Inspection on 24/07/06 for Cambstone Close 1

This inspection was carried out on 24th July 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cambstone Close 1 18/12/06

Cambstone Close 1 09/01/06

Cambstone Close 1 07/07/05

Cambstone Close 1 11/01/05

Cambstone Close 1 09/08/04

Cambstone Close 1 15/01/04

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

CARE HOME ADULTS 18-65 Cambstone Close 1 New Southgate London N11 1JQ Lead Inspector Anthony Lewis Key Unannounced Inspection 24th July 2006 08:50 Cambstone Close 1 DS0000010416.V301132.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 Cambstone Close 1 DS0000010416.V301132.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. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambstone Close 1 Address New Southgate London N11 1JQ 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 8368 5169 amansell@pentahact.org.uk www.pentahact.org.uk Adepta Mr Adam Paul Mansell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: 1 Cambstone Close is a care home registered to provide care for four adults who have learning and physical difficulties. The home is a large bungalow with off street parking for one vehicle to the front. The home is situated on a relatively new housing estate in New Southgate near local shops, a library, Barnet College campus and Brunswick Park. All service users have their own single furnished bedrooms, which are decorated and furnished to the service users personal preferences reflecting their hobbies and interests and with pictures of their family and various activities. There is a large nicely decorated lounge, which has sensory equipment at one corner for service users. There is a large kitchen/diner. There are two male and two female service users living in the home. All have learning, physical and sensory disabilities. Sanctuary Housing Association own the building and the home is operated by PentaHact, a company limited by guarantee, which provide a number of registered and care services in London and the South East of England. The staff team aims to provide a Person Centred Approach to service users individual needs, ensuring that they adhere to the principles of choice, respect, dignity, community presence and community participation. The fee for residents living in the home is £1,600 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 24th July 2006 at 08.50am and was completed at 3.15pm. The registered manager was not available, however, the assistant manager was available throughout the inspection process and was very helpful. On arrival one of the residents was preparing to leave the home for a one week holiday with two members of staff. Since the previous inspection, the organisation has changed its name from PentaHact to Adepta. To gather evidence for this inspection, all four residents’ files were viewed along with six staff files, various documents, policies and procedures and safety certificates. Due to communication difficulties the three residents were spoken to informally, at times the staff were on hand to interpret what some of the resident’s responses may mean. Three members of staff were spoken to formally in private. Residents and staff were indirectly observed and overheard throughout the inspection process. A comprehensive internal and external tour of the home was conducted with the assistant manager. What the service does well: What has improved since the last inspection? What they could do better: Twelve requirements have been made at this inspection, two of which are restated from the previous inspection. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 6 In order for residents’ need to be fully understood and met, more effective communication methods between the residents and staff must be reviewed. To ensure that the staff can meet all of the needs of the residents, the residents or their representatives must be involved in drawing up their care plans. A representative must be appointed to ensure that residents’ needs are conveyed to the staff team and the representative can speak on behalf of the residents. Residents’ risk assessment must be reviewed regularly with the resident or their representatives. Staff must ensure that the identified resident receives professional input to enable him to access his local community. Due to the serious concerns about meals and mealtimes, a review of residents’ likes and dislikes and meal preparations must take place to ensure that residents are being treated with respect, dignity and meals are to residents’ requirements. To ensure that residents are not put at risk, staff must ensure that they follow the correct procedures when administering medication. To ensure that all complaints are taken seriously, the correct procedures must be adhered to. If residents are to be protected from abuse, all staff must receive the appropriate training. All areas of the home must be adequately maintained to ensure that the residents live in a homely environment. Staff must receive the required training to ensure that they have the skills to meet the needs of residents and ensure the health and safety of the residents. The annual quality assurance system and development plan must be available to judge the quality of service delivery to the residents. 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. Cambstone Close 1 DS0000010416.V301132.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 Cambstone Close 1 DS0000010416.V301132.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 and 3. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although the home has an effective assessment procedure, the lack of effective communication methods between the residents and staff means that some of the residents’ needs may not be met. EVIDENCE: All of the residents have lived in the home since it opened in 1997. Their assessments were not available to view however; the service users’ guide was viewed and contained detailed information, in pictorial format, that described the assessment process for prospective residents. All of the residents have some form of communication difficulty and each communicate on a different level. When asked, the assistant manager was not able to describe in detail how the staff communicate with the residents on many everyday matters. It was observed that although staff were able to understand some of what the residents were saying, either through their gestures or sounds, at times they found it difficult and were observed and overheard asking questions until they understood what the resident was saying. Although a requirement was made regarding the reviewing of communication at the previous inspection, this has not been carried out. This requirement is revised and restated. Cambstone Close 1 DS0000010416.V301132.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 and 9. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Due to poor record keeping and reviewing of information, some of the residents’ needs and choices may be overlooked and not fully met by the staff. EVIDENCE: The care plans of all of the residents were viewed and although they were comprehensive in that they contained information such as personal care, domestic skills, health care, and social understanding, there was no evidence to prove that the residents or their representatives were involved in drawing up their care plans. A requirement is made regarding this. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 10 When spoken to about decision-making, the assistant manager stated that the staff make decisions for the residents. When spoken to, staff were able to describe how they support residents to make decisions when carrying out the residents’ personal care, when choosing clothing and with regards to meals. However, out of the four residents, only one has involvement from relatives to support them to make decisions and none of the residents have an advocate to act on their behalf. A requirement is made that where residents have limited capacity to make their own decisions, a representative must be appointed to act on their behalf. When asked for, the risk assessments for two residents could not be found. The risk assessments for another resident dated back to 3rd April 2004 and there was no evidence that the risk assessments available, are regularly reviewed and that the residents or their representatives are involved in the review process of drawing them up. A requirement is made that the registered persons ensure that residents’ risk assessments are reviewed regularly and that the residents or their representatives are involved in the process. Cambstone Close 1 DS0000010416.V301132.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, 15, 16 and 17. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Although most residents are a part of their local community and have the opportunity to meet new people, staff are not doing as much as they could to ensure professional advice is sought to ensure that all residents can access their community The practices that some staff have adopted are not ensuring that residents are treated with respect and in a dignified manner with regards to meals and mealtimes. EVIDENCE: Each resident has an activities timetable, which contains details of all of their activities throughout the week, in the home and outside in the community. According to the assistant manager, one of the residents has a paid part-time paper-round, which he does in his local neighbourhood with staff support once a week. Information about this was seen in the resident’s care plan. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 12 Although residents are relatively active in the community and attend social activities such as, shopping, swimming, going to restaurants, the assistant manager said that one of the residents is visually impaired and agoraphobic and has not left the home for many years. When looked at, there was no evidence in his care plan of a diagnosis of his agoraphobia or any professional input to help him overcome his agoraphobia. When discussed at length with the registered manager, he stated that because of the resident’s phobia, he has not been able to access activities in the local community. A requirement is made that the registered persons must ensure that the identified resident receives a professional assessment and input with regards to his agoraphobia and that information is recorded in his care plan. Most of the residents have no contact with their relatives and no friends. The assistant manager stated that one resident sees members of their family. A support worker spoken to stated that residents are supported to access their community with the potential of meeting new people. She went on to say that some of the residents are known within their local community and at some of the local shops. Some residents were observed moving about the home freely and with staff support when required. Staff were observed and overheard interacting with residents in a supportive, patient and courteous manner at all times. Residents seemed comfortable when in the company of staff. The menu for the past four weeks was viewed and contained a variety of adequately nourishing and healthy meals such as, salads, meets and vegetables. However, there was not enough evidence in residents’ care plans to show what meals they like and dislike, even though there was a section for this information to be added. In addition, the care plans indicate that all residents should have their meals liquidised due to the threat of choking when eating. A member of staff was indirectly observed preparing lunch, which was fish, chips and peas. She was observed adding the fish, chips and peas all together in a blending machine. Once blended, she was observed scooping out the blended foods and placing a huge amount into a large plastic serving bowl and giving it to a resident to eat. The table was not set for lunch and there was no division of the foods and the meal looked unattractive. This was discussed at length with the assistant manager. A requirement is made that the registered persons ensure that a comprehensive review of foods that residents like and dislikes takes place and is recorded and a review of meal preparation takes place and the details are recorded. Cambstone Close 1 DS0000010416.V301132.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 and 20. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The staff are ensuring that residents’ personal and health care needs are being met. However, staff are putting residents at risk by not ensuring that correct medication administration procedures are followed. EVIDENCE: Daily support of residents was discussed with two of the support staff. They were both able to describe how they support the residents, especially when carrying out personal care. The care plans of all of the residents were viewed and all contained information on the residents’ preferences and choices with regards to their personal care, such as whether they prefer a bath or a shower, dressing and how staff should support them with their oral hygiene. On the day of the inspection, a community nurse visited a resident. She was spoken to at length about her connection with the home. She explained that part of her caseload is to ensure that areas of the residents’ health care needs are assessed by her and advice given to staff on how to support the residents with their health care. In addition, each resident’s care plan contained an updated “Health Action Plan,” with information on their present health and changing needs and professional intervention, which was a requirement at the previous inspection. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 14 The assistant manager stated that none of the residents administer their own medication. Whilst looking at the residents’ Medication Administration Record (MAR) sheets, a number of unexplained gaps were found. These gaps were discussed with the assistant manager who was not able to explain the reason for the gaps. A requirement is made regarding this. Cambstone Close 1 DS0000010416.V301132.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 and 23. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Staff are not taking residents’ complaints seriously enough and residents are not being protected from abuse by staff receiving adequate training. EVIDENCE: The home has Adepta’s complaints policy and procedure, which states clearly the philosophy and aims of the organisation. In addition, the home also has a book to record all complaints made. When viewed, the last recorded complaint was on 1st August 2004. There was information about the complaint but no evidence of the investigation and the outcome of the complaint. A requirement is made regarding this. The home has Adepta’s policy and procedure for the protection of vulnerable persons from abuse, which contains information on how to recognise signs of potential abuse and the steps to take when an abuse situation to an adult is suspected or occurs. However, when spoken to, the assistant manager stated that most of the staff have not as yet received protection of vulnerable adults training. A support worker also confirmed this. In addition, when staff files were viewed, there was no evidence to show that any of them had received the training. A requirement is made regarding this. Cambstone Close 1 DS0000010416.V301132.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 and 30. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although the home is clean and tidy inadequate maintenance of some parts of the home is being overlooked, which does not ensure that all areas look homely. EVIDENCE: While touring the home with the assistant manager, most areas were homely and comfortable. One residents was spoken to briefly and asked whether he was comfortable, he replied quite quickly, “Yes I am,” he then smiled. In various areas in the home, a number of cracks were seen in the hallway on walls above doors. With the lights off in the hallway, the home was quite dark and dull looking. A requirement is made that a review of the maintenance of the home is undertaken. Three of the four bedrooms were seen and all were decorated to a good standard with adequate furnishings and fittings. There were also residents’ personal possessions such as photographs of family and other pictures and ornaments giving the rooms a cosy feel to them. The home has a dedicated part-time cleaner who ensures that all areas are clean and tidy and free from any offensive odours. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 17 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): 31, 32, 34 and 35. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although adequate staffing arrangements are in place and the staff have a good understanding of the individual and collective needs of the residents, residents are being put at risk due to staff not receiving all of the necessary training. EVIDENCE: All of the six staff files seen contained a copy of the staff’s job description. The four staff spoken to were able to describe their roles and responsibilities and their understanding of the residents’ needs and individual personalities. The staff rota indicates that there are at least two staff on the early and late shifts. In addition there is also the registered manager. A member of staff said that she felt that there are enough staff on duty to meet the needs of the residents. Throughout the day the staff seemed able to cope with supporting the residents and other duties. A member of staff spoken to said that she felt that there are enough staff on duty to meet the needs of the residents. The personal files of five staff were viewed and all contained the required recruitment information such as a recent photograph, two references, an application form and a Criminal Records Bureau (CRB) check. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 18 Staff training is monitored by a matrix, which lists the courses that staff have attended or have been booked to attend. While looking through the matrix, there were a number of references where staff either did not attend the training or the course were cancelled. There was no evidence to ascertain whether the staff had eventually received the training in areas such as food hygiene, health and safety, adult protection training or moving and handling. In addition, there were very little training certificates in staff files to show that they have received the required training. This was discussed with the assistant manager who was not able to determine whether the staff had received all of the necessary training. A requirement is made regarding this. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The home has a competent manager who is ensuring that people in the home are kept safe. A lack of robust quality monitoring does not ensure that the home is meeting their aims and objectives. EVIDENCE: The registered manager is a qualified counsellor and has a National Vocational Qualification (NVQ) level 4. Staff spoke positively about the way in which they felt the home is being managed. One member of staff said that there have been some positive changes, especially with regards to administrative issues, since the manager took up the post last year. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 20 Adepta has a quality assurance manager, whose role is to co-ordinate reviews of the quality of service provided, through sending out questionnaires to residents, staff and other stakeholders. The information from the questionnaires received back are forwarded to operations managers and registered managers who will structure their development plan according to the views and comments from the questionnaires based on their overall findings. However, the assistant manager was not able to locate the annual quality assurance and development plan for the home. A requirement is made regarding this. The staff are ensuring that all health and safety checks are carried out regularly. Fire drills and tests have been occurring regularly and all safety certificates such as gas, London Fire and Emergency Planning Authority (LFEPA) and the Portable Appliances Test (PAT) were seen and were up to date and in order. Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 21 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 2 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 x LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 2 X X 3 x Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 22 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 YA3 Regulation 12 (2) (3) Requirement Timescale for action 01/12/06 2. YA6 3. YA7 4. YA9 5. YA13 The registered persons must ensure that there is a review of the way in which residents communicate their wishes and feelings and training is provided to residents and staff where appropriate. (Timescale of 31/03/06 not met) This requirement is revised and restated. 15(2)(b),(c) The registered persons must (d) ensure that residents or their representatives are involved in drawing up their care plans. 12 (2) (3) The registered persons must ensure that where residents lack the capacity to communicate their choices or decisions, a representative is appointed. 13 (6) The registered persons must ensure that residents’ risk assessments are reviewed regularly and residents or their representatives are involved in the review process. 12 (1) (a) The registered persons must (b) ensure that the identified resident receives professional input with regards to his DS0000010416.V301132.R01.S.doc 27/10/06 01/12/06 24/11/06 01/12/06 Cambstone Close 1 Version 5.2 Page 23 6. YA17 16 (2) (g) (i) 7. YA20 13 (2) 8. YA22 22 (3) (4) 9. 10. YA23 YA24 18 (1) (c) (i) 23 (2) (b) 11. YA35 18 (1) c (i) 12. YA39 24 (1) (2) (3) agoraphobia and that information is recorded in his care plan. The registered persons must ensure that a comprehensive review of foods that residents like and dislike takes place and is recorded in their care plans and a review of mealtimes and meal preparation takes place and the details are recorded. The registered persons must ensure that the administration of all medicines is signed for on the (MAR) sheets and any nonadministration coded as to the reason why the medication was not administered. The registered persons must ensure that information about all complaints are correctly recorded. The registered persons must ensure that all staff receive adult protection training. The registered persons must ensure that a review of the maintenance of the home is undertaken. The registered persons must ensure that all staff receive appropriate training and that a copy of their certificates are kept in their file for inspection. (Timescale of 31 /03/06 not met) This requirement is revised and restated. The registered persons must ensure that an effective quality assurance monitoring system is in place. 25/08/06 11/08/06 11/08/06 27/10/06 22/09/06 24/11/06 24/11/06 Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Cambstone Close 1 DS0000010416.V301132.R01.S.doc Version 5.2 Page 26 - 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!