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Inspection on 24/08/05 for Matthew Residential Care Home

Also see our care home review for Matthew Residential Care Home for more information

This inspection was carried out on 24th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The carers appeared dedicated, focused and have good insight into the personal care needs, personality and preferences of the current resident. The home also provides accurate and up to date information and guide to the home and services. Good effort is being made by staff to help ensure that the lifestyle experienced by the resident is reflective of her assessed needs and preferences. The home provides appropriate and stimulating activities that help to enhance the current resident`s knowledge and skills in key areas of her daily life. The home carries out regular and timely care reviews and reassessments of the resident`s care needs.

What has improved since the last inspection?

The home has reviewed and updated the statement of purpose and service users` guide in format that is more appropriate to the communication needs and ability of the resident. The service has made good attempts to work closer and get support from relevant services and agencies, including the National Society of Epilepsy. The medication administrative procedures have been revised and better managed, including a section on how staff should manage the wishes of residents in the event of their death. The risk management plans have been updated and leisure and social activities have been created to meet the needs of the current resident.

What the care home could do better:

The provider will need to improve its current employment practices and ensure full compliance with regulatory requirements dealing with staff recruitment checks and equal opportunity. Better work is needed to ensure staff references are verifiable and the names of referees and contact details of referees are recorded on references. Staff should also have full job description outlining their roles and responsibilities. The provider will also need to ensure that gaps in the employment history of staff are accounted for and each staff has the required health immunisation and pre-employment health check reports. The provider will also need to ensure that staff supervision and training is carried out in line with contractual agreement and their professional development needs. The provider must also ensure that residents are appropriately protected by ensuring staff receive required training in prevention of adult abuse plus food and hygiene. The provider will need to ensure that its employer`s liability and home insurance certificates are up to date and on display at the home. The provider will also need to ensure the home has a programme of general maintenance and upkeep for the home. The manager will need to ensure that files and administrative records are better organised and photographic identification for each staff must be on their individual files. Improvement is needed to clarify the roles and responsibilities of all persons working at the home.

CARE HOME ADULTS 18-65 Matthew Residential Care Home 1 Milton Avenue Kingsbury London NW9 0EW Lead Inspector Bernard Burrell Unannounced 24 August 2005, 10:00am 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 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 Stationary 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. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Matthew Residential Care Home Address 1 Milton Avenue Kingsbury London NW9 0EW 020 8907 8435 020 8907 8435 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Matthew Residential Care Ltd Carlene Marshall-Knight CRH Care Home only 4 Category(ies) of LD Learning Disability 18-65 Years registration, with number MD Mental Disorder 18-65 Years of places Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02 March 2005 Brief Description of the Service: Matthews Residential Care Ltd is registered to provide accommodation and care support to up to 4 residents at 1 Milton Ave. The home is a five bedroom semidetached property located in the residential area of Kingsbury, Northwest London. It has five bedrooms, including one ensuite. It also has a communal lounge, kitchen, dining room, designated smoking area, one bathroom and toilet, one shower room and toilet, a utility and laundry room. The home has a well maintained garden. It is close to the town centres of Harrow and Wembley with a variety of local shops, public transportation services, health and social care facilities and services, plus leisure and recreational facilities. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in one day. The inspection process involved tour of the home, reading of documents, case records and files, reviewing the policies and procedures, plus discussions with the manager, staff and resident. The home is managed well but more work is needed to help ensure better clarity,accountability of roles and responsibilities. The findings indicated good effort is made to meet the assessed needs of the one resident currently living at the home, who reported she was happy with the care and support she receives. What the service does well: What has improved since the last inspection? The home has reviewed and updated the statement of purpose and service users’ guide in format that is more appropriate to the communication needs and ability of the resident. The service has made good attempts to work closer and get support from relevant services and agencies, including the National Society of Epilepsy. The medication administrative procedures have been revised and better managed, including a section on how staff should manage the wishes of residents in the event of their death. The risk management plans have been updated and leisure and social activities have been created to meet the needs of the current resident. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 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 standard(s) 1,2,4,5 The home’s admission procedure is clear and enables the process to be straightforward for prospective residents. Adequate and appropriate assessments are carried out before new residents move in. Relevant information is also provided about how support will be given and needs met. EVIDENCE: The services user’s guide has been revised and updated and is now written in a style and format that is more user friendly and meets the communication needs and abilities of prospective residents. The guide also has pictorial references to aid easier understanding by residents. The assessment process is thorough and comprehensive for new residents and involve contributions from the residents, their relatives, social workers/care managers, advocates and other relevant stakeholders. Each new prospective resident is offered the opportunity to visit the home and spend time there before a decision is made whether to move in. The current resident informed the inspector she was happy to be living at the home and that she receives good support from the staff. Each new resident receives a contract with details of the terms and condition of the tenancy and the services and support to be offered by the home. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 9 The home also carries out periodic reviews of care needs. The process involved contributions from the resident, relatives, social workers/care managers and other professionals working with the residents. The inspector noted that updated records are kept for the current resident and her bedroom was decorated and furnished to her style and preference. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 6,7, 8,9 The home is able to fully meet the assessed needs of the current resident. There were good systems in place to help ensure changing needs are recognised and appropriate action plans developed to meet those needs. EVIDENCE: The records examined by the inspector showed that a thorough and comprehensive multi-disciplinary assessment was carried out for the current resident before she moved into the home. There were examples of regular care reviews and updates to reflect changes in the resident’s care needs and preferences. These also reflected the individual views of the resident and proof of consultation with her and other stakeholders. The manager confirmed that the regular reviews of the resident’s care needs aims to ensure that progress is carefully monitored and any issues or difficulties can be identified and assistance offered where necessary. The inspector examined the daily case recordings, the care plan and weekly activities. The inspector also had discussion with the resident about the things she enjoys doing and how she spend her time at the home. The findings indicated she is consulted about all issues relating to her life at the home. She has contributed to the way her room is decorated and furnished and the types Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 11 of activities she takes part in. She is also consulted by staff about the choices in meals and these were recorded on the weekly menu plan and in her personal case diary. The resident confirmed she enjoys the support she received from staff, including prompting and supporting to maintain and develop her independence, ability and skills in key areas of daily living. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 14, 15, 16,17 The resident is well supported by staff to develop her interest in activities inside the home and the local community. The home provides opportunities for the resident to enhance and develop her independence and living skills. The resident benefit from the provision of varied and balanced diet. EVIDENCE: The manager informed the inspector about the range of opportunities and activities the current resident is involved in. The inspector examined the activity timetable and it included in-house and local community activities and programmes. They range from swimming, attendance at college to do a cookery course, personal shopping, eating out, bingo and meeting with her relatives. The resident has made the choice not to attend structured day care services and prefers more outings. The resident maintains regular contact with her mother who phones every Tuesday and also visits her at the home. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 13 She stated she enjoys eating out and shopping and is very interested in listening to music. She also has key input into her nutritional and dietary planning and preferences. She reportedly likes all types of English food and she is able to eat well once the foods are cut up or bones removed. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18,19.20 The health care needs of the resident is adequately assessed and monitored with appropriate measures in place to ensure regular health checks are carried out. The resident’s rights are fully respected by staff who also help to promote her independence and privacy. EVIDENCE: The care plan for the resident was detailed and linked to the assessment with her individual health care needs documented. The manager confirmed that the resident enjoys reasonable good health. In addition, the health care recordings examined by the inspector showed that the resident’s health care needs and conditions are appropriately monitored with good monitoring systems and care planning in place. The resident is registered with a local doctor and also receives health care support from a chiropodist and an occupational therapist. Recorded information in her health care plan gave guidelines that staff are expected to follow, including monitoring of various health related problems and support the resident to have regular health checks, monitoring side effects of medication and referral to OT assessment. There was also evidence of personal risk assessments carried out, plus appropriate mobility equipment ordered and maintained in good working order. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 15 The home’s medication administration procedures were operated in line with regulatory requirements and professional practices, including clear guidelines for carrying out invasive health care support and medication administration. Medication and home remedies were stored safely and appropriately and were reviewed regularly. Several staff are authorised to administer medication. The manager also reported that training has been offered to staff, but certificates of verification could not be found. However, the home has a medication signature verification form that was on display in the office. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22,23 The home has relevant systems and procedures in place to deal with complaints and concerns, including guidelines for residents and their relatives and next of kin. Guidelines and procedures for adult protection are in line with the local borough council. However, there was no evidence of staff receiving training in adult protection issues. EVIDENCE: No complaints, vulnerable adults concerns or investigations have been made in relation to the home and resident since the last inspection. The inspector noted the home had appropriate policies dealing with complaints and adult abuse prevention. These were reviewed in 2004. The summary version of the complaints procedure and guideline has been revised to reflect the communication abilities and needs of residents. However, some pictorial areas were incomplete. In addition, the provider must ensure the telephone contact number of the CSCI and address of other relevant agencies are listed in the service user’s guide and other relevant documents. The inspector was of the view copies of the fire safety and evacuation procedures should be available in communication style and format with pictorial guidance that meets the needs of residents and posted in each room. Regular fire drills are carried out with clear instructions and guidelines plus recorded evidence. The inspector noted that there was no evidence of staff undertaking training in adult protection. In addition, the provider’s staff recruitment procedures were inadequate and do not offer assurance and protection to residents. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 17 There was also no evidence that staff received training in food and hygiene or that health immunisation have been undertaken by care staff. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24, 25, 26 27,28,29 30. The home has received improvements and decoration to the bedrooms and other areas since the last inspection. The home is suitable for its purpose with adequate communal and private facilities. However, a programme of general maintenance is required. EVIDENCE: The home is located in a quite residential area in Kingsbury, Northwest London. It has accommodation for up to 4 residents but there were three vacancies at the time of this inspection. The home is well maintained and each bedroom has been decorated and furnished to a homely standard. There was also adequate parking for several cars in the forecourt of the home. The home is close to a variety of shopping, social, leisure and health care facilities and services. Ii is staffed 24 hours each day. The current resident has appropriate mobility aid to assist with her mobility and she lives in a ground floor room that has been adapted for her wheelchair access. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 19 There was no programme of general maintenance and upkeep. This was a requirement from the last inspection. There was documented evidence of various electrical and appliance test, including gas, fire, home risk assessment and fire drill that is conducted every Monday. However, there was no record to verify that the home’s water system has been tested. There was also the need for the windows to have adequate safeguarded to help enhance safety. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36. The home’s staff recruitment practices have several shortfalls and the process does not offer assurance to residents about the protection of their wellbeing, and the competence and abilities of all staff. EVIDENCE: The manager informed the inspector the home currently has a compliment of six care staff. One staff is on duty in the AM shift and one in the PM to support the resident currently living at the home. The manager or deputy manager is also available on each shift, plus sleep-in staff cover is provided. One bank staff has resigned from the home since the last inspection and now has a full-time job elsewhere. The inspector examined five staff files and found several shortfalls relating to recruitment procedures, references, training and supervision. The staffing files were poorly organised and needed full auditing. The manager gave a copy of the Training and Study Leave Policy to the inspector. This outlined the intention of the provider to provide opportunities for staff to develop their skills, knowledge and experience, including identifying training and development needs and provide financial support. However, the evidence seen on staffing files indicated very little training has been provided and shortfalls still exist in these and other areas of staffing. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 21 The employment references on most files were not signed or verified by the referees who reportedly completed them. There were no evidence of employment contracts, job roles and responsibilities for most staff. In addition, gaps in employment were not accounted for, photographic identification of staff were missing, no evidence of health immunisation checks, no evidence of equal opportunity compliance, training in food & hygiene, adult protection or health and safety. There was inadequate information to verify induction programme has been carried out for all staff. There was also minimal evidence of staff supervision and access to NVQ and other mandatory training in areas such as first aid. There was no reference in the employment policy and procedure about CRB and reference checks, including checks for volunteers or regular visitors to the home. The provider must ensure immediate action is taken to address the above and other shortfalls in the staffing and recruitment procedures at the home. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,40,41,42. Daily operations at the home are conducted in the best interest of the current resident with appropriate measures taken to promote her health and welfare. However, more work is needed to improve key areas of management and accountability of the service in line with regulatory requirements. EVIDENCE: The inspection findings indicated the manager and staff are dedicated to promoting the social, health and personal care needs of the current resident. There was evidence available to verify that staff work closely with the resident to help achieve her personal goals, promote her independence and ensure she lives a comfortable life. The care review notes also indicated satisfactory work is been carried out that is helping to maximise the quality of life experience by the resident; including ensuring her views are incorporated into her daily care planning. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 23 There were evidence of risk assessments carried out for the current resident plus other assessments relating to security in the home, the environment and out of hours emergency contact. The home has relevant policy and procedure relating to staff induction and foundation training, but there was little evidence to verify this has been done for all new staff. The policy on confidentiality needed reviewing and should also have information relating to the Freedom of Information Act and guidelines. There was no record to verify that the home has person designated to have overall responsibility for health and safety matters. This policy was reviewed but not signed at the last inspection. The home has a policy on abuse prevention and a statement that all staff will be trained to recognised the signs of abuse and how to deal with incidents of abuse and report their suspicions. However, the available evidence indicated most staff have not had this training. A number of policy and procedure documents have been reviewed but some were not signed or verified. The medication policy was in place and in line with current best practice, but no documented evidence that staff have received the required training in medication awareness and skills in administration. The manager informed the inspector that training was provided by Boots the chemist, but no documented evidence was provided to verify this. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 4 4 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 2 3 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Matthew Residential Care Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x 2 2 2 2 G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 25 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 23 Regulation Requirement Timescale for action 30 September 2005 10, 12, 13 The provider must ensure that (6) 37 all staff working at the home (g),16, receive training in adult 18, 23. protection. The provider must esnure that fire safety instructions are created in appropriate communication format and posted in each residents room. The provider must ensure that all staff receive training in food and hygiene. 2. 24 16, 23 The provider must ensure the home has a programme of general maintenance. This is a requirement from the last inspection and is still outstanding. The provider must ensure that all bedroom windows are installed with safety device. The manager and provider must ensure that each staff receives a contractual guideline about their roles and reponsibilities. The manager and provider must 30/10/05 3. 31 18,19 30 October 2005 30 October Page 26 4. 32 18 Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 5. 34 & 35 19, Schedule 4.6, 10, 12, 13(6), 18, 37(g) ensure that residents are supported by staff who are competent and with relevant qualifications and experience to carry out their roles and responsibilities The manager and provider must ensure that improvement is carried out in the homes recruitment procedure in line with regulatory requirments and employment legislation. This is an outstanding requirment from the last inspection. The manager and provider must ensure that all staff have satisfactory references, CRB clearance and health immunisation before they start working at home. The manager and provider must ensure an audit is carried out off all staff to ensure all relevant emplopyment procedural guidelines are followed in place. The manager and provider must also ensure that all staff receive opportunity to access relevant training and professional development, including the NVQ. The manager must ensure there is a programme of regular supervison for all staff and records are kept of these. The manager and provider must esnure that the rights and wellbeing of residents are protected by improvements in the homes record keeping, policies and procedures. A full auditing must be carried out of all records,policies and procedures. 2005 30 October 2005 6. 36 18 (2) 30 October 2005 30 october 2005 7. 40 & 41 17, Schedule 3, 4. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 27 8. 42 13(2) schedeule 3,3(i),k The manager and provider must ensure that all staff receive relevant and updated training in medication administration. 30 October 2005 9. 43 9(2) (b) (i),25, Schedule 1,4. The manager must also ensure that the homes water system is tested in line with relevant regulatory requirments. The manager and provider must 30 ensure that the home is September managed in ways that indicate 2005 action is taken to address the shortfalls identified in this report, including clear lines of accountability of the services. 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 32 Good Practice Recommendations The manager and provider should ensure that review of its equal oportunity policy is carried out and incorportated into its employment and recruitment guidelines. The manager and provider should also ensure that its policy and procedure, including servce users guide is revised to incorporate information on the Freedom of Information Act and access to records. Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 4th Floor,Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH 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 Matthew Residential Care Home G62-G11 S59266 Matthew Res.Care Home V245885 240805 Stage 4.doc Version 1.40 Page 29 - 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!