Inspection on 10/08/07 for Community Resettlement Project

This inspection was carried out on 10th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Community Resettlement Project 04/04/08

Community Resettlement Project 10/07/06

Community Resettlement Project 01/12/05

Community Resettlement Project 02/04/05

Community Resettlement Project 01/11/04

Community Resettlement Project 15/04/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Community Resettlement Project 24-28 Argyle Street Kings Cross London WC1H 8EG Lead Inspector Pearlet Storrod Unannounced Inspection 10 August 2007 10:00 th Community Resettlement Project DS0000010342.V332799.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 Community Resettlement Project DS0000010342.V332799.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. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Community Resettlement Project Address 24-28 Argyle Street Kings Cross London WC1H 8EG 020 7278 3629 020 7813 9776 mkerr@communityhousing.org.uk 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) Community Housing Association Mercy Kumah (appointed manager awaiting registration approval) Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/7/06 Brief Description of the Service: Community Housing Association manages the Community Resettlement Project (CRP). This organisation has considerable experience in the housing sector and provide a wide range of care and support services. The home itself provides care and support to adults with mental health needs. It is situated in a residential/commercial street very close to Kings Cross Station. The property is three adjoining houses. House number 24 is registered to accommodate five women; house number 26 is the office-cum-staff area and house number 28 is registered to accommodate thirteen male service users. The houses are interconnected. Accommodation for service users is provided in single rooms, each is furnished with a fridge and a wash hand basin. Communal facilities include toilets, bathrooms, kitchens and lounges. There are two gardens to the rear of the premises. The houses are not suitable for service users with mobility problems and as they are listed buildings, alterations and adaptations are unlikely. The focus of the CRP is on rehabilitation and resettlement. Residents are to be motivated to be able to cook and undertake cleaning and laundry or improve these skills. An average stay is twenty-two months although residents can be there for longer. Prospective service users must have the ability or at least be motivated with regard to social skills, shopping and budgeting, self-catering, domestic cleaning, laundry, personal care and self-medication. The fee charged for the service is £380 - £403.13 Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took over a day to complete. This home has had four managers in post over four years. The new appointed manager assisted with the inspection process and I was able to speak with staff and some of the people who use the service hand observe a handover. Various records were looked at including care plans, training and supervision records, complaints and policy documents. A tour of the home was undertaken and a visit to the provider’s head office also occurred to scrutinise staff files and the policy and procedures in respect to the use of agency workers. The appointed manager stated that the provider has merged and that the name of the organisation has changed to One Housing Group with “One Support” responsible for overseeing the residential services. What the service does well: What has improved since the last inspection? A new manager is in post and has applied for registration. They appear to have innovation and drive and has begun to introduce some new initiatives, which encapsulates social inclusion and healthy lifestyles for everyone. An engineer has visited the home to investigate the heating problems amongst other things. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The previous report required a review of the statement of purpose and service users guide. The home was also taking in referrals without the capacity to fully meet their needs. EVIDENCE: It was a requirement of the last report that the home reviews the statement of purpose and service users guide. The document was not available for inspection and the newly appointed manager states that the statement of purpose is undergoing review though the previous registered manager states in the quality assurance assessment document that the review had been undertaken. A referral assessment is in place and prospective people who use the service are given a trial period to see if their individual needs could be catered for at this service. Each person admitted is required to go through an induction. According to staff the induction programme for people who use services is under review, as some referrals have high levels of needs such as drug and or alcohol problems and it is proving difficult at times to meet needs Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 9 People who use services are required to sign three different contracts upon admission. These relate to local authority contract, an agreement in respect to room allocation and a support contract. Additional agreements are discussed between key-worker and people who use services in unique situations. The contracts needs to be brought together to cut down on the paperwork and cut down on the variation to prevent confusion for people who use services. Community Resettlement Project DS0000010342.V332799.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place that takes account of the changing needs of people who use the service. There was inconsistency in the way that support staff review the support plans and set objectives. Risks assessments are available but needs to be more robust. EVIDENCE: Service users assessed and changing needs and personal goals are reflected in their support plans but the reviews carried out in respect to the plans do not always demonstrate how individuals are to be supported to achieve the set objectives. The appointed manager is aware of this and has given an undertaking to review with the staff team the methodology in respect to this. People who use services are supported to make informed decisions. Key work sessions occur 3 weekly. House meetings occur fortnightly and issues arising out of these are picked up and addressed. At this inspection I spoke with an individual who use the service and he requested that drinking water should be Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 11 made available in the lounge as a way of improving the service. It was good to hear this contribution and the manager has agreed to follow this up. Risk assessments are available but these need to be more robust and take account all the activities undertaken by individual people who uses the service. Community Resettlement Project DS0000010342.V332799.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are supported to integrate into the community and to preclude social isolation. People who use service are encouraged to maintain relationships and friends and their rights and responsibilities are taken into account in all aspects. The previous report required more recordings in respect to the dietary needs of people who use services. EVIDENCE: People who use services continue to be involved in the enhancement of their individual personal development and they are encouraged to participate in everyday living skills, hobbies and interests such as drawing, playing music, shopping, and household chores. I spoke with an individual who had recently completed a brick-laying course; he was delighted with his achievements and was looking forward to take on new initiatives. Another individual talked about his computer course and said it was going well. Group holidays and other Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 13 activities such as barbeques and one-day trips are arranged with involvement from people who use services. One other person talked to me about her interest in the performing arts and they recited a poem, which they said they had written. Staff are in the process of discussing the setting up of various groups in the home, with people who use services taking the lead. Individual people who use the service are encouraged to maintain relationships with relatives and friends and their opinions and desires are respected as appropriate. They are required to sign consent forms as to whether their relatives are to be involved and invited to reviews or notified of any significant events affecting them. The previous report made mention of the need for staff to take more active approach in respect to the dietary needs of people who use the service and to have more robust recordings to get a clearer picture as to individuals cultural and nutritious needs and requirements. In discussion with the appointed manager she asserted that staff members are to receive training in food hygiene and her plan is for staff to support individual people who use services to prepare and cook their individual meals. There was talk about a proposal to set up a cultural cooking group as part of healthy lifestyle. Community Resettlement Project DS0000010342.V332799.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Support with personal care is not provided in this home. Staff tries to ensure that the physical and emotional health needs of people who use services are met. Medication is managed in a way that promotes good health. EVIDENCE: The Community Resettlement Project does not provide accommodation and services to people who require support for more than 24 months. Prompts in respect to personal care are given to individuals as necessary. Support staff pays close attention to meeting the physical emotional and psychological health needs of people who use the service. Individuals are encouraged to access health promoting services such as dietician, prescription for exercises at a gym and other health related issues. It is noted however that staff experience difficulties in meeting the needs of people with dual diagnosis such as alcohol or other complex needs, as mentioned earlier. This problem is outlined the Reg. 26 report for April of this year. The current manager is in the process of addressing this with individual staff. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 15 People who use services that are considered by staff to be capable to self medicate are encouraged and supported to do so. The pharmacist dispenses medication each week; from examination of the MAR chart and medication cabinet the MAR chart did not have the appropriate marking in the signature box where an individual had not showed up for their medication. Another individual had refused to take the medication prescribed for them over 4-week period. It is not good practice to have repeated orders and a build up of prescribed medication for individuals refusing to take their medication. The appointed manager states that two staff members need to be present when medication is being administered. Staff are asked to have agreements with individuals about the dispensing of their medication within a reasonable time during the evening at about 8pm and 9 am each morning. This would allow the practice for two staff members to administer medication during those prescribed times and to go home at the end of their shifts. It would permit staff to finish their evening shifts at a reasonable time. The policy and procedure will need to be kept under review. Staff on duty demonstrated that they had a clear understanding of their roles in respect to the medication needs of people who use the service. Community Resettlement Project DS0000010342.V332799.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints system is in place and people who use services are protected by the policies, procedures and practices of the home. EVIDENCE: Complaints made by people who use the service have either been addressed or in the process of being dealt with. From written information observed, a person who uses services made a formal complaint about the humidity in her room caused by the overheating boiler. The complainant commented that the situation is causing her to continuously sweat and feels uncomfortable each day. This matter is on going. Complaints that have reached resolution have recorded follow up and outcomes. Where necessary people who use services are given an opportunity to take their complaint further to a second stage if they are dissatisfied with the initial outcome decision. Where a complainant makes a complaint about another client, rather than deal with the matter informally in the first instance at the manager’s level, as currently all complaints go through a formal process, which can take time to address and in the meantime, disharmony continues between two individuals instead of being nipped in the bud. Staff should receive training in complaints management and consideration should be given to review the existing policy and procedure to include an informal process initially with the opportunity to go through a formal process if a resolution is not reached. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 17 Staff have received training in respect to adult protection and this is on going and the protocol for vulnerable adults has undergone review and appears satisfactory. Community Resettlement Project DS0000010342.V332799.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not provide a comfortable environment for the people who live and work there. A satisfactory standard of cleanliness continues to be maintained. EVIDENCE: Two previous reports noted that improvements were needed in various areas of the home to make it more pleasant and comfortable for the people who use services to live in. For nearly two years the faulty boiler has not been repaired, which continues to frustrate an individual and caused them to lodge a complaint about the prolonged ineffective heating system that affects her health and well being. The manager reported that an engineer had visited the home and that a main concern related to a faulty boiler, which is evidently passing hot water from cold water taps, amongst other things. This could potentially cause legionella. The home is attempting to ensure that the maintenance works are undertaken Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 19 to improve environmental conditions so that people who use services and staff are safeguarded from risks of harm. The home is not well maintained though support staff attempts to provide a homely environment for those who live there. Fairly recently, new carpeting have been laid in the hall and stair areas of the home; it was plain to see that the job in respect to fitting the stair carpets were not done sufficiently well as pieces of carpets were missing in several places on the staircases, thus presenting an unpleasant appearance. The lounge areas are in need of redecorating and replacement of furniture and carpet. More importantly, the matters outlined in the previous report and others arisen since then must be addressed within a reasonable timescale to ensure the internal and external environment are continuously maintained to a standard that meet the needs of the people living there and for staff. The home continues to be clean with no offensive odours. Community Resettlement Project DS0000010342.V332799.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 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Support workers have the skills and knowledge to meet the needs of the people who use services. A review in the number of permanent staff is necessary. A more robust recruitment and selection policy and practice are necessary. EVIDENCE: The staff team is skilled in respect to the assessed needs of people who uses the service. The newly appointed manager is registered to take up training in respect to the Registered Managers Award. Most staff has achieved NVQ qualifications. I visited the provider’s head office and examined the staff records held there. The records examined showed that CRBs had been transferred. This was discussed with staff at the office who confirmed the current practice was to transfer staff CRB records as opposed to conducting new checks. Staff were advised to apply system in use in respect to the POVA First checks initially to enable staff to begin work whilst waiting for clearance from the Criminal Records Bureau (CRB). Also noted was the process used for the validation of an individual’s references which were not properly verified on letter headed Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 21 paper or company stamp. It was further noted that photo identification were not included on all the files held. Staff photographs must be included in each file and updated as appropriate. The rota indicates the regular use of agency staff. The design and layout of the home and its purpose in respect to rehabilitation and preparation to move into more independent living accommodation in the community, means that the provider may need to increase the number of permanent staff to ensure consistency and continuity of service delivery. This increase in staff numbers has been identified by the previous manager as outlined in the quality assurance assessment document and also by the newly appointed manager for the home. It should be noted however that some staff are concerned that the home is taking referrals with complex needs such as alcohol and they have not as yet received the appropriate training to effectively meet the needs. It is felt by staff that people with more complex needs will be admitted and the manager is in the process of identifying with individual staff their training needs; the manger talked about the plan to invest in a training co-ordinator for the home. The manager must ensure that staff are appropriately trained and possess the capacity to meet the assessed needs of people who use services. A sample of staff files held in the home was examined and these showed shortfalls in supervision and training. The newly appointed manager is in the process of addressing this problem. Community Resettlement Project DS0000010342.V332799.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 adequate. This judgement has been made using available evidence including a visit to this service. Efforts are made to manage this home well but this is compromised by the provider’s lack of focus in dealing with outstanding requirements which impacts on the health, safety and welfare of the people who use services and staff. EVIDENCE: This registered manager left the home in July 2007 and their successor was appointed shortly thereafter. The appointed manager demonstrated experience and skills to manage the home effectively and efficiently on the inspection day. They have applied to the Commission for registration approval and as stated previously, is registered to undertake the RMA qualification course. Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 23 The views of people who use services are sought in various ways. They contribute to the assessment and care planning process and at regular key work sessions. People who use services also make their views known at the two weekly house meetings. The minutes indicate that people who use services make contributions, which are acted upon. Monthly monitoring visits are carried out, which also provide an opportunity for people who use services to share their concerns and have them acted upon. Poor maintenance standards throughout the home impacts on the health, safety and welfare of people who use the service and staff. An individual raised a complaint as the situation regarding the heating was affecting them. Some communal areas of the home need refurbishment. It has taken over a year for the boiler to be looked at by an engineer and some maintenance and repair works have been outstanding since 2005. Staff informed me that the feedback received is that the existing boiler is an industrial model and that a domestic type boiler is needed. A list of outstanding works necessary to make the premises more habitable and fit for purpose must be addressed to prevent action being taken by the Commission. An improvement plan is required with timescale for all the works to be carried out by the provider. Community Resettlement Project DS0000010342.V332799.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 2 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 3 ENVIRONMENT Standard No Score 24 1 25 x 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 2 x 2 x Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement Timescale for action 10/12/07 2. YA17 16(2)(i) 3. YA6 14/15 The registered person must ensure that the statement of purpose is amended to reflect the name of the new manager and the current staff structure Restated from the previous 2006 report timescale was 05/09/06 Nutrition must be a 10/12/07 standard item for discussion at the monthly key working meetings. Key workers must support service users to prepare and plan their meals and to monitor and record these. The monitoring and recording of service users meals is restated. Is being Restated: old timescale were 31/12/05 and 05/09/06. The registered person must 10/12/07 ensure that all service users support plans are updated and reviewed in a consistent manner. Repeated. Previous timescale 10/10/06. DS0000010342.V332799.R01.S.doc Version 5.2 Page 26 Community Resettlement Project 4. YA9 5. YA20 6. YA24 7. YA33 and YA34 The registered person must ensure that risk assessments are conducted of service users personal environment and activities. Repeated Previous timescale 10/10/06 13(2) The registered person must ensure that unused medication are returned to the pharmacy. 23(2)(a) The registered provider (b)(c)(p), 16 (2) must ensure that the boiler (f)(h) and ventilation systems together with other items listed for repair in the previous reports for 2005 and 2006 are dealt with. This requirement is repeated. The previous timescales were 30/01/06 and 10/10/06 The provider must also carry out the repairs and maintenance outlined on a schedule held in the home 18(1)(a) The registered person must 19(1)(a)(b)(i)(c) ensure that sufficient and Schedule 2, numbers of permanent staff Regs. 7,9 and19 are employed to meet the assessed needs of people who use the service and to achieve the home’s objectives. 14/15 10/12/07 10/12/07 10/12/07 20/12/07 8 YA35 18(1)(i) 18 (2) They must also review their recruitment and selection processes to ensure that all staff are provided with identity photo on their personal files, that all references are validated and that each staff have up to date CRB clearance and to discontinue the practice of transferring CRBs previously undertaken. The registered person must 20/12/07 Version 5.2 Page 27 Community Resettlement Project DS0000010342.V332799.R01.S.doc YA36 7. YA42 12(3) ensure that all staff receives appropriate training to meet the needs of people with complex needs. They must also ensure that all staff are appropriately supervised The registered provider must safeguard and protect the health, safety and wellbeing of the people who use services and staff, ensuring compliance with all outstanding requirements outlined in the previous reports are satisfactorily addressed. 20/12/07 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 YA22 Good Practice Recommendations The registered person should consider reviewing the complaints policy and procedure to include an opportunity for concerns to be dealt with in an informal way in the first instance. The registered person should ensure that the home review a number of the organisation’s policies and procedures to fit the service. 2. YA40 Community Resettlement Project DS0000010342.V332799.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Community Resettlement Project DS0000010342.V332799.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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