Inspection on 20/04/06 for Hersham Road (20)

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hersham Road (20) 08/05/07

Hersham Road (20) 10/11/05

Hersham Road (20) 07/06/05

Hersham Road (20) 13/01/05

Hersham Road (20) 15/07/04

Hersham Road (20) 12/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hersham Road (20) 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ Lead Inspector Unannounced Inspection 20th April 2006 11:30 Hersham Road (20) DS0000013464.V289011.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 Hersham Road (20) DS0000013464.V289011.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. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hersham Road (20) Address 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ 01932 269171 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) Welmede Housing Association Ltd To be confirmed Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Physical disability (1), of places Physical disability over 65 years of age (1) Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Of the 6 service users in the category LD, up to 1 may also fall within category PD. Of the 2 service users in category LD(E), up to 1 may also fall within the category PD(E). The age range of the persons accommodated in the home will be: SIX (6) 36-65 YEARS and two (2) 65 YEARS AND OVER One (1) of the service users in category LD(DE) To include one (1) named service user over the age of 65 years with dementia. 10th November 2005 Date of last inspection Brief Description of the Service: 20 Hersham Road is an adapted large house situated on a busy main road in a residential area, which is within walking distance of all community facilities of Walton On Thames. Service provision is for up to eight people with learning disabilities, some of who have physical disabilities in addition to their primary condition of a learning disability. The service affords all single bedroom accommodation on the ground and first floor with the third floor designated for staff use only. Wheelchair users are confined to the ground floor as provision of a lift is not available. There is a spacious combined lounge/dining room overlooking a furnished patio and a large, attractive well maintained enclosed garden. Residents have access to the home’s vehicle, which is equipped for transporting wheelchair users. The service is owned by Welmede Housing Association Limited and staffed by employees of the North Surrey Primary Care Trust through a support agreement between the Trust and Welmede Housing Association. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mrs Vera Bulbeck Regulation Inspector carried out the site visit. Mrs Amanda Salih the registered manager for the home was present. The site visit was undertaken over 6 hours and 15 minutes. There are currently seven residents living in the home, and the majority have lived in the home for some considerable time. A few residents were at a day centre on the day of the site visit; and the inspector was able to speak with the residents during the time spent in the home. A number of staff was spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The inspector received positive comments from the staff team. It was difficult to communicate with residents some were able to express themselves and observation made was that residents and staff have a good rapport and residents were relaxed and comfortable with staff on duty. It was disappointing to note that one requirement from the previous inspection was not met. As a matter of priority the home needs to update the homes Fire Risk assessment to include all rooms and communal areas of the home, as well as introducing a contingency plan in the event of an emergency. The inspector would like to thank the manager and staff members for their time, assistance and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report What the service does well: The registered manager and staff team are committed to providing a safe and homely environment for residents. Resident’s are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of listening, sign and body language. The registered manager informed the inspector that questionnaires have been implemented and there is a plan to send out to families and friends. The inspector advised the home to contact Age concern for an Advocate to be involved with residents who do not have any family or friends. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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. Hersham Road (20) DS0000013464.V289011.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 Hersham Road (20) DS0000013464.V289011.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed and informative statement of purpose and service users’ guide, both documents need up dating. A statement of terms and conditions and a letter confirming that the home can meet their needs are provided to residents. These documents, together with the home’s procedure of carrying out detailed assessments and offering visits prior to admission, enable residents and prospective residents to make an informed choice about a stay at the home. EVIDENCE: The inspector informed the registered manager that the statement of purpose, which details the service provided to residents, needs to be updated, as it had not been updated since April 2003. However, there have been no new admissions to the home in three years. The service user guide needs to be updated and each resident and their relative should be provided with a copy. Please send an updated version of the statement of purpose and service users guide to (CSCI) to be held on file. Care plans or life plans were well documented. However, they are so big they need to be divided to enable staff to use as a working tool. There is a need to ensure that all the relevant documents are included for example, recent photographs of all the residents need to be included. Various assessment Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 9 sheets need signing and dating. Residents need to be involved with their care planning where possible, if not their relatives need to be involved. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected 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. This judgement has been made using available evidence including a visit to this service. An individual plan is drawn up for each resident but these need to be completed and updated. EVIDENCE: The individual plans for three residents were seen. Some of these were in the format that the home has used for some time and for others, the information from the older style plan was being updated. It was noted that some of the plans had not been signed or dated by the person completing them. In some cases, the resident had not signed the plan to show that they had been involved in drawing it up. A photograph of the resident should be on the care plan. Staff were seen to knock before entering resident’s bedrooms. Residents who are able to communicate indicated and were observed that they are supported to make decisions, such as choosing holidays and days out. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 11 The manager stated that areas of risk to the health and welfare of residents are identified, assessed and recorded. A risk assessment covering a resident who is confined to a wheelchair for moving around was seen in the care plan. Falls and personal care are drawn up and were seen. The manager stated that key workers carry out risk assessments and staff have received training to enable staff to undertake risk assessments, the manager oversees all risk assessments. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 this service. The residents have opportunities to take part in appropriate activities both within the home and in the local community. EVIDENCE: Residents attend various day centres, and many are involved in the local community centre meetings. Some residents attend church on Sundays. Residents also attend classes for art therapy and swimming. Several of the residents are involved with jobs around the house these include cooking, emptying the bins, putting their clothes away and gardening. Most of the residents like to go shopping; this is undertaken with their key worker. It was pleasing to note that a member of staff has devised a manual in picture form to enable the residents to choose the food they like, drinks, activities they would like to do. The manual is to be expanded to include holidays and days out. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 13 A number of residents have contact with family and friends. Another resident who does not have any relatives, staff have made contact with the residents solicitor to be able to trace a distant relative. The inspector advised the registered manager to contact an agency for an advocate for those residents who do not have any relatives or friends. Three residents are going on holiday in May 2006 for four days to Disneyland, Paris with three members of staff. One resident has requested she does not want to go on any more holidays and would prefer to go on days out. On the day of the site visit one resident was on holiday with her mother. Meals were observed to be nourishing and well balanced; residents clearly enjoyed their meal. Staff undertake the cooking and residents help with the preparation and laying the table. It was noted that the meat probe temperature needs to be undertaken and recorded on a regular basis. The registered manager advised the inspector that a member of staff is currently compiling various documents in picture form and is currently working on the menu; this includes a wide variety of different foods. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medication. EVIDENCE: From the tour of the premises, it was clear that residents are provided with a variety of aids and equipment to assist with their independence, including wheelchairs specifically designed for individuals. Residents indicated that they are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. From the individual plans and speaking to residents, it was evident that a number of healthcare professionals are involved in the support of the residents. These include general practitioners (G.P.), chiropodists, opticians, dentists and hospital specialists. The manager stated that the administration of medication is carried out by a nominated, “key holder”, members of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. A resident in the home has been prescribed rectal diazepam. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 15 However, it was noted that all staff need up to date training on the use of rectal diazepam A pharmacy inspection was undertaken on 21/01/05 there were no requirements and four recommendations were made these have been met. However, it was noted in a residents bedroom medication had been left in an unlocked cupboard with the key in the door. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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 good. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that residents feel their views will be listened to. However, the policies and procedures need updating, the last review was dated 2002. Policies and procedures should be more specific to 20 Hersham Road. EVIDENCE: All staff has attended the safeguarding of vulnerable adults training and when spoken to by the inspector it was clear that staff are aware of the whistle blowing policy. The complaints procedure needs updating it was last reviewed 2002 and should be applicable for 20 Hersham Road. Residents and relatives should be provided with a copy of the complaints procedure. To enable residents to be clear of the procedure it would be advisable for the document to be in picture form. The home has received one complaint since the last inspection and the registered manager has investigated the complaint and details of the complaint and the findings should be available. However, the details of the investigation and action taken were not available. The inspector advised the management of the home to ensure any records regarding complaints should be maintained in a file. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible and safe. Some areas in the home particularly bathroom equipment and carpets require attention. The home generally was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The home was found to be generally clean and tidy and some areas have had new furniture and bedding including a new pillow and duvet. However, the carpets were badly stained in bedrooms 7 and 2, both need deep cleaning or replacing. It was also noted that a resident had gone on holiday on 14th April and on the day of the site visit soiled sanitary towels were found in the waste bin of her bedroom. The bath seat needs replacing in the upstairs bathroom the inspector was informed that a new bath seat was on order and the ground floor bathroom toilet leaks and the shower holder was broken. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 18 The lounge/dining area is a good size and adequate for the residents to enjoy the surroundings, including a large fish tank. A ramp is to be fitted to the patio doors of the lounge to enable the resident’s easy access to the garden. The inspector was informed that ramps are to be fitted to the outside patio doors of a resident’s bedroom, the resident is wheelchair, bound. It was noted that the fascia boards at the back of the house are peeling and in need of painting. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. Action must be taken to improve the staff training and recruitment procedures. EVIDENCE: The Registered manager stated and staff confirmed, that supervision of staff has taken place. However, on the day of the site visit the staff supervision records were not available the registered manager informed the inspector the staff supervision records were at her home. The staffing rota needs to include the position of staff post held. The current staffing levels are four staff on duty throughout the day undertakes the cleaning, cooking and laundry duties. A number of staff need up to date training, this should include all mandatory training, as well as more specialised training. Medication training for example, rectal diazepam needs to be undertaken as a priority for all staff. In the meantime those staff that have not received the relevant training must not undertake the administering of rectal diazepam. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 20 One member of staff is undertaking NVQ Level 4, two members of staff have completed NVQ Level 2 and another member of staff is to commence NVQ Level 2 this year. The inspector advised the registered manager to produce a training programme. It was noted that a member of staff’s personal records have been lost. Recruitment procedures need to be followed. All staff should have training qualifications and training certificates held on file as well as relevant documentation detailed in Schedule 2 of the Care Homes Regulations 2001. All staff should receive a copy of the General Social Council of Care, code of conduct document. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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, 40, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known, in their environment. Action must be taken to ensure that staff training promotes and protects the health, safety and welfare of residents. EVIDENCE: The manager has recently been registered by CSCI. Since being appointed as manager to the home a lot of work has been accomplished to ensure the home is meeting the required standards and regulations. The registered manager is currently undertaking the Registered Managers Award and should be completed by the end of April 2006. There is also a need for the registered manager to have updates to a number of other training courses. The overall responsibility of the registered manager must ensure the home complies with the Care Standards Act and Regulations 2001. As well as General Social Care Council codes of practice and other legal requirements. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 22 Management needs to introduce a monitoring system in place to measure success in achieving the aims and objectives and statement of purpose of the home. A number of records were observed, these include the accident book, fire records, training as well as health and safety records. There is a need to introduce a fire logbook and this should include a fire risk assessment on the whole building, room by room, and an emergency plan in the event of an emergency. On the day of the site visit the certificate for the testing for Legionella was not available. A copy to be available in the home for inspection at all times. A number of policies and procedures need updating and should be speciiific to 20 Hersham Road. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 2 3 2 X Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation 17 Requirement Policies and Procedures to be reviewed and should be specific to 20 Hersham Road. (Timescale of 09/12/05 not met). Care plans to be completed and updated. The keys must not be left in the door of resident’s lockable cabinet when medication or valuables are inside. (Previous recommendation). The shower holder in the down stairs bathroom is broken and needs replacing. The toilet in the downstairs bathroom leaks and needs urgent attention. The carpets in bedroom number 2 & 7 are badly stained they need cleaning or replacing. Waste bins in resident’s bedrooms to be emptied when bedroom not in use. All staff to receive a copy of General Social Council of Care, code of conduct document. Staff files to be updated and to include details as specified under DS0000013464.V289011.R01.S.doc Timescale for action 26/05/06 2 3 YA6 YA20 15 13 14/06/06 20/04/06 4 5 6 7 8 9 YA24 YA24 YA24 YA30 YA34 YA34 23 23 16 16 18 18 07/06/06 26/05/06 21/06/06 20/04/06 21/06/06 21/06/06 Hersham Road (20) Version 5.1 Page 25 10 YA35 18 11 12 13 14 YA35 YA42 YA42 YA42 17 13 13 16 Schedule 2 Care Homes Regulations 2001. Staff needs to undertake a number of training courses as well as mandatory training and updates to training. A training plan to be produced. To implement a fire risk assessment on the whole house. To implement a contingency plan in the event of an emergency situation. The temperature of the meat needs probing and must be regularly recorded. 07/07/06 07/07/06 26/05/06 26/05/06 20/04/06 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. 3. 4. 5. Refer to Standard YA1 YA18 YA22 YA33 YA42 Good Practice Recommendations The statement of purpose and service users guide to be updated. To contact an agency for an Advocate for two residents without family contact. Details of complaints and action taken to be held on file. The rota to include staff designated posts. Legionella Certificate to be available for inspection purposes. Hersham Road (20) DS0000013464.V289011.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hersham Road (20) DS0000013464.V289011.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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