Inspection on 25/07/06 for Laverstoke Gardens

This inspection was carried out on 25th July 2006.

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

Other inspections for this house

Laverstoke Gardens 01/12/05

Laverstoke Gardens 07/07/05

Laverstoke Gardens 28/12/04

Laverstoke Gardens 20/05/04

Laverstoke Gardens 08/01/04

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 Laverstoke Gardens 49 Laverstoke Gardens London SW15 4JB Lead Inspector Davina McLaverty Unannounced Inspection 25th July 2006 10:30 Laverstoke Gardens DS0000010205.V305421.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 Laverstoke Gardens DS0000010205.V305421.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. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laverstoke Gardens Address 49 Laverstoke Gardens London SW15 4JB 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) 020 8246 6824 020 8788 9382 The Frances Taylor Foundation Ms Barbara Pauline Curley Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: 49 Laverstoke Gardens is a care home for seven adults with a learning disability. The service is located in a quiet residential road in Roehampton close to local shops and transport links. The home is a two-storey purpose built building. All the bedrooms are single, one of which is on the ground floor and wheelchair accessible. The home is run by The Frances Taylor Foundation. A copy of the last inspection report is displayed in the home. The fees per week are between £838.19 - £974.04 Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 25th July 2006, and was conducted by one regulation inspector. The inspector met all seven residents, the manager and four support staff and one visiting relative. A number of records were examined, which included residents care plans, medication records, staff and residents meeting minutes, health and safety and staff records. A tour of the premises took place. Verbal communication with several of the residents was difficult due to the level of their learning disability. However, the inspector spoke at some length with three residents who were all very positive. One resident described the home as “special” as the staff are kind and considerate, take good care of everyone and that there is a nice relaxed atmosphere. Another said that they liked the home and the staff who are all nice. Another resident said that the food is very good and that you always have a choice. All residents seen appeared appropriately dressed, relaxed and at home. Prior to the inspection taking place, questionnaires were sent out by the Commission to all seven residents, six health and social care professionals, and six relatives. Nine questionnaires were returned, six from relatives, one from health care professional and two from residents. All comments received were very positive regarding the home and the care received. Some of these comments are reflected throughout the report. What the service does well: The home is well managed and the manager provides good leadership and is well respected by staff and residents. The home continues to provide high standards of care using a person centred approach. Residents are enabled to participate in their local community setting and are supported in taking up fulfilling and appropriate activities. Resident’s health and social needs are well met and there is good liaison with health and social care professionals as well as with relatives who feel included in their relatives care. The environment is attractive, clean and homely and bedrooms are very well personalised which residents and relatives input into. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 6 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. Laverstoke Gardens DS0000010205.V305421.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 Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 4 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. Prospective resident representatives will have information they need to make an informed choice about the home and its suitability for a prospective resident. An organisational assessment procedure is in place. Details of assessments were seen on resident’s files. EVIDENCE: A Statement of Purpose is in place, which contains information about the organisation and describes the care offered at the home. The document along with the Service users guide enables the resident or their representative to make an informed choice regarding the suitability of the home. However, both documents require updating. The manager said that the organisation will address this once permanent staff are in place. Several of the residents have lived in the home for many years; four files were examined and assessment documentation was seen on all four files. The Francis Taylor Foundation admission procedure encourages several visits to the home for the prospective resident and their representatives. The manager is aware of her role in the assessment and evidence of her involvement was seen on the file of the newest resident. Laverstoke Gardens DS0000010205.V305421.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. Care Plans are good and include clear goals to provide staff with the information they need to satisfactorily meet resident’s needs. Residents continue to be encouraged to make decisions about their lives with support from the staff and where goals have been identified they are specific to the individual. Risk taking is acknowledged by staff as part of developing an independent life and individual assessments are carried out to support this. EVIDENCE: Care documentation for two residents were examined. The files were seen to contain up – to date and comprehensive information about the residents and their needs. They all contained goals that had as far as possible been discussed with the resident and their key workers. Reviews and evaluation was on – going, although the manager reported that as a result of illness and staff changes there had been some slippages in getting care plans up to date which she was in the process of addressing. Person Centred Planning (PCP) profiles were additionally seen to be completed and these included good information such as individual likes/dislikes and preferences for food. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 10 General and individual risk assessments were seen but again several required updating. The requirement made at the previous inspection has been repeated. The home operates a key worker system, which endeavours to promote continuity of care. The residents spoken with were aware of who their key worker was and staff spoken to had good knowledge of their key residents. The manager and staff were seen to be supportive and sensitive to residents throughout the inspection visit. Care staff work to a high standard to ensure residents receive the care they need. Three residents who were spoken to individually, each reported that they were satisfied with the overall service provided. Relatives in their questionnaires all reported that they felt that the home met their relatives individual needs with comments being made such as “We think the home is highly suitable for our daughter”,” It is reassuring to know that 49 Laverstoke is run by caring and professional staff who help our daughter to live and achieve a good quality of life”, and “my sister’s care needs are met in every way physically, socially and spiritually. This is an ideal placement for her”. . Laverstoke Gardens DS0000010205.V305421.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 & 17 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. This home continues to maintain good links with the community, which enriches resident’s lives. The home provides a very good environment for them to develop their social skills as far as they are able. Staff continue to encourage and support residents to be as independent as possible. Individual dietary needs are well catered for. EVIDENCE: There is a range of television, video and music equipment for residents use in the communal lounge area. Residents spoken with stated that they also had their own televisions and radios in their rooms, which the inspector saw. Art and craft materials as well as some games are also available in the home. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 12 Dependency levels varied within the home with three residents attending a day centre Monday to Friday with the others involved in activities of their choice, one of who works. The home has its own transport enabling unplanned trips to take place. Regular trips occur and records showed recent trips to Barnes Wetland Centre, Kew Gardens, Richmond Park, as well as to pubs and local parks. The homes annual barbeque was planned for the 19/08/06 to which relatives and friends were invited. Family members are encouraged to visit and residents reported that their relatives can visit at any time and that they can also go to visit relatives. One resident received a visit from friends from their previous placement. The manager said that they encourage and support residents to maintain relationships. Relatives had nothing but praise for the staff in the home who facilitated some visits, which would otherwise not take place. Comments received included “The home is very good I can see my daughter at any timeShe is well looked after and she is very happy”, “I am always made welcome”, and “I find the staff very friendly and take time to talk to you”, “my sister is encouraged to phone and to send Christmas/birthday cards etc”. As already stated one resident works and is able to go out to known places on their own. This resident wants to move onto more independent accommodation, which is being considered with the person and social services. Two staff members reported that all residents are encouraged to get involve in the preparation of meals, and domestic chores, as they are able. Goals relating to these tasks were seen to be in resident’s files and residents spoken to confirmed that they are encouraged in these practical areas. The menu showed that residents are offered a good range of foods. Staff reported that most meals are prepared from fresh and that healthy eating is encouraged. Residents spoken with stated how much they enjoyed the food. One resident told the inspector that the food is good and that there was always a choice. Staff were observed to treat residents with respect. For example, staff were seen to get down to eye level to talk to two residents in wheelchairs. One staff spoke of knowing the residents who cannot communicate so well from their facial and body language and spoke warmly of their love for the job. Laverstoke Gardens DS0000010205.V305421.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. Residents receive personal support, which meets their physical and emotional needs. Health needs are addressed with evidence of good multi-disciplinarary working taking place. EVIDENCE: Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. Where possible residents are supported and helped to be independent and responsible for their own personal hygiene and personal care. Evidence was seen in the care plans examined of input from health care professionals including: GPs, hospital consultants, dieticians and social workers. Personal aids and equipment are available and well maintained to support both residents and staff in daily living. No concerns were raised from the health care questionnaire received. It was stated, “Individual Care Needs met very well”. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 14 A medication policy is in place at the home and the medication cabinet was locked at the time of the inspection. Storage in the cabinet was appropriate with all medication being labelled with clear instructions as to its administration. A fridge is available for medication, which requires cold storage, and daily temperatures are taken. Medication records seen contained no errors. Two staff members sign when medication is administered. All staff receive training in the administration of medication. The residents GP had agreed an agreed list of homely remedies, which could be used. Laverstoke Gardens DS0000010205.V305421.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. An appropriate written procedure is available, as well as a pictorial one, which is displayed on the notice board. Organisational policies and procedures are in place to protect residents from abuse. EVIDENCE: A complaints policy is in place, it is available in makaton if required. The manager stated that there had been no formal complaints received since the last inspection. No questionnaires received raised any issue regarding people knowing how to complain or being listened to. Relatives said that they would speak to staff or to the manager if they had concerns or complaints regarding the home. Throughout the day no issues were raised regarding the staff and care received at the home by residents. Residents had nothing but praise for the staff employed. Through discussion with residents, visitors and staff the inspector formed the view that the home has an open culture, which enables residents to express their views, and concerns in a safe and non-blame environment. As Stated residents spoken to had nothing but positive comments about the home and care/support receive. One resident said that they feel very safe and well supported by the organisation that has their protection and safety as a priority. Policies and procedures are in place for the protection of vulnerable adults. A copy of the local authority procedure is available in the home. Two staff spoken to were aware of the Protection of Vulnerable Adults Procedures as well as Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 16 whistle blowing. Training of staff in the area of protection is regularly arranged by the home. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 & 30 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. The home was seen to be well maintained. Bedrooms and communal areas were furnished to a high standard. The home was found to be clean on the day of the inspection. EVIDENCE: The home provides comfortable and well maintained accommodation to the residents who live there. Bedrooms were seen to be personalised. Some rooms had fittings and fixtures, which meet the current needs of the individuals and can be changed as their needs change. There is limited choice of communal space for residents as there is a large open plan kitchen/dining room and a large lounge area. The manager reported that no agreement has been made regarding the conversion of the garage space into an activities room or a conservatory being added which would provide more space, which would benefit residents and could be utilised for a number of purposes. Serious consideration should be given to the above as either would enhance the environment for the residents and provide more Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 18 choice and privacy for residents particularly when entertaining friends/relatives. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are sufficient in numbers. Bathrooms were seen to be relaxing places for residents as a lot of thought had gone into the decoration of these rooms. A large well maintained garden, with a patio area is available at the back, which was well used on the day of the inspection. Lunch for some residents was taken outside. Residents said that during the summer extensive use is made of the garden. Appropriate garden furniture was available. The home was found to be was clean and tidy on the day of the inspection. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34 & 35 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. The training provided helps to ensure that a well-informed staff group supports residents. Recruitment checks seen evidence that all the required checks had been carried out. Staff meetings and staff supervision must to be carried out regularly. EVIDENCE: The Acting Manager reported that the home would be advertising for a permanent manager, as well as a senior support staff. The home operates with three staff per shift (this includes the manager). At night there is one waking night and one staff asleep but on call. The manager stated that in her view staffing levels were adequate, although at times shifts can be busy but staff were aware of the importance of team working and in her view the current staff team worked well together. Staff described the manager as “hands on”. The inspector spoke to three support staff who varied in length of service within the home. All were very positive about the support and care given to residents. Comments included “ We look after our residents very well”, “ the care and support here is very good” and “team work is good”. These comments were reflected in comments received during the inspection from the residents and in all the questionnaires received. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 20 Four staff files were examined and were found to contain appropriate information regarding the checks carried out prior to starting in the home. The manager however, was in the process of adding staff training records and supervision records to these files. The manager was also in the process of updating all staff core training and records were available to evidence this. Staff spoken to were all positive about training. The majority of staff had completed their NVQ in Care Qualification and all staff spoke positively of the training offered by the organisation. Staff meetings and individual supervision takes place but records seen evidence that they were not taking place as regularly as they should. The manager was aware of this and stated that she was in the process of addressing it. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 &42 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. A quality assurance system is in place. Systems are in place to ensure the health and safety of residents and staff. EVIDENCE: Since the last inspection there has been a change of managers within the home. The acting manager due to ill health resigned and the previous registered manager returned full time in May 2006 on a temporary basis until a new manager is appointed. The manager reported that she is in the process of updating systems within the home which due to staff shortages have not been updated as regularly as required The home currently employs 14 staff 8 full - time and two part time and uses their own bank staff. The organisation is restructuring staffing within the home and will be deleting the deputy post and employing a further senior staff making three seniors in total. The home currently has a senior staff vacancy, Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 22 which has been advertised. The Commission must be kept informed as to the recruitment of a permanent manager for the home. Staff spoken with were very positive about the home although they acknowledged the difficult time they had been through with staff sickness. However, they remained positive regarding the plans for the future. All three staff spoke positively of the manager who they and residents welcomed back to the home. They described her as “very thorough”, “approachable”, and “hands on” with “high standards, who led by example”. Regulation 26 monthly visit take place and copies of these visits are forwarded to the Commission as well as a copy being retained in the home. A quality assurance system is in place, which seeks the views of residents, relatives and other stakeholders. Questionnaires are sent out annually on return, collated and necessary changes made. However, those seen were not dated making it difficult to know if they were current. The manager said that a date could easily be added to the form. Residents meetings should take place more frequently within the home. Records showed that staff make regular checks on the building and equipment in the home and that the health, safety and welfare of residents are promoted and protected. Sample records seen included the fire system, water temperatures, fridge and freezer temperature, gas and the electrical periodic inspection report, as well as the portable electrical appliance tests. All records seen were in order. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 12 (1) 13 (4) Requirement The Registered Persons must ensure that the risk assessments in place for individual residents are subject to a documented review process and are updated as necessary. (Timescale of the 01/02/06 not fully met) The Registered Persons must ensure that all staff receive regularly supervision. The Registered Person must ensure that the forms used as part of the organisational quality assurance system are dated. Timescale for action 01/10/06 2 YA33 18(1)(2) 24 and 35(a) 01/09/06 3. YA39 01/10/06 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 YA24 Good Practice Recommendations It is recommended that the provision of a conservatory to the rear of the property be seriously considered by the DS0000010205.V305421.R01.S.doc Version 5.2 Page 25 Laverstoke Gardens organisation. 2 3. YA33 YA39 Staff meetings should take place more frequently to ensure that issues raised are followed up and the outcomes reported back to the staff team. Residents meetings should be more frequent to ensure that issues raised are fooled up and reported back. Matters arising should be discussed within the staff meetings to ensure follow through. Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Laverstoke Gardens DS0000010205.V305421.R01.S.doc Version 5.2 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. 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!