Inspection on 03/07/08 for Chandos Road, 91

This inspection was carried out on 3rd July 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Chandos Road, 91 07/01/08

Chandos Road, 91 16/01/07

Chandos Road, 91 17/01/06

Chandos Road, 91 08/09/05

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Chandos Road, 91 91 Chandos Road Stratford London E15 1TT Lead Inspector Lea Alexander Unannounced Inspection 3rd July 2008 1:00 Chandos Road, 91 DS0000062806.V365876.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 Chandos Road, 91 DS0000062806.V365876.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. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chandos Road, 91 Address 91 Chandos Road Stratford London E15 1TT 020 8534 8222 020 8471 9225 info@consenscare.com 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) Consensa Care Nicola Jane Rabey Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th January 2008 Brief Description of the Service: 91 Chandos Road is a registered care home offering accommodation to a maximum of 3 adults with mental health difficulties. The home is one of several operated locally by the Consensa Care organisation. At the time of this inspection there were three female service users living at the home. The home is a terraced house in a residential area. The accommodation comprises a communal lounge, kitchen diner, smoking lounge, downstairs wc, shower room, bathroom and three bedrooms. A staff office is located on the first floor. There is a garden area to the rear of the property. Parking is available to the front of the property and local shops and buses are within walking distance. The current range of fees for the home is between £1218.80 and £1244 per week. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of two half-day visits to the home. During the course of the inspection we spoke with the Manager and care staff on duty. We also sampled a range of documents relating to the running of the home including the personal files of people who use the service and the personnel files of care workers. At the time of our visits only one resident was at home and they declined to speak with the Inspector. The home also completed an Annual Quality Assurance Assessment as requested by the Commission for Social Care Inspection and returned this within the required timescale. The quality rating for this service is ** stars. This means the people who use the service experience good quality outcomes. What the service does well: The home provides a service to women with mental health needs from diverse backgrounds. The home has developed a statement of purpose that accurately reflects the service provided. Detailed individual plans are developed with people who use the service, and these reflect their rights to make decisions about their lives. Residents receive support to manage their finances and to access community and leisure activities according to their interests and abilities. A variety of nutritious meals are provided, and residents are supported to develop daily living skills. Residents are also encouraged to be independent in their personal care. The home investigates complaints and records the outcome and actions taken. Staffs are employed in sufficient numbers, receive regular training and also study for NVQ level qualifications. The homes recruitment practises safeguard people who use the service. The Manager is suitably qualified and experienced. People who use the service benefit from a well-maintained environment with a variety of shared spaces. Residents have their own bedroom. The home is clean and free from offensive odours. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Thirteen requirements are made as a result of this inspection, four of which are restated from an earlier inspection. One good practise recommendation is also made. Each resident must have a front door and room key and any identified risks that prevent this must be appropriately recorded in the risk assessment. The home must ensure that risk assessments are fully implemented. The home must carry out and record weekly fire alarm tests. The home must ensure that resident’s social and family networks are reflected in individual plans. Where appropriate risk assessments must address the potential risk of aggressive behaviour toward visitors to the home from residents and a strategy developed to manage this. All medication including PRN “as required” medications must be listed on the Medication Administration Record (MAR). The homes staffing roster must accurately reflect the staffing situation within the home. All staff must be able to demonstrate an understanding of the different types of abuse vulnerable people may need protecting from. The home must carry out a quality assurance exercise that includes the views of people who use the service and their families. The outcomes of this exercise must be made available to interested parties, including the Commission for Social Care Inspection. Repairs to the homes fire protection system must be carried out in good time. The home must record fridge and freezer temperatures on a daily basis. The home must ensure that started processed foods are appropriately date labelled. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 7 The home should look at ways of making its residents meetings service user led. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chandos Road, 91 DS0000062806.V365876.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 Chandos Road, 91 DS0000062806.V365876.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed a statement of purpose and assesses potential residents prior to their moving in. Residents have a contract for their placement. EVIDENCE: Previous inspections have evidenced that the home has developed a statement of purpose that accurately reflects the service provided. There have been no new admissions since the last inspection. We looked at the personal files for two residents and this evidenced that both had been assessed by the home prior to their moving in. Both of the personal files we sampled also contained a contract between the home and the resident that detailed the fees payable and what these covered. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed comprehensive person centred plans that are easy to understand. These plans are working documents that are reviewed regularly and each plan has a risk assessment. The home should ensure that it regularly consults residents for their views on the running of the home. EVIDENCE: We looked at the plans the home had developed with two people who use the service. These evidenced that for each a range of plans addressing personal, social and healthcare needs had been developed. However, we did note for one resident no plan addressing their social networks had been developed, although the Manager and care staff were able to tell us about different people this resident was in contact with. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 11 The plans we saw were reviewed at least every six months or as residents needs change. The plans also included some life story information and reflected resident’s rights to make decisions about their own lives. The Manager told the Inspector that at present no residents have a front door key as a result of identified risks, and that one resident no longer has a room key after an incident within the home. However, no risk assessments were on file to address these issues. Each of the homes residents receives support in managing their finances. The home has agreed with residents that the home retains money on their behalf that they can access through staff. Staffs complete a log for each deposit/withdrawal. We looked at the homes record of residents meetings. This evidenced that meetings to discuss the day to day running of the home had been held in February and May of 2008. Topics discussed included ground rules for living together, activities and household chores. We noted however that the minutes appeared to suggest that these meetings are management led, and we recommend that the home explore ways of supporting residents to take the lead in these meetings. The home had developed a range of assessments and management plans to address potential risks for the two residents we case tracked. However, a previous inspection had required the home to ensure that tasks identified in the risk assessment are fully implemented, particularly the need for one resident to be encouraged to have blood tests to promote their sexual health. This remains outstanding. Sampling of the homes accident and incident records and an occurrence at the home whilst we were visiting evidenced that visitors to the home may be subjected to aggressive behaviour by one resident when they are experiencing a mental health crisis. An assessment of the potential risk and a strategy to manage this should be developed by the home. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to develop their skills and to maintain personal relationships. People who use the service are supported to engage in meaningful daytime activities according to their interests and capabilities. EVIDENCE: We looked at the homes activity log. This evidenced that residents are supported to undertake personal shopping and have lunch in the community. Residents are also supported to access a local day service and one resident was evidenced as having undertaken some computer skills training. This resident is also being supported to attend the local swimming pool. A second resident had been supported to access local college courses and a local employment advisor although they had subsequently declined to follow these options further. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 13 At the time of this inspection one resident was on remand in custody, and a second resident who had formerly been homeless was absent without leave. The home has developed links with community resources in the area this person previously slept rough and as a result of these links had been able to establish contact and monitor the wellbeing of the resident whilst working with them to arrange for their return to the home Within the home residents are supported to develop their daily living skills through meal planning and preparation and with budgeting sessions and discussion groups. Discussion with the Manager and care staff and sampling of individual plans and other records evidenced that residents are supported to maintain contact with family and friends. During the course of the inspection staff were observed interacting with residents. Sampling of records within the home evidenced that residents choose when to join in an activity or when to be alone. We looked at the record of meals provided for residents over the last four weeks. This evidenced that a variety of nutritious meals are provided that reflect the varied cultural backgrounds of people who use the service. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare services and are encouraged to manage their personal care independently. The home has appropriate medication policies, but must ensure that all medication is listed on the Medication Administration Record. EVIDENCE: Discussion with the Manager and care staff and sampling of individual plans evidenced that resident’s preferences for personal care are known and respected. Observation of one resident evidenced that their appearance reflects their personality. We looked at the homes log of healthcare appointments. This evidenced that residents have been supported to access a range of healthcare services including their GP, optician and dentist. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 15 The Manager told us that at the time of this inspection none of the residents are self-medicating or taking any controlled drugs. We had looked at the homes medication policy at previous inspections and found that this complies with National Minimum Standards. We looked at the available medication within the home and found that this was stored securely. Four medications that had been recently discontinued were awaiting disposal. One resident was prescribed two “as required PRN” medications. One of these was listed on the Medication Administration Record (MAR) and the other was not. Clear guidance on the circumstances in which these “as required” medications should be administered was found on the resident’s personal file. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear written complaints and safeguarding policy and procedures. The home maintains a complaints log. Staff receive safeguarding training, however the home must ensure that all staff are familiar with the types of abuse vulnerable people may experience. EVIDENCE: We looked at the homes complaints log. This evidenced that no complaints had been received from December 2007. From April to December 2007 six complaints were received. A record of the investigation undertaken, outcome and action taken was found for each complaint. We have previously inspected the homes complaints policy and found that this complies with National Minimum Standards. The Manager told us that there had not been any adult protections issues identified since we last inspected the home. We have previously looked at the homes adult protection policy and found that this complies with National Minimum Standards. We spoke with a member of care staff on duty. They were familiar with the term adult protection and understood that this related to abuse. They were able to tell us what their responsibilities were should they suspect someone is Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 17 being abuse, however they struggled to identify the different types of abuse vulnerable adults might experience. Training records evidenced that they had received adult protection training in the previous year. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, well-maintained environment with a range of communal spaces. Residents have their own bedroom. EVIDENCE: The home is situated in a residential area of Stratford. It is in keeping with the other houses in the vicinity and has good access to local shops, transport networks and other amenities. The home has an entrance hall with a communal lounge off. A range of comfortable seating, a TV and a stereo are provided. To the rear of the property there is a kitchen diner a separate smoking room. A small lawned garden can be accessed from the kitchen. One residents bedroom and a WC are also located on the ground floor. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 19 Access to the first floor is via a staircase. In addition to a staff office and two residents bedrooms a large bathroom with tub and WC and a separate shower room are also located on this level. We looked at the homes maintenance log and this evidenced that all maintenance issues that had been reported had been addressed. During the course of our inspection we found the premises to be well maintained, hygienic and free from odours. Chandos Road, 91 DS0000062806.V365876.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffs receive regular training and undertake external professional qualifications. Sufficient staff is rostered on duty to meet the needs of people who use the service. The homes recruitment procedures safeguard people who use the service. EVIDENCE: The Manager told us that the home has five full time care staff and four regular bank staff who work within the home. In addition to a full time deputy manager between one and two care staff are rostered on duty each day depending on the planned activities, and one waking night staff. The Manager also told us that three permanent staff has obtained NVQ level 2 and that two permanent staff is studying for this qualification. Two of the homes bank staff has also obtained NVQ level 2. The deputy manager has obtained NVQ level 3 and is now studying for a manager’s award. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 21 We looked at the homes current staffing roster. Whilst the manager and deputy manager are included on it, the hours they actually work are not included. At the time of the inspection the rota indicated that two care staff should be on duty. However, only one of the staff was working. We raised this with the officer in charge at the time of the inspection and they told us that the rota had been incorrectly completed and that just one member of staff should actually be on duty. Consensa Care has a centralised Human Resources Department, however a summary sheet of pre-employment checks is available on site. We looked at the information available for two care workers. This evidenced that two references and an enhanced Criminal Records Bureau (CRB) check are available for each. It was also evidenced that new staff receive an induction to the home. Discussion with the manager and staff and sampling of the homes training records evidenced that a range of training courses were provided for staff in 2007 including challenging behaviour, infection control, adult protection, health and safety and communication. In 2008 the home has provided medication and fire training for staff and first aid and mental health training are scheduled to take place in July 2008. Chandos Road, 91 DS0000062806.V365876.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has appropriate experience and qualifications and the home has clear policies and procedures. However, the home must ensure that health and safety checks and records are routinely completed. EVIDENCE: The Manager has previous experience of running a care home and has obtained NVQ level 4. They currently manage this home and a second consensa care home in the local area. The Manager told us that since the last inspection the home has updated its feedback questionnaires for people who use the service, but has not yet sent Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 23 these out. The home has also developed its own audit tool to review its performance. There was no quality assurance information for this home available for us to see at the time of this inspection. Senior managers make monthly visits to the home and complete reports on their findings. We looked at these reports and saw that a senior manager had visited the home in February, March, April and June 2008. We looked at the homes fire alarm tests records and saw that these are carried out weekly. We saw from the logbook that repairs to fire safety equipment appeared to be taking some time. For example, a fault with the kitchen door release was first noted in March, and was repeated in April and June. We raised this with the manager who told us that a new system for fire maintenance and repairs had been introduced and that the homes performance in this area should improve as a result. Other health and safety records we looked at evidenced that the home tests and records hot water temperatures on a monthly basis and that these are within acceptable parameters. The home maintains its fridge and freezer temperatures within acceptable limits, however there were three occasions in May when no temperature was recorded and a two-week gap in June when no temperatures were recorded. We looked at the homes accident and incident records and found these to be in order. During our site inspection we noticed that several processed food items had been opened and were being stored in the fridge, for example tomato ketchup. However these items had not been date labelled to ensure that they are used within the manufacturers recommended timescales. Chandos Road, 91 DS0000062806.V365876.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 3 2 3 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes. 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 YA6 Regulation 15 Requirement The home must ensure that resident’s social and family networks are reflected in individual plans. The registered person must ensure that all service users are offered keys to their bedrooms and the homes front door, subject to the completion of a satisfactory risk assessment. This is a restated requirement. The previous target of the 31/03/08 was not met. The registered person must ensure that risk assessments for service users are appropriately implemented. This is a restated requirement. The previous target of the 29/02/08 was not met. Where appropriate risk assessments must address the potential risk of aggressive behaviour toward visitors to the home from residents and a Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 26 Timescale for action 30/10/08 2. YA7 12 30/10/08 3. YA9 13 30/10/08 4. YA20 13 5. YA23 13 6. YA33 17 strategy developed to manage this. All medication including “as required PRN” medications must be listed on the Medication Administration Record (MAR). The home must ensure that all staff are familiar with the types of abuse vulnerable people may experience. The registered person must ensure that the staffing rota clearly records the hours worked in the home by all staff, including the homes manager. This is a restated requirement. The previous target of the 29/02/08 was not met. The homes staffing roster must accurately reflect the staffing situation within the home. The home must carry out a quality assurance exercise that includes the views of people who use the service and their families. The outcomes of this exercise must be made available to interested parties, including the Commission for Social Care Inspection. Repairs to the homes fire protection system must be carried out in good time. The home must record fridge and freezer temperatures on a daily basis. The home must ensure that started processed foods are appropriately date labelled. 30/10/08 30/10/08 30/10/08 7. YA39 24 31/10/08 8. YA42 13 and 23 30/10/08 Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 27 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 YA8 Good Practice Recommendations The home should look at ways of making its residents meetings service user led. Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chandos Road, 91 DS0000062806.V365876.R01.S.doc Version 5.2 Page 29 - 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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