Inspection on 23/05/06 for Beattyville Gardens (116)

This inspection was carried out on 23rd May 2006.

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

Beattyville Gardens (116) 16/01/06

Beattyville Gardens (116) 19/04/05

Beattyville Gardens (116) 18/11/04

Beattyville Gardens (116) 06/07/04

Beattyville Gardens (116) 10/02/04

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 Beattyville Gardens (116) Diamond Lodge 116 Beattyville Gardens Ilford Essex IG6 1JZ Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 23rd May 2006 09:30 Beattyville Gardens (116) DS0000025887.V296803.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 Beattyville Gardens (116) DS0000025887.V296803.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. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beattyville Gardens (116) Address Diamond Lodge 116 Beattyville Gardens Ilford Essex IG6 1JZ 0208 503 9411 020 8550 4511 beattyville@norwood.org.uk 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) Norwood Ravenswood Ms Johannah Diffley Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with mild to moderate learning disabilities Date of last inspection 16th January 2006 Brief Description of the Service: Diamond Lodge is a care home registered to look after six younger adults with learning and physical disabilities. It is run by Norwood, a not for profit Jewish organisation. Hence, the ethos of the home is based around Jewish beliefs, customs and faith. The home is situated in a residential location, close to the local shopping area, providing easy access to all local amenities, nearby leisure facilities and transport services. Service users have mild to moderate dependency needs. They are cared for in suitably adapted premises and all service users occupy their own single rooms, which are well furnished and decorated. All service users are supported by the manager and staff to maintain their independent living skills, attend college for various courses as well as accessing community facilities locally as well as at the John Steiner Centre (Jewish Community Centre) in Barkingside. Activities are organised both within the home and within the local community, and service users are encouraged to attend college, day centres and local clubs. Personal care is provided on a 24-hour basis, and healthcare needs are met by staff supporting service users to attend appointments with health professionals. The fees range from £868.23 - £1,581.15. A Statement of Purpose and Service Users Guide are available to the service users and their representatives. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two separate visits on 23/05/06 and 31/05/06. This was a key inspection visit as part of the inspection programme for 2006/2007. The communal areas of the home were visited on the first day. Staff records were examined on the second day and service user records were examined on both days. Service users were asked to give their views of the service and their experience of living in the home. Questionnaires were sent to service users, comment cards were sent to visitors and relatives. Staff feed back cards were also sent. All the service users returned the questionnaires expressing satisfaction with the service provided and the care they receive. Feedback from a regular visitor to the home was as follows, “I have always been extremely impressed by the care and attention of the staff towards clients at Beattyville. The clients seem very happy and well cared for.” The following comment was received from a member of staff, “all our service users receive a great quality of care. This is a very busy house, with activities and going out in the evenings, which service users are always asking to do.” Relatives also expressed satisfaction with the way the service was operated and the overall care provided within the home. The inspector took the opportunity to speak to a complementary therapist who was visiting the home during the inspection on the second day. Discussion took place with the deputy manager on the first day and the registered manager on the second day. Care staff were asked about the care that service users receive, and were also observed carrying out their duties during both visits. The inspector attended the staff meeting on the first day and was able to hold a group discussion with the staff after the meeting. Service users were spoken to on both days of the inspection. An enforcement notice was issued to on third January 2006 for breach of Regulations in relation to failure to carry out monthly Regulation 26 visits. At this inspection the registered providers were able to evidence that the statutory requirement notice has been complied with. The inspector would like to thank the staff and the residents for their input and assistance during the inspection. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although staff files inspected contained the information required, these should be kept in an orderly manner so that information can be easily accessed. Each staff file must include a photograph of the person employed. A quality assurance questionnaire to be sent to relatives and health professionals annually and views gained from the service users about the operation of the home. Once this information has been gained an analysis should be undertaken to gauge whether the home is meeting its stated aims and objectives in the Statement of Purpose. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 7 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. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 8 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 Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 9 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): 2,3,4 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. A detailed pre admission assessment is undertaken of all prospective service users which ensures that their needs are identified and that these needs can be appropriately met by the home. Prospective service users and their relatives are able to visit the home prior to their admission. Trial stays are offered before the service user decides if they wish to live there permanently. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The registered persons are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. Evidence confirms that the assessment is conducted professionally and sensitively and involves the service user, their family or representative of the service user. The admission will only take place if the registered persons are confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. There have been no new admissions to this home since October 2003. The inspector is satisfied that the above process would be followed by the service should a vacancy arise. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 10 The files for three service users were examined. There was evidence on these files to show that the service users’ needs are re - assessed regularly and care plans are updated if they need to change. Family members and other professionals involved in the care of each individual service user are fully consulted and involved. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 11 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): 6,7,9 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users’ health, personal and social care needs are set out in an individual plan of care, and are detailed enough to provide staff with sufficient information about how to meet the service user’s individual needs on a day-today basis. Staff provide service users with assistance and support to enable them to make decisions about their own lives and appropriate risk assessments are in place. EVIDENCE: The care plans of three service users were examined. Staff and service users were asked about the care being provided. Each service user has an individual personal plan, which outlines the service users individual needs and how these will be met. Evidence was seen on the day of the inspection that the service users are asked about what they would like to do on a daily basis. The service users spoken to confirmed this. The service users knew who their key workers were Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 12 and they said that they would talk to them or the manager or deputy if they had any problems. Evidence was seen on daily logs that staff prompt and assist service users to carry out tasks according to their capabilities and needs. Comprehensive risk assessments are in place for the different activities that service users take part in and service users are supported by staff to carry out their chosen activities, within this framework. Daily records showed that staff record what the service user has done every day which reflects their care plan and daily activity plan. The individual personal plans are reviewed regularly and updated to reflect changing needs. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users have opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. The home is particularly good at being able to meet the cultural and religious needs of people from a Jewish background. Service users’ rights are respected and responsibilities are recognised in their daily lives. Service users enjoy their meals and are asked on a daily basis to choose from the menu which they have already agreed. They often help staff to prepare meals. Special diets are catered for, especially the provision of kosher diets in line with Jewish faith and customs. EVIDENCE: The service users were asked their views, and the lifestyle of the service users was observed over the two days, as well as care plans being examined. Most of the service users attend college, as well as participate in activities in the community and at the local Jewish community centre Leonard Steiner Centre. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 14 Service users go out to the cinema, the pub and various other daily activities including swimming, shopping and eating out. The daily routine is set by the activities that the service users are involved in, which are outlined in their daily activities plan. The service users confirmed that they do activities that were listed on their activity plans. The activity plans show that these routines promote individual choice and freedom of movement. One service user stated that he does not wish to go to the gym any more and this was to be discussed with his key worker when his plan was to be reviewed. Staff support individuals to pursue their own interests and hobbies. Staff support the service users to maintain family links and friendships inside and outside the home and their involvement is encouraged, with individual service user’s agreement. Three service users regularly spend weekends at home and contact with the families of the other service users is encouraged and supported by staff. Relatives and friends are able to visit at any time and no restrictions are placed on visiting times. No relatives were visiting at the time of the inspection. Meals are recorded on a daily form and there is a menu set for each week. Service users spoken to stated that they enjoyed the food and are offered a choice on a daily basis. Staff are aware of individual likes/dislikes and were aware of service users who have special dietary needs. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 15 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 judgment has been made using available evidence including a visit to the service. The medication policies and procedures are clear and the staff had received training to ensure safe administration of medication to the service users. Service users’ physical health care needs are monitored which ensures that service users’ needs are recognised and met. EVIDENCE: Organisational policies and procedures for the handling and recording of medicines in the home are available. The majority of staff had received an appropriate level of training. The care plans examined and records of referrals to specialist healthcare professionals and appointments were being kept. Records examined showed that service users are seen by dentists, opticians, chiropodist, district nurses and doctors as and when required. Staff also support service users to attend outpatient clinics. A record is maintained of the current medication for each service user and most of the staff working in the home have received updated medication administration training. None of the service users administer their own medication as they are not able to do so. Medication administration records were observed to be appropriately completed. Evidence was seen of medication being administered to a service user on the second day of the inspection with staff following the procedure. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 16 Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 17 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 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The manager and staff make every effort to sort out any problems and concerns. All complaints and issues of concern are recorded and followed up so that the service users and their relatives feel confident that their complaints are listened to and will be acted upon. All staff, except two new staff, working in the home have received training in adult protection/abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There is a written policy and procedure for the protection of vulnerable adults and whistle blowing. All newly recruited staff receive abuse awareness training during their induction training. Evidence was seen that most staff have repeated the above training and two new staff are due to complete this training. The staff spoken to as part of the inspection process, confirmed that they have completed adult protection training and were clear as to their responsibilities to report any potential abuse and of what the reporting lines should be. There were two adult protection matters that were subject to investigation. The registered person has followed procedure and kept the inspector informed whilst addressing these matters. Four complaints have been logged since the last inspection which have been appropriately logged and investigated with the appropriate action taken to resolve these issues. The complaints procedure is also available in pictorial format and the service users spoken to confirmed that they would know the procedure to follow should they have a complaint. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 18 Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 19 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, 30 The quality in this outcome area is good. This judgment is made using the available evidence including a visit to the service. The home is comfortable, clean and hygienic which enhances the well-being of the service users. EVIDENCE: The home was clean and free from odours throughout. Individual care plans and daily records show the importance of stressing personal hygiene to the service users for example washing hands frequently. Service users stated that their bedrooms are individually decorated and are filled with personal possessions. Service users spoken to said that they liked their bedrooms and were comfortable and safe in them. The lounge and dining area have been refurbished and were bright and clean. There is a small garden at the back of the house accessed via the kitchen and dining room. This is now a safe area for service users to access and is enjoyed by them during fine weather. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home employs staff in sufficient numbers, to meet the needs of the service users. There is an organisational procedure for the recruitment of staff, which is robust and provides safeguards for people living in the home. EVIDENCE: The organisation continue to recruit staff from overseas who undergo a twelve week induction programme and shadow the existing staff group, which assists their learning and development before working on shifts. On the day of the inspection they were two new staff from the Philippines who were undergoing their training. They confirmed that they are doing induction training at the present time. In discussion with staff, it was evident that they fully support the main aims and values of the home. Staff have developed a good knowledge and understanding of the Jewish culture and faith via the induction and ongoing training provided by the organisation. Service users said that the staff are kind and caring towards them and know what they need. The manager was satisfied with the level of staffing provided at the present time and the use of peripatetic staff has been reduced. The manager acknowledges that permanent staff provide continuity and consistency to the service users which is vital for their safety and security. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 21 Staff records were examined and showed that service users are supported and protected by the homes recruitment policy and practices. Staff supervision is taking place and all staff are having set formal supervision sessions. Training records were also examined and showed that staff are given the opportunity to attend ongoing training as part of effective service delivery. Of the care staff employed four hold NVQ level 2 training, a further two are working towards achieving this qualification. 50 of the staff hold NVQ level 2 qualifications. Although the staff records examined contained a photocopy of the staff member’s identification and photograph, the inspector recommends that the manager includes the employment record form on each staff file together with a photograph of each member of staff for clarity and identification. The staff files to be organised in a way which provide information easily. Beattyville Gardens (116) DS0000025887.V296803.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 The quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The manager is an experienced and qualified person. The home is run in a way which ensures that the service users’ interests are safeguarded by the home’s record-keeping. Staff are aware of the lines of accountability and monitoring systems within the home are robust enough to ensure that the manager is fully appraised of any issues relating to the day-to-day running of the home and the specialist needs of the service users. EVIDENCE: The current manager is experienced and has managed the home for the past six years. The manager has almost completed the Registered Managers Award and has begun the NVQ level 4 course. The home is run in a way which provides a safe environment and the service users health, safety and welfare are met by the staff working in the home. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 23 All records are held securely. Service users would be able to have access to their records. All accidents are recorded and appropriate action is taken when required. Induction training for new stuff is being achieved with further ongoing training being offered. Health and safety checks and the associated records were appropriately completed in line with the Regulations. Individual risk assessments for each service user are in place. A statutory requirement notice was issued on 3rd January 2006 for failure by the responsible individual to undertake monitoring visits to the home in compliance with the Regulation 26 of the Care Home’s Regulations 2001. Since the issuing of this notice the registered individual has complied with this regulation. Monitoring visits are now being undertaken by the designated representative of the organisation to monitor and report on the quality of the service provided in the home. These reports are sent to the commission promptly. The inspector was informed that lay monitoring visits are regularly undertaken by lay monitors appointed by Norwood and one representatives off of relatives in the Perry group, a group of parent representatives. An auditor appointed by the registered persons carries out regular financial audits. However, an annual quality assurance review of the whole service should take place about the operation of the home and opinions from service users, relatives and any health professionals as well as other representatives involved in the care of the service users must be sought. This quality audit should be analysed and the findings should form part of the Service Users Guide. The inspector was informed by the responsible individual that as part of this process a “user lead focus group” has been formed to seek the views of the service users, indicating that this process has begun. See requirement. Beattyville Gardens (116) DS0000025887.V296803.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 X 2 3 3 3 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 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 3 3 X Beattyville Gardens (116) DS0000025887.V296803.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 YA39 Regulation 24 Requirement The registered person to establish and maintain a system for reviewing and improving the quality of care at the care home. A report in respect of any review conducted, to be made available to the Commission and the service users. Timescale for action 31/12/06 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 YA34 Good Practice Recommendations Although staff files inspected contained the information required, these should be kept in an orderly manner so that information can be easily accessed. Each staff file must include a photograph of the person employed. Beattyville Gardens (116) DS0000025887.V296803.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Beattyville Gardens (116) DS0000025887.V296803.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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