Inspection on 18/01/07 for Gibson House

This inspection was carried out on 18th January 2007.

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

Gibson House 20/04/06

Gibson House 06/10/05

Gibson House 20/05/05

Gibson House 07/09/04

Gibson House 27/05/04

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

CARE HOME ADULTS 18-65 Gibson House 12 The Grange Bermondsey London SE1 3AG Lead Inspector Lisa Wilde Unannounced Inspection 18 January 2007 11:00 th Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gibson House Address 12 The Grange Bermondsey London SE1 3AG 020 7252 3762 0207 394 9316 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) www.odyssey-csft.org Odyssey Care Solutions for Today Mrs Phyllis Mary Phillips Care Home 8 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Gibson House is a purpose-built detached home with its own very large gardens. It is close to a lot of bus routes and street parking is available but on meters. There are no train or tube stations very close to the home. The home is spacious, built for eight service users with learning difficulties and sensory impairment who have large single bedrooms with ample bathroom and communal facilities, including a sensory room. There is a lift for people who live on the first floor. There is a kitchen on each floor and generally the home is run as if the upstairs and downstairs are two units. The home was designed as a home for life where service users are supported to be as independent as possible. The borough is currently reconfiguring the local area where this home is placed and the home will be closing in the medium term. The service user part of the fee for a place at this home is £61.80 The home makes the Commission’s reports available in the reception area. On the day of this inspection there was one service user vacancy. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in January 2007. The inspector met with a relative and visiting professional and spoke with the manager and staff. The inspector toured the building and checked records and medication stocks. Most service users at this home cannot speak and the ones that can were not at the home during this inspection. Everyone who spoke with the inspector and further written comments from other relatives said that this home has improved a lot since the last inspection. All previous requirements apart from one were met at this inspection. The manager and staff team should be strongly commended for the work they have put in to significantly improve standards at this home, which has struggled for a long time to offer an acceptable level of care. What the service does well: What has improved since the last inspection? • • • Staff now give medication to service users properly. Staff now protect service users from people who might hurt them. Staff now find out what service users want and write this down for them. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 6 • • • • • • • • • • Staff now write plans so they can help service users do what they want to do. Staff have got better at helping service users make decisions. Staff do more to listen to families and other people who know what service users want. Service users get to go out more and do the things they want to do. The home is cleaner and more comfortable. Care plans are better. Staff have got better at telling service users about the home. Staff get more supervision from a manager. Staff find out what service users and their families think and put in place plans to make things better. The home is better managed. 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. The summary of this inspection report can be made available in other formats on request. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users would be given information about the home and what they could expect if they moved there. EVIDENCE: There were previous requirements that the Registered Individuals must ensure that the Service Users’ Guide is drawn up in a format that can be understood by more people from the service user groups for which the home is registered e.g. learning disabilities and sensory impairment and that the Service Users’ Guide covers all areas required by Regulation 5 and Standard 1. This work has now been done. No service users have moved to this home for a number of years so it would be possible or useful to inspect the procedures for assessing someone’s needs prior to them being offered a place at the home. The judgement for this group of standards has therefore in large part been made on the basis of what the Registered Manager said would happen should someone move to the service rather than what has been seen to happen. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff work with service users to try and find out what they want and write down things that they will do and get better at over the next few months. This means that service users lives do not just stay the same but they are trying new things and improving. Service users are supported to make decisions as far as possible and most of them have family who are involved to help them make those decisions. Staff work with service users to find out what may harm them and what help they may need. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that Service User plans focus on forward planning and how staff will support service users to achieve identified goals, develop positive behaviour and Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 10 minimise negative or challenging behaviour and maximise independence. These plans must be reviewed at regular intervals to allow for plans to be changed if they are not working to ensure (as far as possible) that goals are met by the time the next six monthly multi disciplinary review takes place. New systems are in operation where goals are assessed every three months and all staff are involved in those reviews for the service users they work most closely with. Staff said that this has improved the way they work with service users and motivated everyone to develop service users’ skills. A relative, staff and a visiting professional all told the inspector that service users are generally calmer and seem happier now. The records examined showed that some care plans, risk assessments and support guidelines have not been reviewed every six months as required. (See Requirement 1) Staff talked about how they offer choices to service users and allow them to get involved and make decisions as far as possible. This has improved since the last inspection. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have individual weekly programmes both in and outside the home. Staff support service users to keep in touch with their families. Service users are offered varied and healthy meals. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that service users are engaged in fulfilling and appropriate activities while in the home. Staff talked about new activities that service users are doing. The sensory room is being used more often because the rota has been changed to focus on having more staff on duty at particular times of the day and week when service users want to do things. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 12 Living skill development programmes have been introduced to help service users do more for themselves. Service users have a varied weekly menu and the home is working on picture menus so that they can have a more useful choice at each meal. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 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 by staff in the way that they choose and their health needs are met by going for regular appointments at the GP. When service users need special help, meetings are held with all people involved in their care to make sure that decisions are made in their best interests. Healthcare work that is identified in the annual reviews of the service users’ lives is not always done quickly enough which means that service users do not always get what they want or need when they need it. Medication is given to service users safely. EVIDENCE: One relative said that their service user was happier and calmer and that the service users has been able to visit them at their home which the have not been able to do for a number of years. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 14 Recommendations from recent contract monitoring reviews show that service users still do not have Health Action Plans in place. (See Requirement 2) Recommendations also show that one service user was required to be monitored for changes in behaviour and presentation that may be due to the significant loss and change they have recently experienced. The manager could not describe how he would do this work. This issue will become relevant to all service users as they begin the process of moving on from this, their long term home. (See Requirement 3) Another recommendation stated that one service user’s food intake must be monitored and recorded in terms of type and quantity of food. This work is not being done, only the type of food is being recorded, with some gaps in recording. (See Requirement 4) There was a previous requirement that the Registered Manager must ensure that the systems for checking that service users’ have both sufficient and appropriate clothing, including underwear are improved and that service users’ bed linen and clothing does not get mixed up or mislaid. Staff are more involved in checking laundry and linen now and there have been no complaints about this issue since the last inspection, when previously there had been regular complaints. There were several previous requirements about medication administration and recording all of which were met at this inspection. There were no additional problems noted when checking the medication charts and stock except that on one chart liquid paper had been used. (See Requirement 5) Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Complaints and concerns are taken seriously and investigated properly. Service users are protected from abuse by staff being trained in policies and procedures around safeguarding vulnerable adults. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that a Complaints Book is maintained that provides a chronological record of all complaints at the home, including details of investigations, timescales for action and whether the complainant was satisfied with the outcome. This is now done. There was a previous requirement that the Registered Manager must ensure that day-to-day comments and concerns from service users, their families and others are recorded so that action can be taken to address any patterns of concern and plans can be made to improve the service in ways that service users want. This is now done. Recent allegations about staff have been recorded in the complaints book when they need to be held separately as they are subject to different investigative procedures and confidentiality issues. (See Requirement 6) Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 16 There was a previous requirement that the Registered Manager must ensure that all staff attend effective training around abuse/protection of vulnerable adults. This has been done and staff could talk about what they would do if they suspected someone was being abused. There was one occasion noted from the records where staff had not followed the organisational procedure when finding an unexplained bruise on a service user i.e. the service user had not been referred to a medical professional for an opinion. (See Requirement 7) Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 17 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. 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. Decoration in the home is improving. Service users have individualised bedrooms that are decorated to meet their own tastes and the numbers of toilets and bathrooms mean that they have sufficient privacy. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: There was a previous requirement that the Registered Provider must supply a copy of the planned maintenance and renewal programme for the fabric and decoration of the premises to the Commission. This had been done and the work that was described on it had been done by the time of this inspection. Service user rooms had all been improved, lounges were better laid out with Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 18 more individual decoration to make them appear more homely, there were more pictures through the hallways and carpets had been replaced. There was a previous requirement that the Registered Individuals must ensure that the general decoration of the home is regularly renewed and the environment is homely and comfortable throughout. This is a very large home and is in need of some work in communal areas. There is an organisational plan already in place to assess the lounges in November 2007. This work will need to be done as the wallpaper is in need of replacement. (See Requirement 8) There was a previous requirement that the Registered Individuals must ensure that work is done in all bathrooms to ensure that all repairs are carried out and any worn areas/fittings are made good or replaced. Bathrooms must be decorated and/or additions made to provide a comfortable and pleasant, homely environment. This work has been done. There was a previous requirement that the Registered Individuals must ensure that an Occupational Therapists assessment is made of all service users who need assistance with bathing. showering, transferring or moving to ensure that the most appropriate aids and fittings are being used in the home. These assessments must be reviewed every time a service users needs change. The occupational therapist has assessed all service users and states that they do not need any aids or fittings to assist them with any mobility issues. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 19 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. 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. There are enough staff on duty for service users to do what they want to do. Service users are protected by the home’s recruitment procedures. Staff are offered training but there may be gaps in this training which means that service users may not be getting the best support they could be. Staff are supervised regularly by a manager which means that service users are offered support from staff who are receiving enough support and guidance. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the current deputy manager and senior support worker have the same title and job description if they are to be expected to have the same role and responsibilities. The job descriptions are currently being reviewed but at present there is still one deputy and one senior doing the same job with different job descriptions. (See Requirement 9) Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 20 There was a previous requirement that the Registered Individuals must ensure that the staff undertake training that enables them to identify, understand and meet the needs of the service user group with regard to learning disabilities and sensory impairment issues. Staff have had several in-house training sessions and could talk about how they should met the needs of service users. While there is always work that can be done to improve staff’s understanding of the more complex needs of service users, this requirement has been met. There was a previous requirement that the Registered Individuals must ensure that the home meets the target of 50 of its care staff holding or undertaking the NVQ Level 2 in Care (or equivalent). All staff apart from two either hold or are undertaking the required NVQ. There was a previous requirement that the Registered Individuals must ensure that there are enough staff on shift at all times to enable service users to engage in meaningful activities and not to have to spend time in groups due to there not being enough staff to allow them to undertake individual programmes. As mentioned previously, the rota has been changed to focus on meeting service users’ needs and records showed that more activities are taking place. An occupational therapist and speech and language professionals have been brought into the home to review the activities that service users engage with to assess if they are enjoyable, stimulating and fulfilling. There was a previous requirement that the Registered Individuals must ensure that the Commission’s recruitment form is completed for all staff and held on file at the home. This is now done. There was a previous requirement that the Registered Manager must ensure that all staff are supervised at least six times a year by a line manager who has been trained to offer such supervision. Staff generally receives supervision six-weekly, records showed and staff confirmed that all areas of work are discussed and training or development needs for staff are assessed. There was a previous requirement that the Registered Manager must ensure that staff receive an annual appraisal of their performance which includes an assessment of their training needs. This has now been done although some areas of training needs for staff had been identified by staff and the managers jointly but the training plan that was then drawn up for them did not include some of those areas as the organisation’s training programme did not include those sessions. All training needs that are linked to meeting service users’ needs and identified by managers within the appraisal process must then be met by the training plan. (See Requirement 10) Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 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 well managed. Staff gather the views of service users and their families and tries to make sure that the home gets better in the ways service users want. Service users are generally protected from harm by staff operating health and safety procedures effectively apart from fire systems checking and some water temperatures. EVIDENCE: Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 22 The manager has put in his application to be registered with the Commission but has not yet had his interview. He holds the NVQ Level 4 in Care and the Registered Managers Award. Throughout the inspection he evidenced his understanding of the needs of the service users and how staff should meet those needs. Staff said that the manager was clear, supportive and listened to what staff said. There was a previous requirement that the Registered Individuals must ensure that an effective quality assurance system, based on seeking the views of service users, their families and others is in place in the home. The organisation has plans to introduce the more formal quality assurance system of PQASSO in March 2007. In the interim there are procedures that focus on target setting and improvements at the home. Currently there are no plans put in place in response to unsatisfactory responses in service user relatives’ surveys to show how the home aims to improve the responses by the next time the survey is sent out although specific comments made on the surveys are addressed. (See Requirement 11) There was a previous requirement that the Registered Individuals must ensure that the action identified within the Improvement Plan is completed within the required timescales. The vast majority of the Improvement Plan had been met and the one or two areas that needed further work have been made into specific requirements in this report. This home is no longer under a formal Improvement Plan programme. All health and safety records were check and all were in order apart from the water temperatures which showed that in many hand basins the water was too low that several weekly fire system checks had been missed. (See Requirements 12 & 13) There was a previous requirement that the Registered Individuals must ensure that there is a business and financial plan in place for the home. This is in place and is commented upon regularly by managers using the monitoring procedures in the home. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 23 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 X 3 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 3 Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 Requirement The Registered Manager must ensure that all elements of the care plan are reviewed every six months as required. The Registered Manager must ensure that all service users have a complete Health Action Plan. The Registered Manager must ensure that plans are developed to monitor and assess service users’ behaviour and presentation given the forthcoming changes they are about to experience. The Registered Manager must ensure that if a service users needs to have their food and fluid monitored and recorded that this is done as per external professionals’ recommendations. The Registered Manager must ensure that liquid paper is not used on medication administration charts. The Registered Manager must ensure that allegations are recorded and held separately to complaints. The Registered Manager must ensure that all staff understand and follow the organisation’s DS0000060232.V324732.R01.S.doc Timescale for action 31/03/07 2. 3. YA19 YA19 12 (1) 12 (1) 31/03/07 30/06/07 4. YA19 12 (1) 31/01/07 5. YA20 13 (2) 18/01/07 6. YA23 13 (6) 31/01/07 7. YA23 13 (6) 31/01/07 Gibson House Version 5.2 Page 25 8. 9. YA24 YA31 23 (2) (b) 18 (1) (a) 10. YA35 18 (1) (c) (i) 11. YA39 24 12. 13. YA42 YA42 23 13 (4) (a) & (c) procedure in the event of finding an unexplained bruise on a service user. The Registered Individuals must ensure that the lounges are decorated. The Registered Individuals must ensure that the current deputy manager and senior support worker have the same title and job description if they are to be expected to have the same role and responsibilities. Previous requirement: Unmet timescale 01/08/06 The Registered Individuals must ensure that all training needs identified in appraisals are met by the staff member’s individual training plan. The Registered Individual must ensure that action plans are drawn up to ensure that satisfaction rates improve in response to service user relatives’ surveys by the time of the next survey. The Registered Manager must ensure that the fire system is checked weekly as required. The Registered Manager must ensure that water temperatures in the home are close to 43 degrees centigrade. 30/06/07 31/03/07 31/03/07 31/03/07 26/01/07 26/10/07 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 Individuals should consider introducing a professionally recognised quality assurance system. Previous recommendation. Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Gibson House DS0000060232.V324732.R01.S.doc Version 5.2 Page 27 - 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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