Inspection on 30/08/05 for Compass Cottage

This inspection was carried out on 30th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Compass Cottage 30/05/06

Compass Cottage 21/02/06

Compass Cottage 16/03/05

Compass Cottage 12/01/05

Compass Cottage 17/03/04

Similar services:

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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 Compass Cottage 90 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Roger Farrell Unannounced Inspection 30 August 2005 14:00 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. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Compass Cottage Address 90 Abbs Cross Lane, Hornchurch, Essex RM12 4XW 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) 01708 443086 Compass Residential Homes Ltd Ms Joanna Smith CRH Care Home 3 Category(ies) of LD Learning disability 3 registration, with number of places Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 16 March 2005 Brief Description of the Service: Compass Cottage a registered private care home that accommodates and supports three people who have learning disabilities. It has been operating for nine years, two of the current residents having moved-in in June 1996 when it opened. The owner’s have two other homes in the area, one of which is next door. All residents have single bedrooms, and share the homely ground floor ‘open- plan’ kitchen/lounge. Historically one manager has been responsible for this house and Compass Lodge, a short walk away further along Abbs Cross Lane in Hornchurch, and this remains the case. She is normally based at Compass Lodge. These two homes are inspected separately, though some paperwork covers both settings, such as staff files. Good standards of cleanliness and home-making are maintained, and this is a consistent finding at unannounced visits. The home is less than a mile from the shops and other facilities of Hornchurch town centre. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 30 August 2005, between 3 and 6pm. The assistant deputy manager who takes a lead in this house was on duty. The registered manager, Jo Smith came to the house and took a lead in dealing with the inspector’s enquiries. One resident had just arrived back having bought a new outfit for a family celebration. A second resident arrived back with his dad, having spent a few nights at the family home. The third resident was away staying with her family. The inspector is grateful for the warm welcome he receives from residents, and was pleased to have the chance to speak with a relative. The records asked for at this visit were much better organised, the manager saying this was due to the lead being taken by the assistant deputy manager in some areas. Despite proving a poor ‘action plan’ in response to the last report where a number of items were not covered, the manager was able to show good progress on the matters needing to be tackled. What the service does well: What has improved since the last inspection? This home shares its staff with Compass Lodge, a four-place home just up the road. Compass Cottage has benefited in the past from having a core of two or three main staff who had been in post for some time. One person who has worked at the home for three years is now the ‘assistant deputy manager’. She shows enthusiasm about helping residents with their opportunities, and has contributed to making sure day-to-day arrangements are better, such as safety checks. Seven other staff cover shifts. Most are quite new, but the indications are that staff turn-over is decreasing. One relative told the inspector – “I’m quite satisfied. Staff are capable, but there has been a Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 6 problem with them moving. I am kept well informed though, and I have been asked along to meetings. You do tend to meet new faces….The house is always clean. [My son] helps with the housework, and is encouraged to do his meals.” 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. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. Agreeing new guidelines has decreased concerns about how a new person would be assessed and helped move into the company’s homes. EVIDENCE: There is laminated ‘statement of purpose that covers all areas, including the registered persons’ details and the size of all rooms and photos. The inspector has also seen the much improved ‘service users’ guide’, now presented in a clear style, including using symbols. There have been no new admissions to this home since December 1999. It intended as a ‘home for life’, but one resident is planning to move back to live with family. The inspector has seen the documentation ready to be used in future for assessment. This includes the NCHA’s standardised ‘application form’ and the ‘assessment schedule’. Earlier in the year the inspector raised major concerns about the poor planning around an attempt to quickly move a new resident into the home next door. He asked for a much clearer policy and procedure on assessment and moveins, clarifying the central decision-making responsibility of the registered manager. He has been shown a series of documents that will be used as the framework in the future. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and move-in checklists adopted from the ‘Mulberry’ series. These set out a responsible approach to introducing prospective residents. The assessment standard is rated as met as it accepted that the company will use these guideline if a vacancy occurs. The manager said the homes do not accept emergency admissions. There are now contracts covering each person’s terms of residency on their files. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 9 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, 8, 9 and 10 All three residents are well established in this home, and continue to show high levels of independence. All live active lives, and the help given by staff is well judged in ensuring that the residents follow their chosen lifestyles, which includes being out a lot. EVIDENCE: The ‘Person Centred Planning’ files introduced last year are a significant improvement. Out-of-date bulky notes have been removed from the current files, which are much better organised. Some sections are still blank or only have very basic comment – such as the ’likes and dislikes’ and ‘what I need help with’ sections – but the main ‘care-plan’ sheets are worthwhile. It would be helpful if more recent additions were typed rather than being handwritten beside the earlier typed entries. Nevertheless, the gradual but positive improvement in how practice files are being kept in this home is encouraging. The files seen had recent reviews by the placing agency. The manager said that the next phase would be to introduce a ‘My Life Plan’ section. All three residents are able to say what are their individual preferences, and their daily routines and social activities are arranged around these choices. They all help with household chores and can prepare their own meals with very little assistance. Views expressed by residents about the domestic routines Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 10 confirm that their opinions are routinely sought. For instance, there are times when a resident have to go to one of the neighbouring homes for a short period when staff are out with others. All three residents have been asked about this arrangement, all saying that this was okay – adding they enjoyed the social contact involved. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 11 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. Residents are given very good guidance and support to take part in work, educational and social activities, including holiday breaks. All have good links with their families. A strength of having a senior member of staff working in this home is that there are now better records covering social activities. EVIDENCE: All service users have strong independence skills and lead busy lives. In some limited instances prompting and guidance is necessary, but in general all are confident and competent in their social abilities. They are all able to exercise choice about what activities they take part in. For instance, this has included all three being involved in voluntary jobs such as such as working in charity shops. At this visit one resident and her keyworker explained how applications had been submitted for a number of supported jobs in supermarkets. This person is also starting to act as a ‘peer-tutor’ in teaching Makaton. The inspector was shown photos of a recent short break, and some of the weekly ‘women’s group’ involving a beauty session. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 12 The assistant deputy manager prepares ‘daily planners’ covering community activities. All residents are out most days. One resident attends a number of day and evening clubs and has a wide friendship circle. The two others generally do not wish to go to clubs specifically for adults with a learning disability, preferring alternatives such as going to the pub with staff. The residents of this house regularly pop in to Compass Lodge, and join in social activities there. This is seen as mutually beneficial. Two residents share responsibilities for walking the home’s pet dog. The manager described to the inspector each person’s level of contact with members of their family. All have regular contact and supportive links, including relatives visiting the home. All residents can use keys to the front door and their bedrooms. There are no restrictions other than keeping staff informed of matters such as return times, and one person who needs staff to be with her when she goes out. In general each resident prepares their own meals with a little assistance from staff. There are daily menu sheets recording what each person has had to eat, covering breakfast, lunch and the evening meal. All residents at times assist with the main weekly shop. The kitchen has a good range and variety of foodstuffs, including fresh vegetables and fruit. All three residents tell the inspector that they are satisfied with the catering arrangements. One resident said – “I mostly cook my own meals, but we sometimes take turns. I am happy with the meals. We go shopping once a week……Yes, there are always enough fizzy drinks, but I am trying to stick to water or juice. There’s always enough of the things I need.” This resident showed the inspector the awards she had received for her success on college courses. These standards are rated as met. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 13 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. This home is good at supporting residents with their health care needs, and is now keeping better records of contacts with doctors, dentists, opticians and so on. Better guidance is also available on medication. EVIDENCE: At visits this year the inspector has been given descriptions of the help each resident needs with personal care. This is largely limited to giving prompts, and simple assistance such as helping with hair washing. The care-plan files have a ‘my medical details’ section, with good tracking sheets for contacts with doctors and other health care workers. Attendance at medical appointments is one area where it is necessary to accompany all residents, both to help relieve anxiety and ensure understanding of information or instructions given. The GP is described as helpful, with a good attitude towards listening to residents. One resident said that she was satisfied with the help she had received when she had an accident. The arrangements for storing and recording medication are found to be satisfactory. The medication administration files now have individual profiles, and instructions to follow if an error occurs – though no mistakes are known to have occurred in the past year. Medication is provided by a local pharmacist in blister packs, with printed administration sheets. This pharmacy also provides training sessions, and all staff have to complete a competency test before being responsible for giving drugs. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 14 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 and 23. The manager is aware of the expectations about recording, reporting and following through on complaints and any suspicions of abuse. The necessary range of guidance is available. However, there was not sufficient details about looking into the one complaint made this year. This needs to be tightened up. EVIDENCE: The inspector was shown the revised basic complaints policy, that now includes contact details for the Commission. Assurances were received that the ‘complaints book’ available was the only version now held in the office. This had one entry since the last inspection, but there was not enough detail recorded. A requirement has been made on this point. There is available a file containing the required range of policies and guidance covering protection issues and responses. This includes a copy of ‘No Secrets’; the in-house policy and ‘Pavilion pack’; and the Havering guidelines. Longer serving staff have staff have signed to say they have attended briefing and video sessions and are familiar with the key documents. A training session for more recent staff was planned for the following week. All staff have signed to say that they have been given a copy of the main ‘code of practice’, and those who met with the inspector gave good answers about their responsibilities, including on whistle blowing. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 15 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, 26, 27, 28, 29, and 30. The building is suitable to meet the needs of residents, and has quite a homely appearance. Residents’ rooms show each person’s individual tastes and interests. EVIDENCE: Communal space is an open plan lounge diner, with a countered-off kitchen. All conditions were found to be satisfactory, and residents say they are satisfied with these facilities. The size of each bedroom is now included in the statement of purpose’, and these range from 11.34msq and 12.13msq. The two residents who were at home showed the inspector their bedrooms. These are satisfactory, have the required range of furniture, and, reflect individual’s interests. All three bedrooms are above the minimum space standard. Each has a good range of home entertainment equipment. The bathroom is on the first floor. This has a basic decorative appearance, but was found to be clean and functional. The sheet to record periodic tests of the hot water is now being completed. There is a loo on the ground floor. An occupational therapist has assessed the needs of one person with minor arm Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 16 movement restrictions. Additional handrails with strong wall brackets are fitted along the staircase. There is a support around the toilet in the bathroom. No other adaptations are needed. The washing machine and dryer are in the small room used as the office on the first floor. This is said not to be problematic, and the inspector was told that this arrangement has previously been seen and approved by a fire safety inspector. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 17 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) 31, 32, 33, 34, 35, and 36. Keeping staff was the main problem raised in the last report. The signs at this visit are that the situation has improved, but monitoring this important part of providing the service still needs to be monitored by the registered persons. EVIDENCE: There is considerable overlap between the staff who work in this home and at the main house, Compass Lodge. The last reports on these twinned homes raised the problem of staff retention, saying - “Staff turnover remains the prominent factor restricting the consolidation of {these homes}. At the announced inspection the manager gave a profile of each staff member, including each individual’s training and experience. The problem is illustrated by the fact that when the inspector returned ten weeks later almost 40 of established staff had left or were due to leave….The registered persons must carry out a critical analysis of this matter, and are invited to make comments in the action plan that has been requested in response to this report.” The brief response received sidestepped this issue, saying nothing worthwhile about how this problem was to be addressed. At this visit the manager went through the staff list covering this home. The assistant deputy manager does most of her shifts at the Cottage. Seven other care assistants work at both the Cottage and the Lodge. With one or two Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 18 exceptions, most had been with the company for less than six months. The inspector was told that about three months ago the owners did a staff questionnaire. However, no outcome or proposals were known, including about the issue of how wages are paid. Nevertheless, the manager said that the signs are that the rate of throughput is slowing. Those staff who spoke to the inspector, all of whom were quite recent, talked of there being good unity, which is an important reason why they would stay at a home. Another positive point is that the manager is very pleased that the valued deputy has returned to that post after six-month break, and he is able to help with management tasks like supervision. Therefore, the indications are that the situation has improved, but this is an area that the inspector will continue to monitor. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; deputy; assistant deputy manager; 1 senior care assistant; 9 full-time and 4 part-time care assistants, of which 4 cover night shifts. Cover in this house is 1 staff member on duty on the early and late shifts (7.30am to 10.00pm). Night cover is one waking person. This provides an on-duty ratio of one staff member to three residents through the day. Recent rota’s show that there are occasional ‘long-shifts’, though these were said to be voluntary, and were followed by a day off. Staff said that regular planned and minuted staff meetings are taking place about every four weeks. The manager is good at carrying out the required range of vetting - such as getting two references, a CRB certificate, and checking permission to work. The well arranged staff files have a training profile, induction checklist and copies of course certificates. This reflects the positive steps that have been taken over the last couple of years to have records that meet the standards. The inspector told the manager that she needs to keep her management knowledge up-to-date, such as how to get ‘Pova-first’ clearance. There was also a much clearer plan and support for helping staff gain a relevant qualification, mainly using the NVQ scheme offered by Barking College, though the team are still well below the target of having 50 of qualified staff. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 19 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) 37, 39, 40, 41 and 42. Good evidence was at this visit to support the standards tested under this heading. The manager visits this house a couple of times a week. The benefits of having an assistant deputy manager were apparent, such as having better records of activities, and considerably better files on health and safety. EVIDENCE: The manager has fourteen years experience in the care sector, seven of these in a management position. She commenced with this company in January 2001, managing the smallest of the group of three homes. She took on manager responsibilities for Compass Lodge and Compass Cottage in January 2003. Her title is now ‘Area manager’ as she supervises the manager of Compass Grove. She has got the NVQ level 3 award. After some delay, she is due to start doing the registered manager’s course in September at Barking College. Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 20 The owners and manager do carry out spot-checks, including at nights, and take action where they find deficiencies. The owners use a tick and comment ‘monthly report’ format produced by the NCHA, and have done business plans. At announced inspections the owners have made available information from their accountants confirming the viability of the business. The inspector asked to see a range of records and certificates covering health and safety. This included tests of the battery alarms and the monthly fire drills; contractor tests of the extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. Reports of the last visits by a fire safety inspector and environmental health said conditions were fine. An independent infection control and hygiene audit last year gave the commendable overall score of 93 . Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 21 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Compass Cottage Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 22 No 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 22 Regulation 22 Requirement Maintain in sufficient a record of all complaints, including having details of the investigation and outcome. Have these details available at inspections. Ensure that staff have sufficient training in the core areas, and that there is a plan working towards the target of staff holding a recognised qualification. Timescale for action 9/10/05 2. 32 18 9/12/05 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 Good Practice Recommendations Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Compass Cottage G55 S0000027839 Compass Cottage V246073 300805 Stage 4.doc Version 1.40 Page 24 - 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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