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Inspection on 01/06/06 for Harrow Road, Flats A, B and C

Also see our care home review for Harrow Road, Flats A, B and C for more information

This inspection was carried out on 1st June 2006.

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 no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a good standard of accommodation, which is well maintained, clean and comfortable. The home is well equipped with overhead hoists within all rooms and is fully accessible to wheelchair users. A wellequipped sensory room is available within the home. The home is well located to transport links and local amenities. Service users are supported to make their own choices and are supported to maintain a full programme of activities, which includes taking part in the local community.

What has improved since the last inspection?

Two of the six requirements set at the last inspection have been met. It was noted that the care plan filing system has been reviewed to minimise the paperwork on service users` files with some of the old information being archived. The inspector noted an improvement in the recording of service users` medication with no gaps evident on the day of the inspection. An Assistant Team Leader has been employed on a short contract to assist the Manager in the running of the home. This has enabled the Manager to delegate some of her duties.

What the care home could do better:

A total of 16 requirements were set following this key inspection. Four of the sixteen requirements were repeated from the last inspection report. Two of the sixteen requirements were immediate requirement, relating to maintaining the health and safety of service users.The shortfall in meeting a number of the standards is thought to be largely down to the lack of permanent staff team. Urgent steps must be taken by the Westminster Society to ensure that the recruitment of a full and permanent staff team is made a priority. Staff must be up-to-date in their training in safe working practices including POVA training and the training records must reflect this. Steps must be taken to ensure that care plan reviews take place within timescale and that the care plans and risk assessments are updated to reflect service users` changing needs. Steps must also be taken to ensure that service users have annual health checks and that details relating to any known allergies are noted on the medication administration records. The home`s Quality Assurance system must be improved and must involve service users and their representatives.

CARE HOME ADULTS 18-65 Harrow Road, Flat C, 291 Flat C 291 Harrow Road London W9 3NF Lead Inspector Ffion Simmons Unannounced Inspection 1st June 2006 10:30 Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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 Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Harrow Road, Flat C, 291 Address Flat C 291 Harrow Road London W9 3NF 020 7266 3072 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) The Westminster Society for People with Learning Disabilities Miss Nikky Ajiboye Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: The home is located on the Harrow Road with access to transport links, local shops and amenities. It is registered for up to five people with learning disabilities with each resident having their own bedroom and access to shared amenities. The home is fully equipped with aids required to enable the residents to pursue a full and active life. The Westminster Society for People with Learning Disabilities is the registered provider. There is currently a full occupancy. The home also has access to a minibus that increases residents opportunities to develop interests outside the home and much time is spent attending activities at day centres and on trips out. Current fees as outlined in the pre-inspection information is £1,714.88 per week. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on the 1st June 2006 between 10:30 and 16:20. The inspector spent time talking to staff and observing care practices. A range of documentation was checked including service users’ personal files. Service users were out of the home for the majority of the inspection as they were attending their day services. Upon their return to the home, staff were observed to be very attentive to their needs and demonstrated a good understanding of their individual needs. The staff team were very helpful and friendly during the inspection process. What the service does well: What has improved since the last inspection? What they could do better: A total of 16 requirements were set following this key inspection. Four of the sixteen requirements were repeated from the last inspection report. Two of the sixteen requirements were immediate requirement, relating to maintaining the health and safety of service users. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 6 The shortfall in meeting a number of the standards is thought to be largely down to the lack of permanent staff team. Urgent steps must be taken by the Westminster Society to ensure that the recruitment of a full and permanent staff team is made a priority. Staff must be up-to-date in their training in safe working practices including POVA training and the training records must reflect this. Steps must be taken to ensure that care plan reviews take place within timescale and that the care plans and risk assessments are updated to reflect service users’ changing needs. Steps must also be taken to ensure that service users have annual health checks and that details relating to any known allergies are noted on the medication administration records. The home’s Quality Assurance system must be improved and must involve service users and their representatives. 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. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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 Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Full information is sought on the needs of service users prior to them moving in. Service users have the opportunity to visit the home prior to moving in. EVIDENCE: There have been no new admissions to the home since 1995. The Society has an admissions procedure in place, which includes the opportunity for service users to visit the home prior to moving in. This provides service users with the opportunity to get to know the staff and feel familiar with the environment. The admission policy specifies that service users’ needs would be assessed prior to them being admitted. This is to ensure that the placement is suitable for meeting their needs. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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, 9, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined in their support plan but the plans are not in an accessible format and not regularly updated to reflect changing needs. The assessment of risk to service users had been completed, but is not kept up-to-date to fully promote service users’ safety. Service users are supported to make their own decisions about their lives. EVIDENCE: Three service users were case tracked during the inspection. This included reviewing their personal care plans and personal records. Each service user has a communication plan on file providing a good level of information on their specific communication needs. The individual support profile and risk assessments for all three service users were on file. The care plans currently are not in a format that is accessible to the service users. Service users’ care plans and risk assessments have not been reviewed since May 2005 and must be updated to reflect any change in needs. This requirement remains ongoing. An immediate requirement was set to ensure that manual handling risk assessments were on file for all service users. Some work has been undertaken to minimise the paperwork on service users’ files with some of the old information being archived. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 10 The Manager confirmed that the home is in the process of implementing person centred plans for all service users. Four staff members have completed the multi-media training with the aim of using multi-media within service users’ review meetings to promote service user involvement and choice. Currently these skills are not being utilised in the current care plans as these were heavy in text. The inspector noted that on a day-to-day basis, service users were offered choice. The shortfall in meeting this group of standards is thought to be largely down to the lack of permanent staff team. Urgent steps must be taken by the Westminster Society to ensure that the recruitment of a full and permanent staff team is made a priority. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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): 12, 13, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have a full programme of activities, and are supported to access services and facilities in the local community. Service users are offered a healthy and varied diet. EVIDENCE: The service users have a full programme of activities. On the morning of the inspection all service users were at the day service. Here they are encouraged to take part in structured group sessions classes and activities. Service users are encouraged to be part of the local community and some of the activities accessed within the wider community includes trips to the cinema, concerts, shopping, going to local parks, going to pubs and restaurants, swimming, local walks and bike rides. Service users’ preferences with regards to social and leisure activities are outlined within their care plan. Staff told the inspector that a service user had recently been on a holiday to Brighton. At home, service users have access to a well-equipped sensory room, which contains various lights and musical instruments including drums and a piano. Some service users enjoy music and have access to a music system, video and Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 12 DVD player. The home has a small garden, which is accessible via the living area. Routines in the home were seen to be flexible. Each service users’ daily living skills are outlined in their support care plan. Mealtimes were not observed during the inspection as the service users had their lunch at the day centre. Service users’ preferences are noted and they are offered a choice of meal. A sample of the menu was seen during the inspection and was seen to be varied and healthy. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ personal needs are met but steps must be taken to ensure that service users’ health care needs are fully met. Medication is securely stored and an improvement was noted in the completion of medication administration records thus promoting service users’ safety in this area. A picture of each service user should be on the medication file and any known allergies must be noted. EVIDENCE: Service users’ personal support and physical needs are outlined in their individual support plans. Service users’ health care records reflected that service users have access to support from the multi-disciplinary team. All three service users case tracked had been invited for an annual health check with their GP. The service users’ health records however reflected that some of the necessary health checks including dental and chiropody are overdue. The health records must be kept up-to-date and service users must receive annual health checks. The medication is securely stored in a metal cabinet, which is located within a locked store cupboard. A list of signatures of staff who have been trained in the administration of medication is kept on the file. The records of all five service users were checked during the inspection. The records were found to Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 14 be well maintained with no errors noted. A picture of each service user should be kept on the medication file and any know allergies should also be recorded. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy, a copy of which is made available to service users. This needs to be updated to outline the relevant personnel to contact within the Society. Policies are in place for the protection of service users from abuse. To further protect service user from abuse, all staff should receive training in the protection of vulnerable adults. EVIDENCE: The home has a complaints policy which is available to service users within the service user’s guide. . The policy makes good use of symbols and pictures of personnel to contact. The policy should be updated as some of the information within the policy is out of date and makes reference to individuals who no longer work within the Society. The inspector was informed during the inspection that the Society is currently looking at ways of making the complaints policy more accessible to service users. No complaints have been made about the service within the last 12 months. The Manager confirmed that service users receive advocacy service. The Westminster Society has an Adult Protection policy available for staff reference. One Adult Protection investigation was carried out within the last 12 months and the outcome was that the allegation was unsubstantiated. The Adult Protection procedures were followed and the CSCI were notified and involved. The staff training records indicated that not all staff have received training in the Protection of Vulnerable Adults from abuse and is a requirement. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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, 26, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are accommodated in a homely, safe and comfortable home. The home is clean and hygienic. Service users have access to the public transport and local amenities, which are located nearby. Service users’ bedrooms are personalised but one of the service users is still waiting for a new bed. EVIDENCE: A tour of the building was undertaken. The home is suitable for its purpose, homely, safe and comfortable. The home is fully accessible to wheelchair users and there are overhead hoists fitted in every room. The home is well located, close to public transport and local amenities. The bedroom of one service user was seen. The bedroom was well equipped and contained many personal items. The staff team confirmed that the service user has been assessed by the Occupational Therapist for a new bed. The new bed has been placed on order and is awaiting delivery. The home was clean and hygienic and odour free at the time of the inspection. Staff are responsible for the cleaning of the home and all cleaning materials were seen to be locked away and COSHH assessments available. A separate Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 17 laundry and sluice room is available, equipped with a washing machine and dryer. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are protected by the Society’s thorough recruitment procedures. The number of staff vacancies has resulted in a lack of consistency for service users and has reduced the home’s efficiency. Service users are supported by a team of staff who have been inducted into their role but some staff are not up-to-date in their training in safe working practices. Steps must be taken to improve and maintain the staff training records. EVIDENCE: The staff on duty during the inspection demonstrated a clear awareness of service users’ needs. Currently however there are six staff vacancies, with four of these vacancies being covered by staff on short contracts. The inspector was told that the vacant posts have been advertised in National newspapers with quite a good response. Interviews were due to take place and two service users were invited to take part in the interviewing process. It remains an urgent requirement that vacant posts are recruited into. The Westminster Society’s Human Resources department is responsible for recruiting new staff and for completing the necessary pre-employment checks. Information was available outlining the date of CRB disclosure for each staff member. The Manager confirmed that she receives confirmation from the Westminster Society’s human resources department that all pre-employment checks are completed and satisfactory prior to a new staff member Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 19 commencing work. The checks include three reference checks and a CRB and POVA check. Forty three percent of the staff team are qualified to NVQ level 2 or above. A further 29 of the staff team are currently undergoing training in NVQ level 2 or above. The staff training records were seen during the inspection and demonstrated that all staff have received induction training. Steps must be taken however to ensure that staff receive refresher training in safe working practices. There is a need to ensure that a better system is in place for recording the training undertaken by staff and to ensure that staff training records are well maintained. A training needs analysis should also be in place. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 42 & 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home benefits from a qualified and experienced Manager. The home’s Quality Assurance systems are not sufficiently robust and are not based on seeking the views of service users. Some shortfalls were noted in the promotion and protection of service users’ health and safety. EVIDENCE: The Registered Manager is experienced in working with the client group and has been working at Flat C for the last six years. She is qualified with NVQ Level 4 in care and also holds the NVQ assessors qualification. Since the last inspection, an Assistant Team Manager has been recruited on a short contract. This has enabled the manager to delegate some of her duties and assist in the running of the home. The Manager’s workload, however remains high due to the number of vacant posts. During the inspection she demonstrated a good understanding of the needs of the service users. A tool is available for assessing the quality of the care in the home but the standards of care in the home have not been formally assessed since April Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 21 2004. It was noted that the Westminster Society is currently working on developing an audit tool for use but this needs to be implemented. There was no evidence that service users’ views have been sought and no evidence of a report available based on service users views and others such as families, advocates and healthcare professionals. It is a requirement that the Society ensures that its Quality Assurance system includes service users and their representatives and that the quality of care is regularly reviewed. Monthly visits on behalf of the registered provider are undertaken and the reports are forwarded to the CSCI as per the regulations. The Assistant Team Manager works as the home’s health and safety representative. Health and safety policies are available on file in the home. Up-to-date Gas and Electricity certificates were available and it was noted that the home’s fire equipment has recently been serviced. A fire risk assessment was seen in place and weekly fire alarm tests and monthly fire drills are performed. Weekly water temperature checks are performed but the annual hot water mixer valve test is overdue. The mixer valves must be serviced to ensure that they are working and delivering water at safe temperatures. The inspector noted that manual handling risk assessments were not on file and an immediate requirement was set to ensure that these are on file for all service users. During the inspection, the inspector noted that a number of fire doors were being propped open including the kitchen door. An immediate requirement was set to ensure that wedges are removed from the fire doors and that fire doors are not obstructed. The inspector noted that the home’s insurance certificate had expired. The Manager must ensure that a valid service insurance certificate must be in place and displayed. Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 22 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 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 2 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 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 2 2 x 3 x 2 x x 2 2 Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 23 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 [1] & [2] Requirement Care plan reviews must take place within timescale and be written up within two weeks. Original timescale of 01/03/06 not met. This is a repeat requirement Service users’ care plans and risk assessments must be updated to reflect any change in needs. Service users’ health records must be kept up-to-date and service users must receive annual health checks. A picture of each service user must be kept on the medication file and any know allergies must also be recorded on the MAR sheet. The Society must update the information within the complaints policy. The Manager must ensure that all staff receive training in the protection of vulnerable adults from abuse. The bed in the red bedroom must be replaced. Original timescale of 01/02/06 not met. This is a DS0000010875.V292271.R01.S.doc Timescale for action 01/08/06 2. YA6 15 [1] [2] 13 [4] 13 [1] (b) 01/09/06 3 YA19 01/09/06 4 YA20 13 [2] 01/08/06 5 6 YA22 YA23 22 13 [6] 01/09/06 01/09/06 7. YA25 16 [1] (c) 01/08/06 Harrow Road, Flat C, 291 Version 5.1 Page 24 repeat requirement 8. YA33 12[1](a) & 8[1] (a) (b) Vacant posts must be recruited 01/09/06 to. Original timescales not met. This requirement is repeated for the second time. Staff must receive training in safe practices. refresher 01/09/06 working 9 YA35 13 [4] 18 [1] (c) 17 [2] Schedule 4 18 [1] (c) 10 YA35 11 YA39 18 & 24 A better system must be 01/09/06 implemented for recording the training undertaken by staff. A training needs analysis must also be in place for the staff team. The organisations’ quality 01/09/06 assurance system must be reviewed so that it reflects the situation within the home and more organisational support given to the staff team and care manager. Original timescale of 01/01/06 not met. This is a repeat requirement The Quality Assurance system 01/09/06 must include service users and their representatives and the quality of care must be regularly and formally reviewed. A report must be produced and be made available for service users, their representatives and the CSCI. The Manager must ensure that 01/06/06 manual handling risk assessments are on file for all service users. Immediate The Manager must ensure that 01/06/06 all wedges are removed from fire doors and that fire doors are not obstructed. Immediate DS0000010875.V292271.R01.S.doc Version 5.1 Page 25 12 YA39 24 13 YA9& YA42 13 [4][5] 14 YA42 23 [4] Harrow Road, Flat C, 291 15 YA42 16 YA43 The thermostatic mixer valves 10/07/06 must be serviced to ensure that they are working and delivering water at safe temperatures. Registration A valid service insurance 10/07/06 Regulations certificate must be in place and displayed. 13 [4] RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Harrow Road, Flat C, 291 DS0000010875.V292271.R01.S.doc Version 5.1 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. 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