Inspection on 20/12/05 for Leigham Lodge

This inspection was carried out on 20th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leigham Lodge 18/02/08

Leigham Lodge 02/06/06

Leigham Lodge 16/05/05

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 Leigham Lodge 64 Leigham Court Road Streatham London SW16 2EL Lead Inspector Ms Rehema Russell Unannounced Inspection 20th December 2005 09:00 DS0000044234.V269127.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 DS0000044234.V269127.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. DS0000044234.V269127.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leigham Lodge Address 64 Leigham Court Road Streatham London SW16 2EL 01491 579 270 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) DeniseDoggett@beaconcaregroup.co.uk Leigham Lodge Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000044234.V269127.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Leigham Lodge was registered on 31st December 2004 to provide care and accommodation to six people with learning disabilities with challenging behaviour/autism. It is owned by Beacon Care, a private company, which has other local and national homes. The home is a two storey semi-detached building entered via an electronically operated gate with entry phone. There is limited room for parking on the forecourt inside the front gate and there is a medium sized garden at the rear. On-street parking is available in nearby roads. The home is located on a bus route and within 5-10 minutes walk from a large shopping centre with full community facilities and bus and rail routes into central London and out to the coast. The home also has its own car for individual transport. Inside, the ground floor has two en-suite bedrooms, two lounges, a bathroom with toilet, a dining room and a kitchen. Upstairs there are four bedrooms, three of which are en-suite, a bathroom with toilet, a double laundry cupboard and a small office. DS0000044234.V269127.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the day in late December 2005. At that time the home had been registered for just less than a year. The inspector spoke with the deputy manager, the acting manager, two support workers, observed the three of the four service users who were in the home, looked at the communal areas and the new service user’s accommodation, looked at documentation and looked at records. There were five service users resident at the home, four of whom have severe cognitive impairment and challenging behaviour and are unable to communicate verbally. The fifth service user has mild learning disabilities and is able to communicate, and her placement at the home will be discussed later in the report. At the time of the inspection there was no registered manager at the home but a registered manager from another of the Registered Provider’s local homes had been managing the home for a fortnight. The registered manager had been dismissed. Further information on this has been requested from Beacon Care. What the service does well: 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. DS0000044234.V269127.R01.S.doc Version 5.0 Page 6 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 DS0000044234.V269127.R01.S.doc Version 5.0 Page 7 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 and 3 Prospective users’ individual aspirations and needs are assessed but the Registered Manager must be fully involved in this process. The Registered Provider has not met the assessed needs of the most recently placed service user. EVIDENCE: At the previous inspection it was found that thorough pre-admission assessments had been made but that they had not been dated and signed. At this inspection it was found that a very thorough initial admission assessment had been undertaken for the most recently admitted service user but that this was not dated or signed. It was further found that this assessment had been undertaken by the Registered Provider’s Clinical Manager and that the former Registered Manager of the home had not been part of the assessment process. This is poor practice. The Registered Manager has a daily working knowledge of the home can therefore judge whether the potential service user will fit in with other service users, whether the skills of the staff team are suitable to support the placement and whether the home can meet their needs. A requirement has therefore been made that the Registered Provider ensures that the manager/deputy of the home is always fully involved in the assessment of potential service users. It is the responsibility of the Registered Provider to ensure that the home can meet the needs of any service user accepted for placement. At this inspection DS0000044234.V269127.R01.S.doc Version 5.0 Page 8 it was found that the most recent service user had been admitted to the home on the understanding that certain physical and staffing conditions would be met. The service user was admitted to the home at the end of July 2005 and at this inspection on 20th December 2005 it was found that neither the physical nor staffing conditions had been met. This was of special concern because one condition was that the service user should not have access to the rest of the house and at the inspection it was seen that this condition had not been met and that the service user was having an adverse effect on the quality of life and well being of the other service users at the home. In addition, on perusing the documentation of file, it appeared that the service user’s predominant behaviours and needs arise from mental health issues, for which the home is not registered, which is in contrast with the needs of all other service users and for which necessary skills staff had not been appointed. An immediate requirement was therefore issued for a case conference to be held to fully assess and review the placement of the service user at the home, with a resultant report sent to the Commission by 27th January 2006. DS0000044234.V269127.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 Service users assessed and changing needs are reflected in their individual plans. Service users currently make limited choices about their lives but this is being improved. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: At the previous inspection it was found that care plans were thorough but that monthly reviews were being undertaken verbally and not recorded. The previous requirement timescale to record reviews by 30/06/05 had not been met but the monthly care plan reviews for December 2005 were being recorded and the first one was seen at the inspection. Four of the five service users at the home have limited cognitive abilities and none can verbalise. Staff therefore assist service users to make choices/decisions by interpreting their behaviours but to date this has been limited to choices in regard to food, clothes and going out of the home. The current manager has brought in pictures and intends that all keyworkers will use these and other similar aids to assist in deciphering service users’ preferences so that their range of day-to-day choices can be improved. DS0000044234.V269127.R01.S.doc Version 5.0 Page 10 Risk assessments were assessed at the previous inspection and a requirement was made for changes arising from risk assessment reviews to be recorded. At this inspection it was found that the requirement had been implemented. Standard 8 was assessed at the previous inspection and was found to be met. DS0000044234.V269127.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 and 16 Service users are supported to take part in age, peer and culturally appropriate activities. Service users’ rights and responsibilities are only partially respected at the present time. EVIDENCE: Education and employment are not feasible for service users due to their cognitive impairments. However staff support service users to take part in age, peer and culturally appropriate activities. This includes one service user attending a Jewish day centre once per week, another service user attending a different more appropriate day centre and one service user being taken for walks to a visit a café with which he is familiar. The fourth service user with cognitive impairment does not like walking and is reluctant to undertake any activities but the manager plans to obtain sensory equipment so that he can undertake a suitable activity in the home. The most recent service user who is able to come and go as she pleases goes out regularly to an area that serves her cultural needs and where she has acquaintances. Staffs were observed to speak respectfully to service users and to support them to undertake minor responsibilities according to their cognitive and DS0000044234.V269127.R01.S.doc Version 5.0 Page 12 physical capabilities. For example, one service user is assisted to make her own bed, one service user can make his own tea, and another makes his own breakfast and clears away after a meal. The manager felt that more could be done to support one service user to make tea and another to do his own laundry, and intends to support staff to begin these processes. However, the inspector was concerned that with the placement of the most recent service user, some of the rights, individual choice and freedom of the other service users was being compromised. The most recent service user is far more cognitively able than any of the others, is fully verbal and can be forceful. She had been assessed as needing her own living space with phone or intercom access to staff but without access to the rest of the house. However she had not been provided with adequate kitchen facilities nor prevented from accessing the rest of the house. On the day of inspection she was observed to be freely accessing the home’s kitchen and to be dominating/intimidating other service users by shouting at them and by displaying unsociable behaviour associated with mental health impairment rather than cognitive impairment. This is not the type of behaviour that the other service users are used to or able to deal with and it was observed to be upsetting to some of them. This therefore constitutes an infringement of their rights and well-being. Standards 13, 15 and 17 were assessed at the previous inspection and were found to be met. DS0000044234.V269127.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): 20 Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Medication storage, administration and recording was checked at the previous inspection and found to be in good order with the exception of one PRN/as required medication. At this inspection it was found that the PRN and all other medication were in very good order and that the deputy was checking administration and recording on a weekly basis. This is good practice and the deputy should also sign the records as evidence that they have been checked and found in order. The question was raised as to whether a central record of all medications received by the home was necessary if all medication is received in monitored dosage packs only. This is not necessary as long as the number of tablets received is always recorded on the MAR charts. In this case, only a book for any returned medications to be recorded and signed is necessary. Standards 18 and 19 were assessed at the previous inspection and both were found to be met. DS0000044234.V269127.R01.S.doc Version 5.0 Page 14 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 Service users views are sought where possible and where not, staff ascertain their wishes and choices by interpreting their behaviours. However, the documentation outlining the complaints procedure for the use of staff, relatives and others is unclear, which could prevent them from accessing the procedure. EVIDENCE: The service users’ handbook explains the process of complaint in an attractive and appropriate format and residents’ “complaints”, in the form of challenging behaviours, is closely monitored and acted upon by staff, using specialist advice as appropriate. However it was found at the previous inspection that there were three different complaints documents for relatives and visitors, which al described different and sometime contradictory processes. A requirement was therefore made for the home to a have a clear accessible complaints procedure by 31/07/05. This timescale had not been met but the new manager had the process in hand and expected to have the complaints procedure in order very soon. Standard 23 was assessed at the previous inspection and was found to be met. DS0000044234.V269127.R01.S.doc Version 5.0 Page 15 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 28 Service users live in a homely, comfortable and safe environment. The privacy of shared spaces has been compromised however, and there are two maintenance issues in regard to flooring. EVIDENCE: The home is homely, comfortable and safe. An immediate requirement was left at the previous inspection for a Dorguard to be installed in the dining room, as had been recommended by the Fire Authority, and this had been implemented. At this inspection the home was found to be generally well maintained with the exception of the dining and living room floors. The floor covering in the dining room, which gets heavy wear and tear, was found to be frayed in several places and therefore to be a risk to safety. As the covering was not of sufficient quality to be made good by repair, an immediate requirement was made for the flooring to be replaced by good quality, washable vinyl. In addition, the carpeting in the lounge had ingrained stains and had a large area that had been torn. These two situations arise because of the behavioural characteristics of some of the service users. Staff explained that a washable and durable floor covering was required in the lounge, that was not susceptible to the tearing behaviour that one service users displays towards carpet in the area surrounding his chair. A second immediate requirement was therefore DS0000044234.V269127.R01.S.doc Version 5.0 Page 16 issued for the lounge carpet to be replace with good quality, washable and durable vinyl. There were further issues relating to shared spaces, both arising from the most recent placement at the home. The Registered Provider had agreed to accept a service user whose assessed needs included “her own living space with sufficient cooking facilities”, “her own entrance to her accommodation”, not to have unlimited access to the rest of the house, and a “system in place to contact the staff without having to go into the main house”. The Registered Provider had allocated two rooms to this service user, one a former bedroom and one the former second lounge. The use of the latter has meant that there is no longer an alternative, quiet lounge for service users and also no private space for visitors (apart from service users own bedrooms). A Yale lock had been provided on the former second lounge door, therefore preventing other service users from entering the new service users’ space, but this in no way prevents the new service user from accessing the rest of the home. Nor is there a system in place for the service user to contact staff without having to go into the main house. The other service users’ privacy and quality of life had therefore not been preserved or protected. In addition to this, very poor and inadequate facilities had been provided for the new service user in regard to kitchen facilities. The former bedroom is being used as her kitchen/dining facility and the only provision was a fridge, microwave, kettle, pots and pans, cupboard, 2 chairs and a coffee table. There was no cooker or work surface for food preparation and the only water facility was the washbasin in the en-suite toilet and shower room. In addition, the carpet was unsuitable for a kitchen/dining room and was stained and dirty. These facilities are not acceptable in terms of health and safety nor in terms of proper provision for the care and welfare of the service user. This also informed the issuing of the immediate requirement referred to in Standard 3 above. Standards 25, 27, 29 and 30 were assessed at the previous inspection and were all found to be met. DS0000044234.V269127.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The home has an effective and competent staff team but has not yet achieved the 2005 NVQ Level 2 training target. Recruitment processes are not being completed thoroughly, which does not safeguard service users. The home has a thorough induction programme but did not evidence a training and development programme. EVIDENCE: Staff demonstrate accessibility, approachability, a good knowledge of the disabilities and specific needs and behaviours of service users, and good professional relationships with external health and social care workers. At the previous inspection a relative and a care manager both expressed their appreciation of the qualities and commitment of staff at the home. The home has not met the NVQ Level 2 training target for 2005 but it is progressing towards the 50 target with one support worker having NVQ 2 and five of the remaining seven studying for it. The inspector checked the recruitment files for the two most recently employed support workers. The recruitment had been undertaken by the previous manager, who had worked at the home from August to early December 2005. Most of the required documentation was present, including Criminal Records Bureau checks, but one file had no references on it and the other had only one. DS0000044234.V269127.R01.S.doc Version 5.0 Page 18 This must be rectified as a matter of urgency and the Registered Provider must inform the Commission when suitable references have been received. At the previous inspection the home was found to have a structured and thorough induction programme but a recommendation was made for infection control, abuse and autism training to be added. This had not been implemented yet but the new manager was in the process of doing this. It is considered that autism training is particularly important for staff at this home due to the type of cognitive impairments of service users. Due to the management instability that had occurred during the year, the new manager was unable to demonstrate the training and development programme for the home and individual training and development profiles for staff, and so a requirement has been made for this to be forwarded to the Commission. Standards 33 and 36 were assessed at the previous inspection and were found to be met. DS0000044234.V269127.R01.S.doc Version 5.0 Page 19 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, 38, 39, 40 and 42 The home does not have a registered manager at the moment but suitable cover arrangements have been made. Service users views/desires are sought within the limits of their cognitive impairments. The home has a range of polices and procedures but a few are still not relevant to the client group. Safe working practices are implemented at the home. EVIDENCE: The Registered Manager who had been at the home since it opened had left in August 2005 and a new Registered Manager had taken over. Unfortunately the Registered Provider had had to terminate the employment of the new manager in early December 2005 so at the time of this inspection the home did not have a registered manager. However, the Registered Provider had arranged for an experienced manager from another of their registered homes to transfer to this home to run it whilst a permanent arrangement is made. This manager had only been at the home for 2 weeks at the time of the inspection but had already made considerable improvements. DS0000044234.V269127.R01.S.doc Version 5.0 Page 20 In discussions with staff it was evident that the previous manager had not managed the home effectively and that for the period of his management staff had not been very happy working at the home and morale had been low. However, staff also reported that there had been a complete upsurge in morale since the current manager had started at the home. They said that they found her management open, positive and inclusive but also firm, and that they appreciated her management and leadership skills. They said that staff positive staff morale had returned and that they felt they were working well together as a team. This was supported by observations made on the day. The home had not been registered for a full year at the time of the inspection and had therefore not published its first survey of service users views. Currently there are only two service users whose cognitive abilities would enable them to express effective feedback about living at the home. One of these has communicated that he is happier at this home rather than his previous home. The other service user the most recent service user, whose placement has been referred to earlier in the report, and she has expressed that she is unhappy at the home because of the other service users. For the other service users, who are not able to express effective feedback, the manager said that a Compliments and Comments book would be set up so that their relatives and visitors could express views on their behalf. A representative of the Registered Provider conducts thorough monthly visits but there was no evidence of a quality assurance system as recommended in National Minimum Standards (39.3). At the previous inspection it was found that although the Registered Provider had supplied the home with a range of policies and procedures, several needed to be updated or were not relevant to the home’s client group. The timescale for the resultant requirement had not been met but the new current manager had already updated relevant policies and said that the new Group Operations Manager was in the process of reviewing policies and procedures. A range of health and safety certificates were seen and evidenced that the home is operating safe working practices. Documentation seen included monthly health and safety checks, hazardous waste registration, gas safety certificate and Legionella testing, hazardous substances were stored safely and the testing of small electrical appliances was due to be undertaken during the following week. The fire book could not be located but staff confirmed that call points were checked on a weekly basis and that fire drills were carried out monthly. Standard 41 was assessed at the previous inspection and was found to be met. DS0000044234.V269127.R01.S.doc Version 5.0 Page 21 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 1 1 X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 1 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 1 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 1 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 1 1 X 3 X DS0000044234.V269127.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 17 (3) Requirement The Registered Manager must ensure that all records are signed and dated where relevant. Previous timescale of 30/06/05 not met. The Registered Person must ensure that the manager/deputy assesses all potential service users. The Registered Person must ensure that a case conference is held to review the suitability of the placement of the most recently admitted service user, with a report sent to the Commission. The Registered Person must ensure that the home has a clear, accessible complaints procedure which also includes a suitable assurance for service users and their families. A copy of the procedure should be made available to residents families/friends/visitors. Previous timescale of 31/07/05 not met. The Registered Person must ensure that the dining room flooring is replaced by good DS0000044234.V269127.R01.S.doc Timescale for action 01/03/06 2. YA2 14(1)(a) 20/12/05 3 YA3 12(1)(a) & (b) 27/01/06 4. YA22 22(1) & (5) 01/03/06 5 YA28 23(2)(b) 31/01/06 Version 5.0 Page 23 quality, washable vinyl. 6 YA28 23(2) (a) & (b) 18(1) The Registered Person must ensure that the lounge carpet is replaced with good quality, washable and durable vinyl. The Registered Person must ensure that training in autism, infection control and abuse is added to induction and on-going training. Previous timescale of 30/09/05 not met. The Registered Person must provide evidence of a staff training and development programme, and individual staff training profiles, which meet National Minimum Standards. The Registered Person must obtain the correct recruitment information for the two new support workers and inform the Commission when this is completed. The Registered Provider must implement a system for reviewing the quality of care, including consultation with service users and their representatives. The Registered Person must ensure that all policies and procedures for the home are up to date and relevant to its client group. Partially implemented. Timescale for making policies relevant extended. The Registered Person must appoint a manager for the service and ensure that the manager applies to CSCI for registration. 31/01/06 7 YA35 31/03/06 8 YA35 18(1)(c) 31/03/06 9 YA34 19(1)(b) Sch. 2 01/03/06 10 YA39 24 30/06/06 11. YA40 12(1) 31/03/06 12 YA37 8 15/03/06 DS0000044234.V269127.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 YA20 Good Practice Recommendations The manager/deputy should sign the MAR charts to evidence each time a tablet check is undertaken. DS0000044234.V269127.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000044234.V269127.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. 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!