Inspection on 29/07/08 for Herbert Road, 185

This inspection was carried out on 29th July 2008.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Herbert Road, 185 04/10/07

Herbert Road, 185 29/03/07

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 29/01/2009.

CARE HOME ADULTS 18-65 Herbert Road, 185 London SE18 3QE Lead Inspector Lorraine Pumford Unannounced Inspection 29th July & 6th August 2008 14:00p Herbert Road, 185 DS0000065983.V365815.R02.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 Herbert Road, 185 DS0000065983.V365815.R02.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. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herbert Road, 185 Address London SE18 3QE 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) 020 8854 9393 020 8854 9393 info@hillgreen.co.uk Hillgreen Care Ltd Manager post vacant Care Home 3 Category(ies) of Learning disability (0) registration, with number of places Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 3 4th October 2007 Date of last inspection Brief Description of the Service: The home is registered to provide care for three people who have been assessed as having a learning disability. The home is owned and managed by Hill Green Care Ltd. The home is an older style detached house set back from the road in a large pleasant garden. The home is within easy reach of local transport, services and shops. There is off road parking. Accommodation consists of three single bedrooms, one of which is on the ground floor. There are bath/shower rooms and toilets on both floors. Also situated on the ground floor are a lounge dining room, kitchen, utility room and office which is also used as the staff sleeping in room. Herbert Road, 185 DS0000065983.V365815.R02.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 one star this means that people using the service receive an adequate service. The inspection was a key unannounced inspection. We looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. We were able to observe the support given to the current residents and to talk to residents individually. The inspector was also able to spend time talking to the newly appointed manager as well as the care staff on duty. when we visited the homes service manager was in attendance for part of the inspection and also provided some information. We undertook a tour of the premises and also looked at a range of records including resident records, staff files and health and safety documentation. The home had completed self-assessment questionnaire (AQAA) prior to the inspection. Current fees range from £1,500 to £1,800 per week. What the service does well: Prospective residents benefit from a comprehensive assessment and can testdrive the home before moving in on a trial basis. Residents benefit from being supported to make choices in their daily lives. People living in the home are supported to develop their daily living skills and are also enabled to follow their own routine. Staff support residents to enjoy a range of activities based on their individual interests. Residents are offered a healthy and varied diet. The people living in the home are supported in a manner that protects their privacy and dignity. Each person is supported to access professional healthcare based on their individual needs. Procedures and training on safeguarding vulnerable adults are in place to help protect people living in the home. Herbert Road, 185 DS0000065983.V365815.R02.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. Herbert Road, 185 DS0000065983.V365815.R02.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 Herbert Road, 185 DS0000065983.V365815.R02.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): 2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from a comprehensive assessment and can testdrive the home before moving in on a trial basis. EVIDENCE: The pre admission assessment was seen for one person who has recently moved in to the home. It was apparent that the provider had undertaken a comprehensive assessment to ensure that the home would be able to meet the persons needs prior to admission. It was apparent that relevant health and social care professionals had also been involved in the process and that the resident had been given the opportunity to visit the home prior to being offered a permanent place. Documentation seen also indicated that the resident and his family had been involved in making the decision for him to move away from his family and into Herbert Road. We spoke with the resident who stated he was glad to have made the move and was enjoying living in the home. The person stated he had chosen to live in a home closer to London which would enable him to participate in specific hobbies and interests. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home can be confident that they will be supported with an individual care plan and a risk assessment that promotes their independence. Residents benefit from being supported to make choices in their daily lives. EVIDENCE: We inspected care plans for three people currently living in the home; we also spoke to the manager and care staff about the care plans. All of the people whose records were inspected had comprehensive care plans in place. From discussion with staff and records seen it is apparent that information regarding residents is recorded in more than one book and this meant that initially some key information was almost overlooked. Discussion took place with staff regarding reviewing the current system of storing information into a more manageable format. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 10 There was evidence that regular reviews are taking place for the two people who have resided in the home for over twelve months. Staff stated that a formal review would take place for the person recently admitted, this would occur after approximately 8 weeks and would include the resident and his family as well as relevant health and social care professionals. Each resident had a named key worker. The staff were asked about their role as a key-worker and demonstrated showed that the support they provided was very comprehensive including helping with personal shopping, attending healthcare appointments, ensuring all the residents personal care needs were met, organising leisure activities and accessing education and employment opportunities as well as updating care plans. The staff spoken to said they felt they were well matched as key-workers and are the same gender as the residents they support. The staff also showed a good understanding of each resident’s individual care plan goals. We read the risk assessments for the three people who live in the home. It was possible to see that staff had been able to identify areas of personal risk and looked at how this can be managed without placing unnecessary restrictions on people. Risk assessments were seen in relation to residents using the Kitchen, travelling outside the home etc. Each person living in the home has individual behavioural guidelines as part of their care plan and these were clearly written and gave appropriate guidance for staff i.e. the circumstances which could trigger a resident to behave inappropriately and action to be taken by staff to address the matter. Staff support residents to manage their money according to each residents individual ability and discussion took place regarding the safeguards in place for each person. The three people living in the home have disabilities which affects their lives in very individual ways and therefore residents are consulted and supported on a one-to-one basis to make decisions about their lives. The newly appointed manager stated that he is hoping to arrange resident meetings on an ongoing basis. Staff were observed to be very aware of both verbal and non-verbal communication. In addition it was observed that the staff were supporting the residents with skill and sensitivity. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to develop their daily living skills and are also enabled to follow their own routine. Staff support residents to enjoy a range of activities based on their individual interests. Residents are offered a healthy and varied diet. EVIDENCE: We spoke to the staff and looked at the resident’s activity programmes to get an understanding about the activities that are taking place. One resident requires the support of staff on a one-to-one basis to participate in activities. On the first day that we visited the resident was being supported to play a game of pool outside the home. Staff also support the resident to go out for a walk each day either to local shops or parks. Two of the residents are much more independent and want to be able to make their own choices in terms of how they spends their time. One person enjoys Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 12 spending time with her friends outside of the home and has a part-time job in a local hairdressers, her key worker is currently supporting her through the application process to attend a training course at a local college. The other resident has recently moved into the home to be closer to London as he has a particular interest in the theatre and staff have supported him regarding this interest, staff said they would also support this person in seeking appropriate training courses in relation to his interests when he has settled into the home. Staff stated that one resident lacks confidence and has been supported to attend the Black and Minority Ethnic Mental Health Forum to help address this. Residents are able to have their own televisions and music centres in their bedrooms. Staff stated that residents participate in household tasks depending on their individual abilities. All of the residents require staff supervision in the kitchen, staff support residents to make hot drinks and snacks and residents who are able support staff with preparing and cooking meals. It was apparent from discussion with staff and information provided in the AQAA that staff support residents to maintain family links, friendships and personal relationships with peers of their choice. Records seen indicate that people living in the home are provided with a varied nutritional diet that takes into account their cultural and dietary requirements. The majority of household provisions are ordered via the Internet and delivered weekly. In addition staff support residents to purchase bread, milk and meat etc as required throughout the course of the week. The manager stated that this is an area that he wishes to develop further to help support individual residents develop daily living skills that will help them become more independent. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported in a manner that protects their privacy and dignity. Each person is supported to access professional healthcare input based on their individual needs. The medication system in the home helps safeguard residents however staff must receive more comprehensive training in relation to medication. EVIDENCE: During the course of the visit we observed that staff respected residents privacy and dignity. Residents were addressed by their preferred name. It was observed that all the residents were wearing age appropriate clothing that reflected their individual personalities. We looked at the healthcare records for the three people living in the home. They had all been supported to access a range of healthcare professionals including the GP, psychiatrist and other appointments according to their individual needs. One person living in the home has difficulty verbally expressing themselves and a speech therapist from the Community Learning Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 14 Disability Team is due to meet with the resident and staff to provide help in relation to this. We looked at the medication, administration records and discussed staff training in relation to medication. At present only one person in the home is receiving medication on a regular basis. The home uses the Boots blister pack system. The medication is stored in a medication cupboard in the manager’s office. The following recommendations were made, when hand writing details of additional medicine to the MAR sheet (Medication Administration Record) two members of staff should sign the record to ensure that details of the medicine have been accurately recorded. Staff were advised that guidelines in relation to medication administered in care homes have been updated and staff need to develop a protocol for the administration of medication to residents who are unable to verbally express they require PRN medication. Staff need to maintain an ongoing record of all medicine prescribed to people living in the home. Staff need to be assessed as competent to administer medication on an annual basis. From discussion with staff it is apparent that training with regards to medication is not comprehensive enough. All members of staff responsible for administering medication must receive training from a suitably competent and qualified trainer. Discussion took place with staff regarding the need for the provider to secure appropriate training. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place, however staff must record complaints brought to their attention and action taken to address them. Procedures and training on safeguarding vulnerable adults are in place to help protect people living in the home. EVIDENCE: The provider ensures that people living in the home are provided with information about the organisation complaint procedure. To date we have not received any complaints about the care and service provided. Information provided in the AQAA states there have been no complaints made to the provider since the last inspection. There is a log kept in the home to record any complaint made to staff. Records seen indicated that one person had told staff they wished to make a complaint, however this had not been recorded in the log. The service manager stated that this was part of this persons behaviour trait. The resident has the service managers contact number and phones directly with issues they wish to raise. Discussion took place regarding the need to record any information that residents refer as a complaint, so people can be assured their concerns will be appropriately dealt with. The issue should also be included in the residents care plan with staff working towards managing the behaviour exhibited appropriately. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 16 One incident has occurred in the home which was referred to local authority to be addressed under the joint working safeguarding adults procedure. The service manager has kept us informed of issues that rose in relation to this. Information provided in the AQAA indicates that the provider arranges for staff to receive training in relation to safeguarding adults from a suitably recognised body. Staff spoken with confirmed that they had attended training in relation to safeguarding adults and a copy of the Whistle Blowing policy given to staff was also seen. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from living in a clean, well-maintained home like environment. EVIDENCE: We undertook a tour of the premises and each resident has their own bedroom. One resident has limited verbal skills however staff asked him if he would to show us his room. The residents demeanour indicated he feels happy and relaxed in his environment. He enjoyed showing us pictures he has on his bedroom walls particularly the ones of himself. Two requirements were made at the time of the last inspection one in relation to the decor and maintience of the building and the other that residents must be provided with appropriate bed lien. It was apparent that action has been taken to address both of these issues. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 18 We looked at the bedroom for the other two people living in the home. One person had broken their bed; staff stated that this had happened on a number of previous occasions. A new bed will be purchased and staff are going to incorporate this issue in to the persons care plan. The other resident has only recently moved in to the home and the room has already been personalised with pictures, mementos and his music system. The resident said he was settling in and has everything he needs. There is a shared shower and bathroom and toilets on both floors. The communal spaces consist of the kitchen, lounge/dining area. The house is in a large well-maintained garden. The house has satisfactory laundry facilities and storage for chemical cleaning materials. The home was seen to be clean and tidy during the inspection. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from support from a committed and stable team of staff. The staff all hold an appropriate qualification in care. Recruitment procedures help safeguard people living in the home from harm. EVIDENCE: The staff Roster seen was up to date and an accurate reflection of staff working in the home. Generally there are a minimum of two staff working in the home, however staff stated that there are occasions when a member of staff could be in the home with a resident on a one to one basis and staff were asked to develop a risk assessment in relation to this. The recruitment files were examined for two members of staff who have begun working in the home since the last inspection. There was evidence that checks on employees identity had been undertaken, CRB/POVA checks and confirmation of employees health status had also been undertaken. The application form seen refers to the rehabilitation of offenders act and does not ask staff to disclose any information about offences which may affect their Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 20 application. This information needs to be updated to include that a CRB/POVA check will be undertaken as part of the process. The area manager stated that the application form would be amended to reflect this. Discussion also took place regarding the need for the provider to evidence any offences disclosed had been discussed with the applicant and a judgement made that the applicant actions would not cause any ill effect to people living and working in the home. Information provided in the AQAA indicates Hill Green Care are currently recruiting a dedicated training department. Staff spoken with stated they felt the organisation provided them with appropriate training to effectively carry out their work. All of the care staff working in the home have attained an NVQ 2 in care qualification or above. Record seen indicates that all staff receive appropriate supervision in relation to practice, training and personal development. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living in the home would benefit from having a permanent person in post managing the home on a day-to-day basis. People living in the home benefit from the organisation monitoring the care and service provided. The provider must be able to evidence that all people working in the home have received appropriate fire safety training. EVIDENCE: Since the last inspection one manager has left the home and another person has been recently appointed. Discussion took place with the area manager regarding the fact that we should have been informed that the previous manager had left and of the arrangements put in place to oversee the running of the home on a day-to-day basis until the current manager was in post. The provider must now submit an application for this person to be registered with the CSCI. Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 22 From records seen and discussion with staff it is apparent that some incidents have occurred which affected the well-being of residents and other people in the home, we should have been informed of this in accordance with regulation 37 of the Care Homes Regulations. Staff stated that they have been no accidents in the home since last inspection, however there is a system in place a to record this information as and when required. The area manager ensures that regular audits of the care and service are provided and copies of the report are routinely forwarded to us. During the course of the inspection he was advised that this was no longer required and copies of his audit should be kept in the home and available for inspection. Discussion took place with the newly appointed manager regarding the need for the manager to implement a system of reviewing the care and service provided with a view to developing and improving the service provided. A requirement was made at the time of the last inspection that staff should receive training in relation to fire safety procedures within the home. Since then some additional staff had been recruited and there was no evidence that training had taken place for these people. The newly appointed manager agreed to arrange this. It is recommended that staff attending fire safety training sign to say they have participated in this. Records seen indicate that there are procedures in place to routinely maintain and service all gas, electrical equipment and the fire detection system in the home. Herbert Road, 185 DS0000065983.V365815.R02.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 4 3 3 4 3 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 2 35 3 36 3 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 2 X 3 X X 2 X Herbert Road, 185 DS0000065983.V365815.R02.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 YA42 Regulation 23(4)(d) Requirement Timescale for action 01/11/08 2 YA20 3 4 5 YA22 YA42 YA37 The registered person must after consultation with fire authority made arrangements for persons working in the home to receive suitable training in fire safety. 18 All members of staff responsible for administering medication must receive training from a suitably competent and qualified trainer. 17 The registered person must ensure that a record is kept for any complaint made to them. 37 The registered person must notify the commission of any event specified in regulation 37 Section 11 The registered person must CSA 2000 submit an application to register the manager with the CSCI. 30/11/08 30/09/08 30/09/08 01/12/08 Herbert Road, 185 DS0000065983.V365815.R02.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA9 YA6 YA20 Good Practice Recommendations A risk assessment should be completed in relation to staff working alone in the home with residents. It is recommended that the system of storing and recording information regarding residents is reviewed. It is recommended Staff develop a protocol for the administration of medication to residents who are unable to verbally express they require PRN medication. Staff need to maintain an ongoing record of all medicine prescribed to people living in the home. Staff need to be assessed as competent to administer medication on an annual basis. Herbert Road, 185 DS0000065983.V365815.R02.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 Herbert Road, 185 DS0000065983.V365815.R02.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. 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