Inspection on 30/01/07 for Kynaston Care(80)

This inspection was carried out on 30th January 2007.

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

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

Other inspections for this house

Kynaston Care(80) 04/08/09

Kynaston Care(80) 01/10/07

Kynaston Care(80) 15/12/05

Kynaston Care(80) 29/07/05

Kynaston Care(80) 13/01/05

Kynaston Care(80) 05/07/04

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 Kynaston Care(80) 80 Kynaston Avenue Thornton Heath Croydon Surrey CR7 7BW Lead Inspector James Pitts Key Unannounced Inspection 30th January 2007 10:30a Kynaston Care(80) DS0000025805.V328022.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 Kynaston Care(80) DS0000025805.V328022.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. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kynaston Care(80) Address 80 Kynaston Avenue Thornton Heath Croydon Surrey CR7 7BW 0208 665 4798 F/P 0208 665 4798 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) Mrs Efilidah Smith Mr Alan Ernest Smith Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user over the age of 65 years to be accommodated subject to: (1) A minimum annual review of the service user’s health needs (2) All staff having the necessary skills and training to meet the service user’s needs (3) Should the service user become too physically or mentally frail and/or require nursing care, they will need to move to alternative accommodation. 15th December 2005 Date of last inspection Brief Description of the Service: 80 Kynaston Avenue is registered to provide support to three young adults with learning disabilities with a variation granted to allow one person over the age of 65years to live there. The home is owned and managed by Mr and Mrs Smith and is run as a small family type service. Located in a quiet residential area in Thornton Heath, there are accessible transport links within easy reach, including buses and trains. There is a ground floor bedroom and two bedrooms on the first floor with a staff sleep in room situated in a loft extension. Communal areas include a lounge, kitchen / dining area, bathroom / toilet and a good size garden available to the service users. Kynaston Care(80) DS0000025805.V328022.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 a Tuesday morning although all but one of the service users was out at the time. Questionnaires were left for the service users to complete at a later date if they wish too, and the service user who was present appeared content at the home. Aspects of professional management of the home do still require significant improvement. The manager has previously been required to improve on a number of staff and home management areas and has clearly had significant difficulty in doing so. In order to verify any progress that had been made since the unannounced inspection in June 2006, this visit was pre arranged with the home. It is surprising that the manager was not therefore present and had not been in contact with the Commission to say that he would not be available at this inspection. The Commission cannot permit continued failures in these areas as this seriously undermines and threatens the currently positive direct care experience of the service users. What the service does well: What has improved since the last inspection? What they could do better: The main failures at the home continue to revolve around the generally poor standard of management, not only in applying safe systems and procedures for medication recording, but also in supporting and supervising staff. The need for training and development of the manager is still the significant risk factor that could undermine the positive aspects of direct care that are in evidence. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kynaston Care(80) DS0000025805.V328022.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 Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standard 2 was assessed as being met at the previous key standards inspection and as no new service users have come to live at the home since that time this standard could not be assessed at this visit. This standard will not be assessed again until such time as any new service users come to live at the home. As the home have not been previously identified as having failed in the assessment and admission of service users it is appropriate that the home receives a “good” rating. EVIDENCE: Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 6, 7 & 9 were assessed at this inspection. The service users can feel confident that staff generally know what they need. The home has a keyworker system to further support this work. The service users can be assured that the staff will try their best to make sure that each person who lives at the home is allowed to live the sort of life that they choose. The only continuing risk to this happening well is that management aspects of the home, if not improved, could undermine the effectiveness of care planning for service users. EVIDENCE: A keyworker system is in operation at the home. A keyworker is a member of staff who especially makes sure that individual service users are being supported in the right way. Keyworkers have the primary responsibility for keeping care plans and risk assessments up to date and at this inspection it was seen that this continues to occur. All three service user’s care plans were Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 10 looked at in detail and these show that the preferences and needs of service users are given the proper consideration. One recommended area for improvement is that for two service users who are not able to read, their care plans should be presented in a more accessible way. This would allow these people to have a more in depth knowledge of their care plan should they wish to see what it contains. The home compiles a risk assessment for each of the service users. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff are still very good at doing this about very particular needs for each of the people who live here. Each of the service users has an updated risk assessment that was written in the last year. These are then reviewed every two months although rarely are changes required to be made. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16 & 17 were assessed at this inspection. The service users can feel confident that the opportunity for each to develop and maintain their preferred lifestyle as well as personal and family relations is supported by the staff team. EVIDENCE: The service users are supported by the staff to be as independent as possible and to make as many choices as they can. All of the service users are engaged in activities of their choosing each week and, due in part to the ages of the people who live here, they each have a very settled routine and chosen lifestyle. All of the people who live here are very independent and all more than able to make meaningful choices about how each wishes to live their life. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 12 The staff encourage continuing service user contact with their families and friends. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office. The menus, backed up by comments that have been made in previous inspections, still need to more properly reflect the meals that service users have. The menu is a weekly rotation that does not necessarily provide the accurate picture of the meals that are offered and chosen by service users each week. Records must be kept to evidence what food is provided for service users and show how their choices are respected. All staff involved with food preparation must still be trained in essential health & safety courses i.e. food hygiene practices. Food stocks were looked at and there was a plentiful and varied amount of fresh, refrigerated and frozen food available. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20 were assessed at this inspection. Service users can feel confident that they will get the right support to take care of their physical and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get support to make sure that this happens, however staff need to improve upon the procedures for signing the medication records. EVIDENCE: Each service user has a care plan that tells the staff about the way that each service users wants to be cared for and supported and about what each person likes or does not like. The care plans do indicate the particular degree and type of support that each person needs to manage their personal care. All of the people who live at the home usually go to see a local GP if they are not feeling well. The service users can see any local GP but most see the same one that the staff know very well and get along with. The staff are good at writing down anything that happens if anyone becomes unwell. If any of the Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 14 service users have an illness or something else is wrong with them then the staff do know what this is and how to help them to get the treatment that they need. Two of the service users need to take medicine every day and the staff are very good at making sure that this happens so that they can stay well. The fact that staff have to control these medicines has been previously agreed with the service users placing authorities. The staff are also good at making sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away. Medication training for staff could not be verified and the deputy manager stated that she had attended training g but to her knowledge no one else had. Another area of concern is that the medication charts have the initials of the member of staff who is expected to be on duty pre written onto the medication charts. A tick is then placed next to the initials once the medication is given. This is not acceptable as this would not necessarily mean that the medication has been given by the same person whose initials appear on the chart (as both staff on duty on the day of this inspection were actually not rotered to be). The person who actually administers the medication must be the person who initials the medication chart to confirm that the medication has been given. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 22 & 23 were assessed at this inspection. The service users can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. No complaints have been made to the home or to the Commission since the previous inspection. The staff team are effective at making sure that all of the service users are protected from abuse (this means that the staff at the home do everything that they can to stop any of the service users from being hurt by someone else). None of the service users have said that they are being hurt by anyone else. No concerns have been raised by anyone else who has contact with the home. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 24 & 30 were assessed at this inspection. The service users can feel confident that they are living in a well maintained and clean home. EVIDENCE: None of the fire doors in the home were seen to be wedged open, which had been the case at the time of the previous inspection. Staff record hot water temperature checks and there is sufficient hot water throughout the house, which had not previously been the case. The house is kept very clean, is a warm and comfortable environment and is free of any unpleasant odours. A service user allowed their bedroom to be seen Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 17 and it was furnished appropriately and reflected the preferences of this person in how their room should look. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Standards 32, 33, 34, 35 & 36 were assessed at this inspection. Service users cannot feel confident that there is a well trained staff team or that staffing is managed in an appropriate way. The quality of the support that is offered by the staff team could be compromised if staff are also not supervised in an adequate way. EVIDENCE: The law says that half of the staff must have a proper qualification to work with adults who need support in a care home. The name of this qualification is NVQ 2. It could not be confirmed at this inspection whether any progress has been made with ensuring that at least 50 of the staff team have this qualification, as was required at the previous inspection. This must be addressed without further delay. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 19 There have been no new staff come to work at the home since the previous inspection. As this is the case the previous requirements regarding CRB checks for new staff being taken up prior to their starting work at the home could not be assessed at this inspection. The requirement that was made previously will remain in force until such time as any new staff are employed and the home’s compliance can then be assessed. The two recommendations that were also previously made in respect of staff references and induction will also remain in this report for the same reason that no new staff have since been employed at the home. The staff names appear on a rota, however, this is clearly not accurate as the two staff on duty on the day of this inspection were actually supposed to be off duty. The rota also does not show the hours that staff are on duty, which must be added. Duty rotas must at all times accurately show not only who is on duty but also the hours that they work. Staff appraisal, and training / development plans were not in evidence on the two care staff personnel files that were seen. Staff performance must be assessed at least annually and this must then lead to appropriate ongoing training and development of their skills. The home employs only four people, one being the manager, one being the deputy manager and two care staff. Staff supervision (this is a time that each member of staff spends talking about how they are getting along in their work) is done by the deputy, who is then supposed to be supervised by the manager. Staff are supposed to meet with their direct line manager at least 6 times a year by law. The home cannot show that this is happening as one of the care staff has had no recorded supervision and the other has only had one since the previous inspection in June of last year. Staff must be supervised at appropriate intervals to support the professional nature of the work that they are required to undertake with the service users. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Standards 37, 39 & 42 were assessed at this inspection. Service users cannot feel confident that there have been sufficient improvements to the skills and experience of the manager’s ability to operate the service. EVIDENCE: There is still some concern over Mr Smith’s ability to run the home as he has limited experience in the care profession and of working with people who have learning disabilities. Mr Smith also demonstrated a lack of knowledge about the home during a meeting held at the local Commission office in March of last year. I.e. he was unable to identify the registration category for the home or explain how he would undertake an assessment of a new service user’s needs. In order to meet the needs of the service users and the home’s stated Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 21 purpose, Mr Smith must still develop his skills and knowledge further to demonstrate competency to manage this home. He also needs to demonstrate a better understanding of the National Minimum Standards and Care Homes Regulations in order to fulfil his roles and responsibilities as home manager. The provider has previously been required to submit a plan of training that outlines how these issues will be addressed, and yet this has not been done. As the registered manager, he is aware of the requirement to complete the NVQ level 4 management qualification to comply with current National Minimum Standards and Regulations. Mr Smith has still not been able to provide evidence to the Commission that he has met this requirement. Although there is some evidence that service users have been asked about their views of the home, this has not lead to any form of adequate quality assurance system. This must be established and encompass the views of service users, their family / friends (where appropriate), care managers of placing authorities and other professionals who have regular involvement with the home. The homes fire and most other safety procedures and tests at the home are all up to date, with the exception that a gas safety and legionellosis testing certificates could not be located. A copy of the most recent gas safety certificate and legionellosis test must be sent to the local Commission office. Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 1 X 1 X X 2 x Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 17(2) sch.4 13 Requirement Records must be kept to evidence what food is provided for service users and show how their choices are respected. (The previous timescale of 31/07/06 was not complied with). All staff involved with food preparation must be trained in essential health & safety courses i.e. food hygiene practices. (The previous timescale of 30/09/06 was not complied with). Timescale for action 28/02/07 2. YA17 18(1)(a)(c) 28/02/07 3. YA20 18(1a&c)19(5b) The registered provider must 28/02/07 ensure that all staff attend accredited medication training. ( The previous timescales of 30/11/05 & 30/09/06 have not been complied with from last two inspections.) 13 (2) The person who actually administers the medication must be the person who initials the medication chart to confirm that the DS0000025805.V328022.R01.S.doc 4. YA20 30/01/07 Kynaston Care(80) Version 5.2 Page 24 medication has been given. 5. YA32 19 (5) (b) More care staff need to 28/02/07 obtain the NVQ2 qualification to meet the required standard of 50 of care staff trained in the home. (The previous timescale of 30/09/06 was not complied with). 28/02/07 6. YA33 17 (2) Schedule Duty rotas must at all times 4(6e&7) accurately show not only who is on duty but also the hours that they work. 7. YA34 17(2)19(1)(b,c) The registered provider must 30/04/07 ensure that they obtain an up to date CRB and POVA check for all new staff before they commence employment. Staff must not work unsupervised until such time that a valid CRB and POVA clearance has been received. 18 (1) ( c ) (i) & (ii) 30/04/07 Staff appraisal, and training / development plans were not in evidence on the two care staff personnel files that were seen. Staff performance must be assessed at least annually and this must then lead to appropriate ongoing training and development of their skills. Staff must be supervised at appropriate intervals to support the professional nature of the work that they are required to undertake with the service users. 30/04/07 8. YA35 9. YA36 18 (2) 10. YA37 9(b)(i)& (c)(i) Evidence must be sent to the 28/02/07 Commission that the DS0000025805.V328022.R01.S.doc Version 5.2 Page 25 Kynaston Care(80) registered manager has enrolled on an NVQ level 4 management course. (The previous timescale of 31/08/06 was not complied with). 11. YA37 9(2 b)(i) The registered manager 28/02/07 must develop his skills and knowledge further in order to meet the needs of the service users and the home’s stated purpose. Evidence must be sent to the Commission on how this will be addressed. (The previous timescale of 31/08/06 was not complied with). The registered manager must demonstrate that he has a better understanding of the National Minimum Standards and Care Homes Regulations. Evidence must be sent to the Commission on how this will be addressed. (The previous timescale of 30/09/06 was not complied with). 28/02/07 12. YA37 9(1)(2 b)(i) 13. YA39 24 (1) & (2) all parts 30/04/07 An appropriate quality assurance system must be established and encompass the views of service users, their family / friends (where appropriate), care managers of placing authorities and other professionals who have regular involvement with the home. A copy of the most recent gas safety certificate and legionellosis test must be sent to the local Commission office. If these checks have not occurred in the last 28/02/07 14. YA42 23 (2) ( c ) Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 26 twelve months then updated checks must be carried out without delay. 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 YA34 Good Practice Recommendations The request form for employment references should be improved to determine more fully their suitability and fitness to work. The provider is referred to the amended schedule 2 of the care homes regulations. New staff should sign on completion of each step of their induction process. For two service users who are not able to read, their care plans should be presented in a more accessible way. 2. 3. YA35 YA6 Kynaston Care(80) DS0000025805.V328022.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kynaston Care(80) DS0000025805.V328022.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!