Inspection on 28/11/05 for Kimberley Road (44)

This inspection was carried out on 28th November 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Kimberley Road (44) 01/05/07

Kimberley Road (44) 11/07/06

Kimberley Road (44) 31/01/06

Kimberley Road (44) 18/03/05

Kimberley Road (44) 19/10/04

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

CARE HOME ADULTS 18-65 Kimberley Road (44) 44 Kimberley Road Croydon Surrey CR0 2PU Lead Inspector Barry Khabbazi Unannounced Inspection 28th November 2005 9:30 Kimberley Road (44) DS0000028141.V269294.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 Kimberley Road (44) DS0000028141.V269294.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. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kimberley Road (44) Address 44 Kimberley Road Croydon Surrey CR0 2PU 020 8684 4188 020 8684 4188 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) Ms Kavita Goolaub Ms Kavita Goolaub Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users aged 65 or over to be accommodated for as long as the home can continue to meet all of their assessed needs. 18th March 2005 Date of last inspection Brief Description of the Service: Kimberley Road is a 3 bedded home for adults with a past or present mental illness. It is situated in a residential area, well placed for travel into the centre of Croydon with its wide selection of community facilities. The house forms part of a terrace, and is indistinguishable from any other house in the road. The stated philosophy of the home is to ‘provide a secure, stable and comfortable environment where individuality of care and maintenance of dignity is paramount’. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an un-announced inspection which occurred on 28/11/2005. There was only one resident receiving a service at the time of this inspection and that resident was met during the inspection. This resident had only positive comments to report to the inspector and these are reflected throughout the report. During the inspection the manager and staff were met. Records, policies and care plans, and the building were examined, as were the residents’ bedrooms. A few minor shortfalls were identified and no major concerns were identified. What the service does well: What has improved since the last inspection? The manager has now ensured that there is a member of staff in the house when any of the service users are at home unless it has been clearly documented that a specific resident may, as part of their individual development, spend short periods in the house alone. This will help to ensure that any service user left alone in the home is safe. Although a second reference is still required, the manager has ensured that all of the other staff vetting documentation has been acquired for all staff working in the home to ensure that appropriate staff are employed. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 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. Kimberley Road (44) DS0000028141.V269294.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 Kimberley Road (44) DS0000028141.V269294.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): 2 Prospective service users’ aspirations and needs are assessed before admission to ensure that the home knows these needs so that they can be met. EVIDENCE: The file of the only service user currently placed was examined at this inspection, and others were examined at the last announced inspection. At both inspections the files contained all of the assessment and pre admission documentation required under Standard 2. The files sampled contained assessments and care plans, and the home’s own extensive pre-admission assessments of need and comprehensive risk assessments. There was also evidence that the Registered Provider had also attended a variety of meetings that enabled both the home and the placing authority to establish that this was the correct placement for this service user. There is only one service user currently accommodated at the home out of a possible three service users. If the thorough pre admission practice seen for this service user proves consistent by new placements undergoing the same extensive procedures, good practice could be evidenced under Standard 2. Kimberley Road (44) DS0000028141.V269294.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): 6, 7, and 9. Residents’ assessed needs, changing needs and how the home meets these needs are not all fully recorded. This could affect the home’s ability to meet and show how it has met all a resident’s known and changing needs. Service users make decisions about their lives with support where needed. The service users are generally safely supported to take risks as a part of independent living. EVIDENCE: Files were sampled and care plans were available for all service users. These were all regularly reviewed and updated but they did not reflect all the elements required under Standard 6.2. which is listed under Standard 2. In particular social, educational, employment and religious and cultural needs were not included. The following requirement is set under Standard 6 to address this shortfall: A record of all of a service user’s needs {containing all the elements set out under Standard 2} and how they are to be met and by whom, must be recorded in plans of care. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 10 Although there was some limited evidence of statutory reviews occurring, there was no evidence of all of the home’s own six monthly reviews occurring. In addition the current service user placed is over 65 and falls into older people’s Standards. As it is considered that this group’s needs may change more rapidly due to the aging process, these Standards require monthly reviews. The following requirement is also set under Standard 6 to address this: Internal reviews must occur at least 6- monthly for those under 65, and monthly for those over 65 years old. The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through regular house meetings and individual discussions with their key workers. The current service user is more than capable of making their needs and wishes known, and they are encouraged to make their own decisions about their day-to-day activities, and their lives in general. This was demonstrated in discussions with the service user who raised a number of these issues during conversations. The service user described how satisfied he was with the placement – there was nothing he would like to change, he said he was happy at this home on a number of occasions and said there was nothing he needed, and he had no adverse comments to make. All service users look after their own financial affairs. Advocacy information is available in the home, no service user has to date expressed an interest in using these services. All service users have a range of external professionals from whom they can gain support. Risk is assessed prior to admission and continually updated. There are currently no restrictions of liberty practiced which are required for the protection of service users. The registered manager has completed risk assessments including an assessment of risk to service users while outside the home as required in previous inspections. Risk assessments in relation to the new service user are well documented including assessments undertaken by a consultant psychiatrist and the service user’s forensic social worker. The current risks are assessed to be low. Discussion with the Registered Provider evidenced that she is well versed in the process for monitoring this service user and of further engaging him with services should he become unwell. Kimberley Road (44) DS0000028141.V269294.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): 12, 13, 15, 16, and 17. Residents are part of the local community and are able to take part in appropriate activities to facilitate a fulfilling life. Residents are encouraged to have a healthy diet and support is provided where required. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised. The daily routines and house rules promote residents’ rights, to ensure equality and that all rights are enjoyed by all residents. EVIDENCE: The service user currently placed attends two day centres, a club, and has the opportunity to participate in activities of their choosing. This service user had attended evening classes previously. This service user was positive about the choice of activities that were available, and felt that they were sufficient although he did express a wish to now consider expanding these. Service users access the community independently and engage in activities of their choice. Information about local community resources is available and known to the home. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 12 The service user currently placed talked about going out to the theatre, meals out, clubs, and using the library. The service users are able to go out into the community unaccompanied if they so wish. They make good use of community facilities such as the local shops and library. The service user currently placed has their own front door key so that they can come and go as they please, and a key to their room. The service user currently placed is on the electoral register and has chosen to participate in the political process. Service users are well supported to maintain contact with friends and family. Previous service users have had a wide range of friends and family who have been made welcome in the home, and one service user had a boyfriend with whom she regularly visited. The service user currently placed confirmed that they can receive visitors. No restrictions on having visitors were noted during the inspection. The daily routines do promote independence. All service users are offered keys to the front door and their rooms. Service users can choose when to be alone or when to be in company. Service users have full unrestricted access to all communal parts of the home. Independence skills are promoted as a part of the care plan where required. Service users are fully supported to develop and maintain independence skills; A joint decision between the service users and staff resulted in the home being a smoke free zone. One service user smokes, and is happy to go outside for this purpose. The menu of the home was available for inspection and is recorded along with a record of food actually consumed. The service users are consulted as to their meal preferences and while a menu is drawn up it may frequently change. The service user currently placed did confirm this, said he liked the food at the home and that he had recently been planning the Christmas meal. A wide range of food is offered, this is usually a cooked lunch with a lighter meal for the evening. Where required support from dieticians was seen to have been sought by the home. A range of fresh fruit is also available. The home monitors weight as needed. Monthly records were available for the currently placed service user as his needs required this. This is coincidentally the frequency required under older people’s Standards which apply in this case. The manager was informed of this for future reference. Kimberley Road (44) DS0000028141.V269294.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, and 20. Residents’ personal support needs and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ currently self medicate with support from staff to ensure maximised good health. EVIDENCE: The service users are encouraged to be self-caring. Where required, guidance and support is given to service users to ensure that their personal care needs are met. All service users are able to shop for their own clothes. There are no specific times set for getting up/going to bed, meals or other activities. Personal care is not currently provided by the home or required by the service user accommodated. The service user met was content with the support received from staff. There are no service users currently requiring aids and adaptations although this need continues to be monitored. Inspection of the service users’ files confirmed that all are registered with a G.P. and all have been supported to gain access to NHS resources as required. Regular health checks are also offered and specific referrals are made as and when identified as needed. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 14 The currently placed service user attends their health appointments independently and manages their own medication. The Registered Provider maintains a list of all current medication. All service users have their own keys to their bedrooms so that they can keep their medication safely. A British National Formulary is available for guidance for staff. All staff who administer medication have had accredited training and additional in-house training. Further training is planed to enable all staff to administer medication for potential new service users that may require this. In addition, the manager is a registered nurse. Kimberley Road (44) DS0000028141.V269294.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 and 23. Complaints are generally managed well so that service users feel their views are listened to. The home’s policies and procedures relevant to this Standard generally facilitate protecting residents from abuse, neglect and self harm. EVIDENCE: No complaints have been made since the previous inspection. Discussion with the service user placed clarified that service users are familiar with the complaint procedure. The service user currently placed emphasised how good the home and that he was happy there. The home has a complaints procedure in place, which clearly states how complaints will be investigated, recorded and redressed. This procedure contained all the elements required under Standard 22, including a 28 day response time and details of how to contact the Commission. Records are kept of all complaints. The registered manager does not employ any permanent staff. She carries out most of the care duties, with assistance from her husband. The registered manager has attended the training in adult protection facilitated by Croydon Council and an appropriate in house policy has been written. The home has a copy of Croydon’s Vulnerable Adults Policy. All the policies relevant to this Standard were in place. These included the following: A restraints policy, an adult protection policy, a physical and verbal aggression policy, a whistle blowing policy, an access to files policy, and a gifts and wills policy. All the above policies were present and known to staff. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 16 The current restraints procedure is sufficient as only one service user is placed. This will however need to be expanded once additional placements are made. The specifics of this were raised with the manager, but as only one service user is currently placed and needs identified do not require a more complex policy, a requirement is currently not needed and has not been made at this time. This area will need to be re-examined once further placements are made. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 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, and 30. The environment is homely comfortable and safe, and the environment does promote the residents well being. The home is generally hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: The service user currently placed said that the extension to the lounge was the area he preferred to frequent, other than when he is spending time relaxing in his room. The home’s premises are accessible to the current service user group, in keeping with the local community, and are suitable for their purpose. The premises were generally clean, and well maintained. Records are maintained of all decoration and renewal. There was suitable domestic lighting and ventilation. At the time of the inspection the premises were furnished and in an appropriate style. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Laundry facilities have easily cleanable floors and easily cleanable walls. Kimberley Road (44) DS0000028141.V269294.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): 32, 33, 34, and 35. There are no staff employed to activate the staffing qualification standard. Staffing levels at the home have been previously assessed as sufficient to meet the low level of need assessed for this service user group. The home’s recruitment procedures generally protect the residents through vigorous staff vetting. Induction and foundation training programme within Sector Skills Council training specifications and timescales could not be assessed as there are currently no permanent staff employed other than the original providers. EVIDENCE: As the home does not have any staff Standard 32 and staffing qualifications does not apply. Twenty four hour staffing has been previously recorded as the agreed staffing level. Given the low support needs of the service users this staffing ratio was seen to be appropriate. This cover is provided by the Registered Provider and her husband. However, the last inspection report recorded the following under Standard 33: It was of considerable concern to find a service user alone in the house, with no clear idea when a member of staff would return, or where they had gone. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 19 Once it was possible to contact the manager this was discussed in length. A requirement has been made to the effect that there must be a member of staff in the house when any of the service users are at home unless it has been clearly documented in the relevant service user plan that a specific resident may, as part of their individual development, spend short periods in the house alone. The following requirement was then set: The manager must ensure that there is a member of staff in the house when any of the service users are at home unless it has been clearly documented in the relevant service user plan that a specific resident may, as part of their individual development, spend short periods in the house alone. By the time of this inspection appropriate medical advice had been acquired in writing to confirm that it was seen as appropriate for the current service user placed to be left alone for short periods. In addition the service user in question was aware of who would be coming in on this occasion and when. The previous requirement is currently met. The last inspection report contained a requirement under Standard 34, for the manager ensure that she obtain the necessary documentation from staff (irrespective of whether they are relatives), including references and proof of identification. In particular the brother-in-law of the manager needed to supply proof of identification and references. This person had been identified to cover the provider’s holiday and is not recruited to a permanent post. At the time of this visit one of the references required and proof of identification had been obtained. The manager is still waiting for a second reference. This requirement has, therefore, been only partially met and will remain in force until fully met. Standard 35, An Induction and foundation training programme within Sector Skills Council training specifications and timescales could not be assessed as there are currently no permanent staff employed other than the original providers. This standard will be examined when and if permanent staff are employed. Kimberley Road (44) DS0000028141.V269294.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): 37, 39, and 42. Service users benefit from a well run home. Although there is a quality assurance system there is no annual development plan that provides service users with inclusion in developments in the home, and a way for them to measure improvements in quality for themselves. The health and safety, and welfare of the residents is generally promoted and protected. EVIDENCE: There was a clear line of accountability within the home and the owner/manager demonstrated a good knowledge of resident. The owner/manager has managed this home since 2000, she is a Registered Nurse. The Registered Provider has commenced her studies of the Registered Manager’s award. The Registered Provider is also fully involved in the Partnership Board, which is a forum of homes in the Local Authority that access training and share experience and good practice. The Registered Provider has used this forum to develop her skills, knowledge and practice. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 21 There is a quality assurance system, although this does not fully involve service users. The quality assurance tools include the complaints system, service user meetings, one to one discussions, user satisfaction surveys, audits and inspections. There was an annual development plan but this did not have any service user input as user satisfaction surveys do not include questions that could be used for this purpose. The annual development plan contained only business plans for the future. This process needs to facilitate obtaining improvements required that are relevant to the service users and to allow the service users concerns to be included in development and improving quality. The following recommendation is set under Standard 39 to address this: The home’s quality assurance system needs to involve the service users and make them central to the process. To achieve this the home should expand the user/relatives satisfaction surveys to include those ‘quality’ related service users’ views that could contribute and possibly be included in the annual development plan. Control Of Substances Hazardous to Health policies were observed and these substances were all locked away. Risk assessments covering safe working practices were present. All of the health and safety policies and procedures relevant to this Standard were seen to be present. All of the procedures and testing of systems required in Standard 42 were also present, except the record of regular tank testing to control the risks of Legionella and an up to date gas safety certificate. The following requirement is set to address this under Standard 42: The water supply bacterial analysis testing results and the gas safety certificate must be sent into the Commission. Kimberley Road (44) DS0000028141.V269294.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 x 3 x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x N/a 3 3 N/a 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kimberley Road (44) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x DS0000028141.V269294.R01.S.doc Version 5.0 Page 23 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 34 Regulation 19 Requirement The manager must ensure that she has full documentation (as listed in the Regulations) with regard to all staff who work in the home. {This has been partially met but remains not fully met since March 2005.}. Internal reviews must occur at least 6- monthly for those under 65, and monthly for those over 65 years old. A record of all of a service user’s needs {containing all the elements set out under standard 2} and how they are to be met and by whom, must be recorded in plans of care. The water supply bacterial analysis testing results and the gas safety certificate must be sent into the Commission. Timescale for action 15/12/05 2 6 15[2]b 15/12/05 3 6 15 15/02/06 4 42 12 15/01/06 Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 24 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 39 Good Practice Recommendations The home’s quality assurance system needs to involve the service users and make them central to the process. To achieve this the home should expand the user/relatives satisfaction surveys to include those ‘quality’ related service users’ views that could contribute and possibly be included in the to the annual development plan. Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Kimberley Road (44) DS0000028141.V269294.R01.S.doc Version 5.0 Page 26 - 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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