Inspection on 11/10/05 for Deepdene House

This inspection was carried out on 11th October 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deepdene House 21/12/07

Deepdene House 11/04/06

Deepdene House 14/04/05

Deepdene House 25/11/04

Deepdene House 01/07/04

Deepdene House 26/02/04

Deepdene House 30/10/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Deepdene House 55-57 Stanthorpe Road Streatham London SW16 2EA Lead Inspector Ms Lynn Hampton Unannounced Inspection 10/10/05 14.15 DS0000022723.V252090.R01.S.doc Version 5.0 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 DS0000022723.V252090.R01.S.doc Version 5.0 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. DS0000022723.V252090.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Deepdene House Address 55-57 Stanthorpe Road Streatham London SW16 2EA 020 8769 6297 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) Mr Sam Vindalon Mrs C Vindalon Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places DS0000022723.V252090.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th April 2005 Brief Description of the Service: Deepdene House is a 20-bedded private care home for adults with mental health problems, one of two homes in the Streatham area owned by the same proprietors. It is situated within easy walking distance of transport links, and all amenities offered in Streatham High Street. The building is made up of two large Victorian houses, converted to interconnect internally, and has a large parking area to the front. The proprietors have recently undertaken refurbishment, so that rooms that were previously double are now single with en-suite facilities. The home has a range of communal areas that includes two main sitting rooms, a small kitchen for residents to make snacks, and a dining room. There is a large and attractive rear garden, although this is undergoing digging as further refurbishment is underway. The home has a number of internal stairs, and is not suitable for people with mobility problems. Deepdene Houses accommodates people who have enduring mental health problems, and it aims to provide support and rehabilitation. The home employs a cook and a cleaner, as well as care staff who prompt and support residents in personal care and activities of daily living. DS0000022723.V252090.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place during the afternoon and early evening of a weekday, and lasted nearly five hours. The inspection methods included a tour of the building; meeting service users, (and discussions with approximately six of them); meeting members of staff, (and discussions with three of them, including the Registered Manager); discussion with Director of Operations; and examination of a number of records held at the home. What the service does well: What has improved since the last inspection? 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. DS0000022723.V252090.R01.S.doc Version 5.0 Page 6 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 DS0000022723.V252090.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1, 2, 3, 4, 5 Service users have information about the home before they move, and can visit. Their needs are assessed at referral stage and they are given a contract when they move in. EVIDENCE: The inspector met and spoke to two service users who had moved into the home in the last eight weeks. Both confirmed that they had had information about the home and had visited prior to making a decision about whether to move in. In each case, the person had moved to Deepdene from some distance, as it had not been possible to find a more suitable placement nearer their original home. One user reported that she had agreed to accept the placement at Deepdene, on condition that she is able to move to an area of her choice as soon as a suitable place becomes available. Case records that were examined showed that appropriate assessments had been done before admission, with risk assessments and care plans in place. Licence agreements were in place, that had been signed by the user, their Social Worker, and a representative from the home. (This was a Requirement made in the report of a previous inspection, which is now Met). The home’s Statement of Purpose and Operational Policy (submitted to the Commission) needs to be updated to reflect changes in registered person, number of rooms, and facilities. DS0000022723.V252090.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 6, 7, 8, 9, 10 Service users have individual care plans, and are involved in making decisions about their lives. Service users, relevant care professionals and their family (where appropriate) are consulted in planning and reviewing care. Risk assessments are in place, and records are kept securely in the home. EVIDENCE: Case files seen by the inspector were very well organised, and clearly showed that care plans were generated from comprehensive assessments and referral information. Background information forms had entries written by the user, where the person could indicate if they agreed with the summary, and add extra information, which is to be commended. Care Plans are agreed between staff and service users, with specific ‘Agreements’ being drawn up that are signed by both, which set out how problems will be addressed by them together. The files showed that regular Reviews were held, attended by the user and the multi-disciplinary team involved in their care. DS0000022723.V252090.R01.S.doc Version 5.0 Page 9 Care Plans and Risk assessments were reviewed and updated, and regular Key Worker Meetings held and recorded, which showed how staff consult with residents about progress. However, there were some gaps and incomplete documentation. The Risk Assessment for one resident, who had recently moved in, was incomplete; another recent resident did not have a complete Needs Assessment, and the Functional Assessment was incomplete; there were no ‘Monthly Review of Care Plan’ forms on another resident’s file. See Requirements. The inspector spoke to several residents, who confirmed that they were able to make choices about their life, with support from staff. Each service user has a key to the front room as well as their bedroom, and can enter and leave the home freely. There are restrictions placed upon users, relating to assessed risks or their individual needs. One person had Agreements in place that restricted unsafe behaviour, including smoking in his room, and anti-social behaviour. The person had a history of non-compliance with such agreements, which had contributed to previous placements failing. The Agreement devised did not indicate how the resident was to be supported to comply, what other action would help to promote compliance, or what alternative strategies were in place to respond to problems (other than Warnings and ultimately termination of placement). This was discussed at length with the manager and senior care worker. The manager and key worker are to review and reassess the situation, and consideration should be given to requesting input from the Challenging Behaviour team or other specialist services, who could help develop creative responses. One case file contained a Resident’s Questionnaire, which was undated. The responses about satisfaction with care and the home were generally positive, but the resident had indicated that he wanted more opportunities to make choices, be involved in decisions and to participate in activities. Further checking of this person’s case records indicated that he is offered opportunities to participate in the activities mentioned, but declines to do so. It emerged that this questionnaire had been undertaken some 18 months ago, and it was unclear what follow-up there had been to the responses made or issues raised. It is recommended that this good practice is followed up by either producing a report on how the responses were analysed, and what action was taken, or that the exercise is repeated and updated. DS0000022723.V252090.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12, 13, 14, 15, 16, 17 Service users have individual programmes of activities that reflect their interests and wishes. They are offered some opportunities to participate in routines in the home as well as in activities outside. Rights and responsibilities are respected. Meals at the home are of a very high standard. EVIDENCE: Case files that were examined by the inspector, showed that assessments and care plans refer to residents’ interests and social networks. Residents are supported to attend activities, and maintain links with friends and family unless there are clearly indicated reasons not to do so – in which case, appropriate documentation was in place explaining why. Several residents were out at day centres, or appointments at the time of the inspection. One person was being visited by a relative, and was able to spend time with them in the privacy of her room. DS0000022723.V252090.R01.S.doc Version 5.0 Page 11 The stated aim of the home is to promote rehabilitation. Care plans were seen that aimed to promote personal hygiene or management of personal finances. There is a snack kitchen on the lower ground floor, which would enable residents to prepare light meals and drinks. One of the recently refurbished rooms has a kitchenette area, which will allow a resident to prepare meals and be quite self-sufficient. Residents informed the inspector that they participated in shopping and some meal preparation – one person went out to get supplies of bread for the home during the inspection. However, the home continues to provide two cooked meals a day, which are eaten communally, and a domestic who cleans the communal areas, so there are limitations to the extent to which residents can or do experience independent living routines. The home has a programme of group activities that is scheduled to take place for half an hour each day. The inspector joined the staff and residents for that day’s activity, which was ‘free choice’. This meant that the residents could choose how to use the time. Four residents attended, one of whom had a map of the world and had devised a geography ‘game’ for others to identify cities and capitals. The home does not have a budget for activities. One resident said that the home had used to organise day trips to the coast, which he had really enjoyed, but that these had stopped. Consideration should be given to reinstating these, or otherwise enabling activities that may have some cost. A requirement was made in the report of the last inspection that individual users are supported to apply for funding for holidays. Case files showed that this was being undertaken, and this Requirement is met. DS0000022723.V252090.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18, 19 Service users receive personal support in the way that they prefer and require, and this is undertaken in a respectful and professional manner. EVIDENCE: Staff were seen to consult with residents about their preferences, and to knock on their bedroom doors before entering. Residents that the inspector spoke to reported that they were happy in the home, and that staff were helpful. One said “I can’t fault it here”; another described it as “pukka”. The home’s Operational Policy contains a statement that sexual and racial harassment will not be tolerated. There was evidence on file that culture and ethnicity of residents was assessed, and addressed in care planning. There were two female residents at the time of this inspection. One of these had recently moved in and so had been allocated a bedroom with en-suite facilities. This promotes privacy, which can be a particular issue for females sharing communal facilities with men, and is to be commended. It is recommended that a review is undertaken to ensure that the home is appropriately addressing issues relating to gender and sexuality. Case files seen contained detailed records relating to the health care of residents. DS0000022723.V252090.R01.S.doc Version 5.0 Page 13 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 the following standard(s): N/A These standards were not inspected during this unannounced visit. The finding of the previous inspection (April 2005) was that the standards were being met. No complaints have been made since that inspection, and residents informed the inspector that they had no complaints or concerns. EVIDENCE: DS0000022723.V252090.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 24, 25, 27, 28, 30 Service users live in a home that they find comfortable. Bedrooms are personalised. There are numerous communal areas for service users to use, including lounges, bathrooms and toilets. Improvements have been undertaken in the home to provide single rooms with en-suite facilities. The home was clean. EVIDENCE: The inspector had a tour of the home, and saw all communal areas, two residents’ bedrooms, and two rooms that had recently been converted to have en-suite facilities. These had been refurbished to a high standard. The lower ground floor consists entirely of communal areas; a dining room, kitchen, a smoking- and a non-smoking T.V. lounge; and a small kitchenette for making snacks. Lounge areas were domestic in style and furnishings, but the dining area is less so, having larger groups of tables than would be found in a domestic home, and opening onto an industrial-style kitchen. Meals are served by staff from a trolley, and there are locked units for the fridge and cutlery. DS0000022723.V252090.R01.S.doc Version 5.0 Page 15 There is access through the lounges to a large and attractive paved garden area. There is an administrative office at the home, which serves both Deepdene and Prema House. This is being extended out into the garden patio area, and building work was being carried out on the day of the inspection (foundations were being dug out). The Ground level floor accommodates staff offices, as well as newly refurbished bedrooms, with en-suite facilities (and one with a small kitchenette). Refurbishment had been carried out to a high standard, and the en-suite facilities meant the home now met National Minimum Standards in respect of provision of bathrooms, showers and toilet facilities for the number of residents. Access to the lower ground floor and upper floors is via flights of stairs. There are toilets and bathrooms on all floors, which have locks on the doors. Areas were generally clean, although the resident who showed the inspector round said that it was usually much cleaner – today was the domestic’s day off. Equipment and furniture were in a good state of repair throughout the home. The service users who showed the inspector their bedrooms said that they were happy with them, and that they had everything that they needed and wanted. Each was personalised to reflect their own tastes and interests. DS0000022723.V252090.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Staff are supported by an effective staff team, who have access to training. Policy relating to the recruitment of staff is good, but records of checks were incomplete. EVIDENCE: During the inspection, the inspector met the Registered Manager, two care staff, one Senior, an Administrative clerk, and the cook. The Director of Operations also attended the home to meet the inspector. Staff were observed to interact professionally and in a caring manner with service users. They were able to talk knowledgeably about residents’ individual needs. One member of staff had started at the home eight months earlier, and reported that he had already obtained an NVQ Level II award. There was evidence of training available to staff on file. The organisation pays for training, although a request is made for staff to contribute to half of the fees, payable if the member of staff leaves within twelve months of the training date. Training included Signs & Symptoms of Mental Illness; RecordKeeping; Well-Being of Clients, as well as a range of statutory training in areas of Medication, Fire Training and Food Hygiene. The home Administrative clerk had a well-organised file outlining what had been undertaken, and was able to discuss the programme and training policies in depth with the inspector. DS0000022723.V252090.R01.S.doc Version 5.0 Page 17 Two staff records held at the home were examined by the inspector; both showed that each person had been interviewed, with references taken up. However, there was no evidence that POVA checks had been undertaken (to ensure that people were not listed as unsuitable to work with vulnerable adults). The manager reported that these checks were routinely done, and previous inspections had noted POVA/CRB checks on file. Evidence of this is to be confirmed to the Commission, and placed on file. It was clarified with the manager and Operations Director that staff must not be employed until a POVA check has been undertaken and found to be satisfactory. A new CRB check must be requested for each new member of staff joining the organisation, although staff may start work if they produce evidence of a recent clear CRB check, at the manager’s discretion and with appropriate supervision. There were no copies of Job Descriptions or contracts on staff files, which would help ensure clarity of roles and responsibilities. These, including the Job Description for the manager, are to be forwarded to the Commission DS0000022723.V252090.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, 43 Service users benefit from a well run home. Senior management roles in the organisation are being reviewed to promote clarity, accountability and promote the best interests of users. EVIDENCE: Deepdene House is owned by Mr & Mrs Vindalon, who own a second registered care home called Prema House. They have formed a company, Deepdene Limited. During the inspection, the Director of Operations for the company arrived to speak to the inspector, having been informed that there was an unannounced inspection taking place. She explained that the company was undergoing some review. The Director of Operations is a new post, and she is responsible for reviewing all aspects of operation of both homes, and is developing a new Business Plan. An issue discussed with the Director of Operations following this inspection, is that the home’s Operational Policy and Registration details need to be reviewed and updated to reflect recent changes including the status of the organisation (Deepdene Ltd, rather than individual proprietors). Relevant information will be sent to the proprietors by the Commission in respect of registration issues. DS0000022723.V252090.R01.S.doc Version 5.0 Page 19 The Director outlined that the Company’s aim is to build on the good foundations of the service, but to modernise and possibly expand. The organisation has already identified areas in which they feel positive developments could be made, and this assessment was in agreement with evidence found in inspections. A priority is to ensure stability in management for the home, and to clarify and consolidate the role of the registered manager generally. This is a particular issue for Deepdene, as there have been several changes of manager, and recently several changes in staff. On previous occasions, the owner has provided cover between changes of manager. This could lead to confusion regarding role boundaries, which would not be helpful to the management of the home. Some examples came to the attention of the inspector during this visit, arising from various notices that were seen to be posted on walls. One notice in the staff toilet stated that disciplinary action would be taken if staff did not place the toilet roll properly. This was queried by the inspector as it appeared disproportionate. The notice had not been posted by the current manager, who felt unable to comment on its appropriateness. Another notice in a communal corridor indicated that staff and residents had to approach the Administration office from the garden entrance. This led to a discussion about the changes being made at the home regarding new office space. It was unclear what consultation or information had been given to residents, staff or management regarding the developments being made, which clearly was having an impact on their day-to-day lives (if only in terms of the disruption caused by the building work). The direction of travel outlined by the Director of Operations was very positive, and she demonstrated a commitment to reviewing and resolving issues around communication, clarity of management roles, recruitment and retention of staff, and team building. The updated Business Plans, or any other information relating to proposed changes in the organisation, are to be submitted to the Commission, including details of the organisational structure and roles of the senior management team/Directors. It is also recommended that the revised Business Plan includes quality assurance monitoring, based on service user surveys or feedback, (as outlined in NMS 39). Out-of-hours on-call management of the home is provided by the manager of Prema and the manager of Deepdene, on a one-week-on/one-week-off rotational basis. Due to the nature of the two services, there is a reasonable likelihood that on-call managers will be contacted. This relatively high level of cover provided, could lead to fatigue. This is to be monitored and reviewed, particularly as the manager of Deepdene is due to leave in the near future. The Responsible Individual is to inform the Commission of what systems will be in place to cover this absence. DS0000022723.V252090.R01.S.doc Version 5.0 Page 20 A sample of records held at the home were examined by the inspector, and were mostly found to be in good order, and up-to-date. The manager has made a variety of notifications to the Commission as is required by the Regulations, but it was found that incidents were recorded on the files that had not been notified. See Requirements. The report of the previous inspection contained a Requirement regarding adherence to COSHH regulations (this concerns the control of hazardous substances). The manager outlined what action he had taken to address this, and this Requirement is met. DS0000022723.V252090.R01.S.doc Version 5.0 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 2 3 3 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 4 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 2 3 X 2 X 2 DS0000022723.V252090.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4, 5 Requirement The Registered Person must update and revise the Statement of Purpose and Operational Guide to reflect changes in registration, number of rooms and facilities. The Registered Person must ensure that care planning and documentation clearly indicates how service users are to be supported to achieve goals, and what strategies are in place to help address problems such as poor compliance. The Registered Person must ensure that all care documentation, particularly Risk assessments, are completed and updated regularly. The Registered Person must review the arrangements regarding the programme of activities in the home, including how service users are consulted about activities, and how group activities can be arranged. Consideration must be given to identify funding to support this. The Registered Manager must ensure that staff records kept at DS0000022723.V252090.R01.S.doc Timescale for action 01/02/06 1 YA6 12(1) 13(4) 01/12/05 2 YA9 13(4) 14(2) 15(2) 16(2)n 10/11/05 3 YA14 01/02/06 4 YA31 17(2) Sch4(6) 01/02/06 Version 5.0 Page 23 5 YA34 19 Sch.2 6 YA38 10(1) 12(1) 18(1)(2) 7 YA38 8, 39 8 YA41 17 Sch 4 9 YA43 10, 24 the home contain copies of Job Descriptions and contracts, which contain information specified in Schedule 4(6). A Job Description for each role is to be copied to the Commission. The Registered Person must ensure that information and documents as specified in Schedule 2 are in place for each person working at the home. The Registered Manager is to confirm to the Commission in writing that satisfactory POVA, CRB and reference checks have been undertaken for each member of staff, and this is evidenced on staff files. The Registered Person must review and monitor the on-call rota, and out-of-hours support to the home, to ensure that this is adequate, appropriate, and avoids staff fatigue. The outcome of the review, with timescales for any action agreed, to be notified to the Commission in writing. The Registered Person must submit in writing to the Commission notice of the change in manager, with details of what arrangements are in place to recruit to this post, and to manage the home the home in the interim. The Registered Person must ensure that all events relevant to Schedule 4 are notified to the Commission. The Registered Person must submit revised Business Plans to the Commission, with information relating to any changes in organisation or operation. This is to include details of the organisational structure and roles of the senior DS0000022723.V252090.R01.S.doc 10/11/05 10/11/05 10/11/05 10/11/05 10/01/06 Version 5.0 Page 24 12 YA43 6, 39 management team and Directors. The Registered Person must ensure that the Operational Policy and Statement of Purpose are updated, and that contact is maintained with the Commission regarding any amendments to Registration that may be necessary. 10/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA8 YA18 Good Practice Recommendations The Registered Person should produce a report detailing the results of the previous User Satisfaction Questionnaire, and/or consider repeating the consultation The Registered Person should arrange for a review to be undertaken to ensure that the home is appropriately addressing issues relating to service users’ gender and sexuality DS0000022723.V252090.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022723.V252090.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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