Inspection on 18/08/05 for Good Neighbours House

This inspection was carried out on 18th August 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Good Neighbours House 22/05/09

Good Neighbours House 12/06/08

Good Neighbours House 26/11/07

Good Neighbours House 14/11/06

Good Neighbours House 01/12/05

Good Neighbours House 30/12/04

Good Neighbours House 17/05/04

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

CARE HOME ADULTS 18-65 Good Neighbours House 38, Mary Datchelor Close London SE5 7AX Lead Inspector Ms Alison Pritchard Announced Inspection 18th August 2005 10:00 DS0000007106.V254220.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 DS0000007106.V254220.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. DS0000007106.V254220.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Good Neighbours House Address 38, Mary Datchelor Close London SE5 7AX 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) 0207 703 7451 0207 252 7105 SCOPE Mr Djaki Mathurin Gbedji Care Home 16 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0) of places DS0000007106.V254220.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 16 (sixteen) people with physical disability some of whom may be over 65 years old. 30th December 2004 Date of last inspection Brief Description of the Service: Good Neighbours House is a purpose built care home which provides care and accommodation for up to sixteen adults who have a physical disability. The home is fully accessible to people who use wheel chairs. Each resident has his or her own room. The home has three floors, access to the upper floors is by stairs or the two passenger lifts. None of the bedrooms on the upper floor is in use. Two residents live in accommodation which is used to develop independent living skills and, as appropriate, to facilitate a move to independent living in the community. The home is located close to the centre of Camberwell where there is a busy shopping centre, banks, restaurants and pubs. Public transport routes are close by. DS0000007106.V254220.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced, carried out over one day in mid August 2005 and lasted for nine and a half hours. An additional unannounced visit was carried out on 22nd April 2005 in response to a complaint. The requirements made as a result of that visit were followed up, as were those which arose from the unannounced inspection of December 2004. The inspection methods included reviewing pre-inspection information, a partial tour of the building, discussion with six residents, observation of care practice, interviews with two members of staff, discussions with other staff members and the manager and examination of records. The manager had ensured that residents, their relatives and visitors were informed about the inspection so that they could choose to contribute if they wished. Comment cards were received from three people. What the service does well: What has improved since the last inspection? What they could do better: The CSCI had not been properly informed of the range of matters covered by regulation. An immediate requirement about this was made on the day of the inspection and this has since been addressed. Staffing levels sometimes drop below what has been agreed is adequate. This may contribute to residents sometimes having to wait longer than they would like for assistance. DS0000007106.V254220.R01.S.doc Version 5.0 Page 6 Staff supervision is infrequent and this needs to be improved. Care plans need to be reviewed at intervals of six months as a minimum and to include details of how residents can be helped to maintain and develop skills. 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. DS0000007106.V254220.R01.S.doc Version 5.0 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 DS0000007106.V254220.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 The admission policy ensures that the home gathers enough information about a potential resident to make a decision about the suitability of the placement. EVIDENCE: There have been no admissions to the home since the last inspection. Requirements made at that inspection relating to the management of the admission of one resident have been addressed. The policy of the managing organisation is to obtain assessments for potential residents prior to their admission. They also encourage introductory visits to the home. The first twelve weeks of a placement are regarded as a trial period, after which a review meeting would be held and the suitability of the home as a long-term placement assessed. The manager has confirmed that residents are issued with a contract or statement of terms and conditions with the home. DS0000007106.V254220.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 10 The residents would benefit from improvements to the care planning process including regular reviews, effective consultation with relatives, file audits and reallocation of key work duties in the absence of the permanent post-holder. Residents have opportunities to contribute to the running of the home but meetings have not been held as frequently as was previously the case. EVIDENCE: Each of the residents has a care plan. Those examined showed that there were identified goals, but that reviews of the plans do not take place at the minimum required frequency of six months. The home was not carrying out internal reviews of the plans in addition to the annual placement review. In addition some of the documents in the files were undated making it difficult to assess whether they reflected the residents’ current needs. (See also standard 11 below). A files audit system would be beneficial to ensure that key workers are given any necessary guidance in their care planning work. This will benefit residents by ensuring that the care plans accurately and fully reflect their care needs. DS0000007106.V254220.R01.S.doc Version 5.0 Page 10 There is a key work system in place, but key work duties are not reallocated if the person is away for a period of time, this may have contributed to the failure to review care plans, and for some documents, for example, quarterly monitoring sheets, to be incomplete. Discussion with residents showed that they are able to voice their views about their care, how it is provided and their long-term goals. The ways in which these goals would be achieved was not always clear from the care plans. Records of care plan reviews that have occurred show that residents and, where appropriate, family members are included. Improvements to the reviewing systems will ensure that the goals set are adequately monitored with a view to ensuring that residents’ wishes are reflected in practice. Two of the comment cards received commented that there is insufficient consultation with family members about matters concerning their relatives’ care. Consideration must be given to how this can be improved, and the implementation of regular reviews will be an important part of this. The manager should forward details about how residents are informed about advocacy services. A residents’ meeting had been held in the month of the inspection. This was the first there had been since May 2005, although it was noted that there had been four meetings between January and May 2005. Files are kept securely and confidentially in staff offices. The Registered Manager has confirmed that the organisation is registered under the Data Protection Act 1998. Staff were clear about when information must be shared with their manager or others. DS0000007106.V254220.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Residents would benefit if the care planning system gave more emphasis to residents’ opportunities for the maintenance and development of skills in keeping with their wishes and goals. It is anticipated that the additional member of staff, recently appointed to assist in expanding the activities programme, will enable residents to benefit from a wider range of social opportunities. Residents were positive about the range of meals provided. EVIDENCE: Some of the service users follow a semi-independence programme, which includes preparing their own meals and managing their own medication. Despite this, for the residents whose files were examined, there was little reference in care planning documents to residents’ opportunities for skills development and maintenance. This should be introduced to the care planning system so that residents maintain their skills, are given opportunities to use DS0000007106.V254220.R01.S.doc Version 5.0 Page 12 them and have the chance to learn new skills in keeping with their wishes and goals. There is an accessible minibus available to the home. Some residents attend day centres and adult education classes in the local area. Those residents who are able to do so use the local shops independently, others are assisted to do so by staff. One of the residents told the inspector about his employment in the local community and how much he enjoyed this. At the last visit to the home one of the matters examined was the activity programme for one particular resident. It was found that the resident’s activity programme was very limited and goals relating to activities had not been implemented. At this inspection it was found that there have been some improvements in that an additional member of staff has been allocated the responsibility for arranging activities. In relation to the particular resident some improvements were noted as visits had been arranged to a city farm in keeping with a previously identified goal. Two-day trips to Brighton had been organised over the summer period and a summer garden party was held. Within the home-visiting musicians provide entertainment each month. Several residents have been on holidays over the summer period and others are planned. The inspector was told of a range of outings that had taken place over recent weeks, to local pubs and restaurants and to a garden centre. The inspector was informed that there was scope for the activities programme to be further developed at weekends and that it was anticipated that the newly appointed activities worker was to address this issue. Residents are supported to maintain contact with family members and friends. A telephone is available for residents’ use, and some people have had telephones fitted in their bedrooms. One resident was supported by staff to visit a family member in Scotland for a summer holiday. All of the people who used the comment cards stated that they are welcomed to the home when they visit. Residents confirmed that staff give them privacy when they are with visitors, family members and people of importance to them. They said that they could also choose to spend time alone if they wished and this was respected by staff. Observation of staff interaction with residents was that it was warm and respectful. Several of the staff members have worked at the home for a significant period and are very familiar with and to the residents. Meals are prepared by a cook who works between Monday and Friday. At weekends one of the care staff prepares the meals. The feedback from residents about the food was positive, it was noted that the cook is familiar with the preferences of the residents and prepares a range of meals to reflect them. DS0000007106.V254220.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, The residents benefit from the care of a staff team with whom they are familiar and trust. However sometimes care is provided less quickly than some residents would like. There have been improvements to the referrals to appropriate professionals, in keeping with residents’ needs, this will assist in ensuring that the range of residents’ needs are met. Systems to monitor assistance given by staff to residents need to be completed consistently. Medication is well managed in the home. EVIDENCE: Discussion with residents showed that overall residents are content with the manner in which care is provided. Many of the care staff have worked with the residents for a significant period of time and so are familiar with their needs and how care should be provided. There was feedback that sometimes staff may be busy attending to other people so it may take longer than some residents would prefer for staff assistance to be provided. Two of the comment cards received commented that there are not always sufficient staff on duty and this will have an impact on the care provided. (See section on staffing below). DS0000007106.V254220.R01.S.doc Version 5.0 Page 14 At the additional visit made in April 2005 there was no evidence of referral to physiotherapy services or speech and language therapy services for a resident whose needs indicated that this would be beneficial. The finding at this inspection was that appropriate referrals have now been made to a range of agencies for several of the residents. On this visit staff showed particular care in ensuring that a resident who had dental problems saw the dentist until the problems were resolved. Another resident needed their teeth-cleaning programme to be monitored. The monitoring records showed that they had been completed inconsistently. For instance the monitoring sheets for June 2005 had only one entry. It was unclear whether the programme had been discontinued. A similar issue had been highlighted at the visit in April 2005 when it was required that the home maintain documentary evidence of care procedures such as 2 hourly turning. Records of such procedures at this visit showed that the record keeping systems were inconsistently completed. Some of the residents manage their own medication with any necessary assistance such as supervision provided by staff. The records of medication administration were in good order, although residents’ allergies need to be added to the recording sheets. DS0000007106.V254220.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are familiar with how to make complaints, although some relatives were not aware of the procedure. Records of complaints should be amended to ensure that they show the outcome and action taken. Adult protection and whistle blowing procedures contribute to residents’ safety. An audit is necessary to ensure that property lists are complete and residents’ possessions are protected. EVIDENCE: The complaints procedure is available in written form, in pictorial format and as a video. All of the residents have been given copies of the pictorial and the written formats and the manager has held discussions with residents about the complaints procedure. Although residents confirmed that they would raise issues of concern with the staff all three of the comment cards returned had statements that the correspondents were unaware of the home’s complaints procedure. Consideration should be given to how the home can ensure that relatives are familiar with the action to take in the event of a concern. The recording systems for complaints in the home did not clearly show the outcome of a complaint and the action taken to address any issues raised. The home has an adult protection procedure and there is a whistle-blowing procedure. Staff were clear about the action to take in the event of a concern about abuse. Although some files had details of residents’ property included, some did not. An audit must be carried out to make sure that all residents have completed property lists. DS0000007106.V254220.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 The residents benefit from a satisfactorily clean building which is safe and has adaptations to maximise residents’ independence. There are plans to refurbish the building and this will improve the general conditions. EVIDENCE: The building is fully accessible to people who use wheel chairs, two passenger lifts allow access to the first and second floors. The home is satisfactorily clean and comfortable. The living room and dining area are reasonably homely and safe. All of the bedrooms are single; details of the measurements of the rooms were not examined and should be forwarded for inclusion in the final report. At the visit to the home in April 2005 it was found that there were a number of problems in relation to the cleanliness of and facilities in the bathrooms and WCs. At this inspection it was found that these problems had been addressed. There are plans for a major refurbishment programme to improve conditions in the building, including redecoration and replacing the flooring throughout. There are a number of items of specialist equipment available throughout the building to aid residents’ independence. DS0000007106.V254220.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): 32, 33, 34, 35, 36 The rota showed that on occasion staffing levels drop below those previously agreed. This means that there are insufficient staff to provide responsive care for the residents. Recruitment practices are safe and include residents’ input. This means that the process both protects and empowers residents. Staff supervision must take place more often so that staff are adequately supported and monitored. EVIDENCE: In addition to the Registered Manager the care staff team consists of one team leader, fifteen support workers (two of whom are part time), as well as four support workers who are part of the staff ‘bank’ covering shifts. There is one vacancy on the staff team, at team leader level. Staff turnover is low and many members of the staff team worked at the home for several years and so are very familiar with the needs of the residents. A copy of the rota was supplied during the inspection. It showed that generally, on weekdays, there are five members of care staff on duty each morning and four members of staff each afternoon until 5pm. However in the evenings the rota showed that, on occasions, the staffing dropped to three members of staff. At weekends the staffing levels were five members of staff on duty in the morning, four in the afternoon and the evening. Three waking DS0000007106.V254220.R01.S.doc Version 5.0 Page 18 night staff provide care at nighttime. At the Inspection of 30th December 2004 the staffing level for the home was for there to be at least four members of staff to be on duty throughout the waking day. The manager should discuss and changes to the staffing policy with the inspector, and in the meantime restore the staffing numbers to the previously agreed level. Recruitment practices were found to be safe and well managed with written references being followed up by telephone. Residents have been involved in the recruitment procedure; this is empowering for residents and is commended. Staff training was the subject of two requirements of the inspection report of April 2005. Training had been provided in pressure care as required. Another area identified as a training need at that inspection was in the provision of suitable activities for residents. The opportunities for this were being explored and the requirement was within timescale at the time of the inspection. Nine of the current care staff have achieved training to NVQ level 2 or above. Other training provided over the last twelve months includes moving and handling, communication and report writing, adult protection, medication practices and food hygiene. Further training is planned in moving and handling and first aid. New staff go through an induction process which is appropriate for the home and the role of staff. The induction pack gives a commitment to the staff member being provided with supervision every two months. However this standard is not met. Senior staff acknowledged that staff supervision has been taking place infrequently and that this is an area that needs improvement. In addition an appraisal system must be introduced. Staff meetings are held in the home at approximately monthly intervals. While these are important to maintain communication systems within the home they cannot replace the individual support and monitoring provided by supervision. DS0000007106.V254220.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): 41, 42 At the time of the inspection the CSCI was not being notified of events affecting the welfare of residents. Residents benefit from good management of health and safety matters. EVIDENCE: It was found during the inspection that the CSCI had not been informed about several events which should have been notified under Regulation 37 of the Care Homes Regulations 2002. As a result an immediate requirement was made, the registered person took the appropriate action within the timescale given. A fire risk assessment was carried out in June 2005. Also in June there were a number of discussions at the team meeting relating to health and safety issues. Appropriate checks of the fire safety systems were recorded, as were regular fire drills. One bedroom door needs specialist repair and the inspector was informed that arrangements have been made for it to be undertaken. DS0000007106.V254220.R01.S.doc Version 5.0 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 x 3 x x 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 2 4 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 3 x DS0000007106.V254220.R01.S.doc Version 5.0 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 YA35YA11 Regulation 18(1)(c)(i) Requirement Timescale for action The Registered Person must ensure that training is arranged 01/09/05 for staff in the provision of suitable activities for service users with the range of disabilities of service users in the home. The Registered Person must 01/12/05 ensure that documentary evidence is maintained of care procedures such as 2 hourly turning. Previous timescale of 01/08/05 unmet The Registered Person shall give 19/08/05 notice to the CSCI without delay of the occurrence of events covered by regulation 37 of The Care Home Regulations 2002. The Registered Person must 01/03/06 ensure that an audit of residents’ files is conducted to ensure documents are dated, signed and currently relevant. The Registered Person must ensure that care planning DS0000007106.V254220.R01.S.doc 2 YA19 17(1)(a) 3 YA41 37 4 YA6 15(1) 5 YA11YA6 12, 15(1) 01/03/06 Version 5.0 Page 22 6 YA6 15(2)(b) 7 YA20 13(2) 8 YA22 22 systems are improved by ensuring that there is reference to skills development, enabling residents to maintain their skills, to be given opportunities to use them and have the chance to learn new skills in keeping with their wishes and goals. The Registered Person must 01/12/05 ensure that reviews of care plans are undertaken at intervals of 6 months or more frequently as necessary. The Registered Person must 01/12/05 ensure that medication administration records include details of residents’ allergies. The Registered Person must 01/12/05 ensure that recording systems for complaints clearly show the outcome of a complaint and the action taken to address any issues raised. The Registered Person must discuss changes to the staffing policy with the CSCI, and in the meantime restore the staffing numbers to the previously agreed level. The Registered Person must ensure that staff supervision takes place at least six times in a year. The Registered Person must forward to the CSCI details of the measurements of bedrooms. The Registered Person must ensure that an audit of residents’ property lists is undertaken to ensure that they are complete. 01/12/05 9 YA33YA18 18(1)(a) 10 YA36 18(2) 01/12/05 11 12 YA24 YA23 23(2)(f) 13(6) 01/12/05 01/01/06 DS0000007106.V254220.R01.S.doc Version 5.0 Page 23 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 2 3 Refer to Standard YA22 YA36 YA6 Good Practice Recommendations Consideration should be given to how the home can ensure that relatives are familiar with the action to take in the event of a concern. The Registered Person should ensure that a staff appraisal system is introduced. The Registered Person should ensure that key work duties are reallocated if a key worker is away for an extended period. DS0000007106.V254220.R01.S.doc Version 5.0 Page 24 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. 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