Inspection on 25/07/06 for Hartley House

This inspection was carried out on 25th July 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartley House 15/01/07

Hartley House 17/02/06

Hartley House 05/07/05

Hartley House 07/10/04

Hartley House 06/05/04

Hartley House 07/01/04

Hartley House 12/06/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Brook Drive, 124

Rugby House Project

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

CARE HOME ADULTS 18-65 Hartley House 31 Madeley Road Ealing London W5 2LS Lead Inspector Robert Bond Key Unannounced Inspection 25 and 27th July 2006 10:00 th Hartley House DS0000027732.V300906.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 Hartley House DS0000027732.V300906.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. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartley House Address 31 Madeley Road Ealing London W5 2LS 0208 997 0022 0208 810 5384 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) Turning Point Limited Care Home 12 Category(ies) of Past or present alcohol dependence (0) registration, with number of places Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 3 service users over the age of 65 years including service users resident in the home prior to their 65th birthday. 17th February 2006 Date of last inspection Brief Description of the Service: Hartley House is a well - established service offering rehabilitation for the maximum period of six months, for people who have an alcohol dependency and wish to adopt an alcohol free lifestyle. The establishment is owned and managed by Turning Point. Turning Point is a national social care charity providing a range of community based projects for people recovering from alcohol and drug addictions, mental illness and learning disabilities. Turning Points first service was opened in 1964. Hartley House accommodates a maximum of twelve men or women. The service provides group therapy and one to one key work sessions. Emphasis is also placed on service users participation in the community. The home is staffed from 9am - 5pm Monday to Friday. Service users can contact staff outside of these hours on a free phone number. The cost is £446 per week. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector visited the home unannounced on the 25th July 2006 but the Acting Manager was not present. The Inspector talked to the three members of staff on duty, briefly met the service users present, toured the premises including a bedroom with the permission of the occupant, and examined sample records. The Inspector case-tracked (examined in detail) the care records of two service users. The home was fully occupied at the time of the inspection, but the home was one member of staff short as one project worker was acting up into the position of Manager. The Inspector returned on 27th July in order to interview the Acting Manager and go through the Standards with him. This inspection was a CSCI key inspection during which only those National Minimum Standards (NMS) that are regarded as being ‘key’ were assessed. The Inspector assessed the anticipated outcomes of 25 NMS and found that whereas 14 outcomes were fully met, 10 outcomes were only partly met, and 1 outcome was not met. This led to the Inspector making 13 requirements and 2 recommendations. What the service does well: What has improved since the last inspection? The property is now attractively refurbished. The fire risk assessment has been redone. A faulty shower unit has been replaced. C.O.S.H.H. risk assessments have been undertaken on cleaning materials. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 6 The automatic closing device on the laundry door has been repaired. Moving and handling training is being planned. What they could do better: Complete records of referrals, assessments and assessment decisions must be kept in all cases. A photograph of every service user must be kept on file. Risk assessments of service users must be improved so that all relevant factors and known previous histories of service users are taken into account. Some staff members require additional training in this respect. Complete records of risk assessment reviews must be kept on file, available for inspection. The home must make arrangements for the safe and appropriate destruction of old medication that is held in stock. The home must obtain the London Borough of Ealing’s Safeguarding Adults Procedure, write or obtain an up to date in-house Protection of Vulnerable Adults procedure that refers to the above, and train all staff in applying these policies and procedures. It is recommended that staff vacancies are filled on a temporary basis pending permanent recruitment. Additional training is required in certain areas, and more comprehensive training records are required. Monthly Regulation 26 reports must be sent to the CSCI. It is recommended that systems for the internal quality monitoring of record keeping and risk assessing, are improved. Records of hot water temperatures showed that one wash hand basin in a bedroom was being supplied with hot water that was too hot. No action had been taken to correct it before the Inspector pointed it out. Records of fridge temperatures showed that the refrigerator was not keeping its contents sufficiently cold. No action had been taken to correct it. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 7 Cleaning materials that come under the C.O.S.S.H. regulations and which should be locked away, were found in the laundry and in a bathroom. Cabinets that had been purchased to hold cleaning materials safely had not been installed and were in any case not lockable. The Acting Manager agreed to keep C.O.S.S.H. materials locked in a cupboard under the stairs, when they are not in use. Staff must be trained to take the appropriate action when they come across a health and safety issue. 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. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 8 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 Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Due to the inadequate recording of some referrals and the inadequate recording of some assessment decisions, prospective service users individual needs and aspirations have not been satisfactorily assessed in all cases. EVIDENCE: The Inspector case-tracked the care files of two service users, one of whom who had recently moved into the home, and one who was close to finishing his rehabilitation programme. In both cases telephone referrals had been taken from Social Services Departments in other parts of London. Referral details were written on a Referral Form by a member of staff at Hartley House. If the referral appears to be appropriate, the prospective service user is invited to visit the home and the House Rules are discussed with him or her. An Assessment Check List is then completed by a member of staff. The Inspector found that whereas sufficient information and the correct procedures had been followed in the case of the service user who was nearing the end of his stay, this was not wholly the case for the recently moved in service user. His referral details were not complete, the source of the referral was not complete, and only the first name of the referring social worker was Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 10 given. The assessment check-list had not been completed, and the form that should have been filled in to say whether or not a placement was to be offered, had not been completed. Accurate and complete assessments, agreements and record keeping are essential elements of providing a good service. See Requirements 1 and 2. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is adequate overall. This judgement has been made using available evidence including a visit to the service. Service users are adequately involved in decisions about their lives. Service users are adequately consulted on and participate in most aspects of life in the care home. However the process and procedure for undertaking risk assessments is poor. EVIDENCE: NMS6: The Inspector case-tracked two care files as described in the section above. A service user (care) plan had been written for the service user who was nearing the end of his placement, but one had not yet been complied for the new service user. The Acting Manager reported that it was normal policy not to complete a service user plan until the person had been resident for almost three weeks. Sometimes the referring Social Services Department provides their own care plan as well. The service user plan that was seen by the Inspector had been reviewed appropriately and it was signed by the service user and by the key worker. The contents of the service user plan seen Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 12 by the Inspector were adequate, but the section designed to take a photograph was empty in both cases seen. The Hartley House form says a photograph is ‘optional’ but the Care Home Regulations require photographs. See Requirement 3. Keeping a photograph on file is also recommended in case a service user has to be reported to the Police as a missing person. NMS7: In addition to service user involvement in reviews as indicated by the records the Inspector noted, the Acting Manager reported that service users attend daily therapeutic meetings, and weekly ‘domestic’ meetings, all of which are used to ascertain their views. NMS8: Service users agree to be involved in cooking and cleaning within the care home. The Inspector noted the rota for this. The Acting Manager added that service users are also involved in the recruitment of new staff, which is commended. NMS9: The Inspector examined risk assessment information on the two files he case-tracked. An adequate clinical risk assessment had been undertaken on the service user who was nearing the end of his stay. The check-list on his file indicated that this risk assessment had been reviewed as required but the Acting Manager could not locate for the Inspector a copy of the revised risk assessment. See Requirement 4. A risk assessment had also been undertaken on the service user who had recently moved in. The only risk that had been identified was that of alcohol use relapse. However the referral information for this service user mentioned suicide attempts in the past, and a criminal record for violence. It is important that when a risk assessment is undertaken, full use is made of information that is known about the service user, and that judgements are made about whether there is any risk of similar incidents reoccurring in the care home. If the decision is that the risk is now negligible, this should still be recorded together with the reasons why. See Requirement 5. Additional training for staff in how to undertake risk assessments is indicated. See Requirement 6. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are sufficiently encouraged to take part in age, peer and culturally appropriate activities that do not involve consuming alcohol. Service users are sufficiently encouraged to undertake leisure activities, at home and in the local community, and to maintain family relationships. Service users’ rights and responsibilities are sufficiently recognised, subject to the House Rules. Service users enjoy communal lunches and a reasonably healthy diet. EVIDENCE: The Acting Manager reported that Hartley House is a ‘second stage’ home where service users may stay for up to six months following a programme of detoxification from alcohol addiction. A programme of therapeutic activities is provided such as group therapy sessions, massage, and art therapy. Service users are encouraged to go out and lead a normal life without alcohol. Hence college attendance is encouraged as is going to the gym or swimming. There are particular links with Thames Valley University for IT training. Links with Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 14 family and friends are encouraged provided these are not contra-indicated as likely to encourage the drinking of alcohol. For the first two weeks of stay, service users may not leave the premises without another service user to go with them. Visiting times are restricted so that group therapy times are not disturbed. Service users are provided with a Travel Card. Bedroom searches are not undertaken but rooms are entered by staff to undertake health and safety checks. Random breath and urine checks are undertaken to ascertain whether a service user has started drinking again. Service users are issued with a key to their own room and lockable cabinet. The Inspector noted the record of food eaten. It was reasonably healthy. Lunches are prepared by service users on a rota basis and eaten communally. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive sufficient personal support in the ways they prefer and require. Service users’ physical and emotional health needs are sufficiently met. Service users retain control of their own medication, but are not adequately protected by the home’s procedure as medication that is no longer needed is stored in the home. EVIDENCE: The Acting Manager reported that prospective service users with personal care needs were not accepted by Hartley House. He added that a local GP would take responsibility for new service users if they did not wish to stay with their existing GP. District nurse input into the home was available if required. Service users were assisted to keep hospital appointments. All service users are able to manage their own medication. The home does however have the procedures in place to administer medication should it become necessary. At present the home has a stock of old medication that must be destroyed. Requirement 7. Hartley House DS0000027732.V300906.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor overall. This judgement has been made using available evidence including a visit to the service and is based on the lack of suitable policies and procedures for protecting service users from abuse. However service views are sufficiently listened to and no complaints were noted. EVIDENCE: The Inspector talked to the majority of service users present and asked if any one had any complaints about the home. None were forthcoming. The Inspector examined the home’s complaints log and noted that none had been recorded since before the previous CSCI inspection. The Inspector asked to see the home’s policy on the Protection of Vulnerable Adults. He was shown the home’s Whistle-blowing policy and an out of date POVA policy which pre-dated the establishment of the CSCI and the London Borough of Ealing’s Safeguarding Adults department. Subsequently the Acting Manager posted an updated in house POVA policy to the Inspector. This new policy now mentions the CSCI but still fails to mention the role of The London Borough of Ealing in investigating all allegations of abuse that may have occurred within the borough. The home must therefore obtain the Safeguarding Adults procedure booklet from the London Borough of Ealing, must obtain or write an in-house procedure that refers to the Ealing procedure, and must ensure that all the staff in the home are trained in applying these policies and procedures. Requirements 8, 9 and 10. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service and is based on the fact that although the premises are sufficiently clean and well furnished, equipped and decorated, further action is required to keep the premises adequately safe for service users and visitors. EVIDENCE: The Inspector toured the premises in the company of a member of staff, and inspected one of the service user’s bedroom with his permission. The bedroom was suitably furnished, equipped and decorated but the hot water to the washhand basin was too hot. See Health and Safety section. The home has recently been refurbished, and it was adequately clean through out. Cleaning chemicals that come under the C.O.S.H.H. Regulations were on display in bathrooms and the laundry despite the requirement of the previous CSCI inspection that cabinets be purchased to keep these items safely away from children who visit the home. The Acting Manager agreed that in future Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 18 such items would be locked in the C.O.S.H.H. cupboard under the stairs, when not in use. See Health and Safety section for requirement made. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate overall. This judgement has been made using available evidence including a visit to the service. Service users are adequately protected by the home’s recruitment policies, and do benefit from properly supervised staff. Service users are not well supported by competent and qualified staff as some additional training is required, and fuller training records are required. At the present time service users are not adequately supported by an effective staff team as there is not a complete staff team in place. EVIDENCE: The Acting Manager reported that the home is normally staffed by a Manager, three support workers and a finance administrator. As the Registered Manager has left, one of the support workers is acting up as manager. Thus the home is operating with a vacancy of one support worker. One of the support workers told the Inspector that this affects the amount of group work that can be undertaken in the afternoons, and the Inspector noted how stretched the staffing appeared to be during the afternoon of the second inspection day. Recommendation 1. Staff members reported to the Inspector that they receive good and adequate training. However see Requirements 6 and 10 about training in risk assessments and in the POVA procedure. Two staff members reported that Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 20 they were undertaking the level 3 NVQ in care, and the Acting Manager was undertaking the NVQ assessor’s award. The Inspector asked to see the home’s training records and was shown a large file containing many documents. The home did not appear to maintain a summary of all the training undertaken by individual members of staff, and a list of their identified training needs as identified during their professional supervision. Requirement 11. Staff members however did tell the Inspector that they were properly supervised by the Acting Manager on a monthly basis and that they receive clinical supervision two weekly from a psychotherapist. The Acting Manager showed the Inspector copies of Regulation 26 reports that he receives from his line manager when he receives his supervision. Copies of Regulation 26 reports must now also be sent monthly to the CSCI Inspector. Requirement 12. The Inspector examined the recruitment records of the member of staff who most recently joined the staff team, and found that appropriate checks had been undertaken. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate overall. This judgement has been made using available evidence including a visit to the service. Although quality assurance is undertaken, internal quality monitoring is underdeveloped. Further efforts are necessary to make sure the health and safety of service users, visitors and staff are adequately protected. EVIDENCE: There is no Registered Manager at the home at present and so the management of the home was not generally assessed. However the omissions in record keeping and assessments gives cause for concern and suggests that internal quality monitoring systems need to be enhanced. Recommendation 2. The Acting Manager reported that service user questionnaires had recently been sent out for completion. When a completed set is returned, they will be analysed in graph form, and a verbal report given to the service users, he Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 22 added. Feedback forms are also requested from service users when they leave the home. As reported in the Environment section, hot water temperatures were seen from the records to be too hot in one bedroom. This was correct between the Inspector’s too visits. Also from the records the Inspector was able to determine that the home’s refrigerator had been operating at too high a temperate. It is important that when a member of staff notes a temperature that is either too high or too low, that member of staff must take the appropriate action to correct the problem. Also as reported in the Environment section, all C.O.S.H.H. cleaning materials must be locked away. Requirement 13. As reported under NMS9, more attention to health and safety risks is necessary when undertaking the risk assessment of new or potential service users. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 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 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 2 x Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14(1) Requirement Timescale for action 01/09/06 2. 3 4 YA41 YA6 YA9 5 YA9 6 YA9 7 YA20 The registered person shall not provide accommodation to a service user unless the needs of the person have been properly assessed. 17(1)(a)Sch3(1a) Complete assessments must be kept on file for inspection. 17(1)(a)Sch3(2) A photograph of all service users is required to be kept on file. 14(2)(b) The registered person must ensure that risk assessments are kept under review and revised as necessary, in writing. 14(1)(a) The needs (and associated risks) of potential service users must be assessed by a suitably qualified or suitably trained person. 18(1)© The registered person shall ensure that persons employed in the care home receive the training appropriate to the work they are to perform (undertaking risk assessments). 13(2) The registered person must DS0000027732.V300906.R01.S.doc 01/09/06 01/09/06 01/09/06 01/09/06 01/10/06 01/09/06 Page 25 Hartley House Version 5.2 8 YA23 13(6) 9 YA23 13(6) 10 11 YA23 13(6) 18(1)© YA35 12 13 YA36 26 13(4)(a) YA42 make arrangements for the safe disposal of medications held in stock. The home must obtain the London Borough of Ealing’s Safeguarding Adults procedure The home must obtain or write an in-house procedure that refers to the London Borough of Ealing’s Protection of Vulnerable Adults department. All staff must be trained in new POVA policies and procedures In order to ensure that staff are properly trained for the work they are to undertake, the registered person must maintain adequate records of their training undertaken, and their training needs. Regulation 26 reports must be sent monthly to the CSCI. All parts of the care home must be kept safe by locking away cleaning materials that come under the C.O.S.H.H. regulations. 01/09/06 01/09/06 01/10/06 01/10/06 01/09/06 01/09/06 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 Refer to Standard YA33 YA37 Good Practice Recommendations Staff vacancies should be filled on a temporary basis pending permanent recruitment. Improvements should be made to the internal quality DS0000027732.V300906.R01.S.doc Version 5.2 Page 26 Hartley House monitoring system so that omissions in record keeping and in risk assessments can be spotted and corrected. Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove Hammersmith 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 Hartley House DS0000027732.V300906.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!