspection. A new manager has 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 22 been appointed and must go through the registration process to ensure consistency of care and staff management to improve the services provided. The organisation has a quality assurance system which includes a representative visiting, speaking with people who use the service and staff to comment on the services provided and note any actions needed to improve. We did not see copies of the reports from these visits and do not receive a copy. It is of concern that the issues raised at this inspection had not been acted on at an earlier time and that the organisation had not notified the CSCI of the problems and how they planned to improve the services. Health and safety records were up to date with checks completed at the appropriate timescales with the exception of the weekly test of the fire alarm system. This test must be completed every week to ensure the health and safety of people who use the service and visitors is maintained at all times. 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 23 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 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 3 X 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA2 Regulation 14 (1) a Requirement Pre-admission assessments must be completed and be available at the home, to ensure the service is the right place for people who move in. Risk assessments must be reviewed and updated to ensure people who use the service are protected from harm. To ensure that people’s health needs are fully met any health appointments made by health professionals must be attended. The induction training for new staff must include safeguarding and should cover issues regarding privacy, dignity and equalities and diversity. The staff rota must be available and up to date at all times, to comply with the Care Homes Regulations 2002. To ensure people are protected from harm, the recruitment process must include receiving DS0000007134.V367290.R01.S.doc Timescale for action 10/09/08 2. YA9 12 (1) a 10/09/08 3. YA19 13 (1) b 03/09/08 4. YA32 18 (1) c 10/09/08 5. YA33 17 (2) & Sch 4 (7) 10/09/08 6. YA34 19 (1) b & Sch 3 10/09/08 89 Grosvenor Avenue Version 5.2 Page 25 two written references and a completed Criminal Records Bureau check before new staff start work. The application form should be updated to request a full employment history for all staff. 7. YA37 37 (1) e To comply with the Care homes Regulations, the organisation must ensure that the CSCI is informed of any issues that affect the health and well being of the people who use the service. 10/09/08 8. YA39 37 (1) & 26 (2) e To ensure the needs of people 10/09/08 who use the service are met, more robust systems to check the quality of care provided must be in place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations So that people that use the service have the information they need, the Service User Guide should be updated and put in a format which is easy to understand. Care plans could be developed to be more person centred and include details of the how individuals want to receive care and support. Annual reviews of care provided should take place to ensure the service is still appropriate to meet individuals needs. People who use the service could be more involved in the day to day running of the home with meal preparation, DS0000007134.V367290.R01.S.doc Version 5.2 Page 26 2. YA6 3. YA6 4. YA8 89 Grosvenor Avenue shopping and household tasks depending on their needs and choices. 5. YA13 People who use the service could be more involved in community activities and this should be explored with individuals. The complaints procedure should be developed in an accessible format to ensure that people who use the service are aware of how to make a complaint. 6. YA22 89 Grosvenor Avenue DS0000007134.V367290.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 89 Grosvenor Avenue DS0000007134.V367290.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!