Inspection on 15/06/06 for Addington House

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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

Addington House 12/06/07

Addington House 14/11/05

Addington House 04/10/04

Addington House 17/05/04

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 Addington House Addington House 62 Addington Road Sanderstead South Croydon Surrey CR2 8RB Lead Inspector James O`Hara Key Unannounced Inspection 15th June 2006 09:00 Addington House DS0000039907.V299154.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 Addington House DS0000039907.V299154.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. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Addington House Address 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) Addington House 62 Addington Road Sanderstead South Croydon Surrey CR2 8RB 020 8651 9132 020 8651 9132 Beaconcaregroup@AOL.COM Addington House Limited Shaun Fegan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: Addington House opened in March 2003. The home is situated on the main road in a suburban part of Sanderstead; the home is registered for the provision of support to six service users with learning disabilities. At present the home has six service users all of whom are diagnosed Autistic Spectrum. The home offers six bedrooms; four with en suite facilities, a comfortable lounge and a large garden. The home is within easy reach of Croydon by bus and a short walk to Sanderstead. The current range of fees charged is £1448.00 to £1504.50 per week. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was carried out over five hours between 9 am and 2 pm. Methods of inspection included a tour of the premises, observation of contact between staff and service users, discussion with service users, staff and the home manager Mr. Sean Fegan. Records examined included staff Criminal Records Bureau Checks; service user plans, risk assessments, complaints, adult protection, staffing training records, Statement of Purpose, Service Users Guide, and health and safety records. Requirements from the previous inspection were discussed with Mr. Fegan. What the service does well: What has improved since the last inspection? What they could do better: Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 6 There were a total of three requirements and four recommendations set at the last inspection, one requirement has been met. As a result of this inspection there are nine requirements and two recommendations. The most significant areas of weakness identified during the inspection were the homes recruitment procedures; staff training needs in particular adult protection and guidance for staff working with individual service users who present challenging behaviours. All employers in regulated services are responsible for verifying the safety, competence, integrity and skills of candidates before they employ them as a new member of staff. Unless all staff is trained on the Protection of Vulnerable Adults there is the risk that service users will not be protected in a consistent manner from abuse. The health and welfare of service users could be compromised if staff is not given guidance and support to working with individual service users who present challenging behaviours. The home has also failed ensure that the fire alarm system is checked on a weekly basis. The health and safety of the service users could be compromised if the fire alarm system is not checked on a weekly basis. The inspector would like to thank the service users, the staff and Mr. Fegan for their support in the inspection process. 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. Addington House DS0000039907.V299154.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 Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In the main the home provides prospective service users and their representatives with the information they need to make an informed decision about whether or not to use the service. However the Statement of Purpose and Service Users Guide need to be updated. EVIDENCE: The home has a Statement of Purpose and Service Users Guide. Information included in these documents reflects what is required in regulations 4 and 5 respectively in the National Minimum Standards Care Home Regulations. However the Statement of Purpose and Service Users Guide need to be updated. The home has an admission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. One new service user moved to the home on the 6th of March 2006. Evidence was produced that he had an initial visit and came for a short stay prior to moving into the home. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 9 Evidence was also seen of a care manager needs assessment and a care plan/placement review was carried out on the 15th May 2006. Mr Fegan showed evidence of monthly update reports sent to the service users care managers. These reports are sent to the service users care manager along with any incident reports. As recommended at the last inspection service user contracts now include current charges and are agreed and signed by the service user and the registered provider. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. In general service user plans include detailed information on the service users needs and personal goals. The home hopes to complete a Person Centred Plan for each of the service users. EVIDENCE: Service user individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The service user care plans are completed by the home and the service users care manager. It was recommended in previous inspections that each service user have a Person Centred Plan completed every six months. Mr Fegan stated that he and the deputy manager are continuing training with Croydon Council on Person Centred Planning and other members of staff have attended Person Centred Planning provided by Beacon Care. Two formats were produced however Mr Fegan stated that when he and the deputy manager complete training he will have a better idea of how the home will develop Person Centred Plans. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 11 It is recommended that all service users have a Person Centred Plan completed every six months. For risk assessments see requirements set in Standard 23 of this report. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Appropriate arrangements are made so that service users have opportunities to engage in regular leisure activities both inside and outside of the home. EVIDENCE: Five service users live at the home. Two service users attend college. Two service users own their own bicycles. Mr Fegan stated that emphasis is placed on service users using the community. Service users weekly plans indicate attendance at trampoline classes, arts and crafts, bowling, swimming and local pubs. Service users also go to local cafes and shops. Mr Fegan stated that there are plans to support some service users to a local disco. It was evident on this and previous inspections that service users are encouraged to access the local community. Two service users had gone on a day trip to Brighton the day before the inspection. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 13 On the day of the inspection one service user received money for working in the garden. A drama and movement therapist visits the home on Mondays and an aroma therapist visits the home on Fridays. Mr. Fegan stated that all service users have contact with their families. Some service users visit their relatives and some service users stay with family at weekends. The new service user does not visit his Mother nor does she at the present time wish to visit him but there is regular contact and updates on the service users wellbeing are passed to his Mother. Mr. Fegan produced weekly menus. Service users are involved in menu planning. A varied seasonal menu that is sufficiently nutritious and takes individual tastes into account is on offer. Service users are also involved in preparing and cooking meals. Some service users have fridges in their bedrooms were they store drinks and snacks. Some service users have play stations and computer games, music players, DVD players, TV’s and DVDs in their bedrooms. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. The arrangements for meeting the health care needs of the service users are good and service users receive personal support in the way they prefer. The health and welfare of service users could be compromised if staff is not given appropriate guidance and support to ensure that service users physical and emotional health care needs are identified and met. EVIDENCE: Mr. Fegan stated that most of the service users require little support with personal care and their wishes on how they are supported are outlined in detail in their personal files. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner. Medication is stored in a locked cabinet in the office. Medication administration records were checked and were up to date and accurate on the day of the inspection. The home has the support of a Boots pharmacist for advice on medication. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 15 Mr. Fegan stated that the pharmacist visits the home and signs medication administration records as evidence that a check had taken place however the pharmacist does not leave a report. Mr. Fegan stated that the regional manager is a good source of support with advice on the storage and administration recording of medication. It is recommended that the home manager contact the Boots pharmacist and request a visit and a report. A regulation 37 report was received at the Commission on the 15th of May 2006 following a serious incident of aggression involving a service user and a member of staff. Mr. Fegan stated that guidelines for staff to follow in the event of the service user presenting challenging/aggressive behaviour had been drawn up and risk assessments were in place however Mr. Fegan could not locate these on the day of the inspection. See Requirements set in standard 23 of this report. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using all the available evidence including a site visit to this service. Unless all staff is trained on the Protection of Vulnerable Adults there is the risk that service users will not be protected in a consistent manner from abuse. EVIDENCE: A regulation 37 report was received at the Commission on the 15th of May 2006 following a serious incident of aggression involving a service user and a member of staff. The home followed Croydon Councils Protection of Vulnerable Adults Procedure and an adult protection investigation took place. A senior manager from Beacon Care carried out an investigation and the case was closed following an adult protection case conference on the 30th May 2006. Mr. Fegan stated that guidelines for staff to follow in the event of the service user presenting challenging/aggressive behaviour had been drawn and risk assessments were in place however Mr. Fegan could not locate these on the day of the inspection. The registered manager is required to forward copies of any physical intervention plan/guidance for staff to follow in the event of the service user presenting challenging/aggressive behaviour and any risk assessment relating to physical intervention. The registered manager is required to forward copies of any risk assessments regarding the service user accessing the community alone. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 17 It was recommended at the last inspection that all members of staff attend training on the protection of vulnerable adults. Training records for six members of staff were sampled, one member of staff attended adult protection training on the 2nd February 2005 and no staff had received adult protection since the last inspection. The registered manager must ensure that all members of staff attend training on the homes and Croydon Councils Protection of Vulnerable Adults Procedure. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home is suitable to the needs of the service users and is in good decorative order throughout. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. EVIDENCE: It was recommended at the last inspection that the drawer in the kitchen, the bathroom door and the wardrobe door is repaired or replaced. Since the last inspection a number of doors in the home have been replaced, new windows have been fitted down stairs, a new wardrobe has been built in a service users bedroom, bedroom doors have been fitted with fire alarm sound responsive release mechanisms, two service users have the use of keypad locks on their doors and the hallway, stairs and landing have been repainted. Regulations 26 reports indicate that the regional manager has requested quotes for a new kitchen. The report has also highlighted the immediate need for the tiles in the bathroom to be repaired. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 19 Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using all the available evidence during the visit to this service. All employers in regulated services are responsible for verifying the safety, competence, integrity and skills of candidates before they employ them as a new member of staff. EVIDENCE: During the last inspection Mr. Fegan stated that two members of staff had started work at the home after completing only a POVA First check. Mr. Fegan was given the following advice. Employers must always ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards (Care Home Regulations) before starting work with vulnerable people. POVA First is only to be used were the lack of staff places the service users health and welfare at critical risk. A number of conditions need to be in place if staff are to start work with POVA clearance only. • The employer must write to the Commission requesting and have agreement that staff start work at the home with POVA clearance only. DS0000039907.V299154.R01.S.doc Version 5.2 Page 21 Addington House • • The home must explain the critical risk to the service user/s. The employer must provide evidence that all other documentation as stated in Schedule 2 of the National Minimum Standards has been obtained for the new staff. The employer must ensure that new staff do not work alone with service users. The employer must ensure that the new staff has an identified senior member of staff to supervise them on each shift. The employer must ensure that the new staff completes induction training during this period. • • • During this inspection Mr. Fegan stated that two new members of staff had started work at the home since the last inspection on the 14th November 2005. Both members of staff had started work with a POVA clearance only. There was no evidence in their files that proof of identification had been requested. Both new members of staff had only one reference one of which did not included a company stamp or headed paper. The employer did not write to the Commission requesting that these staff start work at the home with POVA clearance only. The employer did not explain to the Commission the critical risk to the service user/s. The employer did not provide evidence that all other documentation as stated in Schedule 2 of the Care Standards Regulations had been obtained for the new staff before starting them to work in the home. Following this inspection a statutory notice was served on the home in respect of obtaining documentation as stated in Schedule 2 of the Care Standards Regulations Mr. Fegan provided evidence that five members of staff are completing NVQ level 3 in Care. The registered manager stated that five other members of staff to start NVQ level 2 courses at Carshalton College this year. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 22 Records show that some staff has attended training on moving and handling, first aid, epilepsy, food hygiene, fire safety, medication, autism and managing aggressive behaviors however not all staff has and most of the staff need refresher training. The registered manager must evaluate staff training records and identify staff training needs in particular training on fire safety, food hygiene, first aid, moving and handling, health and safety, medication, physical intervention, epilepsy and adult protection. The registered manager must ensure that all staff training in these areas is completed. A written plan of how the registered manager will ensure that staff have this training must be sent to the Commission. Two staff files were examined for evidence of supervisions. One file indicated that one member of staff had supervision in October 2005 and January 2006 and none since then. The other file indicated that the member of staff had supervision in October 2005, January 2006 and April 2006 and none since then. The registered manager must ensure that all members of staff receive formal recorded supervision once every six weeks or eight times a year. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using all the available evidence during the visit to this service. The homes recruitment and selection procedure does not ensure that service users are protected from employees who are unsuitable to work with vulnerable adults. The health and safety of the service users could be compromised if the home does not carry out appropriate fire equipment checks. EVIDENCE: Mr. Fegan and the deputy manager are completing the RMA and NVQ level 4. At the last inspection Mr. Fegan stated that he was not happy with the company he was completing the qualification with and provided evidence that he and the deputy manager planned to move to another company. During this inspection Mr. Fegan stated that he and the deputy manager were still completing the RMA and NVQ level 4 with the same company but things were going slowly. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 24 The registered manager must write to the Commission indicating when he will complete the RMA and NVQ level 4. Evidence was seen for Landlords Gas Safety Certificate 16/05/06, Legionella testing 29/03/06 and an officer from London Fire & Emergency Planning Authority visited the home on 27/10/05. A requirement was set at the last inspection that the registered manager must ensure that the fire alarm system is checked on a weekly basis. The fire alarm system had not been checked since the 22nd of May 2006. The registered manager must ensure that the fire alarm system is checked on a weekly basis. Failure to comply with this requirement represents a serious breach of the Care Homes Regulations and urgent action must be taken by the registered manager to address this requirement in order to avoid the Commission taking further action to enforce compliance. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 2 X Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19 (1) b. Requirement Timescale for action 15/06/06 2. YA42 23 (4) c. The home should obtain all the information required in Schedule 2 National Minimum Standards for all members of staff prior to commencing employment in the home. The registered manager must inform the Commission when the Criminal Records Bureau Check for the two members of staff is available in the home and arrange a date for these to be examined. Requirement not met from last inspection, previous timescale 14/11/05. The registered manager must 15/06/06 ensure that the fire alarm system is checked on a weekly basis. Failure to comply with this requirement represents a serious breach of the Care Homes Regulations and urgent action must be taken by the registered manager to address this requirement in order to avoid the Commission taking further action to enforce compliance. Requirement not met from last inspection, previous timescale 14/11/05. DS0000039907.V299154.R01.S.doc Version 5.2 Addington House Page 27 3. YA23 13 (4) C 4. YA9 13 (4) b 5. YA23 18 (1) c 6. YA32 18 (1) c 7. YA36 18 (2) 8. YA37 9 (2) b The registered manager is required to forward copies of any physical intervention plan/guidance for staff to follow in the event of the service user presenting challenging/aggressive behaviour and any risk assessment relating to physical intervention. The registered manager is required to forward copies of any risk assessments regarding the service user accessing the community alone. The registered manager must ensure that all members of staff attend training on the homes and Croydon Councils Protection of Vulnerable Adults Procedure. The registered manager must evaluate staff training records and identify staff training needs in particular training on fire safety, food hygiene, first aid, moving and handling, health and safety, medication, physical intervention, epilepsy and adult protection. The registered manager must ensure that all staff training in these areas is completed. A written plan of how the registered manager will ensure that staff have this training must be sent to the Commission. The registered manager must ensure that all members of staff receive formal recorded supervision once every six weeks or eight times a year. The registered manager must write to the Commission indicating when he will complete the RMA and NVQ level 4. 31/07/06 31/07/06 31/07/06 31/08/06 15/06/06 15/06/06 Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 28 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 YA20 Good Practice Recommendations It is recommended that service users have a Person Centred Plan completed every six months. It is recommended that the home manager contact the Boots pharmacist and request a visit and a report. Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Addington House DS0000039907.V299154.R01.S.doc Version 5.2 Page 30 - 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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