Inspection on 20/05/08 for Crebor Street

This inspection was carried out on 20th May 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Crebor Street 04/08/06

Crebor Street 20/12/05

Crebor Street 29/07/05

Crebor Street 14/10/04

Crebor Street 09/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Crebor Street 2 Crebor Street London SE22 0HF Lead Inspector Sonia McKay Unannounced Inspection 20th May 2008 09:00 Crebor Street DS0000060238.V365074.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 Crebor Street DS0000060238.V365074.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. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crebor Street Address 2 Crebor Street London SE22 0HF 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) 020 8693 4153 020 693 8198 2crebor@odyssey-csft.org www.odyssey-csft.org Odyssey Care Solutions for Today Care Home 5 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2006 Brief Description of the Service: The home is registered to provide a residential care service for five people with learning disabilities. There are 5 single bedrooms. The home is made up of two houses converted to make one larger home and garden. It is in a residential area of East Dulwich, close to public transport routes and local facilities, which include pubs, shops, restaurants and a post office. Prospective residents are given a copy of the Service Users Guide that gives information about the home and the services provided. A copy of the most recent Commission inspection report is available, on request, from the staff office. Fees range from £1067.48 to £1696.05 per week and depend on the individual care needs of each person. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out over three hours by one inspector. The methods used to assess the quality of service being provided include: • • • • • • • • • • • Talking with the home manager Looking at the Annual Quality Assurance Audit document completed by the home manager (this document is sometimes called an AQAA and it provides the Commission with information about the home) Talking to staff on duty during the inspection Talking to two of the residents A tour of the premises Looking at records about the care provided to two of the residents Looking at records relating to staff recruitment and training Looking at the way medicines are handled by staff in the home Sending surveys to residents, relatives and health professionals Completed surveys were received from five members of staff Discussion with a placing authority social worker involved in the care of one resident The Commission would like to thank all who kindly contributed their time, views and experiences to this inspection process. What the service does well: People get a chance to visit the home and try it out before they move in. Staff have good information about how residents should be helped and residents are asked what they want to do. Staff go out with residents so that they can do things they like and see friends and family. Staff try and help people to eat healthy meals and meals they enjoy. A resident said that the food is good. Staff help people to attend appointments about healthcare so that they stay healthy and staff write down what the doctors have said. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 6 Staff help people to take their medication regularly and safely. The staff ask people what they think of the home and how well it is doing. These opinions are used to make plans for making the home a better place to live. Staff are trained to understand the needs of the people living in the home and how they can help. Staff are trained to see when someone is being abused, and told what they have to do to keep people safe. What has improved since the last inspection? What they could do better: Plans for keeping people healthy must be written down with the help of people who understand each persons health needs, someone like a doctor, and these plans must be made accessible to people. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 7 The manager is experienced and qualified but has yet to register with the Commission. 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. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users guide to the home has been revised to include more information about services and fees, in accordance with recent changes in legislation. The guide is also produced in an accessible format more suitable for people who may find text only documents difficult to understand, making it a suitable form of communication for people with a learning disability. Individual aspirations and needs are thoroughly assessed during a resettlement process that provides an opportunity to visit and to’ test drive’ the home before making a decision to move in. EVIDENCE: The Statement of Purpose was revised in February 2008, and now includes up to date information about staffing. The Service Users Guide to the home is now produced in a visually accessible format making it easier to understand, as required by the Commission in previous reports. This outstanding requirement is therefore met. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 10 The AQAA (the Annual Quality Assurance Audit completed by the home manager to provide the Commission with information about the service) indicates that further revision of the guide is planned this year. Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. There is a set of policies about how the home runs. Some have been produced in a visually accessible format. Accessible policy includes a breakdown of how resident contributions and local authority placement fees are spent. This additional information, along with the Service Users Guide, provides prospective residents with the necessary information about placement costs. Prospective residents have an opportunity to visit the service before making a decision to move in and the registered provider obtains a community care assessment of need from the placing authority before completing their own assessment, records of which are held on file. Records indicate that the needs of a person most recently admitted to the home were fully assessed and they had opportunities to get to know the home before moving in for a trial period. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good plans for how residents should be cared for and supported and there is consultation with residents about their plans and life goals. EVIDENCE: Two individual case files were examined. Both sets of records are well maintained, organised and current. This makes it easier for staff to access up to date information. There are a range of guidelines detailing how each resident is to be supported in each area of their lives. These guidelines are reviewed and amended regularly to reflect peoples changing needs and any skills development/reduction. Individual profile information details the level and nature of support required in the areas of communication, community access, behaviour management and Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 12 personal care. There is also information about important relationships, spirituality and culture, weekly and daily routines and leisure activity choices. The AQAA states that there are plans to make the written plans and planning process more person centred. The multi disciplinary team have assisted by helping staff to develop more accessible formats for monthly key work meetings. Staff work with health professionals from the local multi-disciplinary team to develop a wide variety of methods to aid communication. Visual aids are in place to enable residents to make choices in their day-to-day lives. Each person has a named key worker, a member of the staff team with special responsibility to assist with planning and associated administrative tasks. As recommended in the previous inspection report, the key worker produces monthly reports about how things are going. This is useful when there are reviews of how well the placement is going. Feedback from a local authority social worker indicates that staff are well prepared to assist residents in the review process and there is good communication with the local authority. Breakfasts and lunches are prepared either by the resident themselves or with staff assistance. Menu files and recipe books are available to assist staff and residents to communicate and offer choices using photographs and pictures. All of the current residents require support from staff to manage their finances and to access the community safely. The reason for and nature of this support is documented in individual support profiles. The financial records for each resident are kept safety locked away, along with cash balances, bank account books and other valuable documents, such as passports. Receipts for financial expenditures made by or on behalf of anyone are carefully maintained. The financial records and cash held in safekeeping for each person is checked every day by staff, during the period of handover time between the morning and afternoon shifts. A spot check of records, receipts and cash balances during the inspection provided evidence of accurate accounting and record keeping. The registered provider also completes regular audits. As the residents have a learning disability they sometimes need support to make big decisions. For example, when complex decisions about healthcare arise there is multi disciplinary discussion to consider what course of action is in the persons ‘best interest’. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities and are part of their local community. They are supported to maintain relationships with friends and family. Meals are varied and enjoyed. A healthy diet is provided and mealtimes are flexibly timed to fit in with individual activity plans. EVIDENCE: Residents each have their own weekly programmes of activities and are supported to go out in the evenings and at the weekend. On the day of the inspection, one resident was going to a local museum with a member of staff and said he liked going on buses. Other residents attend a local day service on some days each week. Activity levels for each person are monitored and recorded. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 14 During the previous inspection a requirement was made for the service to review staffing levels as staff had concerns that individual activity levels were hard to maintain, due to staff shortage. This review has recently been completed and staffing levels have increased at specific times, based on the needs of individuals. Given the changing and in some case, increasing needs of the current residents, staffing levels reviews should be carried out frequently to ensure community participation. (See recommendation 1) Residents have access to a computer, and can get Internet access in the staff office until Internet access from the computer in the communal area is arranged. This is planned for later this year. There is information about key people in each resident’s life, and how they are to be supported to maintain these relationships. Residents are involved in planning menus, shopping and meal preparation, and a variety of options are available through the week. There is input from a dietician and healthy meals are encouraged. There are photos of food and meals available in the kitchen for residents to be able to identify what different types of foods are. One resident said that he enjoyed the meals. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support as they require and wish and healthcare needs are well monitored and addressed with input from relevant health professionals. There is regular review and monitoring for someone with a degenerative health condition to ensure that changing health needs are recognised and met. Residents are safely supported to take their medication. EVIDENCE: Current residents do not need a lot of help with direct personal care but they get assistance from staff, as they need it. The nature of the support is clear and detailed to ensure personal care support is as a person wishes and needs. Records of the healthcare of two residents were examined. Additional information about the healthcare of one other resident was also seen. All records are well maintained making it easier for staff to track health appointments and the outcomes and advice given. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 16 Records show that residents’ health needs are monitored well and visits to GPs or clinic are made regularly. One resident has increasing health and support needs and a community nurse is supporting staff so that these increasing needs can be monitored and met. Staff produced good visual information for one resident who was preparing for surgery. This made it easier for the person to understand what was going to happen and why. This is good practice. The AQAA states that there are plans to develop Health Action Plans for each resident in the next twelve months. This is essential to ensure involvement, understanding and pro-active and preventative healthcare. (See requirement 1 & recommendation 2) All current residents need assistance to take their medication. The medication records and stocks were checked and found to be in good order. Medication is securely and appropriately stored in a wall mounted metal cabinet. A previous requirement to ensure that the administration of topical medications be recorded is met. Staff now maintain a recording chart in the residents bedroom for when he uses a prescribed cream. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents views are listened to acted upon and they are protected from abuse, neglect and self-harm. The way that concerns and complaints are recorded has improved and is more accessible to residents with a learning disability. EVIDENCE: The home has an accessible complaints policy and procedure and there is a book for staff to record concerns, complaints or compliments. The record shows that concerns have been addressed appropriately and the outcomes are recorded. The home manager details this as an area of improvement. The complaints procedure is available in an accessible format and widely distributed. Staff encourage discussion and try to monitor issues raised as concerns so that they can be addressed before they develop into problems and complaints. This is good practice and is appropriate in a service for people with a learning disability, who may find formal complaints difficult. A copy of the local authority (Southwark Social Services) safeguarding adults’ policy and procedures are available for staff reference and the home manager demonstrates an understanding of appropriate actions to be taken. Staff also undertake training in safeguarding and recognising abuse. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 18 There has been one allegation against a staff member since the last inspection, which is currently under investigation. The organisation’s procedures to safeguard vulnerable adults is being followed. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 19 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, 27, 28 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable and clean, and steps are being taken to ensure that a resident has the appropriate bathroom facilities to meet an increasing mobility needs. EVIDENCE: The home is comfortable and decorated in a homely manner. On the day of the inspection the home was clean and there were no unpleasant odours. The home is in keeping with other homes in the local area and both interior and exterior decoration are of a good quality. There is sufficient communal space and a large back garden with planting and seating area. Double-glazing was fitted in 2007 and there is a new lounge carpet. The lounge and hallways have been re-decorated and new kitchen equipment such as hob, microwave, dishwasher and refrigerator have been purchased. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 20 All bedrooms are single occupancy and rooms seen during this inspection were personalised. The toilets and bathrooms in the home ensure that privacy and dignity are maintained. One person has an en-suite bathroom that is due for refurbishment. Advice about increasing mobility needs has been taken and quotes have been taken up for the work, as recommended in the previous inspection report. (See recommendation 3) Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 21 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, 34, 35 & 36. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported by a qualified staff team. Additional and statutory training is available and there is a training programme in place for this year. Systems are in place to provide staff with adequate support and supervision and residents are protected by the recruitment procedures in place. EVIDENCE: All staff receive induction and foundation within the Learning Disability Award Framework when they start employment and then begin the NVQ (National Vocational Qualification) Level 2 or 3 in Care. Staff also have access to training provided by a local specialist team for adults with a learning disability. All permanent staff and one locum staff member has the NVQ at level 3 in Care. The home manager is aware of the need to mix staffing skills and experience on each shift and he aims to put more experienced staff on duty with newer staff. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 22 There is a team training needs analysis for 2008, based on the individual training needs of each member of staff, as required in the previous inspection report. Staff receive regular supervision and annual appraisals have been carried out, as required in the previous inspection report. The manager is currently providing all staff supervision and he has received training in supervision and appraisal, as required in the previous inspection report. Staff recruitment records are held at the company head office, but were brought to the home to be examined during this inspection visit. A record of checks made on each member of staff is maintained in the home at all times, as required in the previous inspection report. Recruitment records examined during this inspection indicate that there is adequate vetting of prospective staff before employment. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 23 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. The manager is experienced and qualified but has yet to register with the Commission. The views of residents and other stakeholders are sought and used to inform plans for the home. Health and safety monitoring and checking has improved, making the home a safer place to live and work in. EVIDENCE: There was a previous requirement that the Responsible Individual must ensure that the new manager puts in an application to be registered with the Commission. This requirement was met and the manager was registered. However, she resigned in November 2007 and the service has since appointed a new manager, who was previously the deputy manager. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 24 The new manager has an NVQ at level 3 and is currently undertaking the RMA (Registered Managers Award). He has worked in the home for five years and knows the long-standing residents well. He has yet to submit an application to the Commission to be assessed and registered as a fit person to manage the home. (See requirement 2) In addition to better routes for communicating with and consulting residents, the AQAA states that the annual quality assurance surveys sent to families and other stakeholders to ascertain their views of the service provided are used to inform the local business plan, ongoing monitoring and future development. There was a previous requirement that the weekly fire system tests take place and are recorded as planned. Records show that tests are now done with the required frequency and the results are recorded. There are systems for checking environmental health and safety, and the home manager has identified this element of checking and record keeping as an area of improvement in the last year. Information supplied in the AQAA indicates that electrical and gas appliances have been safety tested in the last year. Requirements from previous inspection reports are met. The home manager should continue to consider ways in which the views of residents can be sought and recorded, including the use of recording equipment such as audio and/or audio-visual. (See recommendation 4) Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X 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 3 25 X 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 26 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 YA19 Regulation 15 Requirement The registered person must develop health action plans detailing the healthcare needs of each person. The Responsible Individual must ensure that the new manager puts in an application to be registered with the Commission. Timescale for action 31/10/08 2. YA37 S11(1) Care Standards Act 11/07/08 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 YA13 Good Practice Recommendations The registered persons should review staffing levels frequently to ensure adequate numbers of staff are available for residents to undertake regular access to the community. The registered persons should involve relevant health professional in developing health action plans for each person. Plans should also be produced in a format that each person understands. The Registered individuals should consider refurbishing and redecorating the olive coloured en-suite bathroom to DS0000060238.V365074.R01.S.doc Version 5.2 Page 27 2. YA19 3. YA24 Crebor Street bring it to the standard of other bathrooms in the home. Previous recommendation. 4. YA39 The home manager should continue to consider ways in which the views of residents can be sought and recorded, including the use of recording equipment such as audio and/or audio-visual. Crebor Street DS0000060238.V365074.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Crebor Street DS0000060238.V365074.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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