CARE HOME ADULTS 18-65
Colegrave Road, 79 79 Colegrave Road Stratford London E15 1DZ Lead Inspector
Seka Graovac Unannounced Inspection 12:55p 30 December 2005
th Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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 Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Colegrave Road, 79 Address 79 Colegrave Road Stratford London E15 1DZ 0208 534 1101 0208 534 1153 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 Limited Post Vacant Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Colegrave Road (79) provides medium-term accommodation, support and care for 3 people with enduring mental health needs who have been discharged either from hospitals or secure units. The building is situated in a residential area in Stratford, close to public transport and other local amenities. The next door house (77 Colegrave Road) is also a registered care home of the same size for people with mental health needs. The homes have direct access to each other via the gardens at the back of the houses. Both homes are owned and managed by the same company, Consensa Care Limited that also owns and manages some other mental health care homes in Newham. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted approximately four hours. The main aim of the inspection was to follow up on the home’s compliance with the requirements that were made at the previous inspection in August 2005. The inspector also assessed the home’s performance against the key National Minimum Standards that had not been assessed on the previous occasion. The inspector was also aware that some staff have expressed their concerns regarding fitness of Responsible Individual since the previous inspection. The Commission for Social Care Inspection dealt with these concerns separately to this report. The inspector had conversations with all three service users separately. She also spoke to the newly appointed manager and the support worker who was on duty. She examined service users’ individual files for all three service users and viewed some other records such as: medication records, temperature records, the latest minutes of staff and service users’ meetings, complaintslog, fire-safety log, etc. The inspector also requested that staff files for three staff were brought from the Head-office for her to view. The inspector saw all areas of the home apart from one bedroom. What the service does well: What has improved since the last inspection?
There was plenty of fresh and prepared food available in the home and the service users were satisfied with this aspect of the service. Service users were protected by the home’s procedures for dealing with concerns, complaints and protection issues.
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 6 The inspector was informed that the home has become a non-smoking environment since the previous inspection. That was seen by the staff and the service users as a big improvement. Service users could smoke in the back garden. What they could do better:
The management must introduce change and significantly improve the service in order to provide care service that is compliant with legislation. Twelve requirements were made on this occasion. Four of these requirement were restated from the previous inspection with the target for compliance expired. The inspector had difficulties entering the home. There were no staff in the building and two service users who were there did not have the key. They advised the inspector through the closed door to go next-door as the staff were at 77 Colegrave Road. The Registered Persons must ensure that the service users are not left on their own while in the building. The Registered Persons also must ensure that legitimate visitors’ access to the home is not obstructed and that the home keeps records of visitors to the home. The inspector also found out that prospective service users’ care and support needs were not always assessed by the home. The Registered Persons must not provide the service until the home has confirmed in writing to the service user that having regard to the assessment, the care home is suitable for the purpose of meeting the service user’s needs in respect to their health and welfare. The needs assessments must be recorded and form the basis for the care-planning process. The service users’ individual files contained comprehensive care plans. However, the home could not demonstrate that the service users agreed with their content. Some service users did not have the individual risk assessments. The Registered Persons must ensure that care plans are written in consultation with the service users and that this process could be demonstrated. The Registered Persons must ensure that staff enables service users to take responsible risks within the context of the individual plans and of the home’s risk assessment and risk management strategies. The home could not demonstrate that the conditions which would facilitate service users’ integration into the community were put in place.
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 7 The home’s dealing with medication was identified as problematic at the previous inspection. The related requirement was repeated. All medicine must be labelled and securely stored. The home was not appropriately maintained to meet the minimum standard. Despite two requirements being made at the previous inspection, the home remained untidy and in need of decoration at the time of this inspection. The flooring in communal areas was torn in places and did not fit properly. The walls were stained. The environment looked “tatty” and was not homely. The inspector observed through the office window that items were scattered over the garden, although there was no wind. Although the inspector is aware that the company is planning a major building and refurbishment work in order to merge two homes, while the service users live there, the environment must be maintained clean, tidy and comfortable. Two related requirements were repeated. Service users were not protected by the company’s practices regarding staffing. The Registered Persons must ensure that all staff is thoroughly vetted and that records are kept to confirm the process (this includes CRB disclosures and proofs of POVAfirst). The manager did not have access to the home’s training plan. She stated that she would have to pay for training herself and would be reimbursed by the company at a later day. She believed that all other staff were doing the same. The Registered Persons must ensure that all staff are suitably trained. A training plan for the home as well as the budget agreed for the payment of the training must be available. This is a repeated requirement. 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. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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 Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Prospective service users’ care and support needs were not always assessed by the home. EVIDENCE: The inspector viewed service users’ files for all three service users. One of them did not contain any evidence of the service users’ support and care needs being assessed by the home. The manager stated that this person was admitted in November 2005 as an emergency. The Registered Persons must not provide the service until the home has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect to their health and welfare. The needs assessments must be recorded and form the basis for the care-planning process. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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 and 9. The service users’ individual files contained comprehensive care plans. However, the home could not demonstrate that the service users agreed with their content. Some service users did not have the current individual risk assessments. EVIDENCE: All service users had comprehensive care plans. However, the majority of them were not signed by anybody. Some were not dated either. The Registered Persons must ensure that care plans are written in consultation with the service users and that this process could be demonstrated. Although one service user had a care plan regarding self-harm and possible medication overdose, no individual risk assessments were available in this person’s individual file. The inspector was shown individual risk assessments regarding the front door keys that have been recorded since the previous inspection. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 11 The Registered Persons must ensure that staff enables service users to take responsible risks within the context of the individual plans and of the home’s risk assessment and risk management strategies. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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): 13, 15 and 17. The home could not demonstrate that the conditions that would facilitate service users’ integration into the community were put in place. Service users were satisfied with food in the home. EVIDENCE: One service user was out on her own when the inspector came. The other two service users were in the building but by themselves. The inspector was later informed that the only staff member on duty went out shopping and the manager was next door at 77 Colegrave Road. The inspector rang the door-bell several times without anybody’s response. After she waited for a while, a service user came to the door and spoke to the inspector through the closed door. She explained to the inspector that she did not have the key and all the staff were at 77 Colegrave Road. The inspector asked her if she could call the staff, but she did not want to. After the inspector stood there for a while longer, a staff member opened the door of 77 Colegrave Road and called the inspector to enter that way. The inspector told him that she came to visit 79 Colegrave Road and would rather enter through its own main door then walk through the connected gardens and the back door of the building. Finally, the inspector was let in by the same staff member who then called the manager.
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 13 The manager stated that she understood that the entrance door of 77 was not in use. The inspector was aware that the company planned to merge the two homes (77and 79) into one. However, while they are still registered as two separate homes and no actual work has commenced, the Registered Persons must ensure that legitimate visitors’ access to the home is not obstructed. The inspector stayed approximately four hours on the premises and at no time she was asked to sign the visitors-log. At the point of leaving, the inspector asked to sign the book. The inspector noted that the information she got from the manager regarding recent visitors to the home did not match the records. A pastor visited the home on a regular basis and signed the visitors-book. The Registered Persons must ensure that the home keep records of all visitors to the home. The service users’ care plans did cover their social and cultural needs and stated how the home’s staff would facilitate the service users’ integration into the community. However, in the light of the above written evidence, the home could not demonstrate that the conditions that would facilitate the integration were put in place. The staff member who was out shopping when the inspector arrived, returned to the home with variety of fresh and prepared food. The food was appropriately stored and dated when opened. The inspector noted that one side of the seal on the fridge-door was torn. The examined temperature records showed that the records were appropriately kept and that the temperature was appropriate. The inspector recommended that the home repairs or installs a new seal on the door of the fridge. The service users told the inspector that they liked food in the home. Once a week they went out for a meal or had a take-away meal that they enjoyed. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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 and 20. The service users were encouraged and supported to maintain their personal hygiene and health. However, the requirement regarding medication had to be repeated. EVIDENCE: The service users were satisfied with the service. Their care plans and the individual records indicated that they were encouraged and supported to maintain their personal hygiene and health. The service users had access to community health professionals such as: opticians, dentists, psychologists and attended regular Care Plan Approach meetings. The examined medication administration records were appropriately kept. However, apart from pill-packed tablets through the monitored dosage system, the medicines for two service users was also stored in a weekly doset-boxes. One of them did not state what medication it contained and how it was prescribed. The staff informed the inspector and the manager that it was chlozapine and that the box was filled in by the Responsible Individual on instructions from Chlozapine clinic. All medicine must be labelled. The label must contain full information about medicine’s name, dosage, times to be administered and to whom. The inspector was concerned to find 14 tablets of paracetamol left on the top of the filing cabinet. The manager stated that the home did not use any homely remedies and that all the medication belonging
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 15 to service users was kept locked away at 79 Colegrave Road. She assumed that the paracetamol the inspector found must have belonged to the night staff. All medicine must be securely stored. The home’s dealing with medication was identified as problematic at the previous inspection. The related requirement was repeated. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 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 and 23. Service users were protected by the home’s procedures for dealing with concerns, complaints and protection issues. EVIDENCE: The service users were satisfied with the service. The service users’ meetings were regularly held and provided the opportunities for discussing any issues about the home. No complaints have been raised with the home since the previous inspection. One allegation was made by a service user against the staff member but was withdrawn. However, the management appropriately followed it through the Protection of Vulnerable Adults procedure and involved Social Services. As this person has a history of making unfounded allegations, a risk assessment was recoded aiming to protect the staff who might be affected. The inspector was informed that all the staff had training in protection in September 2005. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 17 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 and 30. The home was not appropriately maintained to meet the minimum standard. EVIDENCE: Despite two requirements being made at the previous inspection, the home remained untidy and in need of decoration at the time of this inspection. The flooring in communal areas was torn in places and did not fit properly. The walls were stained. The environment looked “tatty” and was not homely. The inspector observed through the office window that items were scattered over the garden, although there was no wind. There was an iron and bedding on the office desk, as well as an ironing board in the corner. Tabs with paintemulsion, an open box with laundry powder and a full black rubbish-bag were also stored in the office. There were no curtains other then net in one of the bedrooms. There was a urine smell present in the same bedroom. Although the inspector is aware that the company is planning a major building and refurbishment work in order to merge two homes, while the service users live there, the environment must be maintained clean, tidy and comfortable. Two related requirements were repeated.
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 18 The inspector was informed that the home has become a non-smoking environment since the previous inspection. That was seen by the staff and the service users as a big improvement. Service users could smoke in the back garden. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Service users were not protected by the company’s practises regarding staffing. EVIDENCE: The inspector was concerned that no staff were present in the care home when she rang the door-bell. Two service users were left unattended despite the home being registered to provide residential care. The risk assessment regarding withholding the key from the service users also stated that the home was 24-hour staffed. The inspector and the service users were aware that there were staff in the next door building. However, the Registered Persons must ensure that the service users are not left on their own while in the building. The team consisted of four permanent support staff and one bank staff. The roster was available for the month of December. The inspector asked to see staff files for the newly appointed manager and two support staff. The inspector was informed that the staff files were held in the head-office and would be brought in for inspection. However, none of the requested staff files were made available to the inspector. The only requested staff information that was brought to the home was a sheet of paper listing what records were available in one staff file. The manager stated that Criminal Records Bureau disclosures were still outstanding for some staff. The home has a history of poor recruitment practises and the related requirement was made at the
Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 20 previous inspection with the target expired on 01/09/05. The manager stated that POVAfirst check was conducted. The staff often worked alone in this home. The Registered Persons must ensure that all staff is thoroughly vetted and that records are kept to confirm the process (this includes CRB disclosures and proofs of POVAfirst). The inspector was informed that out of four permanent staff, three were qualified in health and care trough National Vocational System. The manager did not have access to the home’s training plan. She has been in her post for two weeks prior to the inspection. She told the inspector that she had one full day induction led by the Responsible Individual and was also due to shadow a Registered Manager in a different home that belonged to the same company, but did not have a full schedule of her induction agreed as yet. She stated that she would have to pay for training herself and would be reimbursed by the company at a later day. She believed that all other staff were doing the same. The Registered Persons must ensure that all staff are suitably trained. A training plan for the home as well as the budget agreed for the payment of the training must be available. This is a repeated requirement. The staff turnover has been high in the company since the previous inspection. The staff who was on duty was experienced and demonstrated her knowledge of service users’ needs and how to meet them in her conversation with the inspector. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 21 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. The management must introduce change and significantly improve the service in order to provide care service that is compliant with legislation. Quality assurance systems and health and safety records were meeting the national minimum standards. EVIDENCE: The inspector was informed that the manager has applied for registration with the Commission for Social Care Inspection. She was previously registered working with a different client group (older people) in a different borough. Her experience of mental health was mainly through agency work. She told the inspector that she had a degree in Health Services Management and Advanced GNVQ in health and social care (equivalent to NVQ level 3). She was hoping to commence NVQ level 4 training in January 2005. She was aware of the home’s shortfalls and motivated to improve the service. The staff member told the inspector that in her view the lack of stable management had negative effect on the home. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 22 The Registered Persons must ensure that the home has a permanent manager who is registered with the Commission for Social Care Inspection. The Responsible Individual had keen interest in the service and often visited. Regulation 26 reports were available for inspection. The management also conducted service users’ satisfaction survey in August 2005 and devised an appropriate action plan in relation to that. The inspector also saw the minutes of the most recent service users’ and staff meetings. The inspector checked the following health and safety documentation: gas safety, portable electrical appliances tests, fire-safety log and health and safety risk assessments. All records seen were in date. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 2 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Colegrave Road, 79 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 x DS0000058207.V262635.R01.S.doc Version 5.0 Page 24 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 YA3 Regulation 14 Requirement The Registered Persons must not provide the service until the home has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect to their health and welfare. The needs assessments must be recorded and form the basis for the careplanning process. The Registered Persons must ensure that care plans are written in consultation with the service users and that this process could be demonstrated. The care plans must be dated and signed. The Registered Persons must ensure that staff enables service users to take responsible risks within the context of the individual plans and of the home’s risk assessment and risk management strategies. The Registered Persons must ensure that legitimate visitors’ access to the home is not obstructed.
DS0000058207.V262635.R01.S.doc Timescale for action 31/01/06 2 YA6 15 31/01/06 3 YA9 12 31/01/06 4 YA15 16 01/01/06 Colegrave Road, 79 Version 5.0 Page 25 5 6 YA15 YA20 17 13 7 YA24 23 8 YA30 16 9 YA33 18 10 YA34 19 11 YA35 18 12 YA37 9 The Registered Persons must ensure that the home keep records of visitors to the home. The Registered Persons must implement the appropriate arrangements for dealing with service users’ medication. The previous target expired on 01/09/05. The Registered Persons must ensure that a homely, comfortable and safe environment is maintained for service users. The previous target expired on 01/10/05. The Registered Persons must ensure that all parts of the care home are clean and tidy and reasonably decorated. The previous target expired on 01/10/05. The Registered Persons must ensure that the service users are not left on their own while in the building. The Registered Persons must ensure that all staff is thoroughly vetted and that records are kept to confirm the process (this includes CRB disclosures and proofs of POVAfirst). The previous target expired on 01/09/05. The Registered Persons must ensure that all staff are suitably trained for their jobs. A training plan for the home as well as the budget agreed for the payment of the training must be available. The previous target expired on 01/11/05. The Registered Persons must ensure that the home has a permanent manager who is registered with the Commission for Social Care Inspection. 01/01/06 03/01/06 28/02/06 28/02/06 31/12/05 16/01/06 31/03/06 28/02/06 Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 26 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 YA17 Good Practice Recommendations The inspector recommended that the home repairs or installs a new seal on the door of the fridge. Colegrave Road, 79 DS0000058207.V262635.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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