Inspection on 30/11/07 for Horse Leaze (7)

This inspection was carried out on 30th November 2007.

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

Other inspections for this house

Horse Leaze (7) 25/05/06

Horse Leaze (7) 19/01/06

Horse Leaze (7) 29/07/05

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

CARE HOME ADULTS 18-65 Horse Leaze (7) 7 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 30 November 2007 2:00 th Horse Leaze (7) DS0000063910.V352029.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 Horse Leaze (7) DS0000063910.V352029.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. Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horse Leaze (7) Address 7 Horse Leaze Beckton London E6 6WJ 020 7473 1945 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) deborah.musuka@heritagecare.co.uk www.heritagecare.co.uk Heritage Care ** post vacant ** Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2007 Brief Description of the Service: 7 Horse Leaze is a care home for adults with mental health support needs. The home is operated by the Heritage Care organisation, which provides residential care services to a variety of service user groups across the region. The home is a single storey building located within a residential area of Beckton. There are bus routes and the Docklands Light Railway is accessible nearby. The home aims to provide a supportive environment within which service users can develop confidence, dignity and personal responsibility. Each service user has their own bedroom and access to communal lounge, dining, kitchen and bathroom facilities. The home has three male and three female service users in residence. The home is culturally reflective of the local community with service users from African Caribbean, Asian and White British backgrounds. Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector over the course of two half days. The Inspector had visited the service on several occasions previously, most recently in February 2007 to check on the progress with requirements made at a previous inspection in May 2006. During the course of the Inspection the Inspector spoke with the Officer in Charge, staff on duty and met privately with people who use the service. The Inspector also sampled a range of records relating to the running of the home including the personal files of people who use the service and personnel files. During the course of the inspection key National Minimum Standards were inspected. What the service does well: What has improved since the last inspection? Since the last inspection a range of minor repairs have been completed around the home, and some area’s have been redecorated. The bathing needs of the majority of service users have been assessed by an Occupational Therapist. The home maintains a record of all complaints along with the details of any investigation, action taken and outcome. Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 6 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. Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Evidence suggests that the home gathers relevant information relating to prospective service users. EVIDENCE: The Inspector sampled the personal files for two people who use the service. For one person it was evidenced that the home had carried out its own assessment prior to their moving in. However, for a second person that uses the service it was not evidenced that such an assessment had been completed. Documents on file did suggest that the home had consulted with the Community Mental Health Team as part of the referral process. Horse Leaze (7) DS0000063910.V352029.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has an individual plan and risk assessment. The plans include basic information and are not generally person centred. EVIDENCE: Sampling of the personal files of two people who use the service evidenced that the home had developed individual plans with each. For one person their plans were found to address their personal, social and healthcare needs and it was evidenced that these were reviewed at least every six months. For second resident significant gaps were found in their plans. For example, a plan addressing diet identified that they were diabetic, but there was no information in this or other plans that detailed how their diabetes was managed. In addition their plan addressing personal care identified that they Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 10 required “encouragement and prompting” to attend to their personal care, whilst a recent Occupational Therapy assessment identified that they needed actual assistance to use the shower. The Inspector noted that one residents individual plan contained some information relating to their life history, however individual plans for a second service user were not evidenced as being person centred or including any life story work. The Officer in Charge advised the Inspector that each person who uses the service has his or her own bank account. Some service users are independent in managing their finances, and others receive some support. One of the residents case tracked by the Inspector was identified in their plan as requiring support with finances. Each of the service users case tracked by the Inspector were evidenced as having risk assessments that related to their individual plans. Horse Leaze (7) DS0000063910.V352029.R01.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 & 27. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to maintain family and other personal relationships. They are supported to engage in activities of their choice and can access the local community. People who use the service participate in choosing the menu and enjoy the meals provided. EVIDENCE: The Officer in Charge advised the Inspector that until recently all residents had been involved in the Parkside Gardening project, but that unfortunately this resource had now closed. Both of the people who use the service who were case tracked by the Inspector are older people. One is able to access the community independently and on a daily basis visits either local shopping centres or friends in the community. A second person is able to visit local shops independently, which they do on a daily basis to collect local papers. As Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 12 a result of deteriorating eyesight this person has been assessed as requiring support to access the wider community. They had been supported in the past to attend a culturally specific day service but had decided not to continue with this. At present their wider community activity is limited to shopping trips with staff. However, during discussion with this service user they advised the Inspector that they were happy with their activities and did not wish to be supported to identify or engage with other activities. The homes residents are generally of a more mature age group, and all of those spoken with expressed their satisfaction at the activities that they are involved in. Inside the home a television, stereo and a range of DVDs and CDs are available for service users to access. In addition a bingo and quiz night are held every two to three weeks and an aroma therapist visits fortnightly. Each Thursday night residents choose a takeaway of their choice, and there is also an option for residents to have an evening meal out. The homes service users are culturally diverse, with Asian, African Caribbean and White British heritages being represented. This diversity is also reflected in the homes staff group. The individual plans sampled did contain information relating to residents religious needs. Whilst none are currently attending church, mosque or temple, one service user is supported in their religious observance of fasting each Friday. People who use the service have varying levels of contact with their families. Some have regular visits, while others have occasional phone or letter contact. The Officer in charge was able to advise the Inspector of what contact people who use the service have with their families and how home supports this. Discussion with people who use the service evidenced that they choose whom they see and when, and that they can see visitors in private. Discussion with people who use the service also evidenced that they choose when to be alone or in company, and when to join in an activity. During the course of the Inspectors visits to the home staff were observed sharing a meal with people who use the service and engaging them in conversation and in day to day decision making processes, such as items for the weekly shopping list. Discussion with people who use the service evidenced that each participates in the process of deciding which meals are produced, and that there is always an alternative to the main meal. Each of the service users spoken to by the Inspector said that they were satisfied with the meals provided. Horse Leaze (7) DS0000063910.V352029.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffs encourage people who use the service to be independent and take responsibility for their own personal care. People who use the service are registered with a GP, but are not supported to attend regular optician and dental appointments. Medication records are not up to date and in some instances medication practise is poor. EVIDENCE: Discussion with people who use the service evidenced that routines for getting up, going to bed, meals and other activities were flexible and based on the wishes of people who use the service. Sampling of the personal files for two people who use the service evidenced that they are registered with local GP’s. However for one service user only one record of a medical appointment for a cholesterol test was found for 2007. All other records related to medical appointments in 2006. For a second resident records evidencing several GP and hospital appointments in 2007 were found, Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 14 however there were no records to evidence that they had been supported to undertake annual dental or optician appointments. One person who uses the service was identified as self-medicating, and the Inspector sampled their individual plan and risk assessment. This evidenced that their individual plan did not identify that they are self medicating, however a risk assessment had been completed for this activity, but this was dated August 2005 with no evidence of subsequent review. The Inspector viewed the available medications for two people who use the service and compared these to the homes Medication Administration Record (MAR). The medication for one person is pre packed by the pharmacist into dossett style dispenser, and the available medication was found to correspond with the MAR chart. For a second service user a total of four medications stored in the medicine cupboard were not listed on the MAR. The Officer in Charge at the time of the inspection advised that at least two of the medications not listed were still being administered, and they were unclear why these had not been listed on the MAR. A third medication had only recently been prescribed, and its omission from the MAR sheet was unexplained. The Officer in Charge advised the Inspector that the fourth medication had been discontinued, however they were unable to produce any records or notes to support this. Horse Leaze (7) DS0000063910.V352029.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views. People who use the service feel well supported by staff. EVIDENCE: The home operates corporate Heritage Care Complaints and Safeguarding Adult’s policies and procedures. These have been sampled on previous inspections and been found to comply with National Minimum Standards. The Officer in Charge informed the Inspector that there had been no adult protection allegations since the previous inspection. The Inspector viewed the homes complaints log. This evidenced that the majority of complaints related to minor disagreements between people who use the service. A record of the nature of complaint, the investigation, action taken and outcome was recorded for each complaint made. People who use the service told the Inspector that they have good relations with staff and know how to make a complaint if there is anything they are unhappy about. At a previous inspection it had been identified that one person who uses the service is at risk of making malicious adult protection allegations against staff. The home had been required to address this potential risk in their individual Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 16 plan and risk assessment. Sampling of this resident’s personal file evidenced that this remains outstanding. Horse Leaze (7) DS0000063910.V352029.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has his or her own bedroom, and the home is generally a pleasant and comfortable place to live. However, the bath and shower room environments do not meet the needs of people who use the service, as they have not been adapted or suitable aids provided. EVIDENCE: The home occupies a semi-detached bungalow in a residential area. There is a large entrance hall with resident’s payphone, and a staff office, utility room and large bathroom with tub and hand basin are situated off this. There is a large “L” shaped lounge and dining room and these are comfortably furnished with sofas, armchairs and a dining table and chairs. The rooms are pleasantly decorated and there is a TV and stereo. Off the lounge there are Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 18 doors to a large conservatory that also has comfortable seating and a TV. The lawned garden can be accessed from this conservatory. Off the dining area there is a fitted kitchen with modern appliances. Three bedrooms and a WC are located off of a corridor from the lounge, and a further three bedrooms and a shower room with WC are located off of a corridor leading from the dining area. People who use the service have their own bedrooms that they are able to personalise with their own mementos and in some cases small items of furniture. The home was found to be clean and free from offensive odours. The home has been refurbished with laminate flooring throughout, and one person who uses the service told the Inspector that they found this slippery under foot. A previous inspection had noted that the large bathroom with tub was under utilised with the majority of residents using a small shower room. A restated requirement for an Occupational Therapist to assess the bathing needs of people who use the service was completed in April 2007. The assessments identified that four people who use the service were assessed as unsafe to use the existing bath and shower provision. A requirement to refurbish the bath and shower rooms in line with the Occupational Therapy assessment remains outstanding. Horse Leaze (7) DS0000063910.V352029.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 24, 25 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff numbers on duty to meet the needs of residents. Whilst staffs are supported to undertake NVQ training, it is not evidenced that they undertake regular refresher and update training or that they are regularly supervised. EVIDENCE: At the time of this inspection eight care staff, a deputy manager and part time manager are in post. Three care staff transferred to the home in 2007 following the closure of a different Heritage Care home and there is one vacant post covered by regular bank staff. Of the nine care staff six have obtained NVQ level 2, and four of these have gone on to complete NVQ level 3. During the course of the inspection staff were observed to be accessible to and approachable by people who use the service. The Inspector sampled the personnel records available on site for two staff members. Insufficient information was available for one staff member to Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 20 establish whether two satisfactory references and any gaps in the employment record had been explored, and whether they had been issued with copies of their terms and conditions of employment. For a second staff member it was evidenced that two satisfactory references had been obtained and that they had received a copy of their employment terms and conditions. Documentation on file evidenced that Heritage Care had obtained its own enhanced Criminal Records Bureau (CRB) check as part of its pre-employment checks. Training records available on the personnel file evidenced that one staff member had completed an induction upon joining the organisation. For both staff members the Inspector was unable to find evidence of their completing any training since 2005. The Inspector viewed the available supervision records for two staff members. These evidenced that one part time staff member had received two supervisions in 2007. For a second staff member there were no supervision records after 2005. Horse Leaze (7) DS0000063910.V352029.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home, however, inappropriate and inadequate bathing facilities continue to put the health and safety of people who use the service at risk. EVIDENCE: The home does not currently have a Registered Manager. An acting Manager has been appointed on a part time basis and a full time Deputy Manager is on site full time. Both have a minimum of two years management and supervisory experience within care home settings. At the last inspection the Acting Manager told the Inspector that they were studying for their NVQ level 4. Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 22 The Officer in Charge at the time of the inspection advised the Inspector that Heritage Care is developing a corporate quality assurance process but that since the last inspection the home had not formally obtained the views of people who use the service, their families or other stakeholders on the quality of the service provided. The Inspector sampled a range of records relating to the health and safety. These evidenced that fridge and freezer temperatures are recorded on a daily basis, however there were fifteen occasions in a four-week period when the fridge temperature was outside acceptable limits, with no record of action taken by staff to remedy this. Sampling of the homes water temperature records evidenced that these are checked on a weekly basis and are within acceptable limits. The home was also evidenced as maintaining appropriate accident and incident logs in accordance with relevant legislation. Weekly fire alarm tests were evidenced as being carried out, and an evacuation drill was conducted with residents in November 2006. The Inspector was concerned to note that Occupational Therapy bathing assessments carried out in April 2007 identified four people who use the service as having their health and safety put at risk by the inappropriate and inadequate bath and shower room facilities currently provided by the home. At the time of this inspection no remedial works had been undertaken or were scheduled by the home, and people who use the service continue to be at risk. These matters will now be subject to enforcement action by the Commission for Social Care Inspection. The Inspector noted that the insurance certificate displayed by the home was out of date. The Officer in Charge at the time of the inspection was not able to confirm that insurance was in place or locate a current insurance certificate. Horse Leaze (7) DS0000063910.V352029.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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 1 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 1 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 1 X X 1 2 Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 Requirement New service users must be admitted on the basis of a full assessment carried out by people competent to do so. Individual plans must address all aspects of personal, social and healthcare support. The home must ensure that the healthcare needs of people who use the service are assessed and recognised, and that procedures are in place to address them. Self-medication must be identified in the individual plan and be subject to regular review and risk assessment. Accurate records of the actual medicines being administered must be maintained. The home must evidence that medicines must be administered in accordance with their prescription. Where medicines are discontinued appropriate entries should be made in the service users records and the medicine Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 25 Timescale for action 30/04/08 2. 3. YA6 YA19 15 12 30/04/08 30/04/08 4. YA20 13 30/04/08 properly disposed of. 5. YA34 7, 9, 19 & Sch 2 A summary of information of the personnel information required by regulation must be completed and be available in the home for inspection. This is a restated requirement. Previous targets of the 31/03/06 and 31/08/06 were not met. The home must evidence that all staff complete a structured induction. This is a restated requirement. The previous target of the 30/09/06 was not met. The home must evidence that all staff receive a minimum of five days training each year. Staff must receive regular, recorded supervision at least six times per year. This is a restated requirement. The previous target of the 30/09/06 was not met. The Responsible Individual must ensure that the acting Manager commences the registration process with the Commission for Social Care Inspection. The Responsible Individual must ensure that requirements are progressed within specified timescales and any difficulties with compliance recorded. This is a restated requirement. Previous targets of the 31/03/06 and 31/08/06 were not met. The home must develop its Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 26 30/04/08 6. YA35 18 30/04/08 7. YA36 18 30/04/08 8. YA37 8&9 30/04/08 9. YA39 24 30/04/08 10. YA43 25 quality assurance process including obtaining feedback from service users, their representatives and other stakeholders. The results of this feedback should be published and made available to service users and other interested parties. The home must evidence that it has current insurance cover. 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Horse Leaze (7) DS0000063910.V352029.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Horse Leaze (7) DS0000063910.V352029.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. 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