Inspection on 27/04/06 for Dorriemay House

This inspection was carried out on 27th April 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dorriemay House 15/04/08

Dorriemay House 30/04/07

Dorriemay House 07/11/05

Dorriemay House 04/05/05

Dorriemay House 11/01/05

Dorriemay House 20/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Dorriemay House Dorriemay House 23/27 Eaton Road Margate Kent CT9 1XB Lead Inspector Sandra Crosby Unannounced Inspection 27th April 2006 10:30 Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 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 Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 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. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dorriemay House Address Dorriemay House 23/27 Eaton Road Margate Kent CT9 1XB 01843 292616 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 David Barrie Mirsky Mrs Jacqueline Ann Mirsky Care Home 25 Category(ies) of Learning disability (25) registration, with number of places Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Dorriemay House provides residential care to up to 25 people who require varying degrees of assistance as a result of their learning disabilities. Staffing comprises of the registered provider, a head of care, care staff and ancillary staff. The Home comprises three adjoining terraced properties, with a paved garden area, situated close to the sea front in a residential area of Margate. The Home is within a short distance of amenities such as rail and bus services, shops and churches, a library and a concert hall. The premises lack access for people with impaired mobility. The weekly fees charged at the home are £350.00. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors first visit to the home. The inspection visit was unannounced and carried out over two visits the first on Thursday 27 April 2006 between 10.30 and 15.30, and the second on 02 May 2006 between 14.30 and 18.00. A further short visit was made to the home on the 12 May 2006 to meet with the Registered Persons and provide the Feedback Summary Sheets. During the inspection the Inspector spoke with the Acting Manager, several of the Service Users, and staff members on duty. Various records were seen and an accompanied tour of the premises was made. The key standards were inspected at this inspection visit. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean and orderly at the time of the inspection visit. As this inspection was carried out at short notice, only the Pre-inspection Questionnaire documentation was sent to the home prior to the visit. No Service User Comment Cards or Relatives Comments Cards were sent out for this inspection. The Pre-inspection Questionnaire completed by the home together with observational information and discussion with the Service Users and staff at the time of the inspection, has been used when compiling this report. It was found that the management and staff at the home were working hard towards setting up the necessary systems in order to comply with the requirements of the regulations. The information in this inspection report indicates that the home is striving to comply in full with all aspects of the Standards. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service User Guide documentation has now been updated by the home. Service User Plans are in the process of being updated to include all components as required by regulation. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 6 All records are being updated, and systems are being implemented to ensure that the home complies with regulation. Choice of meals provided has improved, and the written records of the main meal of the day. The room for the storage of medications has been completed and it was seen that an appropriate medication trolley was now in use at the home Medication practices have improved, however further improvement can still be achieved. Improvement was seen in the recording of records of monies held on behalf of Service Users. The system used for the recording of Service Users financial transactions has been improved. The Acting Manager has implemented a written record, recording any maintenance undertaken at the home. Infection control procedures have been reviewed. The procedures used for recruiting staff have improved. Training is ongoing at the home. The management of the home has worked hard to produce and implement the necessary policies and procedures required by regulation. The Fire Risk assessment documentation has been completed. What they could do better: The pre-admission assessments process needs to be improved and appropriate documentation implemented. An application for a variation to the registration needs to be made for those service users admitted over the age of 65 years. Service User Plans need to clearly identify all aspects of the care needed and provide staff with clear instructions on how to meet those needs. Individual Risk Assessments to be undertaken and to be part of the Service User Plan documentation. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 7 Each service user needs to have a nutritional assessment undertaken as part of the Service User plan documentation. The home is to keep written records of the food provided at teatime. Medication procedures and practices need to be improved further to ensure safe handling and administration of medicines. All records in relation to the handling of Service User monies need to be accessible in order to be able to audit train monies from the point of being received at the home. Action to be taken in relation to the position of the office door as to access this area persons have to walk through the laundry area of the home. Staffing levels should be reviewed to ensure sufficient numbers of suitably trained/experienced staff are provided to meet the needs of the service users, including the weekends. The new induction programme seen, to be implemented as soon as possible starting with new members of staff. All staff need to receive regular formal supervision. Those responsible for managing the home need to become more knowledgeable of the National Minimum Standards and Regulations and to implement these fully. An annual quality assurance system must be developed and implemented. Accident Records to be appropriately completed and stored. Environmental risk assessments need to be undertaken and documented 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. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose provides up to date information to enable prospective service users to make an informed decision. The assessment of prospective service users fails to ensure they are not admitted outside of the registration of the home compromising the ability to meet the service users needs. EVIDENCE: The Statement of Purpose and Service User Guide have now been implemented as two separate documents. Small amendments to these documents were discussed with the Acting Manager. The home currently has no pre-assessment documentation, and following discussion in relation to Standard 2 the Acting Manager agreed to address this issue. It was also discussed that Care Management assessment documentation should be received prior to new Service Users being admitted to the home until. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 10 It was evidenced at the last announced inspection visit dated 07 November 2005 highlighted that two service users have been admitted within the last twelve months over the age of 65 years, although over half of the existing service users are now elderly, an application for a variation to the registration to admit these Service Users should have been made prior to their admission. The Acting Manager confirmed that this variation has still not been applied for and he agreed to take action in relation to this issue as soon as possible. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service User plans fail to identify all of the Service Users individual needs, however Service User plans were seen to be in the process of being updated to comply with the requirements of the regulations. Service Users expressed that their views are listened to, and know that their records will be kept securely maintaining confidentially. Staff were seen supporting Service Users needs in a respectful manner that protects privacy and dignity. EVIDENCE: It was seen that work is being undertaken to update the Service User plans in order that the system used complies with the requirements of the regulations. Three Service User plans were cased tracked, and showed that the documentations main focus was on the Service Users physical needs, with a lack of detail regarding behavioural and emotional aspects of their care and how they are supported to make decisions and choices about their lives. The Acting Manager is working towards addressing this issue. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 12 Individual risk assessments have not as yet been implemented with the Service User Plan system, and the Acting Manager said that this issue would be addressed. Records are kept secure when not in use, in the office. The Acting Manager stated, and it was evidenced from the records seen that effort is being made to bring all records up to date and for all records to comply with the requirements of regulation. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The age range of services users influences the activities provided. Links with the local community and activities are limited. Choice is now promoted with meals, however there is no process in place as yet for ensuring Service Users are not nutritionally at risk. EVIDENCE: Many of the Service Users attend the homes own daycentre as part of their daily activity. Over half of the Service Users are now elderly and therefore it would not be essential for those to attend further education. Links with the local community and activities are restricted due to staffing numbers. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 14 The records of the food provided were seen, and showed that an alternative choice of main meal and sweet are available every day. The format of record keeping of the food provided now in use was to a good standard providing information about the size of the meal provided and an indication as to how much of the meal was eaten. The Inspector asked that a record also be kept in relation to the food provided at teatime, as there was no written record at the time of the inspection visit. A nutritional assessment needs to be added to the Service User Plan documentation and the Acting Manager agreed to address this issue. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are supported with their health care needs and in the main appropriate action is taken as necessary. The home is endeavouring to acknowledge and prepare for the ageing service user. Medication practices have improved, but further improvement is needed. EVIDENCE: It was seen that records are kept of attendance to doctors and hospital appointments, however it was also found and discussed that not all information had been recorded that should have been in the records. The medication records were seen, and indicated on the whole that these were appropriately signed and up do date. Some non-recording was seen, and this was discussed with the Acting Manager and Carer responsible for medications. The room for the storage of medications has been completed and it was seen that an appropriate medication trolley was now in use at the home. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 16 The Acting Manager confirmed that a copy of The Administration and Control of Medicines in Care Homes and Children’s Services produced by the Royal Pharmaceutical Society of Great Britain is on order. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place, and there are policies and procedures in place to protect Service Users from abuse, neglect and selfharm. EVIDENCE: The Compliments and Complaints book was seen, and the Acting Manager confirmed that no complaints had been made. The complaints policy for the home has recently been updated. The system used for the recording of Service Users financial transactions has been improved following the last inspection and now shows records of all credits and expenditure. Discussion took place in relation to the setting up of bank accounts for some Service Users. The registered provider is appointee for a number of service users and the Inspector was unable to see all necessary records in relation to the handling of Service User monies, and following discussion with the Acting Manager it was agreed that due to the Registered Providers being unavailable at this visit these would be available at the next inspection visit. It has previously been reported that some of the extra benefits received by Service Users is taken as part of the Service Users top up fees for living at the home. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 18 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): 24,25,26,27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changes have been made to the size of bedrooms without notification to the CSCI. Recent improvements to the communal areas have had a positive impact for the service users. EVIDENCE: It was reported in the last announced inspection visit that some bedrooms have been made smaller to partition the bedroom and the fire escape route. Although these changes have enhanced service users quality of life by promoting privacy as well as maintaining fire exit routes, these changes should have been discussed with the Commission prior to the work being carried out. At this inspection the Inspection has requested that the home provides an up to date Schedule of Accommodation for the home. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 19 Discussion took place in relation to the position of the office door, as to access this area persons have to walk through the laundry area. The Acting manager has agreed to address this issue. There are some areas of the home would benefit from some refurbishment, however there was evidence that this has started, with new furniture in the dinning room giving a homely feel. At the time of the last announced inspection visit over half of the service users are aged of 60 years old, and no preparations have been made to assess the changing needs and to prepare for these. The acting manager confirmed at that visit that no plans have been made to adapt the building to enable the home to accommodate these service users. The layout and design of the building is multiple levels and only stair access available to these. There is no call bell system at the home. The Acting Manager has implemented a written record, recording any maintenance undertaken at the home. Infection control procedures have been reviewed. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home require further review. Carers have the skills and knowledge to fulfil their roles and responsibilities. Recruitment procedures have improved since the last inspection. Staff are not receiving adequate supervision. EVIDENCE: The staffing rota was seen, and it was discussed that an improvement in the staffing levels at the home had taken place following the last inspection visit. The Acting Manager confirmed that the staffing levels at the home were still under review, and it is noted that staff also cover some ancillary duties. Discussion took place in relation to the flexibility of the staffing hours worked in order to meet the current needs of the Service Users at all times. It was also discussed at their being one waking staff and one sleep in staff on duty at night and the implications in relation to Health and Safety. Over 50 of care staff have now completed the NVQ training, and staff training is ongoing at the home. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 21 The staff file of a new member of staff was seen, and showed that the home is endeavouring to undertake a thorough recruitment process, with the majority of required documentation in place. New induction documentation that complies with regulation has been obtained but not as yet implemented and the Acting Manager said that he would address this issue. Although staff receive some formal supervision, it is not as yet up to the required number of times in a twelve month period. The Acting Manager said that this issue would be addressed. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 22 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): 37,38,39,40,41,42,43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is working towards clear lines of leadership and management. Policies and procedures for the managing of the home have been implemented. EVIDENCE: The home has an Acting Manager who is working hard to implement all required documentation. He said that he is to start the Registered Managers Award qualification in the near future and it would be anticipated that the knowledge and skills gained from this training is used effectively. The fire risk assessment for the home has been completed since the last inspection visit, and the environmental risk assessments are to be undertaken in the near future. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 23 The accident record books were seen for the home, and discussion took place in relation to the accurate completion and storing of these documents. The Acting Manager agreed to address this issue. It was seen in the pre-inspection questionnaire information provided by the home that maintenance certification is up to date as required. Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 2 32 2 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 2 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 2 2 2 2 2 2 2 2 Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 25 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. Standard YA2 Regulation 12,14,15, 18 Timescale for action 1) Detailed pre-admission 30/06/06 assessments must be conducted to ensure prospective service users are within the homes registration and their needs can be met. 2) An application for a variation to the registration must be made for those service users admitted over the age of 65 years. Previous timescale 31/01/06 1) Service users care plans must 30/09/06 clearly identify all aspects of the care needed (not just physical needs) and provide staff with clear instructions on how to meet those needs. Previous timescale 31/03/06 2) All individual confidential information to be recorded in the individual service users file. Previous timescale: 30.05.05 and 31/03/06 Risk assessment should be 30/06/06 produced for all service users, where appropriate. Previous timescale 31/03/06 Each service user must have a 30/06/06 nutritional assessment completed and regularly DS0000023391.V291758.R01.S.doc Version 5.1 Page 26 Requirement 2. YA6 12 - 17 3. YA9 12 - 17 4. YA17 12 - 17 Dorriemay House 5. YA17 12 - 17 6. YA20 12-14 16 17 23 sch 3 7. YA23 12 17 20 23 sch 4 8. YA24 12 13 14 16 23 9. YA30 12 13 16 23 18 10. YA33 11. 12. 13. YA35 YA36 YA37 12 13 18 18 19 5 7 9 10 12 18 21 24 reviewed. Previous timescale 31/03/06 A record of all meals provided must be kept for each service user. Previous timescale 31/03/06 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Previous timescale 31/01/06 All service users benefits to be recorded in the records, including money taken as top up of fees. Previous timescale 31/01/06 Any changes to the environment must be approved by the Commission prior to the work being carried out – Provide the Commission with an updated set of plans that include all room sizes. Previous timescale 31/01/06 All infection control procedures must be reviewed – access to entrance to office through the laundry area. The registered person must review the current staffing levels and ensure sufficient numbers of suitably trained/experienced staff are provided to meet the needs of the service users, including the weekends. Previous timescale 31/03/06 To implement the new the induction programme seen for new staff. All staff must receive formal 1:1 supervision 6 times a year. The registered person and the acting managers must become more knowledgeable of the National Minimum Standards and Regulations and to implement DS0000023391.V291758.R01.S.doc 31/05/06 30/04/06 31/05/06 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 Dorriemay House Version 5.1 Page 27 14. YA39 10 12 15 24 15. YA42 13 16 17 23 sch 14 these fully. Previous timescale 31/03/06 An annual quality assurance 05/07/06 system must be developed and implemented. The report of the collated information to be sent to the CSCI. 1) To produce and implement 30/06/06 environmental risk assessments. Previous timescale 31/03/06 2) Accurately record and store accident form records. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Dorriemay House DS0000023391.V291758.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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