Inspection on 24/04/06 for Cavendish Road

This inspection was carried out on 24th April 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 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

Cavendish Road 09/05/07

Cavendish Road 31/10/05

Cavendish Road 26/04/05

Cavendish Road 29/11/04

Cavendish Road 04/06/04

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 Cavendish Road 274 A&b Cavendish Road London SW12 0BS Lead Inspector Davina McLaverty Unannounced Inspection 24th April 2006 & 12th May 2006 10:00 Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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 Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cavendish Road Address 274 A&b Cavendish Road London SW12 0BS 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 8675 9957 020 8675 9057 www.thresholdsupport.org.uk Threshold Housing & Support Ms Carol Hyman Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2), Physical disability (2), of places Physical disability over 65 years of age (0) Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 05 Brief Description of the Service: Cavendish Road is a registered home for nine adults who have a learning disability, two of whom also have a physical disability. The home itself is two adjoining houses. There are two lounges, two kitchens and two separate laundry rooms. Parking for two cars is available. The property is situated within a ten-minute walk from Balham underground and main line station and high street. The home is owned and managed by Threshold and support a locally based housing association. At the time of this inspection the manager reported that the weekly fees were £869.19 per week. Additional charges are made for some outings and holidays. Residents are made aware of the inspection report at the residents meeting. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection, over 8 hours on two days. The inspector met seven of the current eight service users living in the home. Communication with five of the service users was not possible, as they were unable to communicate verbally due to their learning disability. The inspector spoke with four staff members, and the acting manager. A sample of records was examined which included care plans, Health and Safety, staff records and residents meetings minutes. A tour of the premises took place. Due to the needs of the residents only one resident was able to complete a survey regarding the service. A further 10 survey forms were sent out to various professional as well as to relatives. Three relatives surveys were returned and one health care professionals. What the service does well: What has improved since the last inspection? The acting manager has endeavoured to meet all the requirements made at the last inspection and notable improvements was seen in particular with care planning and recording, however, none of the requirements made at the previous inspection had been fully met. Since her appointment, staff spoke of raised morale, more team work taking place, clearer systems now being in place and that they felt included and part of the decision making in the home. One spoke of the “more relaxed atmosphere in the home “ another said “we are now like one big happy family”. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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 Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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): 1& 2 Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service Prospective residents representatives do not have current information they need to make an informed choice about the home and its suitability for a prospective resident. An organisational assessment procedure is in place but was found not to have been followed for a recent admission to the home. EVIDENCE: The acting manager is aware that the Statement of Purpose and Service User Guide will need to be updated; highlighting changes within the staff team. Documents could not be located. A copy of revised documents must be submitted to the Commission. Consideration must be given to the format of the guides, in view of the level of learning disability, which the home supports. For example a video, photographic or symbol format may be more appropriate for the user group. Since the previous inspection a new resident has moved in. A copy of the core assessment by her Care Manager was on file, however, there was no assessment of the resident by staff from the home. This resident has complex needs and is very challenging to the service. The acting manager stated that since this resident’s admission to the home there has been a significant deterioration in their health. Additional funding for 1 to 1 support has been obtained. The same resident was admitted to hospital on the first day of the Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 9 inspection and on the second day the inspector was informed that the resident would not be returning due to her level of need. Any future admission must meet the registration criteria. The care manager must complete his or her own assessment on the resident prior to admitting the resident. Initial assessments for longer-term residents were not on file as they had been archived however, up to date assessments following reviews were seen which detailed current needs. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 & 10 Quality in this outcome group is adequate. This judgment had been made using available evidence including a visit to this service New care plans and risk assessments had very recently been written. Both must be maintained and regularly updated. Residents are encouraged to make choices and to lead a life of their choice. EVIDENCE: New care plans have been introduced which now have clear goals and detail how these should be achieved. The care plans are more person centred and staff have endeavoured to involve the resident and key people in the residents’ life. The care plans seen were all at various stages, none contained a photograph of the resident as required in the Care Homes Regulations. Staff have received training on how to complete and maintain the plans and the manager stated that she and her deputy will be addressing care plans during individual staff supervision and at staff meetings, as resident’s key workers are responsible for updating and reviewing the plans. Evidence was seen in the plans of multi disciplinary input and views of the relatives being considered. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 11 Risk assessments to minimise identified risks and hazards were in hand with several being in place. Again the manager has tried to involve the resident and/or key people in the resident’s life when writing them. This work has yet to be completed. The listening device currently in use for one resident must have a risk assessment for its use in place. All staff spoken to were knowledgeable about residents needs, one staff said “by working closely with residents we get to know what they like and don’t like”. Another staff member spoke of their key client gestures and noises made which they now could interpret. The inspector noted how one resident greeted everyone with a “fist” touch on their return from day centre. Good interaction was seen between residents and staff with residents being very much “at home”. Staff are aware of the importance of confidentiality and the organisation has an adequate policy in place, however, the inspector found that care plans were accessible to visitors to the home. Whilst the inspector understood why they were kept downstairs, for accessibility, they must be kept more securely and recommends that a locked cupboard be used. The home takes responsibility for managing resident’s finances where they are not able and there is no relative/advocate to act on their behalf. Currently resident’s money is checked daily at handover. The manager said that she was in the process of reviewing the system with her manager and looking at signatories on accounts. All the residents’ financial profiles were to be updated. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service Residents participate in activities within the home and the community. Residents are encouraged and supported to maintain contact with their family and friends. Dietary needs seem well catered for with consideration being given to cultural needs. EVIDENCE: Six of the eight residents attend a day centre Monday to Friday. The other two are involved in individual activities of their choice. The manager reported that she wants to develop this area with residents and their key workers to expand on the type of activities residents participate in. Details of current activities were recorded on the care plans and daily notes. Holidays are encouraged and supported. Several residents had gone to Chichester for Easter and one resident spoke of a trip to New Zealand, which was being planned for her, which they were looking forward to. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 13 One resident who now chooses to stay home all day had her hair cut at a local hairdresser. The residents were seen on their return from the day centre and appeared content moving freely around the home. All were seen to be appropriately dressed. As stated earlier the inspector was not able to communicate with five of the residents. One resident spoke of the changes occurring at the day centre and raised some concerns that not as many activities were available there. This was raised with the manager who said she was going to discuss this with the resident’s social workers as well as visit the day services herself, to get an idea of the changes. A small number of activities were seen in the home, which included crayons, art and craft materials, beads, games and puzzles. However, many were old, of incomplete and must be replaced. Residents are able to get involved in some of the domestic tasks around the home such as looking after their own rooms, setting tables and clearing away after meals. Appropriate support would be offered. Residents, who are able, help themselves to snacks and drinks as they wish which the inspector saw. Staff reported that several residents are supported to see their families and friends. The resident spoken to confirmed this. A relative questionnaire received stated that the home “welcomed my son at any time he visits his sister”. Another said that they “found the home supportive in dealing with areas of concern” and another said, “My son is doing very well at the home and is very happy”. The menu seen was satisfactory with a choice offered. The resident spoken to said that she found the food to be alright although she had decided to have her main meal at the centre and a sandwich in the evenings. All three relative questionnaires confirmed that they felt that the home understood their relative’s individual cultural, ethnic and disability needs. Three staff spoken to individually said that one resident received a diet, which met her cultural needs. The inspector saw evidence of this on the menu planner. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this area is adequate. Personal support is offered in a way that promotes and protects service users privacy, dignity and independence. Systems are also in place for the safe administration of medication. EVIDENCE: The personal care needs are appropriately identified in residents care plans, as are health care needs. The acting manager stated that staff offer support with personal care to residents to varying degrees depending on individual abilities. Residents are encouraged to choose their own clothes. Good health and social care support is provided by a local specialist community team. Evidence of this was seen in the files examined. A sample of the Medication Administration Records (MAR) was examined. The inspector noted one gap in which the MAR sheet had not been completed properly as detailed in the key. The allergy section of the form was not completed on the sheets examined, where it is known that residents have no allergies this should be recorded on the MAR sheets. Medications were seen to be stored securely. The controlled drug book could not be located. One resident has been prescribed a controlled drug. Staff reported that this had not been given for over eight months. The book must be found or replaced and the Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 15 resident’s medication reviewed. All staff stated that they had received training in the administration of medication and records evidenced this. The manager reported that currently the deputy takes responsibility for the ordering and overseeing of the medication within the home. Consideration should be given to each residents files to have a photo to ensure that medication is being administered to the person it has been prescribed for. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is adequate. This judgment had been made using available evidence including a visit to this service. Policies and procedures are in place to help protect service users from abuse and harm. The local authority are contacted when a Protection of Vulnerable adults issues arises. EVIDENCE: Wandsworth Local Authority Protection of Vulnerable Adults Policy (POVA) was seen to be in place and a staff member said that staff follow these guidelines. A whistle blowing procedure was also available on the day of inspection. POVA issues concerning a resident at the home have arisen since the previous inspection and the correct procedures were seen to have been followed to ensure the protection of the resident. Evidence seen in the resident’s care plan demonstrated that the appropriate social care professionals had been informed. Two staff demonstrated a good knowledge of the whistle blowing procedure however, the inspector found that they had failed to evoke it when a recent situation arose. The Area Manager reported that this issue had been discussed with the staff team as part of the investigation carried out. The complaints log was examined and found to have one new complaint in since the last inspection, which included a brief record of how the home dealt with it. A copy of the organisations complaints policy was seen which contains information about the Commission for Social Care Inspection (CSCI). A Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 17 pictorial version of the complaint procedure was seen to be displayed in the home. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28, 29 & 30 Quality outcome in this area is adequate. This judgment had been made using available evidence including a visit to this service Attention must be focussed on certain areas of the premises such as the resident’s bedrooms, carpets and laundry areas, which do not present as homely or attractive. EVIDENCE: As stated earlier the home is divided into 2 units with their own kitchens, lounges, bathrooms, and laundry rooms on the ground floor. The home was seen to be comfortable although many areas require redecoration. The kitchen/dining rooms, despite being recently decorated were showing evidence of wear and tear. Several cupboards were missing their drawers; also the fridge in House B lacked sufficient shelves and drawers. Several bedrooms seen required decorating, broken furniture replaced and at least two of the carpets in the bedrooms must be replaced. Personalisation of bedrooms could be improved upon. Bedrooms can be locked and those residents that are able have a key. Three residents said that they liked their rooms, one resident said that their privacy is respected in that they can go up to her room when they choose. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 19 Both laundry areas require redecoration and the hallway carpet particularly in House A must be replaced as it was badly stained. Consideration will soon need to be given to replacing the lounge furniture in House B, which has become shabby and worn in appearance. Progress had been made regarding getting the curtains re-hung with appropriate hooks /fittings but this was still incomplete. The outdoor areas both back and front required clearing, discarded furniture and old wheelchairs must be removed from the back garden and both the front and back garden cleared of the excessive weeds. Bathrooms seen were functional rather than homely but staff stated that this was primarily due to some of the residents needs and that it is not been safe to leave things in the rooms. However, soap, toilet and paper towel dispensers must be made available in all bathroom /toilet areas. Evidence was seen in some bathrooms of aids and adaptations for individual residents use. The home was observed to be clean and hygienic and free from offensive odours on the day of the inspection Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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 & 36 Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. Staff are able to support residents in meeting their needs, however, permanent staff must be recruited to vacant posts. A lack of recruitment documentation could place residents at risk. Staff are able to support residents in meeting their needs however, core-training courses must be monitored and regularly updated. EVIDENCE: One relative in her questionnaire reported concern regarding the frequent staff changes in the home. The Acting Manager reported that Threshold is addressing this and that following an interview she has been appointed manager of the home. Also two long term bank staff are now permanent staff in the home. Another relative reported that they found the staff “supportive”. Currently there are three staff on each shift, one based in each house and a float. At night one waking night and one staff asleep. One resident currently receives one to one support from 4.00pm to 8.00pm Monday to Friday and on Saturday10.00am to 6.00pm. The home has 4 vacancies for which long term agency staff are used. The manager said that she will be reviewing staffing levels and the shift planner with her manager, to try to ensure that shifts can Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 21 run smoothly and that as resident’s individual activities increase staff are able to support them both inside and out of the home. Staff was seen to have a good rapport with residents at the time of the inspection visit. Minutes of team meetings were seen. One staff member stated that “the team meetings were now more structured and constructive.” Staff reported that one to one supervision was taking place. Evidence of this was seen on three files examined of this however, the manager must ensure that staff receive a minimum of six supervisions a year. Currently two staff have achieved their NVQ Level 3 and two staff are undertaking their NVQ Level 2. The Manager is aware of the need to ensure that 50 of the staff on duty have achieved Level 2 qualification. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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, 38, 39 & 42 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. A new manager is in post that has a good understanding of the residents needs. Appropriate Health and Safety systems are in place to ensure the safety and welfare of the residents. EVIDENCE: The manager started working in the home in February 2006 and was appointed manager in May 2006. An application to be registered as the manager must be submitted to the Commission. All staff spoken with were very positive in regards to her management style stating that they now felt “included, listened to and that morale in the home was high”. The home has copies of monthly monitoring visits by the provider but these had not been forwarded to CSCI. Since the inspection, monitoring reports have been sent. The inspector was informed that the organisation is still in the Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 23 process of reviewing its quality assurance system. This issue has been the subject of several requirements and must be given priority. Health and Safety systems are in place. A number of records were seen and found to be in order. These included the fire alarm system, which is tested weekly, fire drills, which are carried out quarterly and the servicing of the fire extinguishers and the fire blanket. Fridge and freezer temperatures are taken daily and again records seen were satisfactory. Appropriate documentation was seen for the fixed electrical installation, gas safety certificate and portable appliances. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 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 1 2 2 3 x 4 x 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 3 X Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 25 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 YA1 Regulation 4, 5 & 6 Requirement The Registered Persons must ensure that the Statement of Purpose and Service user Guide is updated and that copies of both documents are forwarded to the Commission. Timescale for action 30/07/06 2 YA2 14 (1) 3. YA6 14(2) & 15 The Registered Person must 30/05/06 ensure that a full assessment has been carried out on prospective residents prior to admission and that the home can meet their assessed needs. The Registered Persons must 30/07/06 ensure that continued work takes place on support plans and that they are regularly reviewed and updated. The Registered Persons must ensure that risk assessments are completed. The Registered Persons must ensure that all records are kept securely in the home. The Registered Person must ensure that • the Medication administration sheet has no gaps in it following DS0000010177.V289572.R01.S.doc 4 5 6 YA9 YA10 YA20 13 (4) 17(b) 13(2) 30/07/06 30/07/06 30/05/06 Cavendish Road Version 5.1 Page 26 7 YA23 18 (c) 8 YA24 23(2) (b) 9. YA26 23(2) (d) administration of medication. • The allergy section on the form is completed • The controlled medication record book is located or a new one purchased. The Registered Person must 30/10/06 ensure that all staff receive training in protection of vulnerable adults. The Registered Person must 30/09/06 ensure that the premises are kept in a good state of repair both internally and externally. The premises work identified in Standard 24 must be addressed The Registered Persons must 30/07/06 continue to ensure that all curtains have appropriate hooks/fittings to ensure that they hang properly and can be closed. The Registered Persons must ensure that individual staff record are maintained as per requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation as to all checks carried out on agency staff. Previous date of 28/2/05 & 30/12/05 not fully met. 30/07/06 10. YA34 19 1(b) 11 YA37 8(1) 12. YA39 24 The Registered Person must 30/06/06 ensure that the manager submit an application to the Commission be assessed as the homes registered manager. The Registered Persons must 30/07/06 ensure that the quality assurance framework takes into account the views of family, friends and other stakeholders and that the whole process of quality monitoring is consolidated. Previous date of DS0000010177.V289572.R01.S.doc Version 5.1 Page 27 Cavendish Road 31/3/05,30/07/05 & 28/02/06 not met RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard YA2 YA28 Good Practice Recommendations The Registered Persons should ensure that the service user guide is in a format that the resident can understand. The Registered Persons should ensure that 50 of care staff in the home are working towards their NVQ Level 2/3 in care. Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Cavendish Road DS0000010177.V289572.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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