Inspection on 05/06/07 for Angel Lodge

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Angel Lodge 23/02/09

Angel Lodge 04/10/06

Angel Lodge 19/10/05

Angel Lodge 16/06/05

Angel Lodge 25/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Mayfield Road (12) 12 Mayfield Road Sanderstead South Croydon Surrey CR2 0BE Lead Inspector James O`Hara Key Unannounced Inspection 5th June 2007 10:00 Mayfield Road (12) DS0000028130.V341623.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 Mayfield Road (12) DS0000028130.V341623.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. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield Road (12) Address 12 Mayfield Road Sanderstead South Croydon Surrey CR2 0BE 020 8657 9046 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) Mrs Rosina Beatrice Annan Mrs Rosina Beatrice Annan Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users over the age of 65 to be accommodated until such time as their needs can no longer be met in the home. 4th October 2006 Date of last inspection Brief Description of the Service: Mayfield Road is a 3-bedded home providing care for younger adults with a past/present mental illness. The house itself is roomy, well decorated and comfortable. It is situated in a residential street, close to a rail station and within reasonably easy reach of the centre of Croydon and its many community facilities. People who use the service are provided with a single bedroom, and they share a bathroom. They also have use of a large lounge, a very nice, newly refurbished kitchen, and a spacious rear garden. The registered provider, Mrs Annan, has applied to the Commission to increase the number of people living at the home from three to five. The current fees charged at the home range between £405.00 and £475.00. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 10 am and 12.30 pm on a Tuesday morning/afternoon. Methods of inspection included a tour of the premises, observation of contact between the registered provider, Mrs Annan, and people who use the service and discussion with Mrs Annan. Mrs Annan has applied to the Commission to increase the number of people living at the home from three to five. The application is currently under consideration. Records examined included care plans, needs assessments, risk assessments, complaints, adult protection, training, medication, finance, and health and safety. Requirements and recommendations from the previous inspection were also discussed with Mrs Annan. What the service does well: What has improved since the last inspection? Mrs Annan has attended adult protection training. The homes electrical equipment was checked. Legionellas-testing was carried out. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 6 During the visit one person’s bedroom was being decorated. Mrs Annan said new carpet was also being laid and that she planned to do the same in another person’s bedroom when that one was finished. New carpet has been laid in the hallway. 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. Mayfield Road (12) DS0000028130.V341623.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 Mayfield Road (12) DS0000028130.V341623.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: A requirement had been set at previous inspections that all information required in Schedule 1 of the National Minimum Standards be included in the Statement of Purpose. The registered provider, Mrs Annan, has applied to the Commission to increase the number of people living at the home from three to five. As part of the application Mrs Annan sent a proposed Statement of Purpose. An inspector from the Commission’s Central Registration Team visited the home on the 4th of June, the day prior to this inspection, to discuss the application. Mrs Annan stated that the inspector had recommended that the proposed Statement of Purpose should be amended to accurately reflect what the new service would offer to potential new residents. No new people have moved into the home since the last inspection however the homes admission procedure would ensure that a thorough assessment of prospective peoples needs would be carried out before they moved in. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 9 All people who use the service have contracts that include terms and conditions, fees and charges, the homes responsibilities and their responsibilities. These have been agreed and signed by people and the registered provider. Mrs Annan stated that the current fees charged at the home had not changed since the last inspection and ranged between £405.00 and £475.00. Mayfield Road (12) DS0000028130.V341623.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are having their placements reviewed on an annual basis so that they and their care managers can be sure that the home is meeting their assessed needs. People have care plans that include information on their needs and personal goals. The home could make sure that people have their risk assessments and risk management strategies updated so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: Currently three people live at the home. One person’s file was examined. This person had a Self Centred Plan. The plan considered his relationships with other people, food that he likes, his hobbies and his opinion about living at the home. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 11 So that the diverse needs of people who use the service are considered, care plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. Mrs Annan stated that a care-planning meeting took place on the 3rd of April 2007; the persons care manager, a mental health practitioner and a Doctor, attended this. Mrs Annan stated that the report from the meeting has yet to be received at the home. Mrs Annan stated that another persons care-planning meeting had taken place in May 2006 but again the report has yet to be received at the home. Mrs Annan stated that he remaining persons care manager had completed a review over the phone and stated that a care manager would attend to complete the assessment but as yet no arrangements have been made. It is recommended that the registered provider contact peoples care managers and arrange for placement reviews to take place and request copies of the assessments to keep on peoples files. People have risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. However some of these had not been reviewed since September 2004. Mrs Annan stated that the risk assessments had remained the same over that period of time. It is recommended that all people who use the service have their risk assessments reviewed, signed and dated on a regular basis. The current group of people living at the home are capable individuals, and able to make most decisions independently. These people have signed to say that they do not wish to hold/attend house meetings. Mrs Annan stated that people prefer to carry on with their own routines and lifestyles, they are quite happy to discuss their own issues with her if they feel the need. Mayfield Road (12) DS0000028130.V341623.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 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. Provision is made so that all people can attend appropriate social activities, day centres and become part of the local community. Arrangements are made so that people can have regular contact with their friends and families. EVIDENCE: In general people like to use the community as they wish and risk assessments have been carried out for going out alone. See Standard 9 of this report. One person prefers to spend most of his time at home; Mrs Annan stated that he goes to an Art Class on Wednesday’s. Mrs Annan stated that this person had previously visited his mum on a regular basis but had stopped. He had recently visited her again. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 13 Mrs Annan stated that his mother was very pleased to see her son. Mrs Annan stated that she is trying to encourage him to keep regular contact with his mother. This person had a self-centred plan in place and his placement is kept under review by the home and his care manager. People are free to use the kitchen, and each has an allocated space in a cupboard where they may keep some of their own provisions. There is also a designated fridge for the people use. It was observed during this visit that people where in the kitchen cooking breakfast for themselves. Those spoken to said that they were quite happy living at the home. One person explained that he was going to visit some people at an old peoples home and had other plans for the rest of the day. As recommended at the last inspection Mrs Annan has written down on the homes menu the actual food offered so that people know what they will eat that day. Mayfield Road (12) DS0000028130.V341623.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 and 20. 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 general the arrangements for meeting the health care needs of the service users are good however the home could do more to improve systems for monitoring self medication. EVIDENCE: The current group of people living at the home are capable individuals, and able to make most decisions independently. Mrs Annan stated that two people administer their own medication. These people collect their own medication from the pharmacist. Mrs Annan stated that she monitors their self-medication by checking when they obtain medication and asking them on a regular basis how things are. It is recommended that the registered provider complete risk assessments for people that self medicate. It also recommended that the home develop an appropriate recorded system for monitoring and supporting people to self-medicate. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 15 A requirement was set at a previous inspection that Mrs Annan ensure that a risk assessment is carried out and guidelines developed for the event of her not being present to administer medication. At the last inspection Mrs Annan produced general written guidence for staff to follow in the event of the her not being present including administration of medication. It was recommended at the last inspection that the registered provider complete a risk assessment that would include the arrangments for the administration of peoples medication if she was not able to do so. Mrs Annan stated that only one person needs support with medication. Mrs Annan stated that her daughter lives with her at the home. If Mrs Annan was not able to administer medication then her daughter would be supervised to do so. It was agreed that this recommendation be re submitted in this report. Mrs Annan stated that this person’s medication is kept in her bedroom. It was recommended at the last inspection that medication be stored in a locked cupboard in a part of the home so that it is accessible for inspection. Mrs Annan stated that she had purchased a medication storage cabinet but that it was too small and that she had reordered a larger one. She pointed out an area in the kitchen where the cabinet was to be fixed. Medication records were examined and were found to be up to date and accurate. As recommended at the last inspection Mrs Annan has kept a record receipts and returns of medication. All people who use the service are registered with a General Practitioner. There was evidence that peoples health care appointments are recorded in their personal files. People have access to chiropdists, dentists, optitians and Mrs Annan stated that people have an annual medication review carried out by their General Practitioner. Mayfield Road (12) DS0000028130.V341623.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 and 23. 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 has an appropriate complaints procedure in a format that people who use the service can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place so that people are so far as reasonably practicable protected from abuse. EVIDENCE: Mrs Annan stated that there have been no complaints made at the home since the last inspection. The home has a complaints procedure that people understand. At present Mrs Annan does not employ staff so there is no necessity for the home to have a whistle blowing procedure in place. The home has a copy of Croydon Councils Protection Of Vulnerable Adults Policy. Mrs Annan attended training on adult protection with Croydon Council on the 27th of February 2007 as required at the last inspection. Mayfield Road (12) DS0000028130.V341623.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 and 30. Quality in this outcome area is excellent. This judgement has been made using all the available evidence including a site visit to this service. The home is comfortable and very well decorated and people’s bedrooms reflect their individual taste. The home was clean and free from offensive odours throughout. EVIDENCE: The home is roomy, well decorated and comfortable. People have a bedroom that reflects their individual taste. They also have use of a large lounge, a large kitchen and a spacious rear garden. It was noted that one persons bedroom was being redecorated. Mrs Annan stated that new carpet was also being laid and that she planned to do the same in another person’s bedroom when this one had been finished. The home was free of odours, clean and hygienic. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 18 As previously stated Mrs Annan has applied to the Commission to increase the number of people living at the home from three to five. Mrs Annan stated that she plans to move out of the home and refurbish two bedrooms for prospective new people. Mayfield Road (12) DS0000028130.V341623.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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Residents can be assured that their individual and joint needs will be met by appropriately trained staff. EVIDENCE: Mrs Annan and her families Criminal Records Bureau Checks were observed at a previous inspection at the home. Mrs Annan sent copies of the homes staff rota’s to the Commission with the pre inspection questionnaire, the rotas indicated that Mrs Annan had been on double shifts everyday from the 23rd of April until 21st of May 2007. Mrs Annan stated that the current group of people living at the home are capable individuals, and able to make most decisions independently. Most need minimal support and none require support with personal care. Mrs Annan stated that although she carries out the majority of the care duties, there are times when she is not available and family members help out or agency staff is employed. Mrs Annan stated that she did not always record this on the staff Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 20 rota. It is recommended that the registered provider completes a staff rota that accurately reflects who is on shift and indicates when she has time off. Mrs Annan stated that she had attended training on first aid, food hygiene, fire safety, moving and handling and health and safety but that these had been some time ago. The registered provider must attend training or refresher training on first aid, food hygiene, fire safety, moving and handling and health and safety. As previously stated Mrs Annan has applied to the Commission to increase the number of people living at the home from three to five. Mrs Annan stated that she would develop a staffing rota that would reflect the assessed needs of people who use the service, she would ensure that all appropriate checks as stated in schedule 2 of the Care Standards Regulations Care Homes for Younger Adults are carried out before employing staff and that staff would attend an induction and all of the above mentioned training. Mayfield Road (12) DS0000028130.V341623.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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Residents can be assured that their independence and lifestyles will be supported by the way in which their home is managed on a day to day basis. EVIDENCE: Mrs Annan, formally a Registered Nurse, completed the Registered Managers Award at Bromley College on 16/08/06. Peoples self-centred plan includes a section on their opinions about living at the home. The current group of people who use the service are capable individuals, and able to make most decisions independently. People have signed to say that they do not wish to hold/attend house meetings. Mrs Annan stated that people prefer to carry on with their own routines and lifestyles, they are quite happy to discuss their own issues with her if they feel the need. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 22 It was observed that a resident’s questionnaire had been completed in the persons file sampled. Mrs Annan stated that everyone had completed the questionnaire. The questionnaire was not dated and Mrs Annan was not sure of when these had been completed. It is recommended that resident’s questionnaires be completed on an annual basis and dated when completed. The Commission Inspecting for Better Lives Annual Quality Assurance Assessment (AQAA) was discussed with Mrs Annan. As required at the last inspection Mrs Annan has made sure that the homes electrical equipment was checked. Mrs Annan produced evidence that Portable Appliance Testing had been carried out on the 26/01/07. LABA Electrical Services carried out the test but the engineer did not leave a certificate. Mrs Annan was advised to request a certificate for her records. It was recommended at the last inspection that Mrs Annan seek information on legionellas and produce a risk assessment to reduce the risk of legionnaires disease. Mrs Annan produced a legionellas-testing certificate for 23/02/07. Mrs Annan produced a Landlords Gas Safety Certificate for 25/05/07. Mrs Annan produced evidence that the homes fire alarm system is checked on a regular weekly basis. Mayfield Road (12) DS0000028130.V341623.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 3 X 3 X 3 X X 3 X Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 24 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 YA35 Regulation 18 (1) c Requirement The registered provider must attend training or refresher training on first aid, food hygiene, fire safety, moving and handling and health and safety. Timescale for action 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the registered provider contact peoples care managers and arrange for placement reviews to take place and request copies of the assessments to keep on peoples files. It is recommended that all people who use the service have their risk assessments reviewed, signed and dated on a regular basis. It is recommended that medication is stored in a locked cupboard in a part of the home that is accessible for inspection. It is recommended that the registered provider complete risk assessments for people that self medicate. It recommended that the home develop an appropriate recorded system for monitoring and supporting people to DS0000028130.V341623.R01.S.doc Version 5.2 Page 25 2. 3. 4. 5. YA9 YA20 YA20 YA20 Mayfield Road (12) 6. YA20 7. 8. 9. YA32 YA39 YA6 self-medicate. It is recommended that the registered provider complete a risk assessment that includes the arrangments for the administration of peoples medication if she is not able to do so. It is recommended that the registered provider completes a staff rota that accurately reflects who is on shift and indicates when she has time off. It is recommended that resident’s questionnaires be completed on an annual basis and dated when completed. So that the diverse needs of people who use the service are considered, care plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Mayfield Road (12) DS0000028130.V341623.R01.S.doc Version 5.2 Page 27 - 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!