Inspection on 12/06/08 for Hall Road

This inspection was carried out on 12th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hall Road 12/06/07

Hall Road 26/06/06

Hall Road 30/11/05

Hall Road 10/05/05

Hall Road 10/02/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Hall Road 7 Hall Road Wallington Surrey SM6 0RT Lead Inspector James Pitts Unannounced Inspection 12th June 2008 10:28 Hall Road DS0000060793.V366012.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 Hall Road DS0000060793.V366012.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. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hall Road Address 7 Hall Road Wallington Surrey SM6 0RT 020 8254 9895 020 8669 1288 diane@independencehomes.co.uk 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) Independence Homes Limited Manager post vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 7 is for the use of a service user in a wheel chair only. Date of last inspection 12th June 2007 Brief Description of the Service: 7 Hall Road is a registered care home for up to seven people with learning disabilities, specialising in providing a service to people who also have epilepsy. Seven people are currently living there. Hall Road is a large, detached house situated in a residential road in Wallington, fairly close to local shops and public transport links. The home is owned and managed by a private organisation, Independence Homes limited, who have three other similar services in the local area. Accommodation is provided over two floors. Three single bedrooms, a lounge, dining room, assisted bathroom and staff office are on the ground floor. The remaining four bedrooms, an assisted bathroom and a soft room are on the first floor. A further office and meeting room are on the second floor, which is not accessible to residents. A garden is accessed through the lounge and has a swing, summerhouse and trampoline. The ground and first floor are served by a lift. Staff have access to a car, which enables people to get out in the community. The current fees are from £1,700 to £3,500, depending on the level of support individuals require. Inspection reports and details of the CSCI are available. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Most of the service users who live here are not able to hold lengthy vocal conversations but all can make at least some of their needs known in other ways. It is encouraging to note that staff continually demonstrate a significant knowledge of the individual communication techniques that each person who uses this service employs and the specific ways in which each makes their needs known. Independence Homes Ltd provides services that are geared toward people who suffer from epilepsy and the risk associated with this specific condition. People can, and do, have a range of complex needs that the services cater for in addition to this, as is the case for the people who live at Hall Road. This inspection involved a visit to both the home and company offices (in order to review staffing recruitment, training and supervision records). Questionnaires were also supplied to the people who live here and for relatives who may wish to make comment. At the time of writing the draft report no questionnaires had been received, although the reason was that the Commission had made an error with issuing these. Should any subsequent comments be received the Commission will consider these and include examples of comments to the final public report if possible. The charge for the service is presently between £1700 to £3575 per week. The quality rating for this service is 2 stars. This means people who use this service experience good quality outcomes. What the service does well: The home effectively ensures that the people who use this service are supported appropriately in all aspects of their day-to-day living. This includes providing the necessary support to enable each person to be a part of the wider community and to have aspirations, expectations and goals. There is active encouragement and support for the people who use the service to maintain family relationships / friendships and develop social and life skills, within an ethos of recognising the limitations but exploring the opportunities for each person to do so. The ethos of the home is clearly aimed at working with people users in a way that acknowledges and respects their rights as human beings. The home benefits from having made the necessary improvements to management, staff recruitment and training as well as organisational oversight. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hall Road DS0000060793.V366012.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 Hall Road DS0000060793.V366012.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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards1 & 2 was assessed at this inspection. The people who use this service and others are told what the home does and how it will do it. The service user guide could, however, still be presented in a more appropriate way to enable at least some of the people who use the service to understand it. EVIDENCE: There has been no new people move into the home since the previous key standards inspection in 2007. As this is the case, standard 1 does not require any further comment at this time. The Statement of Purpose has been updated as was previously required. This document now includes information about the specific nature of the services provided, the organisation and the aims and objectives of the home. The Service Users Guide has been updated as was recommended at the previous key standards inspection. In discussion with the manager of the home and two senior managers from Independence Homes it was recognised that the people who use this service would not find either a written or pictoral format accessible. However, it was evident in this discussion that at least some of the Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 9 people who live at Hall Road may find a video explanation of the service helpful and it was agreed that this would be looked into. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 10 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 6, 7 & 9 were assessed at this inspection. The people who use this service can feel confident that staff know what they need. They can also be assured that the staff will make sure that each person has the opportunity to maximise their opportunities to live the sort of life that they can meaningfully chose to. EVIDENCE: All of the people who live at Hall Road continue to have a detailed care plan. This tells the staff in a lot of detail about the best ways to support each person. It also tells the staff about what each service user likes to do each day, the things that they like, how to respect and support each person’s unique culture, religion and identity and how the staff should do the best things to help in the right way. The care plans are written in the first person, for example using terms such as “I Like” and “What you need to know about me”. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 11 Each person also has an allocated key worker. This is a member of staff who especially makes sure that each the individual is being supported in the right way. Each keyworker makes sure that the care and support plan is kept up to date and regular records of any significant event in each person’s life are also kept. Everyone has had a review of his or her care needs The staff remain committed to making sure that all the people who live here are allowed to make choices about how to live their life. The complex needs of each person are recognised and there is an evident focus on maximising opportunities to make choice in as meaningful a way as possible. Given that spoken communication is either very limited or, for most, non existent it is necessary for the staff team to remain diligent in recognising and responding to the unique ways in which each person communicates. It is encouraging to see that this was happening during this inspection. The home writes a risk assessment for each of the people who use this service. A risk assessment tells the staff how to make sure that each of the people living at Hall Road is kept safe from anything that might harm them, but are also about enabling people to take reasonable risks. The staff are good at doing this and they review the risk assessments regularly to make sure that these are changed if they need to be. There are also risk assessments written about anything in the house or garden that might cause harm if it is not taken care of. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 12 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14, 15, 16 & 17 were assessed at this inspection. The people who use this service can feel confident that the staff of the home will provide active support for each person to participate in the community both in terms of the activities of daily life and leisure interests. The opportunity for each to maintain personal and family relations continues to be encouraged and is actively supported by the staff team. EVIDENCE: Each of the people who live here is supported by the staff to be as independent as possible and to make as many choices as they knowingly can. All of the people who live here have a varied programme of activities. These include therapies that are geared to maintaining each person’s wellbeing as well as social and leisure interests. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 13 The staff at the home keep up to date with what is going on in the community. There are two cars and a people carrier that the home shares with three other services in the local area. There is a driver employed by the company to ensure that when a driver is needed, not least for important appointment etc, there is someone available. The people who live at Hall Road do also use public transport where possible and having the vehicles does not limit this but does provides more transport options. The staff team continues to encourage the people who live here to keep in contact with their families. Family members are made very welcome when they visit the home. There are not many rules at this home. The most important one is that no one is allowed to smoke in the house, and in fact no one does smoke in any case. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office if a meeting is happening. Each of the people who live at this home is allowed to make as many choices as possible about what they want to eat. The staff make sure that healthy food is always on offer and that the meals take into account the input of the dietician who regularly advises the home about appropriate menus, not least for those who may have allergies or sensitivity to certain types of foods. During this visit people were seen having their lunch, which was prepared by the home’s cook. The meal that was provided was in line with the menu and the needs regarding diet that is referred to earlier. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 14 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20 were assessed at this inspection. The people who use this service can feel confident that they will get the right support to take care of their personal and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get the proper support from staff to make sure that this happens. EVIDENCE: The staff that were on duty during this inspection showed that they are very aware of what each person needs and they are sensitive about how they should meet those needs. Most of the people who live at Hall Road do require a large degree of technical aids or equipment to help them to be independent. These technical aids can range from those needed to monitor epilepsy, to physical care support / mobility equipment and those required to assist in providing therapies. Individual care plans tell the staff in great detail the way that each person wants to be physically cared for and supported, this also includes details of personal preferences. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 15 All of the people who live at the home usually go to see a local GP if they are not feeling well. They can see any local GP but most see the same one. The staff write down anything that happens if anyone becomes unwell. If someone has an illness or something else is wrong with them then the staff do know what this is and how to help them to get the treatment that they need. All of the people who live here need to take often large amounts of medicine every day and the staff are very good at making sure that this happens so that they can stay well. The staff are also good at making sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away in a cabinet in each person’s own bedroom. As was required at the previous inspection there have been no further errors in medication administration recording. The staff team have updated guidance and training in the use of diazepam in the event that any of the service users suffers a series of seizures (Also known as “status”). Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 16 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 22 & 23 were assessed at this inspection. The people who use this service can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances and complaints recording has achieved the necessary improvement. EVIDENCE: The people who live here, and others, are given clear information about how to complain and what happens when they make a complaint. Seven complaints have been made since the previous key standards inspection in June 2007. These were mostly raising concern about practises and procedures, as well as staff changes. Each was satisfactorily resolved and it is evident that stability has returned to the home in more recent months. As was required at the previous key standards inspection the complaints that were made are now more fully and accurately recorded. The Commission has not received any formal complaints, although copies of e-mail correspondence between the home, registered provider and a placing authority care manager indicate that care plan implementation has been of concern. The Commission is satisfied that this matter can and is being clarified and resolved by the provider and placing authority in question. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 17 There is clear written guidance and information for staff about what to do if they think that anyone who lives here is being hurt or abused by another person, or if an allegation is made by a third party. One concern was reported in August of last year and the necessary authorities were informed. This matter was investigated under statutory safeguarding procedures and it was concluded that no actual harm had been caused to anyone who uses this service. Training is provided to staff about safeguarding and this type of training is now a standard aspect of the induction process for new employees. On the day of this inspection the homes manager had attended a morning briefing about the safeguarding procedures in use by the London Borough of Sutton. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 24 & 30 were assessed at this inspection. The people who use this service can feel confident that they are living in a well maintained, clean and pleasant home. EVIDENCE: Each of the people who live at Hall Road has their own bedroom. They all have access to a lounge, dining room, soft room and a fairly large garden. Bedrooms are personalised to individual tastes and have space for any technical equipment that may be necessary in providing care and support. Bedrooms have a monitor so staff can hear if anyone has an epileptic seizure and can then respond appropriately. A notice board on the ground floor contains information about each person’s routine for the day and a computer room for the users of the service has been Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 19 developed on the first floor. There is also a sensory room on the first floor in which each of the people who live here can spend time relaxing and listening to music. They are also able to spend time in the lounge or dining room where they can watch television, listen to music or take part in art and craft activities. The garden has a summerhouse, swing, trampoline and a number of adapted bicycles, providing various forms of exercise and activity for the people who live here. The second floor has an office and meeting room for staff, which are not accessible to anyone else. A lift serves to ground and first floor; appropriate ramps are located at the front door and for access the garden. Bathrooms are appropriately adapted to meet the care needs of those who use the service. The house is well maintained and it is noted that there is a comprehensive repair and refurbishment programme in place to ensure that the environment is kept of an acceptably safe and comfortable standard. The home is kept clean, tidy and hygienic and there are effective procedures in place to minimise the risk of cross contamination or infection. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 32, 34, 35 & 36 were assessed at this inspection. The people who use this service can feel confident that there is a committed staff team to meet their needs and that these staff are safe people to support them. Necessary improvement to staffing recruitment and training has also been successfully achieved, although the frequency of staff supervision needs improvement. EVIDENCE: The staffing rota continues to show that on average there are seven members of staff on duty during the day with two members of staff awake at night. The manager and deputy manager are super numery to the staffing rota and ancillary staff are also employed. Specialist staff also visit whether this is to provide advice, support and therapies. The staffing levels continue to provide for one to one support on most days, which creates the opportunity for supporting people to participate in leisure and social activities and generally be involved in the wider community. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 21 Staff files were examined 11 days after this inspection at the Company’s head office as these had been undergoing a review at the headquarters. The recruitment drive that the company has undertaken has resulted in a much improved level of permanently employed staff at the home. The previous key standards inspection identified that the recruitment process needed to take account of exploring reasons for gaps in employment and that references must be addressed to the service rather than ‘to whom it may concern’. Since then the company has addressed the need to make requests for references from named person’s rather than generic requests. The sample of recruited staff records that were seen showed that any gaps in employment are now being explored during the interview process. As a result of the key inspection in 2007 it was identified that CRB checks had not be taken up prior to the individual’s who were employed at that time commencing their work. All CRB checks were seen at the company headquarters during this inspection and it is now the case that all new staff have these completed prior to commencing direct unsupervised care and support work with the people who use this service. The staff team continue to have access to a comprehensive training and development programme. Appraisals were in the process of being completed at the time of this inspection in order to evaluate performance as well as identify training needs for the coming year. All but one member of the staff team have now completed training in the use of PECS, which is the communication system used by two of the people who live at Hall Road. This training has now been added to the induction programme for newly recruited staff. The previous key standards inspection identified that supervision records showed that some staff had not received supervision every other month. A monthly pre planned supervision schedule has now been put into place, which should help the service to monitor supervision levels. This should also assist to quickly identify if any staff are not achieving the monthly frequency of supervision that the company expects. A requirement will be made in this report to ensure that the steps proposed achieve the necessary success with addressing the need for all staff to have at least six supervision sessions within any given twelve month period as is required by regulation. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 37, 39 & 42 were assessed at this inspection. The people who use this service can feel confident that they are living in a home that has improvingly effective internal and external management oversight. The organisational issues that were previously identified are, and continue, to be addressed in order to achieve the necessary improvement. EVIDENCE: Since the previous inspection in June 2007 a new manager has been appointed. This person is currently completing the application process in order to register with the Commission. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 23 Monthly visits under Regulation 26 are occurring and copies of the reports of these visits are being sent to the Commission as requested. This will continue for the time being in order for the Commission to monitor that the improvements that were previously required are continuing to be successfully achieved. The necessary health and safety checks have all been completed and fire alarms are being tested at regular intervals as previously required. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 25 No 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 YA36 Regulation 18 (1) (a) Requirement Staff must consistently achieve the minimum of six supervision sessions in any twelve month period. Timescale for action 11/12/08 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 YA1 Good Practice Recommendations Further consideration should be given to the Service Users Guide being made more appropriately accessible as discussed during the inspection. Hall Road DS0000060793.V366012.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Hall Road DS0000060793.V366012.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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