Inspection on 13/07/06 for Delrose House Ltd

This inspection was carried out on 13th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Delrose House Ltd 15/10/07

Delrose House Ltd 23/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Delrose House Ltd Delrose House Ltd 23 The Drive Ilford Essex IG1 3EZ Lead Inspector Sandra Parnell-Hopkinson Key Unannounced Inspection 13th July 2006 10:00 DS0000063030.V303793.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 DS0000063030.V303793.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. DS0000063030.V303793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delrose House Ltd Address Delrose House Ltd 23 The Drive Ilford Essex IG1 3EZ 020 8518 0926 020 8518 0925 info@delrosehouse.co.uk www.delrosehouse.co.uk Delrose House Ltd 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) Kulvinder Kaur Swalli Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places DS0000063030.V303793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2005 Brief Description of the Service: The home is a residential home for 6 adults with learning disabilities and/or associated mental health problems, providing a 24 hour service with waking night staff. The home is situated off The Drive, Ilford within the London Borough of Redbridge and is within easy access of shops and bus routes. All bedrooms are single and spacious each with an en suite, and two bedrooms have an en suite shower. There is a large lounge/dining area and a spacious kitchen/diner on the ground floor and a small quiet/visitor’s room on the first floor. All rooms are furnished and decorated to a good standard. There is disabled access to the front of the home. Access to the rear garden is from the lounge/dining room or from the utility room. The rear garden has a patio with a small lawn area and flower beds which are well maintained. Seating for residents to enjoy the garden is available. At the time of this inspection the fees ranged from £1074. - £1100.85 per week. DS0000063030.V303793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on the 13th July, 2006 from 2p.m. The manager was not present during the inspection but the deputy manager and the responsible individual were both present during the inspection. The home was clean and bright and well maintained. At the time of the inspection there were two permanent residents but assessments had been undertaken on several other prospective residents with a view to them moving into Delrose House in the near future. The care plans were very comprehensive and needed some minor adjustments. Both residents were very happy and both said that they liked living at the home and that the staff were very kind and the food good. As the home is registered for both learning disabilities and/or associated mental health problems, staff are receiving training in both areas. The deputy manager has experience in working with people with mental health problems as well as with those who have a learning disability, and the responsible individual is a trained trainer for training staff in crisis intervention. Currently the registered manager is at the home on a part time basis, but as more residents move into Delrose House this situation will change so that both the manager and the deputy manager will be working at the home on a full time basis as agreed with the Commission. In the meantime, the manager has been asked to ensure that a monthly rota is available at the home which shows the days that she will be on duty at Delrose House. This cannot be on an ad hoc basis as the deputy manager and the lead inspector for the Commission need to know the working days for each employee at the home. Also as the number of residents increases so will the staffing numbers both during the day and night shifts. Additional information relevant to this inspection has been gained from a preinspection questionnaire, monthly Regulation 26 reports and discussions with other professionals involved in the care of the residents at Delrose House. The Inspector was pleased to note that both the responsible individual and the deputy manager had made themselves very aware of the recent joint report, produced by the Healthcare Commission and the Commission for Social Care Inspection, on the NHS services for people with a learning disability in Cornwall. What the service does well: DS0000063030.V303793.R01.S.doc Version 5.2 Page 6 All prospective residents have a comprehensive assessment undertaken prior to moving into Delrose House, and then a detailed care plan together with any necessary risk assessments and strategies are compiled with the service user, relatives if appropriate, the manager and other professionals. 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. DS0000063030.V303793.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000063030.V303793.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management ensures that all prospective service users have an individual needs assessment, are given the opportunity to visit the home and are provided with a written contract or statement of terms and conditions, so that they are able to make an informed choice about where to live. EVIDENCE: The files of two residents were viewed and both showed evidence of a comprehensive pre-admission assessment, pre-admission visits to the home and a statement of terms and conditions. The management has invested a lot of time in ensuring that the contracts and statements of terms and conditions are in line with the guidance provided by the Office of Fair Trading. The statement of purpose sets out the admission criteria, the needs that can be met and the support that can be offered. The service user guide has been produced in an easy to read format, with pictures, for those people with a learning disability and work is being done to provide other information, including menus, in easy to read formats for the residents at Delrose House. DS0000063030.V303793.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The assessed and changing needs and goals of service users are reflected in their individual plans, and they are enabled to make decisions about their lives with the necessary assistance. Service users are consulted on, and can participate in, all aspect of life in the home and are supported to take risks as part of their independent lifestyle. Information on service users is handled appropriately and service users can be assured that their confidences are maintained. EVIDENCE: There are currently two service users resident at Delrose House, and the files of both of these residents were inspected. Both files showed clear evidence of a comprehensive assessment of need and personal goals for both residents had been reflected in their individual plan. It was clear that residents were enabled to be as independent as possible within a risk management framework. One of the residents enjoyed going out DS0000063030.V303793.R01.S.doc Version 5.2 Page 10 for a newspaper and to the park and during the inspection he returned to the home on his own having enjoyed his trip. He said that “he liked the home and was free to do things that he wanted to.” The other resident needed support when leaving the home due to identified risks around road safety, and this was very clearly documented within his care plan. During discussions with the deputy manager it was clear that although sexuality had been addressed in the care plans, this area needed further exploration so that staff were not put at risk when working alone. The deputy manager has undertaken to discuss this with the manager and ensure that robust emergency systems are in place, together with the ability to employ additional staff if needed for emergencies, or to take residents out separately and not to leave the home unattended if one resident did not wish to participate in the community activity. During the inspection one resident was sitting in the garden reading with one of the care workers. He said that “I like books and gardening and I can do this at the home.” Staff will help residents participate in a local independent advocacy group operated by a voluntary organisation. With regard to finances, support is available to enable the residents to purchase toiletries, clothing and other miscellaneous items, but the bulk of their estates is managed by either the local authority or the Court of Protection. Receipts and records are being maintained for all expenditures. From observation it was evident that the two residents are involved in the day to day running of the home, and the inspector has been assured that as the numbers of residents increase then more structured residents’ meetings will be organised. The inspector was satisfied that information about residents is handled appropriately and that confidences are maintained where necessary. DS0000063030.V303793.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are able to take part in age, peer and culturally appropriate activities, are part of the local community and are encouraged to maintain appropriate relationships with family and friends which is to the benefit of all parties. Service users’ rights are respected and responsibilities recognised in their daily lives. A healthy diet is offered so that service users can enjoy meals and be assured that their dietary and nutritional needs are being met and monitored. EVIDENCE: It was evident from inspecting the care plans of the two residents currently at Delrose House, that they have been able to inform staff as to their wishes and needs. Both residents are white British and activities are culturally appropriate for them. The religious needs of these residents have been addressed but neither of them wish to participate in any religious activity at the present time. DS0000063030.V303793.R01.S.doc Version 5.2 Page 12 All care plans are under monthly review, or sooner if the need arises, and this area will again be discussed in the future. One of the residents obviously enjoys going out to the shops and he does this regularly within a risk management framework. The other resident also enjoys going out but his sometimes challenging behaviour requires him to be supervised, and again this is properly documented within the care plan. The inappropriate sexual activity of some people with a learning disability or brain injury was discussed with the deputy manager, and he will ensure that all staff receive training in how to manage this, and that all staff are made aware of emergency procedures to be implemented if working alone, or if two female members of staff are on duty. Family and visitors are welcome at Delrose House and there is a quiet room on the first floor if residents wish to entertain visitors in areas other than their bedrooms. A support worker from a voluntary organisation visits one of the residents on a regular basis which enables him to further participate in community activities. A comprehensive menu is available and the management ensures that residents are receiving a healthy and balanced diet with plenty of fresh produce. Residents are encouraged to make their own choices with regards to meals and are encouraged to participate in the preparation of these. However, it was also evident that much work is required in the motivation of residents to encourage them to undertake tasks that currently they have no interest in. The deputy manager is undertaking work on producing menus in a pictorial format. The interaction between staff and residents was very good and the residents appeared very comfortable and relaxed in the presence of the staff. It was evident from observation that staff showed respect and valued the residents as individuals. DS0000063030.V303793.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can be assured that they will receive personal support according to their wishes and that they physical, emotional and health needs will be met by the involvement of appropriate professionals where necessary. Where appropriate service users will be able to retain, administer and control their own medication within the protection of the home’s medication policies and procedures. EVIDENCE: From viewing the care plans of the two residents it was evident that their physical, emotional and health care needs had been identified. Both had been registered with a local GP. However, there was no evidence that the residents had visited an optician or dentist for a check to ensure that there were no problems. This was discussed with the deputy manager who will be arranging for these areas to be addressed in the very near future. It is essential that residents receive regular checks as they may not be able to immediately identify any problems. For instance any swellings or lumps which may indicate areas of concern around such things as prostate/testicular cancer DS0000063030.V303793.R01.S.doc Version 5.2 Page 14 for males, or breast cancer for females. Also it is important that residents receive regular check-ups at the opticians and the dentist. The management has a close working relationship with the other professionals, such as social workers, currently involved with both residents and one social worker has stated that she will now visit every two weeks instead of weekly because she is satisfied with the progress being made by her client. Discussions were had with the deputy manager regarding the inclusion in the care plans of the areas of ageing, illness and death of a service user, and he has undertaken to gradually discuss and include these areas at future reviews. DS0000063030.V303793.R01.S.doc Version 5.2 Page 15 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): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can feel that their views are listened to and acted upon and that they will be protected from abuse, neglect and self-harm. EVIDENCE: There is a complaints procedure in accordance with the requirements of the Care Home Regulations and the inspector is confident that the management and staff will listen to, and act upon, the views and concerns of residents and others before being allowed to develop into problems and formal complaints. Each resident has been given a copy of the complaints procedure but this could be in a more simplified format for use by people with a learning disability, and would also be dependent on the level of understanding and communication. From viewing training records and discussions with staff it was evident that current staff have received training in adult protection. At the time of the inspection there had not been any adult protection issues. DS0000063030.V303793.R01.S.doc Version 5.2 Page 16 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, 28 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can feel confident that they can live in a homely, comfortable and safe environment which is well maintained, clean and hygienic and that their bedrooms can be personalised to suit their individual needs and choices. EVIDENCE: A tour of the premises was undertaken and it was obvious that the home was being maintained to a good standard of both décor and furnishings. All of the bedrooms have an en suite and two of these include a shower. The other toilets and bathrooms provide sufficient privacy to meet the individual needs of all residents. Currently the two residents do not require any specialist equipment, but it was evident from discussions with the responsible individual and the deputy manager that if any specialist equipment was required by any current, or future, resident then such equipment would be provided. DS0000063030.V303793.R01.S.doc Version 5.2 Page 17 All of the bedrooms have been decorated and furnished to a good standard but it was evident that residents are encouraged to personalise their bedrooms in accordance with their own needs and choices. The shared spaces complement and supplement residents’ individual bedrooms and there is a small quiet lounge on the first floor where residents can meet visitors in private if they do not wish to use their bedrooms. During the inspection one resident had just come back from visiting the shops and was sat enjoying watching television. He told the inspector that he was very happy at the home, and it was evident from the interaction between himself and the deputy manager that there was a good relationship. The rear garden was well maintained with seating areas for the residents, and one of the residents said that he enjoyed gardening and that “I helped to plant the flowers and cut the grass.” The kitchen area was clean and tidy and food was appropriately stored and labelled. There is a utility room which leads onto the garden and the storage facilities for COSHH materials was appropriate. Some parts of the home had recently been repainted and therefore, some of the fire exit signs were missing. This was discussed with the responsible individual who undertook to ensure that these were put back. The inspector expressed some concern that the two fire exits, one off the utility room and the other leading from the kitchen, had doors which could be, and were locked. The key was kept by the deputy manager, or whoever was on duty but the inspector stated that this was not acceptable. Following discussions with the responsible individual and the deputy manager, it was agreed that duplicate keys would be obtained and kept in a small case on the wall by each fire door so that these would be easily accessible in the case of an emergency. There is disabled access to the front of the building. DS0000063030.V303793.R01.S.doc Version 5.2 Page 18 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, 34, 35 and 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although service users are supported by staff who have, and are receiving training, are supervised and have been recruited through a robust recruitment policy and practice, some clarify if still required as to the roles and responsibilities of some staff. EVIDENCE: As part of the inspection process all of the current staff files were viewed and were found to be in good order with the necessary two references, enhanced criminal records bureau disclosure, application forms, interview notes, supervision contract and employment contract. Staff have received induction training and two members of staff will be commencing the NVQ level 2 later this year and other have achieved a certificate in mental health level 2. Ongoing training is available and includes crisis intervention, adult protection, effective communication, anxiety disorders, mental health and learning disabilities. Although some staff members may have English as a second language, the management are ensuring that all members of staff can effectively DS0000063030.V303793.R01.S.doc Version 5.2 Page 19 communicate with residents and other staff members. One member of staff is currently studying English at a college. Some clarity is required for when the responsible individual is working at the home as a care worker. In this dual role it is essential that all members of staff are aware of the role of this person at a particular time. For instance when he is in a position of “owner/registered person” and when he is operating as a care worker. This dual role can be confusing for both residents and staff, and especially for the senior person on duty. Therefore the manager must ensure that the staff rota indicates the name and role of each person on duty at the care home at any one time. As previously stated, there are times when there is only one member of staff on duty with access to an “on call” person. However, this is not always acceptable or practicable if one resident wants to participate in activities which the other resident/s do not want to. There must be freedom of choice for each resident and more forward planning of activities would better inform the compilation of the staff rota. Staff are receiving supervision but this must be extended to both the manager and the deputy manager who will also require effective support and supervision. DS0000063030.V303793.R01.S.doc Version 5.2 Page 20 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, 40, 42 and 43 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users do benefit from a well run home, and can be confident that their views underpin self-monitoring and development by the home. The rights and best interests of residents are safeguarded by the homes policies, procedures and record keeping. EVIDENCE: All maintenance records such as regular checking of fire alarms, insurance certificate, gas and electrical maintenance and water were viewed and found to be in good order. The deputy manager has worked hard to ensure that the policies and procedures have been reviewed and these are available in the office. DS0000063030.V303793.R01.S.doc Version 5.2 Page 21 The responsible individual undertakes the monthly quality visits required under Regulation 26 of the Care Home Regulations, and a copy of these reports are sent to the Commission to inform the inspection process. During the inspection it was very evident that the home is benefiting from the ethos and leadership approach of the deputy manager and the responsible individual who appear to have a good working relationship, with the best interests of the service users as a paramount objective. It is for this reason that the judgement of “good” has been made with regard to this outcome area. Because of the absence of the registered manager at this, and the previous inspection, it is difficult to reflect her views as these are not known. The registered manager is reminded that the Commission regard her as the person with overall responsibility for the day to day operation of the care home. It is the registered manager who should be communicating a clear sense of direction and leadership which staff and service users understand, and she must ensure that there is a rota available at the home indicating her periods of duty. DS0000063030.V303793.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 2 2 3 3 3 X 3 3 DS0000063030.V303793.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 12(1)(a) Requirement Timescale for action 30/07/06 2 YA15 12 (3) 3 YA19 12 4 YA21 15 The registered manager must ensure that the care plans reflect any areas which may pose a risk to staff during the care of a resident, and that a risk assessment is in place, and that sufficient staff are on duty at all times so that service users are not restricted in the community activities they wish to undertake. The registered manager must 30/07/06 ensure that the care plans include support with friendships, inside and outside of the home, including physical relationships. The registered manager must 31/08/06 ensure that all residents are enabled and encouraged to have regular check ups with the GP, the optician, the dentist and any other health services that may be required. The registered manager must 31/03/07 ensure that the question of ageing and death is addressed, with the involvement of each resident, on the individual care plan. This will be a gradual process dependent upon each resident. DS0000063030.V303793.R01.S.doc Version 5.2 Page 24 5 YA24 23 (4)(4A) 6 YA31 18 7 YA36 18 8 YA37 18(1)(a) The registered manager must ensure that all fire escapes are adequately and appropriately signposted and that these escapes are easily accessible to all staff at all times. The registered persons must ensure that all staff are made aware of the roles and responsibilities of each worker when on duty at the home. The registered persons must ensure that both the registered manager and the deputy manager receive regular support and supervision. The registered persons must ensure that all staff working at the home appear on the rota with the days to be worked and the roles 30/07/06 30/07/06 30/08/06 30/07/06 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. Refer to Standard YA19 Good Practice Recommendations The policies and procedures should include a formalised method of the process of registering service users with local services DS0000063030.V303793.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000063030.V303793.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!