Inspection on 16/05/05 for Colham Road, 3

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Colham Road, 3 15/08/07

Colham Road, 3 12/10/06

Colham Road, 3 06/04/06

Colham Road, 3 01/11/05

Colham Road, 3 21/10/04

Colham Road, 3 10/06/04

Colham Road, 3 19/01/04

Colham Road, 3 10/12/02

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 3 Colham Road Hillingdon Middlesex UB8 3UR Lead Inspector Robert Bond Unannounced 16th May 2005 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 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 Stationary 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. 3 Colham Road Version 1.10 Page 3 SERVICE INFORMATION Name of service 3 Colham Road Address 3 Colham Road Hillingdon, Middlesex UB8 3UR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 271 245 01895 236 588 mwhite3@hillingdon.gov.uk London Borough of Hillingdon Ms Monica Spargo Care Home 13 Category(ies) of LD Learning disability registration, with number of places 3 Colham Road Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2004 Brief Description of the Service: 3 Colham Road is managed by the London Borough of Hillingdon and owned by the Health Authority. It provides residential care for ten permanent and three respite care service users. The service users have profound multiple learning, sensory and physical disabilities. All are non-verbal and two require PEG (pecutaneous endoscopic gastronomy) feeding. The home was purpose built in 1987 and is set on one floor, divided into four units: North, South, East and West Lodges. Each lodge is designed for four Service Users and leads out to an attractive central courtyard laid out with paved sitting areas and fringed with shrubs and trees. Each lodge is self – contained with a lounge, kitchen/diner, bathroom with toilet facilities and single bedrooms for each resident. All the bedrooms are attractively decorated with individual colour schemes and furnishings. The home is clean and bright and well maintained. Seven of the bedrooms do not meet the National Minimum Standard of 12 square meters for service users needing to use a wheelchair within their bedroom.All except two residents attend day centres for which London Borough of Hillingdon provide a special minibus. Service users attend medical appointments and use the home’s specially adapted transport for this. The home is set in it’s own large grounds near Hillingdon Hospital and is about three miles from central Uxbridge. The home has ample parking facilities and is easily accessed by public transport, having a bus stand just outside the gate. 3 Colham Road Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the day of the inspection four service users were in the home, the remainder were attending day centres. There was one permanent service user vacancy and only two out of the three respite places were occupied. There are currently nine respite care users. Seven staff members including the Registered Manager, plus two agency employees, were on duty and all were spoken to. Two permanent and two respite service user’s care files and associated records were examined in detail. The inspection lasted from 10am to 4pm. An Acting Senior Residential Social Worker showed the Inspector around the home and he was able to discuss the operation of the home in detail with the Registered Manager. As the position of Manager (Head of Home) is vacant, the Registered Manager, who is Hillingdon Council’s Resource Manager is also responsible for several establishments and is the person who is registered with the CSCI as manager, pending the recruitment of a new Care Manager. All members of staff are thanked for their courtesy and assistance during the inspection process. Questionnaires were sent to relatives, and doctors whose names were provided by the home. All those who responded are thanked, and their views have been incorporated within this report. The care being provided to service users by staff in the home was observed to be professional and delivered in a caring way that respected service user’s rights, choices and privacy so far as possible. Two service users receive PEG feeding. As a result they are not able to attend a day centre pending special arrangements being made for them at the centre. The recording of the details of their feeding needs urgent attention by the management of the home as records were found to be very inadequate. Care planning, respite care files, health and safety issues arising from five bedrooms being very undersized, the absence of a specific Manager, and the high number of agency staff used are the other concerns the Inspector has raised in the report. 3 Colham Road Version 1.10 Page 6 What the service does well: What has improved since the last inspection? Staff are now more careful to record all aspects of the giving of medicine. The storage and recording of medication has improved. These aspects have reduced the danger of medication errors, to the benefit of service users. New flooring has been installed in South Lodge’s corridor and bedrooms which improves the visual aspect and assists in the movement of hoisting equipment. Some areas of the home have been redecorated. The Snoezelen room has been refurbished and an activity room created for the benefit of service users. Eight members of staff have additionally been trained in ‘invasive procedures’ such as the use of rectal diazepam. Twelve members of staff have been trained in the PEG feeding technique. Both aspects should improve the service residents receive. The home has a business plan based on quality assurance feedback from relatives. 3 Colham Road Version 1.10 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 Colham Road Version 1.10 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 Standards Statutory Requirements Identified During the Inspection 3 Colham Road Version 1.10 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 standard(s) 1, 2 , 3 and 5 The management of the home must apply to the CSCI for a variation to the registration of the home to include the physical and sensory disability categories in order to accurately reflect the needs of the current service users. In addition the Statement of Purpose and Service Users Guide will have to be amended to make clearer the types of need that the home is registered to accept. The latter also must be updated to make it clear that complaints can be addressed to the CSCI. By these means potential service users, relatives and care managers will gain a clearer idea of the types of need met within the home, and where complaints may be reported to. Contracts and terms and conditions still do not match those required by the National Minimum Standards. Referral information for respite care service users was patchy. Hence a full and complete assessment of their needs prior to moving in was not comprehensive, which is cause for concern. Permanent service user’s aspirations and needs are however generally met, but some service users who use wheelchairs are housed in bedrooms where staff have difficulty meeting those needs due to the bedrooms restricted size. 3 Colham Road Version 1.10 Page 10 EVIDENCE: The registration of the home is currently only for people with learning disabilities, with a condition applied that one service user may also be accepted who has dementia. That condition is now obsolete as the service user who it applied to is no longer at the home. The condition will therefore be withdrawn. The registration of the home for learning disabilities alone however does not recognise the profound and complex needs of the service users, all of whom have severe physical disabilities and sensory disabilities. The existing Statement Of Purpose and Services Users’ Guide and good documents in need of a little updating. Hillingdon Council’s Performance and Quality section have not yet produced new contracts for residents that match the requirements of the National Minimum Standards. The care files of two respite care users were examined. The referral details of one service user were inadequate. There was a completed assessment form for the second service user but it was neither signed nor dated. Only one out of four files contained a comprehensive community care plan. Referrals from Hillingdon’s Community Team for People with Learning Disabilities have recently improved. Service users with physical disabilities are admitted to rooms whose sizes do not meet the minimum size recommendation for wheelchair users. 3 Colham Road Version 1.10 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,and 8 After each review, care plans that have been changed must be typed, dated, and signed by the parties to them who are able to sign. Because of the severe disabilities of the service users, it cannot be said that they all know what is in their care plan but decision making, consultation and responsible risk taking are undertaken as appropriate to achieve the best possible outcomes for service users. Individual service plans (care plans) require further development and consideration needs to be given to a more extensive format for care plans such as the ‘person-centred planning’ concept in order to improve outcomes for service users. EVIDENCE: None of the service users are vocal but a few are able to communicate by other means. Care plans and review documents demonstrate that service user’s wishes, needs and interests are taken into account, and their relatives are encouraged to attend review meetings and contribute their views. Care plans are updated on a regular basis, but the alterations were often in handwriting that was not dated or signed. 3 Colham Road Version 1.10 Page 12 The extent of the information contained in the care plans is limited. However the three monthly diary summaries and service user profiles seen were of a good standard. 3 Colham Road Version 1.10 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, and 17 All these outcomes were met, as evidenced below, except possibly for the two service users who have PEG feeding. Permanent staff have been trained and are hence more confident in dealing with the PEG feeding but the recording of the details of the feeding was poor. The Registered Manager accepts this finding and has agreed to introduce an improved recording system and to train the staff in its use, and the importance of accurate recording. The two service users who are PEG fed are not able to attend their day centre at present whilst negotiations continue concerning whether they may receive PEG feeding at that centre. Consideration must be given urgently to resolving this issue, and to whether the stimulation these service users receive in the home is comparable to that offered in the day centre. EVIDENCE: Service user’s care plans record their interests and hobbies and care staff encourage these using resources within the home, the community and local 3 Colham Road Version 1.10 Page 14 day centres. Most service users attend one of two day centres (Pheonix and Parkview), which offer cookery, music, swimming etc but the two service users who are PEG fed are currently unable to attend. However the home’s care staff offered alternative activities such as massage, cookery, shopping, and being read to. The home is well equipped with a Snoezelen and an activity room. Service users have their own collections of videos and music. Service users go on trips out, to the cafeteria, garden centre and shopping generally. The Salvation Army provide a Carol Concert in the home. Family members attend review meetings and Family Days in the centre. Staff knock on service user’s doors before entering. Meals are cooked by the care staff within each of the four units. The standard of food and its preparation and cooking was not observed on this inspection, but the Registered Manager considered it to be of a high standard that reflected service user’s tastes and dietary needs. She estimated that £20 per service user per week is spent on food and a dietician is involved in menu planning. Clear written instructions have been issued to staff concerning PEG feeding. However the standard of recording of the daily details of the feed is poor. Inspecting the records for the last two months indicated unexplained gaps existed when it appeared no feeding had taken place, the duration of feed was not always given, the total amount of the feed was not always given, dates were sometimes not adequately recorded, and the format did not require any signatures. 3 Colham Road Version 1.10 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 20. The evidence indicates that all these outcomes for service users have been met. EVIDENCE: Personal care was seen to be provided in a sensitive and caring way. Care plans and personal profiles made clear that personal preferences were taken into account. The home has all the specialised equipment that is necessary to met service user needs. District nurses visit the home as necessary and provide for example advice on PEG feeding techniques. An occupational therapist, physiotherapist, speech therapist and consultant psychiatrist are available as required. A choice of GP is possible, with two GPs being registered for existing permanent service users, and a further 8 GPs for the respite care users. None of the service users, permanent or respite, are able to retain control of their own medication. Medication records were accurate and uptodate. All the 3 Colham Road Version 1.10 Page 16 requirements of the CSCI Pharmacist Inspection on 16th March 2004 have been met. 3 Colham Road Version 1.10 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 On the basis of the evidence below, the above outcome has been met except that the complaints procedure for must be amended to make reference to the CSCI and to indicate that complaints may be made by the complainant directly to the CSCI at any stage. EVIDENCE: Service user’s views are ascertained where possible, and are taken into account as evidenced by written documents. Relative’s views are also ascertained at reviews and by the use of quality assurance questionnaires. There have been no recorded complaints and no recorded allegations of abuse during the period since the last inspection. The complaints procedure in use is Hillingdon Council’s, which is under review due to changes in Local Authority complaints investigations whereby stage 3 complaints will in future be investigated by the CSCI. The complaints procedure for registered services such as 3 Colham Road needs to be amended to make reference to the CSCI and to indicate that complaints may be made by the complainant directly to the CSCI at any stage. The home has in place a ‘whistleblowing’ policy for staff to report any concerns, and Hillingdon’s multi-disciplinary adult protection policy. These will be considered in more detail at the next inspection as the latter is ‘under review’. 3 Colham Road Version 1.10 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 standard(s) 24, 25, 28, 29 and 30 On the basis of the evidence, all the outcomes have been met except 24 since there are five bedrooms that are too small to be used by service users in wheelchairs, and are so small that they do not even meet the Standard for mobile service users (10 square meters). The size of room is important as service users and staff members are potentially at risk when manoeuvring a wheelchair, hoist or other special equipment in a bedroom that is less than the required size. As this is an existing home, exceptions have been applied previously but this finding has a major implication in light of the requirement to register the home for physical disabilities to reflect the needs of the current service users. Thus Hillingdon Council will have to carefully and urgently consider the most appropriate future use of the home as part of their Modernisation Plans. EVIDENCE: The home is comfortable and homely. Bedrooms were seen to be decorated and furnished in a personalised way to meet the service user’s needs and wishes and to promote their independence as far as possible. With the exception of one bathroom, the home was adequately decorated and furnished, including the communal areas. The garden is attractively 3 Colham Road Version 1.10 Page 19 landscaped. All specialist equipment required by service users to assist in meeting their needs is present. The home is clean and hygienic throughout. However seven out of 13 service users bedrooms do not meet the National Minimum Standard size of 12 square meters for service users who need to use a wheelchair within their bedroom. Two of these rooms are only slightly undersize but all three in the respite care wing are, two being 9.36, and one only 8.21. One room in North Lodge and one in East Lodge are only 8.70 square meters. (Measurements are taken from the home’s Statement of Purpose). 3 Colham Road Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34,and 35. Training receives a high priority and the Registered Manager of the home and Hillingdon Council’s Social Services Department are commended for this which will create better outcomes for residents. Unfortunately despite this, the home has not been able to recruit its full complement of care staff. To continue to operate the home with such a high percentage of agency staff is not recommended due to their turnover, unfamiliarity with the service users and their needs, and their relative lack of training. The extent of staff vacancies is calculated to be 43.7 , which is very high and is bound to adversely affect outcomes for service users. EVIDENCE: Of the 21 permanent care staff, 4 are currently undertaking NVQ level 2 or 3, and 11 have achieved the qualification. Thus the requirement to have more than 50 of the care staff with these qualifications by 2005 has been achieved. Since the last inspection 12 staff have been trained in PEG feeding and 8 in invasive techniques, amongst other training records seen. 3 Colham Road Version 1.10 Page 21 Two care staff are undertaking by day release Social Work qualifications, and one an Occupational Therapy qualification. The two agency staff on duty reported that they had been given a satisfactory induction when they started working at the home. The home was not fully staffed on the day of inspection as there should have been eight care staff on duty whereas there were only six as one had been sent home sick and another agency member of staff who telephoned to say they would be arriving late, was told not to bother coming in that case. Only one new member of staff was recruited from the last recruitment drive. Another drive is currently under way and it is hoped that this will be much more successful. The staffing establishment as detailed in the Statement of Purpose is 29.96 wholetime equivalent members of staff. At the present time vacancies are: 1 manager, 0.62 team leader, 9.22 residential care workers, 1.75 night care workers, and 0.5 handyman. This adds up to a wholetime vacancy total of 13.09 which is a vacancy rate 43.7 . 3 Colham Road Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 . 38, 39, 41, and Despite the staffing difficulties and the absence of a fulltime manager there was no evidence that service users suffered as a result but permanent staff are preferable to temporary staff in terms of providing a consistent high quality service. The recruitment of a temporary manager should lead to better outcomes for service users than having no dedicated manager at all. However a permanent manager is required to lead the team, and improve staff morale, which should lead to further improved outcomes for service users. Records and files are areas where further work is necessary in order to safeguard service useres rights and best interests. The parlous state of the PEG feeding records is evidence of inadequate management arrangements at the present time. The health and safety and welfare of service users (and staff) are not being promoted because of the continued use of five very under-sized bedrooms. 3 Colham Road Version 1.10 Page 23 EVIDENCE: The Registered Manager of the home does not fulfill fully the duties as manager for the home. Instead, the Registered Manager is the Resource Manager for a number of Hillingdon Council’s establishments, as well as overseeing the management of 3 Colham Road. Hillingdon Council are due to advertise the manager’s post at this home as a one year temporary post, pending the transfer of a permanent manager from a facility that is due to close. A member of staff reported that staff morale was currently low due to the large number of vacant posts being covered by agency staff. Record keeping was at best patchy. PEG feeding records were very poor, care plans need to be extended in their range, but summaries were good. The respite care referrals and files were poor. It was also noted that few relatives or GPs addresses held on file included postcodes. Quality assurance is maintained by Regulation 26 visits from a Hillingdon Team Manager and by questionnaires sent six monthly to relatives. Accident reports, first aid box content records, COSHH policies signed by all staff and a workplace risk assessment all demonstrate that Health and Safety is given appropriate prominence in the home. However, staff are having to work with service users who are extremely physically disabled within the confined space of bedrooms that fall far short of the National Minimum Standard for bedroom sizes for wheelchair users. The home has a Business Plan, but this was not examined at this inspection. 3 Colham Road Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 2 x 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 x x 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 1 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Colham Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 2 3 x 1 1 x Version 1.10 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 43 Regulation 25(2)(e) Requirement The homes insurance must cover staff who carry out health related activities (including all invasive procedures) Previous timescale of 17th December 2004 not met. The Placement Agreement (contract/terms and conditions) must be in accordance with the Standard and Regulations. Previous timescale of 28th January 2005 not met. The Registered Manager or Responsible Individual must apply to the CSCI for a variation to the categories for which the home is registered so that they accuratlely reflect the needs of the current residents. The Statement of Purpose and Service User Guide will then need to be amended to reflect the changes in registration. New service users including those for respite stays must only be admitted on the basis of a full assessment and a copy of a single care management assessment, both of which must be signed and dated. Service user plans (care plans) Version 1.10 Timescale for action 31 July 2005 2. 5 5(1) (b) and (c) 31 July 2005. 3. 1 4 and 5 31 July 2005 4. 2 and 3 14 30 June 2005 5. 6 15 31 August Page 26 3 Colham Road 6. 17 and 41 16 (2) (i) and 17 7. 12 and 14 16 (2) (m and n) 22 and 5 8. 22 9. 24,25 and 42 12, 13 (4 and 5) and 23 (2) (a, e and f) 10. 33 18 (1) 11. 38 8 must be further developed in order to consider all aspects of residents needs. Amendments to them must be signed and dated The procedure for recording of PEG feeding must be improved, and staff trained in the recording procedure and the importance of accuracy of recording The issue about whether the two service users who are PEG fed may return to their day centre must be resolved quickly. The complaints procedure, leaflet and service Users guide must be revised in order to make reference to the CSCI and that complaints may be referred to the CSCI at any stage. As the current service users all have physical disabilities and the home will therefore have to apply for registration for this category, the management will have to consider how to deal with the fact that five rooms are too small for safe work with wheelchair users. In order to create an effective and skilled staff team, the use of agency staff must be greatly reduced A dedicated Registered Manager must be recruited as a matter of priority. 2005 30 June 2005 30 June 2005 31 August 2005 31st July 2005 31st July 2005 31st July 2005 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 6 6 Good Practice Recommendations The Person centred planning concept should be further considered. Care plans should be retyped after each review Version 1.10 Page 27 3 Colham Road 3. 41 Address details of relatives and doctors should include their postcodes 3 Colham Road Version 1.10 Page 28 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 3 Colham Road Version 1.10 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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