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Inspection on 13/07/05 for Cumberland Road, 84

Also see our care home review for Cumberland Road, 84 for more information

This inspection was carried out on 13th July 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a group of staff that are working together in the interests of the service users identified needs. The home aims to provide a variety of activities in the community for each individual service user and is aware of service users likes and dislikes. A new service user moved into the home four months prior to this inspection. Care and attention was paid to ensure this was a slow and smooth transition for both the new service user and the existing service users living in the home.

What has improved since the last inspection?

The home has continued to meet some of the previous requirements and to identify ways to improve the service offered to service users. The Manager Designate has continued working to identify areas needing attention and improvement and has generally settled into managing the home.

What the care home could do better:

The Manager Designate must consider the best system to hold personal information and care plans on service users. It was difficult to understand how care plans were written and in what context. In addition, although documentation existed on the new service user, from their previous home, new care plans and risk assessments must be completed to ensure any assessed needs have not altered or new needs ignored. Menus must reflect the meals service users have eaten when staff are with them, either out in the community or in the home to ensure the health of the service user is considered at all times. Documentation for the two new members of staff was not available for the Inspector. Details were held at the Head Office and it was not clear what, if any of the documents would be held in the home. The checks carried out on staff are essential to protect vulnerable people. These must be viewed and inspected to ensure the organisation is following relevant legislation. At several inspections a quality assurance review was made a requirement. This continues to be outstanding. There are questionnaires for service users to ascertain their views and are due to be completed by the end of July 2005. There were no surveys/questionnaires for family members and professionals available to view and it was not clear if their opinions would be sought. The home must review the care offered and the systems in place to ensure it offers a high quality service for the people living in the home.

CARE HOME ADULTS 18-65 Cumberland Road, 84 Hanwell London W7 2EB Lead Inspector Sarah Middleton Unannounced 13 July 2005 10.30 AM 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. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 84 Cumberland Road Address Hanwell, London W7 2EB 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) 0208 566 2404 0208 566 2404 Ealing Consortium Limited Care Home 3 Category(ies) of Learning Disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 18/1/05 Brief Description of the Service: 84 Cumberland Road was originally registered as a small home, under the Registered Homes Act 1984 and 1991 Ammendment Act, for three service users. The Registered Providers are Ealing Consortium. The staff team comprises of a House Manager and five support workers. One of these posts has been divided into two in order to have a male worker in the team to work with the male service user. There is at least one member of staff working on each shift, with a person working a middle shift, to offer the opportunity for service users to receive one to one support during part of the day. The home provides a service for adults with a learning disability and or mental health needs. The home is a terraced property, which is situated in Hanwell. There are shops nearby in West Ealing or Ealing Broadway, both accessible by public transport, which is nearby. The accommodation consists of three single bedrooms. Service users are required to manage stairs to access the bedrooms, bathroom and toilet which are located on the first floor. There is a lounge, a kitchen/dining room and office/sleeping in room on the ground floor. A small garden is to the rear of the property, which is mainly paved, with some shrubs. Service users access day centres and community resources as appropriate. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of almost four hours, 10.30am-2.15pm was spent at the service. The Inspector carried out a tour of the home and inspected service user care plans, staff files and maintenance records. One service user and one member of staff were spoken with as part of the inspection process. It must be noted it is sometimes difficult to ascertain the views of service users with learning and communication difficulties. The House Manager is in the process of applying to CSCI to become the Registered Manager of the service. They will be referred to in this report as the Manager Designate. There were two outstanding requirements from the previous inspection and eight new ones set from this inspection. What the service does well: What has improved since the last inspection? The home has continued to meet some of the previous requirements and to identify ways to improve the service offered to service users. The Manager Designate has continued working to identify areas needing attention and improvement and has generally settled into managing the home. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 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. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 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 Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 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) 2, 3, 4 & 5 Prospective service users needs are assessed prior to their move into the home to obtain a full picture of the individual needs. The staff team are experienced and competent to meet the needs of the service users. Prospective service users have the opportunity to visit and spend time at the home, which encourages them to make an informed choice about the home. EVIDENCE: A new service user was admitted into the home four months ago from a home under the same organisation. An assessment was completed which offered a detailed picture of the prospective new service user. Additional relevant documentation was gathered in order for the staff team and service users living in the home to make a decision regarding the suitability of the prospective new service user. This service user had an advocate who also became part of the process of the introduction to the home, ensuring, where possible, that the service user was happy to move into a new home. This person also met the existing two service users to ascertain if they were happy with a new person moving into their home. The staff team are skilled to work with people with learning disabilities and work in a positive way with the service users who live in the home and so could meet the needs of the prospective new service user. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 9 The introduction was gradual, with the new service user having short visits, then overnight stays. The Manager Designate organised visits so that the new service user met all the staff during different visits. The service user spoken with during the inspection initially stated they didn’t like the new service user, but then nodded their head as if to say they did. The organisation has devised new terms and conditions which were comprehensive. These were to be signed by relevant external professionals, as the service users could not fully understand its contents or sign the documentation. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 There were shortfalls in the care plans on the new service user. They had not been completed by the home or reviewed and the various locations of the paperwork made it difficult to follow the assessed needs of the service user. Service users needs must be identified and reviewed to ensure staff can meet those needs and are fully aware of them. In addition and where possible, service users or their representatives must be involved when devising and reviewing a care plan. Service users are encouraged to participate in their every day life, with staff or advocates supporting them. Risk assessments on the new service user were from their previous home and did not outline any potential risks at night. As staff sleep in downstairs and bedrooms are upstairs, risk assessments must be carried to minimise any potential incidents occurring. EVIDENCE: The new service users care plan and other documentation was viewed. A review was held after the move into the home, however details outlining the service users needs were from their previous home and not the new home. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 11 The Manager Designate acknowledged they had not updated or reviewed the care plans since the new service user had moved into the home. Care plans are reviewed, but the contents of the care plan were not clear to follow and it was difficult to fully inspect the paperwork on the service user, as there were several files that held various pieces of information. There was no evidence of any service user consultation as part of the care plan or review process. The staff member spoken with stated service users are encouraged to make decisions where possible. Two service users have advocates, who can also work with the service user in making every day decisions in their lives. Service users have meetings held approximately every two weeks. Here they can raise any issues or questions they might have about the house. Staff encourage service users to contribute to the meeting as much as possible. Minutes were seen and detailed who attended and topics discussed. Risk assessments were not up to date for the new service user. The home had not reviewed or completed any new risk assessments since the service user had moved in. Due to their health needs, risk assessments must be carried out for both day and night periods, to ensure all staff are informed about any identified current risks. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15 & 17 There are different activities on offer for service users, with each individual service user having opportunities to meet others and to access local community resources. Service users choose the menus with the assistance of staff. Accurate records of meals must be noted to ensure the health and welfare of the service users is maintained and monitored. EVIDENCE: Service users can attend a place of worship if they choose to. Two service users attend a local church every Sunday. The service users do not work, but attend a variety of resources, such as day centres, activity centres and local colleges. Within the week, there is time to spend relaxing at home and having one to one support from staff. The service user spoken with said they enjoyed all of the activities they take part in every day. One service user is due to start a drama course at a local theatre. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 13 The home seeks to use community facilities, such as public transport, horse riding and the local pub. Plans have begun for a holiday this year, not necessarily as a whole group. Different activities and likes are encouraged and supported in the home. The service users have family, but there is currently no contact with them. This would be encouraged and supported if there was an opportunity to build on family relationships. The home is exploring ways to establish a relationship and visits with one of the service users and their relation who also lives in a residential home. Service users choose the weekly menu with staff. The fridge had fresh fruit and vegetables in it and dates of opening on food were clearly labelled. Previous menus were checked and many had gaps on what service users had eaten for breakfast and lunch. If there was a change to the planned meal, alternatives were noted. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Personal care is provided in a manner that is respectful for the service users. There were shortfalls in recording health appointments. Monitoring the health of service users is important to ensure regular checks are carried out. Overall the medication systems in place are generally robust. However, there are still shortfalls in accurately and consistently recording the administration of medication. These shortfalls could jeopardise the health and safety of the service users. EVIDENCE: Service users require support regarding their personal care. This is provided in private and in a sensitive manner. The service user spoken with confirmed they choose their own clothes each day. The Manager Designate has employed a part time male support worker, as there are now two male service users living in the home and the staff team had comprised of female support workers. One service user has a Psychiatrist and they have regular reviews at the local community learning disability team. The Speech and Language Therapist has also visited the home since the new service user moved in to advise staff on how to communicate effectively with the service user. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 15 The Manager Designate stated all health appointments are recorded and weight checks on service users are carried out regularly. However, when viewing the new service users file, there was no evidence of this having taken place. Samples of the medication administration records were tracked. As noted at the previous inspection, there was a gap where there should have been a signature. All medications were appropriately stored. The home has one controlled drug, in liquid form, which after consultation with the Pharmacy Inspector they recommended this was monitored on a separate recorded sheet, to ensure no mistakes occur. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 There are robust systems in place for making a complaint and for the protection of vulnerable adults, (POVA). Training is in place on POVA issues to inform staff on how to protect the welfare of service users. EVIDENCE: There is a clear complaints policy and procedure that is visible in the home. There have been no complaints recorded and the CSCI have not received any complaints. There is a policy and procedure for the protection of vulnerable adults, (POVA). There have been no POVA investigations. The staff member spoken with was aware of what action to take if they suspected a POVA incident had taken place. The organisation provides training for all staff on POVA. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 28 & 30 The home has completed risk assessments on the environment, including areas such as radiators. These could prove hazardous to service users, if they became hot. Work has been agreed to cover them in order to prevent any incidents occurring. Service users bedrooms were personalised and offered them time alone, when they choose to be. The home was clean and tidy with procedures in place to prevent the spread of infection. EVIDENCE: A full tour of the home was carried out. Overall the home is homely and pleasant, with good furnishings and fittings. The radiators in the home were uncovered however risk assessments had been completed on each service user. The organisation has a maintenance programme to cover all the homes radiators. The Manager Designate was hopeful this would work would be carried out over the next few months. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 18 The service user spoken with showed the Inspector their bedroom. This was personalised with sufficient furniture to meet their needs. The home has a separate lounge area where service users can watch television. The dining area is in the same room as the kitchen. Service users can choose to be in these communal areas, or in their bedrooms. There is adequate space for the three service users living in the home. The home has policies and procedures for infection control and the home was clean and tidy at the time of the inspection. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35 & 36 A competent and stable staff team supports Service users. They receive appropriate training and supervision to meet the different needs of the service users. There are shortfalls in the location of employment files. There were no records available on the two latest employed staff members. This issue must be resolved, as the home must demonstrate that appropriate recruitment procedures and checks have been carried out on all members of staff, in order to safeguard service users. EVIDENCE: The staff team is stable, with no vacancies. Staff are aware of their roles and responsibilities. It is recommended that staff receive the General Social Care Council codes of conduct and practice. The home has an additional part-time support worker who has recently joined the team. The home aims has two members of staff working during the day to offer one to one support at certain times, including week-ends. Regular staff meetings take place and minutes were seen. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 20 Staff are able to communicate effectively with all the service users. One service user is non-verbal, but responds to some pictures, which are being used in the house. The two latest recruited staff member’s employment details were not available in the home. All of their details were held at the organisation’s Head Office. Staff receive a full induction and mandatory training within the first six weeks of joining the organisation. The member of staff spoken with had joined the team recently and confirmed they had completed all the mandatory training and the Learning Disability Award. As there is one service user who has Autism, there will be training and information for staff on this topic. The Manager Designate stated the aim is for all staff to attend workshops on working with the focus being a person – centred. This entails keeping the service user central when planning and reviewing their every day life. Some staff in the team have either completed their NVQ course, level 2 or 3 or due to begin the level 2 in October 2005. Samples of supervision files were viewed. These are held every four weeks and notes detailed discussions that took place. The staff member spoken with stated they found supervision useful. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 42 & 43 The home benefits from an open style of management. There is a continued shortfall, as the home has not carried out a quality assurance review. Incorporating service users opinions is a part of the process and must be carried out to ensure the care offered meets the needs of the service users. All doors kept open must be fitted with appropriate equipment, which protects the welfare of both service users and staff. Water temperatures must be checked in all parts of the house to ensure the safety of service users is considered at all times. EVIDENCE: The home is managed well, with clear leadership. The staff member spoken with stated the Manager Designate was approachable. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 22 The Manager Designate is planning to start the Registered Managers Award and the NVQ assessor’s award before the end of 2005. They are also a personcentred planning facilitator. It was a requirement at the previous inspections that a full quality assurance review, incorporating service users, their representatives and professionals opinions be carried out. This has not taken place. Plans are in place to complete service user questionnaires, which the organisation has recently devised. Servicing records were viewed at random. These were all up to date. The office door was propped open at the time of the inspection. This was not fitted with any systems that would respond and close the door in the event of a fire. Water temperatures for the bathroom are taken on a regular basis. However the washbasin, although regulated by a safety valve, in the service users bedroom had not had the water temperature checked. The home has a business and financial plan, which was detailed and is monitored regularly. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 2 Standard No 31 32 33 34 35 36 Score 3 x 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cumberland Road, 84 Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 1 x x 2 3 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 24 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. 2. Standard 6 6 Regulation 15 Requirement Timescale for action 1/9/05 1/9/05 3. 9 4. 5. 17 19 6. 20 7. 34 The Registered Person shall make a service users plan available and kept under review. 15 The Registered Person shall ensure that where possible, service users, or their representatives are consulted with, when devising/reviewing their care plan. 13 (4) (c ) The Registered Person shall ensure that unnecessary risks are identified and kept up to date, this is to include both during the day and night. 17 (2) Records of foods provided for Schedule service users must be recorded 4 in sufficient detail. 12 (1) (2) The Registered person shall (3) & 13 ensure and record that service (1) (b) users receive all the health care they require to maintain positive health. 13 (2) The Registered Person ensures that staff comply with the homes policy and procedure for the recording of medicines. (Previous timescale 19/1/05 not met) 17 (2) Staff employment details must Schedule be available and held in the 4 home for inspection. G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc 1/9/05 1/8/05 1/8/05 14/7/05 1/8/05 Cumberland Road, 84 Version 1.30 Page 25 8. 39 9. 42 10. 42 3/10/05 The Registered Person must make available a quality assurance review, incorporating service users & their representatives views. A report in respect of any review must be made available to the CSCI and service users. (Previous timescale 31/3/05 not met). 13 (4) The Registered Person shall 31/8/05 ensure that water temperatures are taken in service users bedrooms and any other areas where service users have access. 23 (4) (c ) Consultation must take place 1/9/05 (i) with the fire authority to ensure that any doors kept open, for example the office door, which does not have a suitable door releasing equipment fitted to it, does not pose a risk to the health & welfare of service users and staff. 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 9 19 20 31 Good Practice Recommendations The Registered Person should review if the monitor is used by all staff at night. The Registered Person should explore using all health resources in the community. The Registered Person should consider recording the controlled drug on a separate sheet of paper to minimise any risks occurring. The Registered Person should make available to all care staff copies of the General Social Care Council codes of conduct & practice. Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cumberland Road, 84 G61-G10 s27728 Cumberland Road v214256 130705 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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