Inspection on 17/10/05 for George Lane, 103

This inspection was carried out on 17th October 2005.

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

The inspector found 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

George Lane, 103 27/08/08

George Lane, 103 29/08/07

George Lane, 103 09/11/06

George Lane, 103 26/01/06

George Lane, 103 22/06/04

George Lane, 103 24/02/04

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

CARE HOME ADULTS 18-65 George Lane, 103 Catford London SE13 6HN Lead Inspector Ms Lynn Hampton Unannounced Inspection 17th October 2005 01:50 George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service George Lane, 103 Address Catford London SE13 6HN 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) 020 8265 8671 Providence Project Care Home 4 Category(ies) of Learning disability (0) registration, with number of places George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2005 Brief Description of the Service: 103 George Lane is a converted Victorian house situated on a quiet road between Lewisham and Catford. It is one of a group of homes for adults with learning disabilities, all of which are in the London Borough of Lewisham. It is close to shopping centres, local transport and a range of public amenities. The Registered provider, Providence Project, has recently merged with two other care organisations to form PLUS (Providence, Linc, United Services). The organisation is in the process of negotiating the appropriate change in registration/certification with the Commission. The building is owned and maintained by London & Quadrant Housing Association. The home accommodates four adults with learning disabilities. It aims to provide a comfortable, homely atmosphere in a safe and clean environment. Each service user has their own bedroom, and shares communal facilities, which includes lounge, kitchen/diner and garden. At the time of this inspection, there were two male and two female service users. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in the afternoon of a weekday, and lasted nearly four hours. During the visit the inspector met four care staff, and spoke to all four service users. A range of documents was examined and a tour of the building took place. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Service users have individual contracts, but these need to be updated. EVIDENCE: The home has a stable group of residents, and there have been no new admissions for over two years. Standards 2 – 4 were not inspected for this reason. They were found to be met at the time of the last inspection. Case files seen had individual written contracts and Assured Tenancy agreements. However, these were in need of updating to reflect the changes in the organisation. That is, the registered provider (Providence Project) has merged with another care provider to form PLUS (Providence, Linc, United Services). The new organisation must also ensure that action is taken to have amended Certificates of Registration to reflect this change, or to address any registration issues arising, and to update the home’s Statement of Purpose and Service Users’ Guide as a matter of urgency. See Requirements. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users’ needs are assessed and reviewed with their input. Service users make decisions about their lives, and are enabled to have an independent lifestyle. Records are securely kept. EVIDENCE: Residents are enabled to lead very independent lifestyles. Individuals told the inspector that they had keys to their room, as well as the front door, and were able to go out to activities or events that they chose. Some residents are able to go out without staff assistance, and said that they visited friends and relatives nearby. Transport is arranged for residents who need it, and staff accompany residents to shops and cafes, etc. Residents said that they had a key worker, who helped them with things like choosing and buying paint to redecorate their bedrooms, shopping, holidays and so on. Routines in the home were user-led; residents are able to choose when they have meals and drinks individually, although some communal meals are prepared (especially on a Sunday). Residents explained that they help out with household chores, including gardening. One resident said that he was the Chair of Speaking Up (a user consultation forum within Providence Project), and so had been kept fully informed about the recent merger. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 9 Records are held in the staff office, or in locked cabinets on the landing outside the office. Two case files were looked at during the inspection, and these showed that comprehensive assessments had been undertaken for each resident. An Annual Review, and a Six-Monthly review is held, attended by the resident, care staff, relatives and other people involved in their care (such as Day Centre key workers, Counsellors, and social workers). Records showed that service users views and opinions were sought and listened to. Also, there were records showing that specialist assessments were undertaken as and when necessary. These included referrals to the Challenging Behaviour team, Physiotherapy, and audiology. Risk Assessments were in place, linked to promoting independence. Reviews focussed on monitoring progress towards the resident’s personal goals. There were notes on one person’s file that the user’s Counsellor and a relative had requested to attend the next Review. It emerged that this was slightly overdue, and no date had been set (due to the illness/absence of the Key Worker). The Key worker reported that the manager makes arrangements for Reviews, and kept a record of when they were due. It is recommended that a system is put in place to more clearly track when Reviews are due, to enable them to be planned and organised in advance, and to ensure that attendees have sufficient notice. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Service users are able to take part in activities that they choose, and each has a full programme of activities within the community as well as the house. Service users are treated with respect in the home. They are supported to maintain relationships. EVIDENCE: Each resident has an individually tailored programme of activities that reflects their personal interests and needs. Users told the inspector that they attend Day Centre, evening clubs, and visit friends and relatives. One resident has a job. He also plays in a music group, and played the inspector a CD that they had recorded, of which he was justifiably proud. One resident told the inspector about her boyfriend, who she visits and who can visit her at the home once a week. All residents had photographs of friends and family, as well as of holidays and outings in their rooms. Two were going out to an evening club on the day of the inspection, and transport was arranged to pick them up and return them to the home. One resident has a pet canary, which she enjoys looking after. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 11 Records on resident’s case files contained information about their rights and responsibilities, including information in symbols, relating to the Freedom of Information Act, voting, and Sexual Rights. Staff talked knowledgeably about residents’ preferences and interests, and their care needs. The rota is arranged to ensure that there is appropriate support for users to attend activities; there are clear guidelines about how support is to be given, and when users can be left alone. Staff spoke enthusiastically about working with residents, and took pride in the standard of care that they are able to provide. Staff have been active in promoting users’ rights in terms of achieving personal goals. Examples were given on staff ensuring that residents were able to decorate their rooms (with staff support) and to choose holidays abroad. See also Conduct and Management of the home. Throughout the inspection visit, residents were seen to choose or to be prompted by staff to make themselves drinks and snacks. One resident told the inspector that he helps cook meals, and was seen to be making drinks and clearing up the kitchen. Another resident said that he liked the freedom in the house, particularly as a previous placement had placed restrictions on when he could use the kitchen. Staff were seen to knock on resident’s rooms before entering, and to consult residents about their care (for example, checking that it was convenient time to help them with skin creams). The routines of the home were very clearly user-led, and this is to be commended. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Service users receive support in the way that they prefer. Storage of medication is good. Further work is needed to ensure that user’s views on ageing and death are properly addressed. EVIDENCE: The residents indicated that they understood the role of the inspector, and were keen to show their rooms and talk about their views on how the service was run. They were very positive in their comments, and clear that they were able to make life choices in terms of meals and activities, and that staff were available to support this if needed. Case files contained detailed information on how staff should offer support to residents in terms of their personal care, and there was evidence that health issues are quickly identified, assessed and referred to appropriate professionals if necessary. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 13 A Requirement was made in the report of the previous inspection, that consideration was to be given to consulting residents about their views and wishes regarding ageing, illness and death. The manager (who had not been present during this inspection) later informed the inspector that he had started to address this, and the matter had been discussed at the one Review that had been held since the Requirement was made. He confirmed that this would also be discussed at the Reviews of the other three residents, which are to be held soon. It was discussed with the manager that there might be benefits from Key Workers raising the matter for discussion with residents in 1:1 meetings, and with relatives/advocates where appropriate, in addition to formal Reviews, given the personal nature of the subject. Any such discussions should be documented. The Requirement remains in force until discussions have taken place with all the residents. A Requirement made in the report of the previous inspection, that the medication cabinet conform to guidance issued by the Royal Pharmaceutical Society, had been met. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 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 the following standard(s): 22 Service users feel that their views are listened to. EVIDENCE: Residents were clearly able to express their views and wishes, and felt that staff listened to them. They reported that they had no complaints, and that they could talk to staff if they did have any concerns. No complaints had been recorded since the time of the last inspection (January 2005). A recommendation was made in the report of the previous inspection, that the manager keep up to date with POVA legislation. The manager was not on duty during the inspection, but he later confirmed that he had attended training, which is documented at the home, and provided briefing for the staff team there. This recommendation is met. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 28, 30 Service users live in a homely, comfortable and safe environment that suits their individual needs, although it would not be suitable for a person with mobility problems. The home is very clean and tidy. EVIDENCE: The building is accessed by steps to the front door, and there are steps to the rear garden. In addition, the number of stairs throughout the home would mean that this building is not be suitable for a person with mobility problems. George Lane has restricted parking along its length, which is being extended to the surrounding areas. This means that staff and visitors to the home cannot park in the near vicinity. Staff reported that users had been told that they were not eligible for permits, and would be charged to create a disabled bay outside the home, as none of them were drivers or car owners. However, this inconvenience may undermine quality of life for service users, due to the difficulty presented to carers, family and care professionals visiting the home. It may be discriminatory (as neighbours would be eligible for parking permits). Issues around eligibility for permits, Visitors’ permits or a designated parking bay for the home are to be raised for further discussion with the appropriate Council Departments. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 16 A resident showed the inspector around the building. The ground floor consists of a hallway; shared lounge; one resident’s bedroom; a toilet; and kitchen/diner. The lounge was provided with a range of very comfortable sofas, and a large television. The kitchen was very attractively laid out, with all modern appliances, and was clean to a high standard. A door from the kitchen leads onto a paved patio area, which has an attractive patio furniture set, and on to a gravelled garden, which has potted plants, and a shed at the bottom. Residents told the inspector that they helped keep the garden tidy and look after plants. Stairs lead from the hallway up to a middle level, where there is one resident’s bedroom, a shared bathroom and a separate toilet. A shorter flight of stairs leads up to the top floor, which houses the remaining two residents’ bedrooms, and a small staff office/sleep-in room. All areas seen by the inspector were meticulously clean and tidy. Residents said that they help with the cleaning chores around the home. All furniture and fittings around the home were domestic in style, and of good quality. No hazards were seen, and no repairs were seen to be needed. Three of the residents agreed to show the inspector their room. One was very pleased that staff had helped him to redecorate. His large and attractive room was equipped with items that reflected his interests and tastes. There was a laminate flooring, which he had chosen rather than a carpet. Another resident was having his room decorated in the near future, and he had been out to buy paint with his key worker. He too wanted to have a laminated wood flooring rather than a carpet, although he said that he may ask for a mat if he finds it too cold. All residents were proud that they had been able to decorate and personalise their rooms to their own tastes, and they all looked very attractive. All had a television, and one had a computer. There was adequate storage space for clothes and possessions, and furniture was of good quality. Each room had a hand basin and mirror. Not all rooms had comfortable chairs provided – one resident said that she would like one, and also a coffee table to use when she does jigsaw puzzles. The manager reported that she had chosen a chair and it would be purchased (currently out of stock), and that she had a folding table specifically for her jigsaw puzzles. The staff room is very small, with only just enough space to accommodate a single bed for staff who sleep over, a side cabinet and chair. This is not comfortable or very convenient when having handover, but there is no alternative space, and staff spent their time on shift with users in their bedrooms or in communal spaces, rather than in the office. The office has a built-in cupboard, which contains records and equipment. As this is not big enough to hold all the confidential records in the home, some are held in locked cupboards on the landing outside. Staff were aware of the need to keep records securely, and ensured that cupboards were kept locked. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 17 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, 35, 36 Service users are supported by an effective and competent team, although there have been several changes recently. Staff have access to relevant training. Greater clarity is needed on the rota, regarding the role of the volunteer worker. EVIDENCE: There were five members of care staff on the rota, plus the manager, plus one Community Service Volunteer. Two members of staff were new; another two staff members had worked at the home before, but had moved to other homes within Providence Project and had recently returned to George Lane. The CSV worker had recently left and they were hoping to have a replacement soon. This is a high level of turnover within a relatively small staff group. While there was no evidence that this undermined care practice in the home, consideration should be given to reviewing recruitment and retention of staff to promote stability and continuity of care. Staff indicated that they had experiences of feeling unsupported by senior management in the organisation, which had undermined morale and may have effected staff retention. This was discussed with the manager after the inspection visit, who indicated that some difficulties had now been resolved and that he hoped that he and the staff team at the home would feel more supported now and in the future. This will be monitored at future inspections. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 18 Staff that the inspector spoke to said that they were offered opportunities for training, which had included NVQ training, although some staff reported that they had not taken up this opportunity. This was in part due to changes in staffing at the home. Two of the current staff team were reported to be on NVQ Level II training. Staff interaction with residents was observed to be warm, friendly and appropriate, and staff demonstrated an in-depth knowledge of residents’ preferences and needs. Some staff were able to use Makaton signs to supplement their communication with one resident. The staff rota indicated that a minimum of two care staff were on duty during the day (9 a.m. to 10 p.m.), with one on duty after 10 p.m., who undertakes a sleep-over. At the weekend, there are two staff on duty 9 – 5 p.m., with one member of staff on duty for the remaining hours. It appeared from the rota that the CSV volunteer sometimes acted as the second member of staff on duty. The roles and duties of the volunteer are to be clarified, and the manager is to ensure that volunteers are supplemental to the staff rota. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 19 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, 41 The home is well run. Good communication systems in place, although recording systems may benefit from review, and all relevant notifications must be made to the Commission. The manager must apply for registration in respect of this home, without delay. EVIDENCE: The inspector arrived just before handover of staff. This was observed, and staff made good use of a Communications book, diaries and shift planners to ensure that a full and comprehensive handover took place. The inspector examined a number of records held, including service user’s case files and Activity recording. These contain relevant information, but also had a number of out-dated documents – such as previous Guidelines, copies of old Activity recording sheets, as well as old monthly summaries. It appeared that monthly summaries of activity were no longer being written, and the inspector queried with staff what was useful and still relevant. Daily recording appeared to be mainly concerned with activities, rather than recording other information George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 20 relevant to resident’s well-being and health. For example, recording incidence of challenging behaviour. Team meetings minutes showed that this was regularly discussed and addressed by the staff, but there did not appear to be active recording on a daily/weekly basis to support care interventions being made. Records should be reviewed to ensure that they focus on pertinent needs beyond activity attendance, and that old guidance and monitoring charts are archived. The home maintains full and comprehensive records of accidents and incidents, although these had not always been notified to the Commission as is required. Reports of visits by the Person In Control (Regulation 26 visits) were held in the home, but the most recent of these was dated 28/6/05. See Requirements. The current manager was previously registered in respect of another Providence Project home for a similar user group. He informed the inspector that he had made enquiries of the Commission regarding his registration at the time that he transferred to George Lane. Registration is not currently transferable, and an application to be registered in respect of this home must be now be submitted to the Commission. See Requirements. A Requirement was made in the report of the previous inspection, that the Responsible Individual develop quality assurance monitoring systems, and that an annual development plan is put into place. This was discussed at length with the manager, who reported that there were systems in place to undertake annual audits and regular monitoring of the home. The details of this are to be submitted in writing to the Commission, until which time, this Requirement remains in force. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 2 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 4 4 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 3 X 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 George Lane, 103 Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 3 2 X 2 X X DS0000025621.V256256.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA11 Regulation 17(2) Schedule 4(8) Requirement The Registered Person must ensure that all service users have accurate and up-to-date contracts and tenancy agreements in place, that reflect any change in the organisation’s name or registration, and that all relevant documentation is updated, including the Statement of Purpose and Service User’s Guide. The Registered Person must take action to ensure that Certificates of Registration are amended, or to address any registration issues arising from the recent organisational merger. (Registration Regulations). The Registration Person must ensure that consideration is given to the most appropriate way forward concerning service users wishes around the subjects of terminal care and death. The previous timescale of 30th June 2005 was not fully met. Timescale for action 01/02/06 2 YA55 6 01/12/06 3 YA21 12(2) 15(1) 01/02/06 George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 23 4 YA24 23(1)a The Registered Person must ensure that issues around eligibility for permits, Visitors’ permits or a designated parking bay for the home are to be raised for further discussion with the appropriate Council Departments. The Registered Person must provide written clarification to the Commission, regarding the role and duties of volunteer workers, and the manager is to ensure that volunteers are supplemental to the staff rota. The Registered Person must provide the Commission with written details regarding how the organisation will ensure that 50 of staff will achieve NVQ Level II certification. The Registered Person must undertake a review of recruitment and retention of staff in the home, in order to assess options for promoting stability within the staff team. The outcome of this review, with timescales for any action to be taken, are to be notified in writing to the Commission. The Registered Person must ensure that an application for registration of the manager is submitted to the Commission. The Registered Person must ensure that a formal quality assurance monitoring system and annual development plan are put into place. The previous timescale of 30th September 2005 was not met. DS0000025621.V256256.R01.S.doc 01/02/06 5 YA31 18(1)b 01/02/06 6 YA35YA32 18(1)a 01/12/05 7 YA33 18(1) 01/02/06 8 YA37 8, 9 01/12/05 9 YA39 24(1)a, b 01/02/06 George Lane, 103 Version 5.0 Page 24 10 YA41 15(2)b 17(3)a The Registered Person must 01/02/06 ensure that care records are reviewed to ensure that they are relevant and up to date, and that old guidance and monitoring charts are archived. The Registered Person must ensure that the home retains a copy of, and notifies the Commission in respect of, all reports of visits undertaken by the Registered Provider. The Registered Person must notify the Commission in respect of all events as specified under Schedule 4[12]. 01/12/05 11 YA41 17, Sched 4(5) 12 YA41 17, Sched 4(12) 01/12/05 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 YA6 Good Practice Recommendations The manager should ensure that a system is put in place to more clearly track when Reviews are due, to enable them to be planned and organised in advance, and to ensure that attendees have sufficient notice. George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI George Lane, 103 DS0000025621.V256256.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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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