Inspection on 12/07/06 for Jesmond

This inspection was carried out on 12th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jesmond 27/04/07

Jesmond 28/02/06

Jesmond 01/08/05

Jesmond 29/09/04

Jesmond 21/06/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Jesmond 23 Jesmond Close Merton Mitcham Surrey CR4 1EQ Lead Inspector Davina McLaverty Unannounced Inspection 12th July 2006 10:00 Jesmond DS0000027210.V303737.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 Jesmond DS0000027210.V303737.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. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jesmond Address 23 Jesmond Close Merton Mitcham Surrey CR4 1EQ 0208 646 8319 0208 646 8319 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) www.thresholdsupport.org.uk Threshold Housing & Support Ms Valerie Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five Adults (M/F) with Learning Disabilities Date of last inspection 28th February 2006 Brief Description of the Service: Jesmond is a care home providing residential care and accommodation for residents with learning disabilities. The home is owned by Threshold Housing and Support and is located close to shops, pubs and other amenities. It is a three-storey domestic style property. All accommodation is provided in single rooms. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. At the time of this inspection the manager reported that the weekly fees were £869.19 per week. Additional charges are made for some outings and holidays. Residents are made aware of the inspection report at the residents meeting. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 12th June 2006 and was conducted by one regulation inspector over 7 hours. The inspector met all five residents, the manager, and two support staff. A number of records were examined, which included residents support plans, medication records, staff and residents meeting minutes, health and safety and staff records. A tour of the communal areas of the home took place and three residents bedrooms. Prior to the inspection taking place, questionnaires were sent out by the Commission to six health and social care professionals, four relatives and five care managers. Three questionnaires were returned from health care professionals, who did not raise any concerns. Two relatives questionnaires were received and their comments are reflected in the report. Three residents were spoken to about life at the home. Comments from residents included “Its alright here”, “ the staff are good” and “the foods good”. The atmosphere at the home was relaxed with residents helping themselves to drinks as and when they wanted one. What the service does well: What has improved since the last inspection? What they could do better: Support plans could be improved in order to be more individualised and reflect the social and emotional needs of residents. This information could be used to review the activities currently provided for residents. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 6 Each staff member must have a training profile, which clearly evidence when mandatory training has been provided, with dates. This must include refresher courses. It was not clear from the training record seen that this is being addressed. Evidence of all staff details must be available in the home. This must also include bank/agency. 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. Jesmond DS0000027210.V303737.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 Jesmond DS0000027210.V303737.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Prospective residents representatives do not have current information they need to make an informed choice about the home and its suitability for a prospective resident. An organisational assessment procedure is in place. EVIDENCE: The acting manager is aware that the Statement of Purpose and Service User Guide needs to be updated; highlighting changes within the staff team and organisation. Neither document could be located at the time of the inspection although at the last inspection both documents were seen. A copy of revised documents must be submitted to the Commission. Consideration must be given to the format of the guides in particular the Service User Guide, in view of the level of learning disability, which the home supports. At the time of the last inspection a new resident had moved in and it was sought that they did not meet the registration category. A requirement was made for a variation to be requested. However, on receipt of documentation this was found not to be required and the requirement was rescinded. Since that inspection no new residents have been admitted. The manager is fully aware of the importance of carrying out his own information on receiving referrals. Threshold Housing and Support has an adequate referral and assessment policy in place, which includes visits to the home and overnight stays. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 9 Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 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, & 9 Quality in this outcome group is adequate. This judgment has been made using available evidence including a visit to this service Support plans are in place but require updating. Residents are involved in making decisions about their lives and offered appropriate support. Individual risk assessments were in but require review and updating. EVIDENCE: At the previous inspection the inspector was informed that the organisation is introducing a new care planning system, which is more person centred. To date this has not occurred although the manager said that staff are due to receive training in the new system. Two support plans were examined only minor changes were seen since the last inspection and requirements at the inspection have been repeated. Support plans seen identified goals and included resident’s strengths and weaknesses but did not give a clear picture of residents needs. Evidence of residents involvement in their support plans was lacking. The same applied to Risk assessments, which had not significantly progressed since the last two inspections and must be seen as a priority. In discussion with the manager, he acknowledged that these areas needed to be Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 11 improved upon and staff were aware that files needed to be updated and the information better organised. The home must also ensure that all the information detailed in Schedule 3 of the Care Homes Regulations is available for each resident. On one of the files examined there was no photograph and very little personal information in it e.g. emergency details. The home operates a key worker system and two of the three residents spoken with were aware of who their key worker was and their role. Residents are consulted about how the home is run and meet as a group on a regular basis. Minutes of these meetings were seen. Both the manager and the staff spoken to demonstrated a good knowledge of the residents’ individual needs and a commitment to supporting residents to lead a life which makes them happy and fulfilled. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 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): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents participate in activities within the home and the community. Resident’s dietary needs are catered for. Residents confirmed that they retain contact with family and friends. EVIDENCE: Residents continue to participate in a variety of activities both inside and outside of the home. Residents are encouraged to pursue individual activities such as keep fit, horse riding, and supporting their football team. On the day of the inspection, one resident spoke to the inspector about their love of films. The same resident also spoke of their job in the cinema, which they enjoyed. This resident leads a fairly active life and said that he enjoyed living at Jesmond as he got to do what he wanted as well as trying new things e.g. going to the gym. This resident said that he enjoyed the gym and as a result of going and changing his diet he had lost quite a bit of weight, which was good. Another resident said that they enjoyed singing alongside their karaoke Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 13 machine as well as watching their favourite television programmes in the evenings. Resident’s day care packages varied and are individualised which is good. The staff are looking how best to expand activities which residents are involved in. Holidays are encouraged and four of the five residents were due to go to Cornwall for a caravan holiday on Saturday. Three of the residents were clearly very excited about this trip; two had finished their packing! Two residents spoke of their visitors to the home, which they said staff encouraged and that they could entertain them in their rooms if they chose to. One resident spoke of their visits to family functions, which he enjoyed. One relative in their questionnaire reported that the home provides “ excellent care for their relative”. Another said that “staff are always friendly and the place is always kept clean and tidy”. The same relative however said that they would like to see more consistency in the following areas personal hygiene, toenails and fingernails need supervision. Also cleanliness in washing of sheets. This was raised with the manager who was aware of these issues and reported that the resident had seen a chiropodist privately due to lengthy waiting lists. In regards to the other issues raised this is on –going and is being addressed with by the residents key worker. The lounge was seen to be equipped with television and music equipment though residents were seen to have their own equipment in their bedrooms. Daily living skills continue to be encouraged with residents being supported to do more for themselves and to acquire new skills. Two of the residents spoke positively about what they could do. A copy of the menu was seen which appeared, varied and nutritionally balanced. Individual cooking takes place, as well as one resident cooking for the others. Residents have their own shelves in the fridge to keep their own food supplies. Healthy eating is encouraged within the home. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 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 & 20 Quality in this area is adequate. This judgment has been made using available evidence including a visit to this service. Personal support is offered in a way that promotes and protects service users privacy, dignity and independence. Systems are also in place for the safe administration of medication. EVIDENCE: Evidence was seen in the care plans of multi- disciplinary input from health care professionals including GP’s, social workers, opticians and dentists. One resident spoke of being supported by staff to attend health appointments. Residents are able to carry out their own personal care although on occasions staff may support residents with the washing of their hair or verbally encourage residents to carry out personal care tasks adequately. All five residents are responsible for choosing their own clothes daily. A medication policy is in place, which addresses the receipt storage and handling of medication. A sample of staff signatures was also seen. Two of the residents currently self medicate. One of who collects his own medication from the pharmacy. The other resident dispenses her own medication into a dosette box each week and has responsibility for taking it, which is monitored by staff. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 15 Adequate risk assessments in respect of both these residents were still outstanding and the requirement made at the previous inspection has been restated. The inspector also noted that PRN medication for one resident had been given on the 10th June as it was recorded on the back of the Medication Administration Record (MAR) sheet but not on the MAR sheet itself. The allergy section on the MAR sheets must also be completed. If none is known then this must be recorded. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is good. This judgment has been made using available evidence including a visit to this service. Policies and procedures are in place to help protect service users from abuse and harm. The local authority is contacted when a Protection of Vulnerable adults issues arises. EVIDENCE: The manager reported that no formal complaints had been received since the last inspection. The three residents spoken to all stated that they were happy living at the home and had no complaints. All also said that they would talk to staff or their family if they were not happy. A copy of the organisation’s adult protection policy is available to staff as well as the organisation’s whistle blowing policy. The staff member spoken to was aware of both policies and would take appropriate action if the need arose. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27 28 & 30 Quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. The premises continue to be homely, however, attention must be given to decorating in particular, the lounge. The carpets on the stairway and in the lounge will require replacing in the near future. EVIDENCE: A homely atmosphere was apparent however; attention needs to be given to the decorations and curtains particularly in the lounge area. The three residents spoken with were clearly happy with their rooms, all of which were of a good size. All were personalised with some pictures, equipment chosen by the residents themselves. Consideration must be given to decorating and replacing some of the furniture, as one room was seen to be an inappropriate colour for the resident in another room seen, one of the dressing table drawers was broken. This was seen to be the case at the last inspection. The manager reported that the drawer had been repaired but had broken again. The chest of drawers must be replaced as a matter of urgency. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 18 Residents said that they had the keys to the house and to their bedrooms. Residents are encouraged to lock their bedrooms. Bathrooms seen were functional but could be more homely if some thought is given to them. Adequate communal space is available. The lounge is large as is the kitchen/diner. The lounge opens out onto a large garden, which was well attended to. One of the residents mowed the lawn during the inspection. The manager said that he felt that the garden was underused and he and his staff team are encouraging residents to sit out during the warmer weather rather than go to their rooms or stay in the lounge area. Outdoor furniture is available. The home was seen to be adequately clean on the day of the inspection. A separate laundry room is available with a locked cupboard where COSHH materials are stored. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are able to support residents in meeting their needs, however, staff records were incomplete making it difficult to know that residents are protected. Training records must be maintained. EVIDENCE: Staff were seen to interact appropriately with the residents and two residents spoke positively of all the staff. All three confirmed that staff would knock on their doors and wait to be asked to come in. The inspector was informed that there are usually two staff on duty during the day when all residents are at home. At weekend two staff are rostered 7.00am –10.00pm. Staff spoken to felt that there were sufficient staff to cover each shift however, due to the behaviour of one resident this is currently being reviewed. Staff spoke positively of the organisations training and said that they are encouraged to obtain their NVQ Care qualification. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 20 Threshold Housing and Support has an adequate recruitment policy. However, evidence of the checks carried out on staff were not available in the home, therefore the inspector could not be satisfied that the residents are protected. Written evidence that all checks carried out in Schedule 2 of the Care Home regulations must be available in the home. This must also include bank and agency staff. This requirement was made at the previous inspection and has been repeated. The manager was in the process of updating all staff core training and records were available to evidence this. The home must ensure that their induction programme addresses all areas detailed in the Skills for Care training set. Evidence was seen on two files examined of supervision taking place, however, this must be carried out regularly and a minimum of six sessions must take place a year. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. A new manager is in post that has a good understanding of the resident’s needs and how he would like to develop the service provided. Appropriate Health and Safety systems are in place to ensure the safety and welfare of the residents however, these systems must be effectively monitored. EVIDENCE: The manager started working in the home in October 2005. He stated that his application to be registered as the manager has been submitted to the Commission. All staff spoken to were very positive in regards to his management style, stating that they felt that the manager wanted them to become more involved and welcomed any ideas. The manager reported that the organisation has a quality assurance system in place but it was not clear how resident’s views, relatives and stakeholder’s views were being sought. Residents meetings were seen to be taking place. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 22 Regulation 26, visits reports are still not being forwarded to the Commission. Failure to comply is in breach of the regulation. The requirement made at the previous inspection has been repeated. Health and Safety systems are in place, although the manager must ensure that regular checks are carried out to ensure that the system is working. At the time of the inspection the testing of the alarms had not taken place weekly. The last recorded test was the 29th June. The inspector requested that a test be carried out immediately and the system was found to be satisfactory. The hot water temperature checks again exceeded the recommended 43 degrees but no risk assessments were seen in respect of the residents being safe. Fridge and freezer temperatures are taken daily and these records seen were satisfactory. Jesmond DS0000027210.V303737.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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 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 YA1 Regulation 4(1) (1)& 5(1) (2) Requirement The Registered Person must ensure that there is a current Statement of Purpose and Service User Guide available in the home. Copies of both documents must be forwarded to the Commission. The Registered Person must ensure that care plans are reviewed and updated (Timescale of the 30/08/05 & 30/04/06 not met). The Registered Person must ensure that risk assessments are updated. (Timescale of the 30/08/05 & 15/04/06 not fully met) The Registered Person must ensure that when PRN medication is administered that the Medication Administration Record Sheet is signed. Timescale for action 30/09/06 2. YA6 15(1) (2) 30/09/06 3. YA9 13(4) 30/09/06 4 YA20 13(2) 12/09/06 5. YA20 13(2) The Registered Person must 15/09/06 ensure that where residents self medicate the risk assessment is in sufficient detail to identify how the risks has been minimised. DS0000027210.V303737.R01.S.doc Version 5.2 Page 25 Jesmond (Timescale of the 15/08/05 & 15/04/06 not met). 6 YA24 23(2) (b) The Registered Person must ensure that the hallway and stair carpets are replaced. The carpet in the lounge requires cleaning. The Registered Person must ensure that the lounge is redecorated The Registered Person must audit resident’s bedrooms and devise a maintenance plan, as some of the bedrooms seen required decorating. The Registered Person must ensure that broken drawer in one of the residents rooms is replaced or repaired The Registered Person The Registered Persons must ensure that individual staff record are maintained as per requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation as to all checks carried out on agency staff. The Registered Person must ensure that all staff has a training plan, which includes evidence of when core training was attended. The Registered Persons must ensure that all new staff receive induction training to national ‘Skills for Care’ specification. Full records must be maintained to evidence this. 12. YA39 26 The Registered Person must ensure that monthly visits are completed and that a copy of the written report is kept in the home as well as sent to the Commission. (Timescale of the DS0000027210.V303737.R01.S.doc 15/12/06 7 8 YA24 YA26 23 (2) (b) 23 30/11/06 30/12/06 9 YA26 16(2) (c) 30/09/06 10 YA34 19(1) (b) 30/09/06 11. YA35 18(1)(c) 30/09/06 30/09/06 Jesmond Version 5.2 Page 26 30/08/05 & 30/04/06 not met) 13 YA42 42 The Registered Persons must 30/08/06 ensure that systems in place to monitor health and safety within the home are overseen to ensure that regular checks are taking place. 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 YA33 Refer to Standard Good Practice Recommendations The Registered Persons should keep staffing levels under review. Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Jesmond DS0000027210.V303737.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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