Inspection on 03/08/05 for Dunton Road, 71-73

This inspection was carried out on 3rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunton Road, 71-73 27/06/06

Dunton Road, 71-73 01/12/05

Dunton Road, 71-73 02/03/05

Dunton Road, 71-73 27/07/04

Dunton Road, 71-73 30/03/04

Dunton Road, 71-73 27/01/04

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 Dunton Road 71-73 Dunton Road Bermondsey London SE1 5TW Lead Inspector Lisa Wilde Unannounced 3 August 2005, 10:00am rd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dunton Road Address 71-73 Dunton Road, Bermondsey, London, SE1 5TW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0207 232 0016 Three Cs Support CRH Care Home 7 Category(ies) of Mental Disorder registration, with number of places Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Seven people male or female with mental disorder other than dementia some of whom may be over 65 years old. Residents with disabilities which restrict their mobility must be accomodated on the ground floor. Date of last inspection 2ND March 2005 Brief Description of the Service: The home consists of two large, older properties that have been joined together. The home is indistinguishable as a care home from the outside. There are seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues. The bedrooms meet the space requirements of the standards as does the communal space. The premises are comfortable. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. The home is close to several bus routes into central London and the surrounding area. The Old Kent Road, which offers shopping facilities, pubs, restaurants and a large supermarket is close by. There are a number of smaller shops and a Post Office in Dunton Road. The service users handbook states that the aim of the home is to create a home in the community for people needing supoprt and to provide a high standard of care which encourages independence and individual choice and repsects your rights and dignity. The home provides care for up to seven people with mental health issues. On the day of the inspection there was one vacancy. Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in August 2005. The inspector spoke with service users, staff and the Residential Services Manager. The Chief Executive came to the home for part of the inspection as well as the Housing Officer from the home’s housing association, Hexagon. What the service does well: What has improved since the last inspection? What they could do better: Prospective service users are not being given enough information to make a clear choice about whether they want to live at this home. Current service users are not being given clear and up–to-date information about what services they can expect at the home. Service users needs and personal goals are not being recorded in their individual plans and are not being reviewed regular to make sure that their changing needs are being identified and met. Risk is not being assessed effectively in the home and identified risks are not being managed or minimised by clear action plans being put in place around any behaviour that may challenge staff. This means that service users and staff are being made vulnerable and put at risk in the home. Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 6 Service users are not being protected by the home’s medication systems. Policy and procedure is not being adhered to and identified areas of risk are not being addressed. Sufficient care and management control is not being paid to the area of medication and this is not supporting the mental health of service user’s and potentially putting service users and staff at risk or harm. A significant piece of work is necessary to ensure that procedure is followed and that action plans are drawn up to address already identified areas of risk. Although there are systems in place for enabling service users to complain there is not sufficient evidence to be sure that service users know that their views are listened to and acted on. The lack of advocacy and robust consultation systems a the home means that service users may not be certain that they have the right to complain, may not know how to complain or may not know that there are other people they can complain to than just staff at the home. More work must be done to make sure that independent advocates are found to help service users voice their opinions. There is some evidence that the staff team is not always effective in that sometimes staff are working alone at the home and recent incidents have lead to staff being hurt and service users being put at risk. Service users are not being completely protected from abuse by the recruitment practice at the home as the required checks are not being gained for all staff prior to them starting work at the home. Staff are not being supervised or appraised regularly which means that they are not receiving the ongoing support they need to be able to work effectively and safely with service users. The management of the home is not effective. Systems in the home are failing and service users are being placed at risk. There is no comprehensive quality assurance tool or system in place at the home which means that there is no way for failings in the systems to be identified or for the home to develop and improve in a way that is based on the views of service users, families and other stakeholders. There is little evidence that health and safety at the home is being regularly monitored and that the required checks are being consistently carried out which again is placing service users at risk of harm. 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. Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Prospective service users are not being given enough information to make a clear choice about where they want to live. Current service users are not being given clear and up–to-date information about what services they can expect at the home. EVIDENCE: There was a previous requirement around the Service User Guide and the Statement of Purpose. The Residential Service Manager informed the inspector that this had not been met and the documents had not been revised. The timescale for this requirement had been set at 01/09/05. The requirement is repeated. (See Requirement 1) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 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 standard(s) 6 & 9 Service users needs and personal goals are not being recorded in their individual plans and are not being reviewed regularly to make sure that their changing needs are being identified and met. Risk is not being assessed effectively in the home and identified risks are not being managed or minimised by clear action plans being put in place around any behaviour that may challenge staff. This means that service users and staff are being made vulnerable and put at risk in the home. EVIDENCE: The inspector looked at all current service user files. Only one care plan had been reviewed in the last six months and was signed by the service user. Other plans had not been reviewed since December 03. One new service user did not have any care plan other than the CPA assessment. The previous requirements in this area are therefore unmet and repeated. (See Requirements 2 & 3) Risk assessments were not in place for all service users around all behaviours that may challenge the service. There has been an issue in the service with one service user becoming more aggressive and violent, hitting staff and chasing service users. There was no evidence in the file of any increased monitoring or emergency care planning/risk assessments that had taken place to ensure staff and service user safety during this period. The previous Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 10 requirement in this area is therefore unmet and repeated. (See Requirement 4) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 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 standard(s) X The outcomes of these standards were assessed and met at the last inspection. EVIDENCE: Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 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 standard(s) 20 Service users are not being protected by the home’s medication systems. Policy and procedure is not being adhered to and identified areas of risk are not being addressed. Sufficient care and management control is not being paid to the area of medication and this is not supporting the mental health of service user’s and potentially putting service users and staff at risk or harm. EVIDENCE: The inspector examined the medication stocks and records. The inspector also saw the report from the last Community Pharmacist visit. The inspector found several gaps in the MAR charts and no system of stock checking which meant that there was no way of ascertaining exactly how much medication should be held in the home. The courier from the chemist came to collect the unused medication from staff and although they signed the prior record that staff had made of all medication, no mediation count took place which meant that no one could confirm how much medication was being handed over. The letter from the Pharmacist from February 05 had highlighted serious concerns both in this home and the other Three C’s home in the local area and asked that senior management write a comprehensive action plan to address the issues they raised. The Residential Services Manager stated that this action plan had not been done. Staff are currently issuing as required (PRN) medication to service users to control and manage anxiety and other behaviours but the pharmacist had highlighted that the recording book for staff and management to monitor the use of this medication was not being used consistently so it was not Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 13 possible to effectively monitor the use of these drugs. (See Requirements 5, 6, 7, 8 & 9) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Although there are systems in place for enabling service users to complain there is not sufficient evidence to be sure that service users know that their views are listened to and acted on. The lack of advocacy and robust consultation systems at the home means that service users may not be certain that they have the right to complain, may not know how to complain or may not know that there are other people they can complain to other than staff at the home. EVIDENCE: There is a Complaints Policy and a Complaints Record. Guidance on the book stated that the record was specifically to record informal complaints as well as more serious complaints. There were no complaints recorded in the book. Given the vulnerability of this service user group, the lack of service users guide and the lack of independent advocates at the home the inspector was not confident that the lack of complaints was because everyone was completely happy with this service. The requirement to update the service users guide (which would include the complaints policy) is made under Standard 1. (See Requirement 10) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 and 30 The shared spaces of the home are large enough to meet the needs of the service users and the home is comfortable and clean. Service users rooms are all big enough to meet requirements. EVIDENCE: The home consists of two large, older properties that have been joined together. The home is indistinguishable as a care home from the outside. There are seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues. The bedrooms meet the space requirements of the standards as does the communal space. The premises are comfortable. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. On the day of the inspection the home was clean. Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 There is some evidence that the staff team is not always effective in that sometimes staff are working alone at the home and recent incidents have lead to staff being hurt and service users being put at risk. Service users are not being completely protected from abuse by the recruitment practice at the home. Staff are well trained and able to support service users and meet their individual and joint needs. Staff are not receiving the ongoing support they need to be able to work effectively and safely with service users. EVIDENCE: Staff reported that generally they felt there were enough staff on duty except when there may be issues of risk i.e. there is only one waking night member of staff and there are two periods during the day 8-9am and 7.30-9.30pm when staff are on their own in the home. Recently, due to one service user’s increasing need, the waking night shifts were doubled up until that person went to hospital. Staff are concerned about what will happen when this service user returns. In addition they described another service user who wanders out of the building if not watched and another who recently got up and went outside at night in a vulnerable condition. (See Requirement 11) The recruitment standard was not fully assessed as records are held centrally. An issue had arisen at the other Three C’s home inspected earlier the same Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 17 week with regard to Criminal Bureau Checks for staff. The same issue applied to this home in that some staff had been employed without receiving back a new CRB check prior to them starting work. (See Requirement 12) The inspector could not examine any training records as by the time this standard was assessed all managers had left the building. Staff described the training at the home as excellent and none of them felt that they had any training needs that were not being met. This standard was not fully assessed but the inspector was satisfied that staff were confident in their abilities to understand the service users needs. Supervision records were not seen as the managers left before they could be accessed. Staff stated that generally they have not been having supervision, that this has only recently started when the new part-time manager began at the home and that some of them are just beginning to have their appraisal interviews. The previous requirement in this area is repeated. (See Requirement 12) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 , 39 & 42 The management of the home is not effective. Systems in the home are failing and service users are being placed at risk. There is no comprehensive quality assurance tool or system in place at the home which means that there is no way for failings in the systems to be identified or for the home to develop and improve in a way that is based on the views of service users, families and other stakeholders. Health and safety at the home is not being regularly monitored and the required checks are not being consistently carried out which again is placing service users at risk of harm. EVIDENCE: There was a previous requirement that an application be put to the Commission for Registered Manager as there had not been a Registered Manager present at the home for a considerable time (due to the previous Registered Manager’s long term sickness). The planned recruitment happening at the last inspection failed to recruit a manager and a further internal applicant did not take on the post. The Registered Person stated that recruitment is about to take place again for the Manager post but in the Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 19 interim a manager is in post for 18 hours a week with additional clinical support being provided by the Residential Services Manager. The Business Manager is providing around 12 hours support per week to the service. The inspector was highly concerned that there had not been a Registered Manager at this service for over two years now and evidence throughout the inspection showed that systems are failing and risk is increasing. Even though there are a number of managers present at different time at this service there does not appear to be any consistency and the inspector could get no sense of who was taking responsibility for the serious issues highlighted in this and previous inspection reports. The Housing Officer described the Housing Association’s serious concerns about their service users at this service not having had effective management in place for a considerable time. Staff described things as having been difficult without a manager, better since the part time manager was put in place recently but that they still are not sure what is happening. (See Requirements 13 and 14) There is no formal, externally recognised professional quality assurance system in place. This standard and issue was not assessed fully but evidence throughout the inspection showed that systems are failing (Care planning, risk assessment, medication, supervision, health and safety) throughout the home and there is no overall system in place to monitor and improve this. (See Requirement 15 and Recommendation 1) The COSHH cupboard in the laundry was open and hazardous substances were stored openly in the laundry. Fire drills and weekly fire tests have been missed. The health and safety check and risk assessment had not been completed in the health and safety file. (See Requirements 16, 17 and 18) Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 20 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 x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 2 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dunton Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 1 2 1 x x 2 x G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 21 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 YA1 Regulation 4&5 Schedule 1 Requirement The Registered Provider must ensure that copies of the Statement of Purpose and the Service User Guide are sent to the Commission by the target date. Previous requirement. Unmet timescale 01/12/04. The Registered Person must ensure that care plans are in place for all service users resident in the home, even if they are admitted for a short period. Previous requirement: Unmet timescale 01/06/05 The Registered Person must ensure that care plans are reviewed at a minimum of sixmonthly intervals. Previous requirement: Unmet timescale 01/07/05 The Registered Person must ensure that documented risk assessments are in place to support staff in dealing with difficult behaviours displayed by service users. Previous requirement: Unmet timescale 01/07/05 The Registered Person must ensure that the systems in place for recording and monitoring the Timescale for action 30/09/05 2. YA6 15 (1) 30/09/05 3. YA6 15 (2) (b) 30/09/05 4. YA6 YA9 15 (1) 30/09/05 5. YA20 13 (2) 30/09/05 Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 22 6. YA20 13 (2) 7. YA20 13 (2) 8. YA20 13 (2) 9. YA20 13 (2) 10. YA22 22 (2) 11. YA33 13 (4) (c) !8 (1) (a) administration of medication in the home are used effectively and consistently specifically that staff sign the medication adminstration records for all mediciation administered or notes are made when medistration is not administered.. The Registered Person must ensure that an effective system of stock tracking and checking all medication is in place. The Registered Person must ensure that medication is counted and checked when it is handed over the the chemist courier for collection. The Registered Person must ensure that the systems in place for recording and monitoring the use of PRN medication is used effectively and that management regularly check the use of these medications. The Registered Person must ensure that a comprehensive action plan (drawn up by senior management as requested) is in place that addresses all the issues highlighted in the last Community Pharmacist letter of January and February 2005. The Registered Person must ensure that independent advocates are sought for all service users with a specific brief to ensure that they are aware of their right to complain, how to complain and supported to voice any current concerns they may have. The Registered Person must ensure that a review of staffing is undertaken, specifically with regard to the lone waking night and the lone periods during the day including reference to all 30/09/05 30/09/05 30/09/05 30/09/05 31/12/05 30/09/05 Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 23 12. YA34 19 (1) (b) recent incidents when staff or service users had been vulnerable. This review must be sent to the Commission The Registered Person must ensure that POVAFirst checks are completed for all staff who have not received back enhanced CRB checks. The Registered Provider must ensure that staff receive regular recorded supervision at least six times a year covering all the issues detailed in standard 36.4 and ensures that the appraisal system is implemented. Previous requirement: Unmet timescale 01/10/04 then 01/07/05 The Registered Provider must ensure that full-time manager is in post at this service who is able to fulfil the requirements of the post and of the Registered Manager role with the Commission. The Registered Person must submit an application for a manager to be registered under the Care Standards Act 2000. Previous requirement: Unmet timescale 01/07/05 The Registered Person must ensure that an effective quality assurance system, based on seeking the views of service users, their families and other stakeholders, is in operation at the home. The Registered Persdon must ensure that the COSHH cupboard is locked at all times and that hazardous substances are stored safely in this cupboard. The Registered Person must ensure that the Fire Safety systems are operated consistently and as planned 13. YA 36 YA 38 18 (2) Immediate (This was actioned the day after the inspection) 30/09/05 14. YA37 YA38 8 30/09/05 15. YA37 11 (1) Care Standards Act 24 07/10/05 16. YA39 31/12/05( 17. YA42 13 (4) (a) & (c) 18. YA42 23 (4) 07/08/05 (This was actioned during the inspection) 07/08/05 Dunton Road G52-G02 S7100 DuntonRd V243146 030805 Stage 4.doc Version 1.40 Page 24 19. 42 13 (4) (a) & (c) specifically with regard to fire drills and fire system testing.. The Registered Person must ensure that all health and safety risk assessments are completed and on file and that regular health and safety checks occur as per policy and are recorded. 31/10/05 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 YA39 Good Practice Recommendations The Registered Person should consider using an externally recognised professional quality assurance tool in the home. 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