Inspection on 09/11/06 for Beatrice Road, 36

This inspection was carried out on 9th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beatrice Road, 36 09/08/07

Beatrice Road, 36 08/02/06

Beatrice Road, 36 09/08/05

Beatrice Road, 36 08/02/05

Beatrice Road, 36 29/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beatrice Road, 36 London SE1 5BT Lead Inspector Ms Alison Pritchard Unannounced Inspection 9 November 2006 3:30pm th DS0000007107.V306479.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 DS0000007107.V306479.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. DS0000007107.V306479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beatrice Road, 36 Address London SE1 5BT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7252 0302 jo.morgan@choicesupport.org.uk www.choicesupport.org.uk Choice Support Mr Keshorsingh Beegun Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000007107.V306479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th February 2006 Brief Description of the Service: The home provides accommodation and care for 3 men with multiple and profound disabilities. It is one of a number of homes operated by Choice Support Southwark, which provides staffing and daily operational support services. The building is owned and maintained by Habinteg Housing Association. The property is similar in design to others in the street and is indistinguishable as a care home. As the home is a bungalow it is accessible throughout and there are a number of adaptations for people with disabilities. The home is located in a residential street in South East London, close to a shopping area with banks, cafes, pubs and public transport routes. The building has 3 single bedrooms, a lounge, dining area, kitchen, WC /laundry room, bath, shower room and a garden at the back of the house. There is an additional room that is used as an office and was previously used as a sleeping in room. Now that two waking night staff are on duty each night sleeping in duties are no longer necessary. At the time of this inspection, all of the residents were male, this has been the case for several years. The Registered Manager has informed the inspector in November 2006 that potential residents are given information about the home and the services available through the Statement of Purpose. Copies of CSCI inspection reports are made available to service users’ relatives, advocates and social workers. The current residents each make a weekly rent contribution of £32.95 and the weekly contribution for food costs is £29.40. The remaining costs of the placements are paid by placing authorities. There are no additional charges. DS0000007107.V306479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over a late afternoon and early evening in early November 2006. The inspection methods included observation of care practice, discussion with staff, inspection of service user files, as well as a range of records and policy documents. All of this information has been taken into account in compiling this report. All of the residents were at home during the inspection but none is able to communicate verbally so unfortunately it has not proved possible to include specific things that they said to the inspector. The Inspector spent time with residents and their activities were observed. Involved professionals were sent survey forms so that they could contribute to the inspection process. Feedback was received from one professional. The CSCI also has access to information gathered through notifications from the home. The inspection visit was facilitated by staff who were helpful and courteous throughout the process. What the service does well: What has improved since the last inspection? What they could do better: There should be more consideration of residents’ needs for activities in the home. There is scope for more specialist equipment to be provided to DS0000007107.V306479.R01.S.doc Version 5.2 Page 6 contribute to a more stimulating environment for the residents. This need could also be addressed through an unmet recommendation that the home provide a sensory garden. Some minor improvements are needed to the building, a review of the available storage could improve the homeliness of the environment. Some aspects of record keeping need to be improved – specifically – • some guidelines require review to ensure they are still relevant; • the complaints book and visitors book needs to be completed fully and • monitoring records should not be completed retrospectively. • there is an outstanding requirement concerning the need to arrange residents’ files so that information is easily accessible. Choice Support needs to be sure that the changes that have led to the Registered Manager of this home being responsible for the management of a near-by home are subject to agreement by the CSCI. 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. DS0000007107.V306479.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 DS0000007107.V306479.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): 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The policies and procedures for admission ensure that both the home and the potential resident have enough information to decide whether it would be an appropriate place for the person to live. When there is a need to be more flexible about an admission the best interests of the resident are protected. EVIDENCE: The admission policy of Choice Support includes provision for introductory visits to take place and for social work assessments to be obtained prior to admission. Placements are subject to a twelve week trial period. An assessment of need carried out under the Community Care Act by a social worker was on the file of one of the residents, along with other assessments by health care specialists. However the admission of this person was made in circumstances which were outside of the organisation’s usual procedure. This was in the best interests of the resident and the CSCI was properly informed about the process. Each resident is issued with a statement of terms and conditions about the services they will receive from the home. DS0000007107.V306479.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans are in place but residents would benefit further if the information was easier to access and if programmes and guidelines were reviewed regularly. The home ensures that people who are concerned about the residents are involved with decisions about their lives. EVIDENCE: Each of the residents has a file which includes details about how their care should be provided. The files each hold a substantial amount of information but it is not divided into sections in a way that allows easy access to the information. These files were examined, two in particular detail. The files include detailed guidelines which have been drawn up with, or in some circumstances, by specialist professionals such as speech and language therapists. Some of the guidelines were in need of review such as one person’s sensory programme which is dated April 2004, and another programme for communication using objects of reference had the same date. Review is necessary to ensure that the programmes meet the residents’ current needs and whether new aspects need to be added to reflect changes which may have DS0000007107.V306479.R01.S.doc Version 5.2 Page 10 occurred. Even if there are no changes to the programmes there should be confirmation that the review had taken place by signing and dating the document. This would indicate to care staff the programme’s current relevance. The residents need the help of other people to make sure that their needs are taken into account and their best interests promoted. Each resident has a key worker who is involved in planning meetings. Key workers and the manager of the home, relatives, advocates and social work staff are involved in planning decisions, appropriate for each resident’s situation. Residents are visited by an advocate who helps to promote their best interests. The managing organisation has links with a service called ‘Customer Watch’ which is a forum through which people with learning disabilities can express their views on the services provided through Choice Support (Southwark). This ensures that the opinions of service users generally are included in the overall planning of the organisation. Risk assessments were in place to help manage aspects of residents’ activities which may present risks. They had all been reviewed within the last year and were relevant and appropriate to the residents’ needs. Residents’ personal information is stored with due regard for confidentiality. Choice Support is registered under the Data Protection Act and there is a confidentiality policy to ensure that staff handle residents’ personal information with care. DS0000007107.V306479.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to take part in a range of activities but they would benefit from more equipment, appropriate to their needs. The meals provided meet residents’ health, cultural and nutritional needs. EVIDENCE: Guidelines were seen dealing with assisting a resident with sensory activities. When the inspector arrived at the home this resident was involved in this activity in his bedroom. Later a member of staff showed him a magazine with colourful pictures. Another resident has a computer in his bedroom and he later took part in computer games with the assistance of a member of staff and earlier had been to a local shopping centre. The third resident watched television, he has an exercise programme in place, which staff assist him with. A member of staff told the inspector about a recent holiday which he and the manager had accompanied a resident on. DS0000007107.V306479.R01.S.doc Version 5.2 Page 12 The residents would benefit from some specialist advice about the leisure equipment in the home. For example advice should be sought about access to adapted equipment to enable the resident who enjoys computer games to operate them more independently. This could enhance his enjoyment and develop his independence skills. Similarly the resident who likes sensory activities would benefit from a larger range of equipment to use. There is also an outstanding recommendation that the issues of gaining funding for a sensory garden continue to be explored. Residents take part in a range of activities in the community including shopping, trips to the local park, visiting a Pop In social club, and lunches in local cafés. Two of the residents have access to a vehicle which staff may drive and this allows them to access a wider range of leisure facilities in the community. The third resident’s access to the community is rather limited by his wheel-chair which is unsuitable. He has been assessed for a new wheelchair and is awaiting its arrival. Residents are supported to maintain relationships with family members and friends. The visitors’ policy takes into account a range of factors to the benefit of the residents. All staff are aware of the policy and have signed the policy document to confirm this. The routines of the home allow residents to have free access about the building. Staff were kindly and respectful when talking to residents. The meals are suitable for the residents’ cultures, varied and include fresh vegetables and fruit. The meals are liquidised for the residents and staff showed awareness of the need to blend the items separately so that they can experience the different tastes. Staff were seen to assist residents with their meals with patience and regard for their dignity. DS0000007107.V306479.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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 the service. There is careful attention paid to residents’ medical needs. When monitoring charts, for example of fluid intake, are completed this must be at the time of the procedure rather than from memory. Medication is safely managed. EVIDENCE: All of the residents have multiple disabilities and require a lot of assistance with their physical care. It is important that staff are familiar with the residents and their needs and routines as the residents forms of communication are not verbal. The staff have access to guidelines and risk assessments to ensure that there is a consistent approach to care. The staff were warm in their approach with residents and were seen talking to them calmly and with sensitivity. Residents looked relaxed and comfortable with staff. There has been a high level of input from health care professionals about the residents’ needs. Their advice has been incorporated into guidelines for care, daily routines and risk assessments – such as moving and handling procedures. DS0000007107.V306479.R01.S.doc Version 5.2 Page 14 As the residents are not able to give informed consent for medical procedures the home is familiar with the need to hold meetings with involved professionals, advocates and family members as appropriate to assess whether procedures would be in the residents’ best interests. there was plenty of information to show that the home follows up the residents’ health care appointments efficiently. The District Nurse visits the home regularly to carry out procedures which are outside of the home’s registration status. There were a number of monitoring forms for residents to monitor aspects of their health care needs, these included frequency of continence pad changes, food and fluid intake. Some of these charts had not been completed at all during the day of the inspection. Staff said that it was intended that the charts be completed at the end of the day. This practise can affect the accuracy of the records and it is required that the charts are not completed retrospectively. The records of continence pad changes is particularly important as a change by the PCT in the brand of these items has been judged by an advocate to be detrimental to the residents. A complaint has been made on the residents’ behalf about the issue. None of the residents is able to self medicate so this aspect of residents’ care is looked after by the home. The medication is stored safely and had been reviewed by the GP during 2006. the medication administration records were in good order. All staff have received training in how to administer a medication given rectally. The home had been visited by the PCT Community Pharmacy service in September 2006 and their assessment was that the home had a ‘well managed medication system’. DS0000007107.V306479.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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 the service. The complaints and vulnerable adults procedures contribute to the protection of residents. A record should be made of whether complaints are upheld or not. EVIDENCE: The complaints procedure is included in the home’s statement of purpose. It includes the timescales within which the managing organisation will respond to complaints. The details of other organisations to whom a complaint may be made are included – such as the CSCI and advocacy organisations. One complaint was recorded in the home’s complaints records, the matter had been followed up there was no record of whether the matter had been upheld or not. The CSCI has not received any complaints about the home. There are no adult abuse issues under investigation, and none had been investigated over the last year. All of the staff have undertaken training in adult abuse issues. There are safe procedures for dealing with residents’ finances which are managed on their behalf by the home. Balances of cash are checked at each shift handover and management checks are conducted to ensure that the record is accurate and that money has been spent appropriately. DS0000007107.V306479.R01.S.doc Version 5.2 Page 16 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, 25, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Bedrooms and communal areas are comfortable, well furnished and suitable for the residents. Some improvements will improve the homeliness of the building. The home is very clean. EVIDENCE: The home is a bungalow, accessible to all of the residents. Each resident has their own bedroom which is suitable for their needs. The communal areas are a living room, a dining room and a kitchen. There is a bathroom with adaptations and a separate WC which adjoins a laundry. To the rear of the home is an accessible garden which has been improved by a new higher fence which allows more privacy for the residents. Some things detracted from the homeliness of the building: • a notice on the wall of the bathroom had been damaged by water and was covered in mildew, making it illegible and unsightly; • there was a lot of rubbish in the garden awaiting removal; • there were two spare commodes awaiting collection; • in the living room aids and other items were stored in the corner. DS0000007107.V306479.R01.S.doc Version 5.2 Page 17 The storage arrangements in the home need review and to be improved if possible. The home has liaised with specialists to ensure that the residents are supplied with the equipment they need to meet their needs and assist them to maintain their independence. The home was clean and there were no offensive odours. DS0000007107.V306479.R01.S.doc Version 5.2 Page 18 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, 33, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents benefit from a staff team which is familiar with their needs, well supported and trained and which works well together. The staffing levels are high and appropriate to the high support needs of the residents. EVIDENCE: In addition to the team manager there are seven permanent care staff, including two who work solely at night time. In addition a member of the Choice staff bank works at the home regularly. Vacancies caused by sickness and staff holidays are covered by bank workers familiar to the residents and by members of the permanent staff team working additional hours. There are measures in place to ensure that permanent staff do not work an unreasonable amount of extra hours. During the day time there are always three members of staff on duty. At night time, a member of staff is awake in the home. Additional support is available at night- time through the on-call system. Staff were observed to be relaxed and warm to residents. All but one of the staff team have already achieved NVQ level 2 and the other person is currently studying towards the qualification. Additional training is DS0000007107.V306479.R01.S.doc Version 5.2 Page 19 provided by Choice Support in a range of topics including those which are considered mandatory for the role such as fire safety; health and safety; adult protection and food hygiene. The staff said that the managing organisation provides very good training opportunities, one staff member was looking forward to a course about working with families soon after the inspection. Staff said that the team works very well together and observation during the inspection verified this. They confirmed that they receive regular supervision and annual appraisals, also that there are staff meetings regularly. One member of staff commented that it was a pleasure to come to work. DS0000007107.V306479.R01.S.doc Version 5.2 Page 20 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, 42, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The Registered Manager has been given additional responsibility for managing another home in a neighbouring street. This must be subject to CSCI agreement through the registration process. The residents’ interests will be further safeguarded by ensuring that the home is visited each month by manager from Choice Support. The visitors’ book must be completed for all visitors to the home. Residents are protected through careful attention to health and safety matters. EVIDENCE: The Manager of the home has been registered as Manager of this home under the Care Standards Act since February 2005. The Manager was unavailable at the time of the inspection. The inspector was told that the Manager and a DS0000007107.V306479.R01.S.doc Version 5.2 Page 21 member of care staff had accompanied a resident on holiday illustrating his close involvement with the residents of the home. The management arrangements at the home changed shortly before the inspection took place. The changes mean that the manager is now responsible for the management of 36 Beatrice Road and another home in a neighbouring street. This will mean that there will be less management input to this home. This arrangement needs to be subject to consideration by the CSCI as it is required by the Care Standards Act that a person who manages more than one establishment must make a separate application in respect of each of them. A requirement is made that applications for registration are made to reflect the management changes which Choice Support has introduced. The last report on file in the home of a manager’s visit as required by Regulation was dated August 2006. Examination of the visitors’ book showed that there had not been a manager’s visit since then. This indicates that a more robust approach is required to internal monitoring systems. On examining the visitors’ book it was found that there were very few entries of the name of a regular visitor to the home. The visitors’ book must be maintained as an accurate record and if a visitor is reluctant to complete the record it can be completed by staff. Regular checks of health and safety matters in the home are carried out, including checks of the operation of the fire safety systems and fire drills. DS0000007107.V306479.R01.S.doc Version 5.2 Page 22 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 3 X DS0000007107.V306479.R01.S.doc Version 5.2 Page 23 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 YA41 Regulation 17 (3) Timescale for action The Registered Manager must 01/02/07 ensure that case files are maintained in an orderly manner that ensures that current needs, goal and risk assessments are clearly visible The risk assessments were accessible as they had been put in another file. However the residents’ main files remain in need of reorganisation. The previous date for compliance was 01/05/06, a new date for compliance is set. 2 YA6 15(2)(b) The Registered Person must 01/02/07 ensure that support guidelines are reviewed to assess their relevance. The Registered Person must 01/02/07 ensure that they investigate the availability of specialist leisure equipment to meet the residents’ needs. The Registered Manager must 01/12/06 ensure that the record of complaints includes details of the action taken in respect of DS0000007107.V306479.R01.S.doc Version 5.2 Page 24 Requirement 3 YA14 16(2)(n) 4 YA22 17(2) sch4 para 11 complaints. 5 YA24 23(2)(d) The Registered Person must 01/12/06 ensure that the water-damaged notice in the bathroom is removed. 26(1)(4) The Registered Person must 01/12/06 (c) ensure that visits as required by Regulation are carried out each month. Reports of visits must be available in the home for inspection. CSA 12(4) It is required by the Care 01/01/07 Standards Act that a person who manages more than one establishment must make a separate application in respect of each of them. The Registered Person must ensure that the applications to the CSCI are made to reflect the management changes. 17(2) sch4 para17 The Registered Person must 01/12/06 ensure that the visitors’ book is an accurate record of all visitors to the home. 6 YA39 7 YA37 8 YA39 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 YA24 Good Practice Recommendations The issues of gaining funding for a sensory garden continue to be explored. This matter is not yet resolved. 2. YA23 The Registered Provider must clarify their arrangements with regard to how residents money is managed, hold a best interest meeting to make decisions about this and how to unfreeze the residents bank account DS0000007107.V306479.R01.S.doc Version 5.2 Page 25 The Inspector was informed that this matter is still being addressed and is not yet resolved. 3. YA24 Consideration should be given by the Registered Person to how the storage arrangements in the home can be improved. The Registered Person should ensure that monitoring charts are not completed retrospectively as this can lead to errors and inaccuracies. 4. YA19 DS0000007107.V306479.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000007107.V306479.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. 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