Inspection on 15/07/08 for Albany House

This inspection was carried out on 15th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 08/11/2008.

CARE HOME ADULTS 18-65 Albany House 75 Southwood Road New Eltham London SE9 3QE Lead Inspector Lorraine Pumford Unannounced Inspection 15th July 2008 15.00 Albany House DS0000071411.V366315.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 Albany House DS0000071411.V366315.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. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albany House Address 75 Southwood Road New Eltham London SE9 3QE 020 8850 1659 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) Precious Homes Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission are within the following category: 2. Learning disability - Code LD The maximum number of service users who may be accommodated is: 6 N/A Date of last inspection Brief Description of the Service: Albany House is a detached property that can accommodate up to six people who have been assessed as having a learning disability. Accommodation is spread over three floors. There are two large rooms on the ground floor which are used for dining and recreational space. There is also a large kitchen, laundry room and the office is also situated on the ground floor. All bedrooms have en-suite facilities and there are additional bathrooms and toilets. There is a garden to the rear of the property with a seating area. The home is situated in a residential area close to local amenities, bus and train links to London. There is parking to the front of the building for a limited number of cars. Albany House DS0000071411.V366315.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 one star this means the people living there receive an adequate service. This was the first key inspection of Albany House since it was registered in February 2008.This announced visit was undertaken by one inspector. To date only one person has moved in the home on a trial basis with a view to living there permanently. One other person is currently spending weekends at Albany House with a view to moving in on a trial basis. The home is currently operating without a registered manager; a manager from another service run by Precious Homes is over seeing the running of the home on a day-to-day basis. During the course of this inspection we met with the person who has recently moved into the home, the staff on duty and the Director of Personnel and Quality. Some policies and procedures were examined and parts of the premises inspected. The fees are currently from £1,200 to £2,000 per week. What the service does well: People living in the home benefit from being provided with written information regarding all of the care and services provided in the home. People in the home benefit from living in a clean, bright comfortable and appropriately furnished home. Prospective residents benefit from a comprehensive assessment and can testdrive the home. Residents are supported to make decisions affecting their day-to-day life. Risk assessments in place help promote residents independence. Residents are provided with and varied nutritional diet. Daily routines help promote individual s independence. People living in the home can be confident they will receive appropriate support from health care professionals. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 6 Residents benefit from staff providing personal support in a manner that respects their privacy and dignity and reflects their individual personal preferences. Comprehensive recruitment procedures help safeguard residents from harm. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albany House DS0000071411.V366315.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 Albany House DS0000071411.V366315.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): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from being provided with written information regarding all of the care and services provided in the home, however must be updated as the document refers to National Care Standards Commission which was replaced by The Commission for Social Care Inspection some years ago. Prospective residents benefit from a comprehensive assessment and can test-drive the home. EVIDENCE: A copy of the homes Service User Guide and Statement of Purpose were examined. These provides prospective residents and their advocates with comprehensive information about the care and services that people living in Albany House can expect to receive. The Statement of Purpose must be updated as the document refers to National Care Standards Commission which was replaced by The Commission for Social Care Inspection some years ago. The telephone number for the Commission also needs to be updated. Pre admission Records were seen in relation to the person who has recently moved into Albany House. Care staff who had cared for the person in a previous residence had provided very detailed information regarding the Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 9 persons historical background, daily living skills and day-to-day life enabling staff at Albany House to know the actions required by them to meet the persons needs. There was evidence that relevant health and social care professionals have also participated in collating relevant information and had recently attended the persons review to ensure that the resident had settled into the home and staff were able to meet the assessed needs. Prospective residents are able to visit the home and complete a test-drive before moving in on a trial basis. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident accommodated would benefit from staff formulating information they have been provided into a comprehensive care plan. Residents are supported to make decisions affecting their day-to-day life. Risk assessments in place help promote residents independence. EVIDENCE: As previously stated a comprehensive package of information was provided at the time the resident moved into Albany House. Whilst staff were able to provide verbal information about how they support the new resident, there was no detailed written care plan in place at the time we visited and action is required to address this. When admitting further residents to the home staff should aim to have a care plan in place at the time of the admission to ensure continuity of care for the new person. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 11 It was evident from talking to the resident and records seen that staff include the person living in the home when plans are being made for the day, for example there was evidence that the residents is able to choose which clothes to wear, the food they would like and what activities they would like to participate in. Staff stated each resident would have a named key worker to support them with attending health-care appointments, personal shopping and general support on a one-to-one basis. Precious Homes has produced a set template which staff use to record key information regarding the individuals health, how the person has spent their day and their general demeanour. Whilst this is a useful tool to provide prompts for staff on areas they need to address, there is a limited space for staff to record a comprehensive report of the individuals day. The Director of Personnel and Quality said that action would be taken to increase the amount of space staff have to record information in. The organisation has a comprehensive risk assessment format. Staff had completed this well and had identified particular areas where the resident requires support to maximise independence, for example in relation to use of the bathroom, using the kitchen and spending time out side of the home. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with and varied nutritional diet. Daily routines help promote individual s independence. The resident currently accommodated will benefit from opportunities to spend time with people of her own age group in both educational and social activities that are presently being arranged by staff. EVIDENCE: As previously stated the resident living in Albany House moved into the home approximately a month ago, the person previously lived some distance away and therefore staff are currently exploring appropriate educational opportunities for the resident to participate in as well as looking at a range of social and recreational activities and social groups based on the residents hobbies and interests. This will to enable her the opportunity of spending time with people of her own age. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 13 From records seen and discussion with staff it is apparent that the resident has had limited contact with family members. Staff stated that since moving in to Albany House a relative has made contact and staff said they are hoping to support the resident to re-establish more regular contact in time. The Service User Guide states that residents are given the opportunity of a one-week holiday each year. From discussion with the resident and records seen it is apparent that staff help the resident to participate in the house daily routines to help promote individual’s independence. The resident spoken with said she helps staff with shopping and meal preparation and also assists with laundry and household cleaning tasks. This was also recorded in her daily log. The resident living in Albany House has unrestricted access to the house and garden. The person living in the home stated she is able to choose her own food eaten at each mealtime. Information provided prior to the residents admission indicated the residents likes and dislikes and preferred mealtimes etc. There was evidence that staff had acted on this information. Records seen indicate that staff maintain a record of food provided. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home can be confident they will receive appropriate support from health care professionals. Residents benefit from staff providing personal support in a manner that respects their privacy and dignity and reflects their individual personal preferences. Medication procedures must be improved to safeguard residents. EVIDENCE: Information provided about the person when they moved into Albany House provided staff with guidance on the assistance required in relation to personal care. From discussion with the person and records seen it is apparent that they are able to get up and go to bed when they prefer and that there is also flexibility in relation to bathing and mealtimes. Information provided at the time the person moved into the house indicated that the resident likes to wear favourite items of clothing which may not be appropriate for the weather. On the day that we visited staff were seen to interact appropriately with the resident to encourage her to wear appropriate clothing for the hot sunny day. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 15 Medication procedures were examined in relation to the resident accommodated. Details of the residents medication are recorded on a preprinted MAR sheet (Medication Administration Record) and the medication stored tallied with the MAR sheet. However staff responsible for administering medication were asked to address the following points, in one instance the directions for the administration of one medicine did not tally between the prescription and the details on the box, we also discussed the need for two staff to sign handwritten entries in order to reduce the risk of error. There is a secure cupboard and medication is stored appropriately. The person in charge was advised The Royal Pharmaceutical Society have updated their guidelines on medication procedures in care homes, so it is necessary to have a medicine profile for each resident with evidence of regular medicine reviews. The need to have protocols in place for administration of ‘as required’ medicines such as pain relief for residents with poor or no communication skills. It is also necessary for staff responsible for medicine management to be assessed annually as being competent to do so. A protocol was seen for one resident in relation to the administration of medication to reduce anxiety. Staff spoken with stated they had received training in relation to the administration of medication at previous establishments they have worked in. Senior staff stated that as additional staff are employed the provider would ensure that appropriate training is provided before people are given the responsibility of administering medication. From discussion with the resident and staff it was apparent that the resident had slipped whilst using the bath in her en suite bathroom. Staff stated that appropriate equipment has been ordered, however until it is installed the resident is using a shower in an alternative bathroom. Staff ensure that residents are supported to attend routine health checks with the GP, opticians etc. On the day that we visited staff had assisted the resident to collect a new pair of glasses from the optician. The resident will require ongoing specialist health support and staff have taken action to ensure that an appropriate referral has been made to the health authority. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who bring concerns to the attention of the provider can be assured that action will be taken to address their complaints. Comprehensive safeguarding adults procedures help safeguard people living in the home. EVIDENCE: The provider has a comprehensive complaints procedure which is included in both the Service User Guide and Statement of Purpose. However this needs to be updated to reflect the change of the National Care Standards Commission to the Commission for Social Care Inspection with contact details also updated. The Service User Guide states that any complaint received will be investigated within five days. Discussion took place with the Director of Personnel and Quality about increasing this to 28 days as recommended in the National Minimum Standards this is because it may not be possible to conclude a full investigation in such a short period of time. Staff stated that has been one complaint made since the home was registered. The Director of Personnel and Quality stated that she had recently met with the parties concerned and it was hoped that the issue would be satisfactorily resolved in the near future. The CSCI have received no complaints since the home was registered. The provider has a Safeguarding Adults Policy. No incidents have occurred in the home that required referral to the local authority. Staff spoken with stated Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 17 that they had undertaken training in relation to safeguarding adults at the time of their induction. The acting manager was advised to contact the local authority safeguarding adults coordinator to obtain a copy of the local authoritys joint working procedures and to ascertain if any training is available. Senior staff stated training would be arranged for staff in relation to managing residents who may have challenging behaviour to ensure that any incidents that may arise are safely managed. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home benefit from living in a clean, bright comfortable and appropriately furnished home. EVIDENCE: Accommodation is spread over three floors and bedrooms have en-suite facilities. There are additional bathrooms and toilets. There are two large rooms on the ground floor which are used for dining and recreational space. There is a large kitchen, laundry room and office. There is a garden to the rear of the property with a seating area. The house is light, bright and airy and the rooms are appropriately furnished for the purpose. The building was free from unpleasant odours. Windows to the front of the building have an opaque film over most of the glass, whilst this restricts passers by and people in properties over the road looking in it also restricts people in the house looking out and detracts from a Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 19 homelike environment. Discussion took place with staff regarding the sighting of more appropriate blinds or curtains to create a more home like environment. The home does not have a designated smoking room and people who choose to smoke are asked to do so in the garden. The resident who came home during our visit showed us her bedroom, she stated that she liked her room very much and it was apparent that staff have assisted her to personalise and make the room feel homely. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive recruitment procedures help safeguard residents from harm. Residents benefit from staff being appropriately trained and supervised to provide the care they are assessed as requiring however the staff roster was not an accurate reflection of staff working in the home. EVIDENCE: On the day we visited the home the staff roster was not an accurate reflection of staff working in the home and action is required to address this. The roster indicated that at present there are a minimum of two members of staff on duty 24 hours a day. At night one person is awake and one member of staff sleeps in. Staff stated there are occasions when one member of staff could be in the home alone with a resident and discussion took place regarding the need to complete a risk assessment in relation to this to help protect both parties. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 21 The acting manager stated that all staff have a number of years experience of working with people with learning disabilities and this was confirmed by staff spoken with. The files of two members of staff were examined in relation to recruitment and training. There was evidence that Precious Homes operate an appropriate recruitment procedure. Records in relation to recruitment indicated that staff had been required to provide proof of identity, POVA/CRB checks had been completed and two references provided. The application also requires staff to complete a health declaration form. Staff had been provided with a job description. Staff files also contained copies of training certificates in relation to safeguarding adults and other courses appropriate to their role. Some training courses had been entered directly on to the staff file and discussion took place regarding the need to include dates that training took place. A copy of the skills for care induction programme was seen. The Director of personnel and Quality stated the organisation was committed to providing appropriate training for staff and people who did not already hold an NVQ2 qualification in care would be supported to undertake the course. Staff had signed a supervision contract, the acting manager stated that she was aware that supervision had not taken place on regular basis and this was something she intended to address imminently. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living and working in the home would benefit from a permanent person in charge on a day-to-day basis. People using the service benefit from the provider having a system in place to monitor and improve the service they provide. Issues identified in relation to fire safety need to be addressed to safeguard people living and working in the home. Incidents or accidents that adversely affect the wellbeing or safety of the resident must be reported to the CSCI. EVIDENCE: There have been two managers since the home was registered in February 2008. At present a manager from another service managed by Precious Homes is over seeing the day-to-day running of the home. The Director of Personnel and Quality stated they are continuing to try and recruit to the post. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 23 From records seen and discussion with staff it is apparent that two incidents have occurred which the Commission should have been informed of as they potential effected the safety or wellbeing of the residents concerned. Action is required to address this issue. The Director of Personnel and Quality stated monthly audits of the care and service provided in the home are generally undertaken by the Area Manager however this post is currently vacant. At present these audits are undertaken by one of Precious Homes senior managers. Record seen indicate that comprehensive policies and procedures were developed at the time the home was register. In relation to fire safety we looked at the risk assessment and emergency plan and this was complete, however the documents states that the home is a nonsmoking establishment when in fact residents and staff smoke. The risk assessment needs to be amended to reflect this. Staff stated they were unable to manually check the fire alarm system at present as the company responsible for installing and monitoring the system had not provided staff with an appropriate key and action is required to address this. The AQAA showed that all other health and safety maintenance checks had taken place. Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Albany House DS0000071411.V366315.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must ensure that the statement of purpose and service users guide contain up to date information in relation the commissions name and contact details. The registered person must ensure that a care plan is developed for the resident recently admitted to the home. The registered person must ensure the instructions on the medication administration records tally with that on the medicine. Two staff member should sign handwritten entries on the MAR sheet to reduce the risk of error. The registered person must ensure that the staff roster is an accurate reflection of staff working in the home. The registered person must inform the commission of any event in the care home which adversely affect the well-being or safety of any service user. The registered person must ensure that routine checks to the fire detection system can be DS0000071411.V366315.R01.S.doc Timescale for action 29/08/08 2 YA6 15 29/08/08 29/08/08 3 YA20 13 4 YA33 18 29/08/08 5 YA42 37 29/08/08 6 YA42 23 29/08/08 Albany House Version 5.2 Page 26 completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA6 YA6 YA22 YA23 YA26 YA42 Good Practice Recommendations Whenever possible it is recommended that care plans are in place at the time residents move into the home. ensure continuity of care. It recommended that the daily record sheet for each residents have sufficient space to enable staff to write a comprehensive record of events. It is recommended that the timescale for the provider to investigate complaints is increased from five days to twenty eight days. It is recommended that a copy of the local authoritys joint working Safe guarding adults procedure be obtained. It recommended that alternative method of screening to windows be sought. A risk assessment should be developed in relation to staff working in the home alone. Albany House DS0000071411.V366315.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 Albany House DS0000071411.V366315.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!