Inspection on 22/09/05 for Kairos Community Trust

This inspection was carried out on 22nd September 2005.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kairos Community Trust 04/01/07

Kairos Community Trust 03/02/06

Kairos Community Trust 01/03/05

Kairos Community Trust 02/11/04

Kairos Community Trust 12/03/04

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Kairos Community Trust 59, Bethwin Road London SE5 0XT Lead Inspector Lisa Wilde Unannounced Inspection 22nd September 2005 11:00 Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kairos Community Trust Address 59, Bethwin Road London SE5 0XT 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) 0207 701 8130 0207 701 8130 Kairos Community Trust Mr Maurice Lyons Care Home 16 Category(ies) of Past or present alcohol dependence (16) registration, with number of places Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: The Kairos Community Trust rehabilitation centre sited at 59 Bethwin Road provides a therapeutic programme for individuals with support needs related to alcohol/drug dependency who have completed a detoxification programme. The programme is of 12 weeks duration after which service users move on to alternative accommodation. Service users commit to the programme by signing a contract, which includes regular attendance at counselling and daily attendance at group meetings at which personal weekly objectives are agreed. The service is based in a detached house over three floors and is located close to community facilities. The home has a stair-lift, which is not currently needed for present service users, but which is maintained should the need arise. The service is accessible via public transport. A number of bus routes run within walking distance of the home with Underground and train stations sited slightly further away. Accommodation at the home consists of seven double and two single bedrooms. There are a number of communal areas on the ground and second floors and a patio to the rear of the building. Toilet/bathrooms are located on each floor. The home operates the Minnesota method of treatment based on the twelve steps of alcoholics/narcotics anonymous. A care plan is devised between service users and staff by the end of their second week at the service and is subsequently reviewed half way through what is a three-month programme. Links are maintained with service users when they leave the service and they are able, if appropriate, to move on to supported housing, which is run by Kairos Community Trust. The contract, which all service users must agree to upon admission, makes it explicit that the use of alcohol or mood altering drugs is not tolerated. The staff team consists of a Team Manager, four full time staff, two part time staff and two volunteers. A cook is employed to cook regular main meals but service users participate in this and a range of household activities. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in September 2005 with the deputy manager, staff and service users. The inspector examined files, toured the building and spoke with the manager following the inspection. Service users at this home were highly appreciative of the service and support they were offered. Different service users said “This is a system that operates on trust, I feel trusted so it works better than other places”, “I’ve learned more here in three weeks than I have in any other programme”, “The staff are great, I don’t want to leave”, “Staff are really supportive and caring but they don’t let you get away with anything” and “This place is fantastic, I have no problems and I’m really getting help.” Most of the standards that were assessed at this inspection were met with the home showing again that it consistently offers a very high standard of support and treatment. What the service does well: From the standards assessed at this inspection the home showed that: • potential service users are provided with all the information they need to decide whether to take part in this programme and current service users are provided with information about what they can expect from the service and what is expected of them. • potential service users are offered appropriate opportunities to visit the home and speak with service users and staff before they choose to begin the programme. • service users are supported and encouraged to take responsibility and make decisions about their lives while at the home. • service users are supported to take reasonable risks. Risks are identified with service users prior to them coming to the home and then on a regular basis throughout their stay. • service users know that information about them will be held within the home’s confidentiality policy by staff and service users. • service users are free to maintain their lives outside of the programme and are supported to establish effective links with the community into which they will be moving when they leave the home. • there is significant emphasis on rights and responsibilities throughout the programme and service user behaviour or choice is only limited as part of individual risk management programmes or as part of the established boundaries of the home. • service users are offered a healthy nutritious diet based around their choices, which they all take part in preparing for the group. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 6 • • • • • • • • service users receive support to maintain their self-care programmes on an individual basis and have their healthcare needs met by linking into community service such as GPs and clinics. generally service users are protected by the home’s medication policies and procedures as service users who take prescribed medication are not allowed to self-medicate while at the home. the home is comfortable and homely and suitable for the needs of the service user group. staff are comprehensively trained in the core statutory areas and the specialist needs of the service users group. generally the recruitment procedure is robust and effective. the manager of the home is clear and effective whilst supportive and inclusive. the health and safety of the service users is protected by how staff operate the policies and procedures in the home. the business planning and financial management of the home means that service users benefit from effective and open management of the home. 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. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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&4 Potential service users are provided with all the information they need to decide whether to take part in this programme. Current service users are provided with information about what they can expect from the service and what is expected of them. Potential service users are offered appropriate opportunities to visit the home and speak with service users and staff before they choose to begin the programme. EVIDENCE: The brochure now needs to be revised to include details of changes to key personnel within the organisation. (See Requirement 1) The deputy manager discussed the process by which someone is introduced to the programme. Although it is not appropriate for someone to visit for an overnight stay prior to them beginning the programme, potential service users who have undergone a successful assessment, are invited to look around the home and speak with service users and staff over lunch. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Service users are supported and encouraged to take responsibility and make decisions about their lives while at the home, within a framework of boundaries necessary for the safety of service users and staff and to enable service users to focus on their issues around their recovery. Service users are supported to take reasonable risks. Risks are identified with service users prior to them coming to the home and then on a regular basis throughout their stay. Action plans are in place to manage and minimise any identified risks. Service users know that information about them will be held within the home’s confidentiality policy by staff and service users which means that they feel safe to share their experiences and feelings as necessary within the programme. EVIDENCE: There was a previous requirement that the registered manager must ensure that the home’s policy of not allowing service users complete control of administration of their medication is included in each service users individual plan as a limitation applied by the home. Examples of plans were seen and this information is now included in them. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 10 There was a previous requirement that the registered manager must review the home’s policy on management of risk to include a system or process for carrying out in house risk assessments and reviews which meet the requirements of National Minimum Standard 9 and regulation 13, and ensure that staff receive training in this as part of the homes training programme. One member of staff has recently attended risk assessment training and has shared this information with the team. The deputy manager has extensive experience of and training in risk assessment. New staff observe risk assessments undertaken by permanent staff. Staff said that they felt entirely comfortable assessing the risks involved with working with this service user group and devising appropriate action plans to manage or minimise those risks within the framework of the programme. Evidence from files showed that risk are documented and reviewed effectively. All confidential information is held in locked cabinets in the staff office, which is locked when staff are not using it. The confidentiality and information sharing policies are explained to service users when they begin the programme and then regularly throughout their weekly groups. Service users said that they understood the boundaries in place around information that they share within the programme and trusted that staff would maintain their confidentiality absolutely. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 16 & 17 The focus of this service is to enable service users to successfully undertake and complete the twelve-step programme and as such the emphasis is not on additional activities such as personal development or community participation. Service users are free to maintain their lives outside of the programme and are supported to establish effective links with the community into which they will be moving when they leave the home. There is significant emphasis on rights and responsibilities throughout the programme and service user behaviour or choice is only limited as part of individual risk management programmes or as part of the established boundaries of the home. Service users are offered a healthy, nutritious diet based around their choices, which they all take part in preparing for the group. EVIDENCE: Service users are expected to attend all groups during the week and take part in all rota’d activities and chore sharing. They are asked not to go out alone on Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 12 the first day of attending the programme but following this they are free to come and go as they please and undertake what activities they choose. There is significant focus on rights and responsibilities throughout the programme at this home. There are certain boundaries in place including that all prescription medication must be taken as directed, all groups must be attended, service users must be home by 12 midnight, visitors are allowed up to 9pm but not upstairs, service users must agree to be breathalysed and have urine tests, there should be no intimate relationships within the house, no smoking in non-designated areas and the Code of Conduct must be adhered to. Service users said that the boundaries are not too intrusive and they understand and agree with the need for them. These boundaries are in place in order for service users to be able to focus on the issues around their recovery and to maintain safety within the home. Evidence gathered during the inspection indicated that service users are offered a healthy diet and that they enjoy meals and mealtimes at the service. The inspector was invited to share a lunchtime meal and the food was well presented, tasty and nutritional with choice available. Discussions with service users indicated that they have ample opportunity to decide on menus and are involved in shopping and cooking. A cook is employed to provide many main mid-day meals but a rota is devised to involve all service users in preparing lunch and evening meals through the course of the week. The residents forum is used to decide what individuals would like to eat and to allocate responsibility for buying fresh produce. In addition to main meals a range of snacks and drinks are available to service users at all times. Specific nutritional needs are assessed via the home’s GP who is also able to refer for specialist assessments. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users receive support to maintain their self-care programmes on an individual basis and have their healthcare needs met by linking into community service such as GPs and clinics. Generally service users are protected by the home’s medication policies and procedures as service users who take prescribed medication are not allowed to self-medicate while at the home. There are certain areas where the medication systems of the home could be improved to make sure that medication is stored and administered safely. EVIDENCE: Generally service users do not need physical assistance with personal care although staff do offer support and prompting to enable people to maintain any treatment plans around self-care. One service user talked about how they had been supported through illness, built up their weight appropriately and felt significantly better. Service users are appropriately linked in with local services such as GPs and clinics for healthcare support. The deputy manager has responsibility for monitoring the administration of medication. Staff dispense/prompt and encourage service users to self medicate at the appropriate times. A risk assessment is undertaken for each service user on their ability to self-medicate. Service users’ consent to Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 14 medication is obtained and recorded in the individual care plans. A record of the current levels of medication is also maintained in care plans. Medication is stored in a locked secure cabinet. The home also seeks regular advice from the pharmacist who supplies the medication and who visits the home on a frequent basis. On inspecting the stock of medication the inspector found that there was medication in bottle without labels that was waiting to be returned to the chemist and no record is currently kept of homely remedies held in the home. There was not list maintained of all staff who are trained and assessed as able to administer medication including sample signatures of those staff and there were no photos of service users held in the medication files. (See Requirements 2, 3, 4 & 5) Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 EVIDENCE: There was a previous requirement that the registered manager must ensure that all current service users are advised of the detail of the home’s complaints policy and given a copy of it special attention is paid to explaining this policy to all new service users. Service users are now asked to sign statements saying they have had the complaint procedure explained to them. Service users told the inspector that they knew how to complain and felt that their complaints were listened to and acted o where possible. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 16 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, 28. 29 & 30 The home is comfortable and homely and suitable for the needs of the service user group. The home is not wheelchair accessible but there is a stair lift should someone need it. There is no additional specialist equipment, as service users at this home do not have any specialist physical needs. On the day of the inspection the home was clean and hygienic. EVIDENCE: There are seven double rooms in the home and one single. Service users are expected to share rooms as a means of encouraging openness and challenge as part of the programme. The single room is available to ensure that women are never expected to share with men. Service users said that they found this system to be helpful to them as previously some of them had been prone to secrecy because of their substance issues and sharing a room meant that they had someone to talk to about issues at the home. Although there are requirements within the standards that 80 of rooms be single rooms by 2008, this would defeat the aim and purpose of the programme within this home. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 17 The communal areas are comfortable and suitable for the numbers of service users the home. The home was clean and hygienic on the day of this inspection. Service users at this home do not need specialist equipment as they are fully able but there is a stairlift available should someone need it. The home is not wheelchair accessible currently and there has not been an assessment undertaken under the Disability Discrimination Act. (See Recommendation 1) Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 18 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): 31, 34 & 35 Volunteers’ job descriptions are misleading in certain areas, which means that they are not benefiting from absolute clarity with regard to their roles and responsibilities. Staff are comprehensively trained in the core statutory areas and the specialist needs of the service users group, which means that service users receive support from an effective staff team. Generally the recruitment procedure is robust and effective which means that service users are protected however the home is not receiving back all required checks before staff start employment which means that there is one area of potential risk. EVIDENCE: The inspector saw the job descriptions for the volunteer housekeeper and found it to be misleading in some areas. The deputy manager was not certain that the other volunteer used had a job description (one was not on file). (See Requirement 6). There is a student counsellor at the home who is completing their hours to be registered. There is a volunteer policy that is appropriate and which states that no volunteers will be used to substitute for the work of paid staff. The inspector was concerned that currently the student counsellor may be being used to undertake work that should be undertaken by permanent members of staff as per the organisational policy. (See Requirement 7) Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 19 There was a previous recommendation that the registered manager to provide a formal record for staff as to who is responsible for on call management support out of office hours. This has been done. Staff are fully trained in both the core statutory training such as fire safety and first aid and the specialist needs of the service users group. The deputy manager holds diplomas in addiction counselling, humanistic integrative counselling and clinical supervision. Training needs of staff are identified during supervisions. One member of staff and one volunteer have been recruited and started working at the home without receiving back an enhanced CRB check and without undertaking the POVAFirst check. (See Requirement 8) There was a previous recommendation that the registered manager should give consideration to employing more female staff when next recruiting staff, to reflect a gender balance between the composition of staff and service users. Two of the female service users said that they had not difficulty working with male staff. The organisation aims to provide balance within their recruitment but currently still has more male than female staff, although this is always the case with the service users group as well. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 20 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): 38, 42 & 43 Staff said that the manager of the home is clear and effective while supportive and inclusive. This means that service users are benefiting from a staff team that is consistent in its approach and knowledgeable about the ethos and management approach of the home. The health and safety of the service users is protected by how staff operate the policies and procedures in the home. There is one area of slight risk with regard to the weekly fire checks. The business planning and financial management of the home means that service users benefit from effective and open management of the home. EVIDENCE: Staff said that the manager has a sense of humour and he is caring and supportive. Decisions are made as a team and the yare not railroaded, even though he is clear about his management approach and requirements. The health and safety records were checked and found to be in order apart from the weekly fire checks, which had not been recorded since 28/08/05. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 21 There were no health and safety issues found on the tour of the building. (See Requirement 9) There is a business plan in place that identified annual goals for the service. An external accountant audits the finances and business accounts of the organisation. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 2 X X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kairos Community Trust Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X 3 X X X 2 3 DS0000007078.V251995.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 24 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 5 Requirement Timescale for action 31/12/05 2 YA20 13 (2) 3 YA20 13 (2) 4 YA20 13 (2) 5 YA20 13 (2) 6 YA31 18 (1) (a) 7 YA31 18 (1)(a) 8 YA35 Kairos Community Trust 19(1)(b)& Schedule 2 The Registered Individuals must ensure that the Service User Guide is revised to include the personnel changes within the organisation and home. The Registered Manager must 31/10/05 ensure that all medication due to be returned to the chemist is stored in appropriately labelled containers. The Registered Manager must 31/10/05 ensure that a record is maintained in the home of any homely remedies that are held and dispensed. The Registered Manager must 31/10/05 ensure that a list is maintained of all staff who are trained and assessed as able to administer and dispense medication, including samples of their initials or signatures. The Registered Manager must 31/10/05 ensure that photos of service users are held on their medication files. The Registered Individuals must 30/11/05 ensure that all job descriptions for volunteers at the home are revised and made clear in all aspects including jobs to be undertaken and any remuneration to which they may be entitled. The Registered Individuals must 30/11/05 ensure that volunteers’ duties’ are clear to all staff and that volunteers are used only in accordance with the volunteer policy. The Registered Manager must 29/09/05 ensure that all staff for whom DS0000007078.V251995.R01.S.doc Version 5.0 Page 25 the organisation has not received an enhanced CRB check undergo the POVAFirst check, pending 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 Refer to Standard YA29 Good Practice Recommendations The Registered Individuals should consider conducting an assessment of the building with relation to the Disability Discrimination Act, section 3 and complying with any recommendations from such an assessment. Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Kairos Community Trust DS0000007078.V251995.R01.S.doc Version 5.0 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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