Inspection on 09/11/05 for Montbelle Road, 88

This inspection was carried out on 9th November 2005.

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

Other inspections for this house

Montbelle Road, 88 22/12/08

Montbelle Road, 88 02/01/07

Montbelle Road, 88 04/05/05

Montbelle Road, 88 04/11/04

Montbelle Road, 88 25/05/04

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 Montbelle Road, 88 88 Montbelle Road New Eltham London SE9 3NY Lead Inspector Sue Grindlay Unannounced Inspection 9th November 2005 09:15 Montbelle Road, 88 DS0000006878.V257015.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 Montbelle Road, 88 DS0000006878.V257015.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. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Montbelle Road, 88 Address 88 Montbelle Road New Eltham London SE9 3NY 020 8851 5999 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) LINC Ms Janet Woolnough Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Montbelle is a large, semi-detached house in a quiet residential street in New Eltham. The Home caters for five younger adults with mild to moderate learning disabilities. The residents have their own bedrooms, furnished and decorated to their own tastes, and use of communal facilities that include a lounge/diner, kitchen, laundry room, conservatory (which doubles as a staff office) and a large garden. There is a toilet and bathroom on the first floor, a shower room and toilet and a separate toilet on the ground floor. There is unrestricted parking in the road at the front of the house, and close by are bus routes to Catford, Bromley or Lewisham. Residents are supported to live as independently as possible. There is a Manager, Deputy manager and up to six support workers, and there is 24-hour cover in the Home. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the inspection year, and took place over five hours. The manager, acting deputy and a new member of staff were spoken to and four of the five service users were present for some or all of the inspection. Two service users showed their bedrooms, and all the communal areas were viewed. Two care plans were looked at, and documentation was seen in respect of complaints, accidents, incidents, fire regulations and staff supervision. Staff records were seen at the company’s head office in Penge on another day. What the service does well: What has improved since the last inspection? What they could do better: All the staff members spoken to were hard pressed to say what they could improve on! Staff records need to be audited to ensure they comply with the regulations, and policies and procedures need to be consolidated between the two merged companies to ensure consistency of practice. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards in this section were assessed on this occasion. All five service users have lived in the Home since it opened. Montbelle Road, 88 DS0000006878.V257015.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): 8 Service users are consulted on, and participate in, all aspects of life in the Home. EVIDENCE: Service users at Montbelle are involved in all aspects of the running of the Home. The menu for the week was worked out with the residents after dinner on Tuesday night, and on the day of the inspection the acting deputy manager took one of the residents out with her to do the shopping. Service users take it in turns to cook a meal for the others. As she compiled the shopping list she asked residents what fruit and breakfast cereals they liked. Minutes of the last residents’ meeting on 7th October showed that residents were consulted about the colour of the walls in the lounge. There seemed to be as many suggestions as people, but the manager said that they look at paint charts and try to reach a consensus. All the residents have jobs to do in the Home, and one of the service users was mopping the kitchen floor on the morning of the inspection. The residents’ meeting commented that two of the residents said they were happy with their domestic duties. During the course of the inspection the manager spoke to one service user about a Christmas event. She showed him the flyer and asked him to consider whether he would like to participate. One Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 10 staff member put it like this, “Everything is their choice – you’re here to support them”. Montbelle Road, 88 DS0000006878.V257015.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, 14, 15 and 17 Residents at Montbelle enjoy a fulfilling and stimulating lifestyle. EVIDENCE: Montbelle is particularly successful in helping service users to take up employment opportunities and make constructive use of their time. One service user left the Home on the morning of the inspection to travel to Catford where she works in McDonalds, another works in Sainsbury’s two afternoons a week. Both these service users also do some voluntary work in addition. Service users engage in a whole raft of activities over the course of the week, with event such as horse riding, visits to the pub to play snooker and day trips keeping them very busy indeed. The quarterly report for one service user listed no less than twenty-six different activities over the period, many of them on several different occasions. Earlier in the year the three male residents went on holiday to an historic hotel in Nottingham that boasted a heated pool, spa, sauna, plus facilities for bowls, croquet, tennis and snooker. All the housemates enjoyed a day trip to Belgium. Indoors service users play board games, do craft activities or listen to music. One service user was pleased to Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 12 show his widescreen television and electronic keyboard. These standards were exceeded on the last inspection report, and are exceeded once again. Staff at the Home have considerable contact with the families of the service users, and the visitors’ book showed a great many family visitors to the Home. Relatives of the service users are routinely involved in reviews and care planning and all receive a summary of their son or daughter’s progress from the quarterly report. One service user wanted to go to clubs, and through discussion with his mother, an appropriate social club through the church was identified. Another parent has frequent contact with the Home, and offered to pick staff up for her son’s hospital appointment that day. Residents are also involved with family events. One service user has become an Auntie, and has visited her sister with the new baby. Another attended a family funeral in the summer, travelling unaccompanied on the train. A telephone with big buttons is available in the hallway for residents to take or receive calls. Family and friends, including residents from other Homes who were known to the service users, attended a barbecue at the Home in the summer. Staff at the Home are to receive training later this month from the Autistic Society on personal relationships and sexuality. New guidelines are due on this issue later this month, and it is recommended that a copy be sent to the Commission to inform future discussions (Recommendation 1). At the last inspection it was recommended to introduce more culturally varied meals, given that three of the five service users are black. This topic was raised at a residents’ meeting in May. The record states. “[Named resident] said she understands she is to tell staff when she wants a Caribbean meal put on the menu but she does like a mix of foods.” Another service user agreed. Staff said that meals such as salt fish and ackee are on the menu from time to time and are enjoyed by all the residents. The menu for the week showed a good range of dishes, including some such as stewed pork or salmon and new potatoes that use fresh ingredients. A set of recipe cards was in the kitchen to give some ideas for meals. One of the residents has an NVQ in catering and he likes to cook without any help from staff. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Service users are supported with their personal care according to their individual needs. EVIDENCE: Each service user needs a varying degree of support with their personal care. One service user has a bath aid that gives her more independence in getting in and out of the bath. Two staff members said that hair and skin care for the two young women is now better as there are more black support workers, and three of the workers are able to braid hair. Staff checked with clients before showing their files, and before opening a drawer in the client’s bedroom. Service users can choose what clothes to put on, and are given guidance only for what is appropriate for the weather. One service user had had some new clothes for her birthday. All the service users were clean and well presented. One young man was sitting in the lounge in his pyjamas for the first part of the morning. The manager said that there was no written guidance for how to dress in the house. It is recommended that all service users be encouraged to wear a dressing gown when they are in communal areas in their nightwear in order to maintain dignity and propriety (Recommendation 2). One service user has medication. This was checked and was found to be correct. This also correlated with the record of medication in the service user’s Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 14 profile at the front of his file. One service user uses an inhaler, and keeps this in his room. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents at Montbelle are safe and their welfare is protected. EVIDENCE: A copy of the complaints procedure is by the front door and a copy is available in the Service User’s Guide. There have been no complaints since the last inspection. Most minor issues raised are resolved easily through discussion with family members. However it is recommended that the Home has a log to record all compliments, complaints and suggestions, and that these are numbered to correspond with letters in the complaints file. The log should be a record of who investigated, what action was taken, the complaint resolution, whether the complainant was satisfied and be signed and dated as a true record (Recommendation 3). Training in Adult Protection is to be arranged for all staff and is a renewed recommendation of this inspection (Recommendation 4). The manager and one staff member are going on a ‘Capacity to Consent’ training day later this year. Service users’ money is checked at each handover, and both staff members sign the record. The company is promoting the idea of service users having their tin of money in their own room, and this is being trialled with one service user to see how it works out. Some items of value such as a ring or a passport are looked after, but there is no record of these, and it is a requirement that the Home ensures that the service user sign to say they are asking for it to be looked after, and again if they reclaim it (Requirement 1). Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Montbelle is a homely and comfortable environment. EVIDENCE: Since the last inspection a further pane of glass has been cracked and subsequently replaced in the door to the conservatory, and a doorstop put in place to prevent the door swinging back. A window restrictor was in place on a window overlooking the flat roof at the back of the house. The area around the doorframe in the bathroom has been repainted, and a new storage unit has been purchased for the lounge. The manager said that the new company formed by the merger of LINC with Providence is investing in some refurbishment. The lounge and the hallway are to be redecorated and the garden slabs are to be re-laid. The slabs have become very uneven, and the adjacent wall is falling down. The manager has drawn up a risk assessment for garden use, and a senior manager has visited to draw up a schedule of work. A report generated from this visit stated that, “poor maintenance in the past has been a false economy”. This robust approach to the environment is very encouraging. Although there are plans to carry out work on the garden, this is a popular area for residents, and this is therefore a requirement of this inspection (Requirement 2). Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 17 The Home was clean and tidy on the day of the inspection, and liquid soap and towels was available in the bathrooms, toilets and laundry. The kitchen work surfaces were clean and tidy, and the Home practised recycling as evidenced by the large container in the kitchen. A bottle of toilet cleaner had been left in one toilet, and this could be hazardous for service users if left unattended. This is a further requirement (Requirement 3). Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 36 Staff are competent and are well supported to carry out their duties. EVIDENCE: Two new staff members have been recruited since the last inspection. A service manager had highlighted the need for two workers in a Person in Control report in June. One transferred from another Home. The other is new to the work, but clearly has a good understanding of the role, and has been brought up around service users with a learning disability. She had covered First Aid, Moving and Handling, Health and Safety, Food Hygiene, Adult protection and Risk Assessments during her week’s induction. Staff spoken to were cheerful and enthusiastic about their work. They had a good rapport with service users and engaged with them in a straightforward and friendly manner. Five staff files were seen at the newly merged head office in Penge. No information about staff is now kept on the premises at Montbelle, although this is a requirement under regulation 17(2)(Requirement 4). A photograph, fitness form and criminal records bureau check were missing for a new staff member, but these might still be in the pipeline. Three of the four other staff files had standard checks only, and new enhanced checks should be obtained for all staff with a standard disclosure (Requirement 5). Photographs were missing from all the files, two had no evidence of identity in the form of birth certificate or passport and one had no references. Files should be audited to ensure compliance with these requirements. It is recommended as a minimum Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 19 that the Provider devise a record in the form of a checklist to be held at Montbelle to evidence the person’s suitability to work at the Home. This should provide basic information about the staff member, including a photograph, their address, date of birth and an emergency contact number. In addition it could usefully show signed and dated verification that the information contained in Schedule 2 of the Care Homes Regulations 2001 has been obtained in respect of that member of staff (Recommendation 5). Despite the Deputy manager leaving, staff supervision has been maintained, and there was evidence that one to one supervision had taken place with agenda items contributed by both supervisor and supervisee. The supervision record included any action required, by whom and within what timescale. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Service users benefit from living in a well run Home, where their views are taken into account. EVIDENCE: The manager was registered with the Commission in August and a new certificate issued, which was displayed in the Home. She confirmed that she has begun her Registered Managers’ Award and NVQ4 in Health and Social Care. The manager has worked in the Home since it opened, and knows the residents well. She has adapted readily to the role, and has produced her first quarterly monitoring report, which was well written. The manager said that the Home’s computer will not be updated, and she has been told to work from another office or handwrite reports if required. This does not give a very professional impression of the organization and is likely to impede her work. This is a further recommendation (Recommendation 6). The Home is organized in a calm and orderly way, and the manager has a good knowledge of the systems and procedures. She is responsive too to the changes brought about by the company’s merger, and is keen to improve Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 21 conditions in the Home. One staff member said, “I think it’s perfectly run”. The manager expressed her confidence in staff similarly, saying that she feels able to “sleep at night” knowing the clients are in safe hands. Only one Person in control report for a visit on 2/6/05 has been received at the Commission, and this may be due to the merger. Senior managers made visits to the Home on 14/9/05, 20/9/05 and 26/10/05 and copies of the reports from these visits were available in the Home. Person in control reports should also be sent to the Commission and this is a restated requirement (Requirement 6). The Commission has not received formal notification of the change in the organizational structure, and this is a requirement also (Requirement 7). Routine safety checks are carried out in the Home, and responsibility for health and safety matters is to be delegated to the new Acting Deputy manager. Risk assessments have been drawn up for the use of the garden given the uneven paving slabs and the broken wall. Staff were asked to sign these to say that they had read them, and this is good practice. Portable appliance testing took place on 1/3/05. The electrical survey was conducted in September 2001 when the house opened, and is due to be reviewed next year. Gas testing was done this week, but no certificate has been received, and this should be forwarded to the Commission when it is received in the Home. Fire extinguishers were checked in May this year. A fire alarm inspection and servicing certificate was issued on 1/11/05. All staff members have signed to say that they have read the emergency fire plan. A fire drill took place on 24/10/05 and this noted the names of all staff and residents who participated but the time the drill took place was not recorded. This is a further requirement (Requirement 8). One Regulation 37 report was not processed in accordance with the company’s procedures, and a copy was not sent to the Commission. This is also a requirement (Requirement 9). Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 4 13 X 14 4 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 1 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Montbelle Road, 88 Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 3 X DS0000006878.V257015.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 16(2)(l) Requirement Valuables should be recorded on a log with the date they are deposited, and the signature of the service user agreeing for the items to be held. The garden area should be made safe, specifically the paving should be re-laid and the wall rebuilt. Unnecessary risks to the health or safety of service users should be eliminated; specifically staff must ensure that no heavy-duty cleaning materials are left unattended. Records, as specified in Schedule 4, specifically the records relating to all persons employed in the Home, must be kept in the Home. Enhanced criminal records bureau checks must be obtained for all staff members. Copies of all Person in Control reports must be sent to the Commission (Restated requirement – previous timescale not met). The Registered Provider should notify the Commission in writing DS0000006878.V257015.R01.S.doc Timescale for action 30/12/05 2. YA24 23(2)(o) 30/12/05 3. YA30 13(4)(c) 30/12/05 4. YA34 17(2) 30/12/05 5. 6. YA34 YA39 19(4)(b) 26(5)(a) 30/12/05 30/12/05 7. YA39 39 30/12/05 Montbelle Road, 88 Version 5.0 Page 24 8. YA42 23(4)(e) 9. YA42 37(1)(e) 10. YA42 23(2)(c) of the detail of the organizational changes brought about by the merger of LINC with Providence, including any change to the named responsible individual or address of the organization. The fire drill record should record 30/12/05 the time of day, and drills should be conducted at different times (Restated requirement – previous timescale not met). All events affecting the wellbeing 30/12/05 of service users must be notified to the Commission without delay. The Home should produce 30/12/05 evidence that equipment is in good working order; specifically the gas service record should be forwarded to the Commission when it is received. 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. 2. 3. Refer to Standard YA15 YA18 YA22 Good Practice Recommendations It is recommended that a copy of the new guidelines on sexuality and personal relationships be sent to the commission when issued. It is recommended that all service users wear dressing gowns when in communal areas in their nightwear. It is recommended that a log is kept of all complaints, compliments and suggestions, and that this enables staff to record the name of the complainant, who investigates, action taken, complaint resolution, whether the complainant is satisfied, and is signed and dated to ensure compliance with complaint timescales. It is recommended that adult protection training be accessed for all staff on an ongoing basis. It is recommended that the registered person consider introducing a checklist of staff information that includes verification of receipt of the information in Schedule 2 in DS0000006878.V257015.R01.S.doc Version 5.0 Page 25 4. 5. YA23 YA34 Montbelle Road, 88 6. YA37 respect of each staff member, and a senior member of staff signs this. It is recommended that the registered person ensure that the Home has adequate IT support to enable the manager to carry out her role effectively. Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Montbelle Road, 88 DS0000006878.V257015.R01.S.doc Version 5.0 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!