Inspection on 06/11/07 for Randolph Avenue, 248

This inspection was carried out on 6th November 2007.

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

Other inspections for this house

Randolph Avenue, 248 29/09/09

Randolph Avenue, 248 18/12/06

Randolph Avenue, 248 06/02/06

Randolph Avenue, 248 18/07/05

Randolph Avenue, 248 11/01/05

Randolph Avenue, 248 26/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Randolph Avenue, 248 248 Randolph Avenue London W9 1PF Lead Inspector Ffion Simmons Key Unannounced Inspection 6th November 2007 11:30 Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Randolph Avenue, 248 Address 248 Randolph Avenue London W9 1PF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7625 8975 020 7624 8948 randolphavenue@together-uk.org www.together-uk.org Together Working for Wellbeing Faye Patricia Widdowson Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 Brief Description of the Service: Randolph Avenue is a home for up to 12 service users with a mental health disorder. The aim of the project is to provide a structured, rehabilitative accommodation for a maximum period of two years. The home is managed by Together Working for Wellbeing and Octavia Housing Association is responsible for maintenance. The home is situated in Maida Vale with good transport links and access to community services. Each service user has their own single bedroom and have access to communal areas. The home has a lounge equipped with TV, video and hi-fi. There is a kitchen on the lower ground floor, which opens into a spacious garden. There is also a quiet room on the lower ground floor equipped with a computer printer and TV. The weekly fee for the service is £509.54. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced visit took place on the 6th November 2007 and lasted a total of 5 ½ hours. This was the home’s first key inspection for the inspection year 2007/2008. The inspector spent time talking to the Registered Manager, staff and residents. A range of documentation was checked including residents’ personal files and staff files. Residents, health professionals and staff were given the opportunity to comment on the service. A total of 14 questionnaires were returned to the Commission, and some of the comments received appear in the body of this report. What the service does well: What has improved since the last inspection? The home has met three of the four requirements set at the last inspection. The statement of purpose and service user’s guide has been updated to reflect the qualifications and experience of the Registered Manager and staff working in the home. Residents have been provided with a more secure facility to store their medication. The Registered Manager commented that the home has identified more local resources, linked with local neighbourhood police officer and are accessing in depth training on substances for staff. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. EVIDENCE: The home’s statement of purpose and service user’s guide was checked during the inspection. It was noted that the requirement of the last inspection report to include the experience and qualifications of the manager and staff has been actioned. Information taken from the Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager confirmed that the statement of purpose is reviewed annually. Residents commented that they had received enough information about the home before they moved in, so that they could decide if it was the right place for them. The files of three residents were checked during the inspection. This included the file of a resident who had recently been admitted. A very good level of information relating to the needs of the residents had been forwarded to the home prior to admission. Some of the information included referral information, risk assessments and discharge summaries. Following receipt of this information, the home undertakes its own needs assessment, which includes their spiritual and cultural needs. A placement recommendation Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 9 report is set outlining how the home aims to meet the needs and the responsibilities of all parties. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are encouraged to make their own decisions and choices. The care plans are person centred and are agreed with the individual. A key worker system allows staff to work on a one to one basis and contribute to the care plan for the individual. EVIDENCE: The files of three residents were checked during the inspection and their care was tracked. Care plans are drawn up with the input of the resident to cover their needs including physical health, mental health needs, house routines, activities and future plans. Care plans are regularly reviewed to identify progress made and to reflect any changes in the needs of the residents. The home aims to offer one-to-one key working sessions on a weekly basis. The sessions are recorded but the records on the files did not reflect that weekly key working sessions are taking place. It remains a recommendation that weekly key working sessions are offered as outlined in the statement of purpose. Daily contact notes are maintained and provide a good insight into the life of the residents. A health professional commented “I found the staff in general most professional and proactive on the interactions, care planning and implementation of care, being inclusive of the clients needs and wishes”. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 11 Detailed risk assessments and risk Management plans are in place for residents. The plans identified warning signs, risk factors and actions to be taken and included all risks identified pre-admission. Staff aim to review the risk assessments on a three monthly basis or more frequently if changes occur. There was evidence that the Manager had audited the files in October 2007 to check for compliance and to check that relevant information is in place and upto-date. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to develop their independent living skills through involvement in the domestic routines of the home, and they take responsibility for their own room, menu planning and cooking meals. EVIDENCE: The routines in the home are flexible and residents commented that they are able to do what they want to do during the day, in the evening and at the week-end. Residents also commented that they make decisions about what they do each day. Feedback from health professionals outlined that they felt the home support individuals to live the life they choose of what is best for the resident. The following comments were received about the service “They encourage optimising their options to progress”. The aim of the project is to provide a structured programme, which encourages the residents to develop their independent living skills. Residents as part of their rehabilitation programme are required to take part in general household chores such as cleaning, cooking, attending to their laundry and food shopping. Their allocated days for attending to the chores are outlined in their care plans. At the end of the two years, the aim is for the resident to have the skills for living in a more independent setting. Since the last inspection, two Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 13 residents were successfully discharged into a less supportive environment. Staff commented “the service supports individuals to achieve their chosen goals. Being a rehab, individuals are supported to regain independence and move on to their own accommodation.” A resident explained that they take it in turns to cook the evening meal for the group. There is a menu on the notice board outlining what meal will be provided and who will be responsible for cooking it. The Registered Manager outlined in the Annual Quality Assurance Assessment (AQAA) that staff are discussing breakfast and lunch options with residents to increase satisfaction with these meals. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs relating to personal care, mental health and general health are identified within individual care plans. Residents are supported to administer their own medication within a risk-assessed framework. EVIDENCE: The residents’ needs for personal support, mental health needs and general health needs are outlined within their care plans. The feedback received indicated that the care service respects individuals’ privacy and dignity. Residents are registered with a GP and are offered support to attend various appointments. Residents are allocated a key worker who will meet to offer support and to review progress against the goals set within the care plan. Residents benefit from the input of the multi-disciplinary team, which includes CPN, Diabetic Nurse, Psychiatrist and Social Workers. Health professionals who provided feedback on the service, commented that individuals’ health care needs are met by the home. “the home has responded very well to the needs of a clients who has developed a health problem and has required a lot of support.” The three residents case tracked are not currently self-medication, however a five stage self-medication programme is in place for residents who have been assessed as able to self-administer. The staged self-medication programme aims to gradually and safely promote their independence in this area. Each stage is risk assessed and residents are given a form to sign outlining their Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 15 agreed responsibilities. Staff undertake spot checks of the medication to ascertain service users’ compliance with the self-medication plan. A health care professional commented “The service has supported my client’s needs as regards taking his medication very well and are now adapting their care plan to respond to ‘move-on’ plans for client to move to increased independence”. Other comments highlighted how a client had progressed with the staff’s commitment to supporting them with their medication and commented “staff are now looking towards developing his self medicating skills”. Since the last inspection, a more secure area to store the residents’ medication that are self-medicating has been provided. Residents have a lockable drawer within a cupboard in their rooms and residents have signed for the keys. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear and well publicised complaints policy in place. Policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. EVIDENCE: The home has a complaints policy in place, which is made available to residents within a jargon free booklet. The policy is also available in the service user’s guide. Feedback from residents indicated that they know who to speak to if they are not happy and know how to make a complaint. Staff made the following comments about the complaints policy “the organisation’s policy and procedure regarding this is well detailed and easy to follow”. Since the home’s last inspection in December 2006, the home has received two complaints. The complaint records demonstrated that residents are encouraged and supported to make complaints and records are in place to demonstrate action taken in response to these complaints. The home has a policy for the protection of vulnerable adults from abuse. Where incidents have occurred which fall under the protection of vulnerable adults policy, these have been promptly referred to necessary parties including the CSCI. Staff receive training in this area within their induction. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment, which is kept clean and hygienic. EVIDENCE: Randolph Avenue is a large, terraced, five-storey Victorian building situated close to the local amenities of Maida Vale. The communal areas were seen during the key inspection. The home has a lounge on the ground floor equipped with a small kitchen area. Residents were observed to be spending time in here watching TV, and socialising. This is the main lounge area and smoking is not permitted in here. On the lower ground floor there is a small lounge, which is used as quiet lounge area and is equipped with TV and computer. The main kitchen is on the lower ground floor and opens into a spacious and well maintained garden. Since the last key inspection in December 2006, the hallways have been redecorated with colours chosen by the residents. This has contributed to the home looking fresher and brighter. The Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager indicated that issues with regards to the home are discussed in weekly house meetings and on an annual basis, residents are asked if they would like their rooms to be redecorated. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing structure is based around delivering outcomes for the people using the service. The home’s recruitment policy and practices are robust and a full staff team is in place. EVIDENCE: The home has been successful in recruiting into vacant posts and now has a full and permanent staff group working in the home. Where cover for sickness for example is required, the home uses experienced relief staff from the organisation’s bank. Rotas were checked during the inspection and indicated that there is a minimum of two support staff on duty between the hours of 9am and 9pm. Between 22:00 and 08:00, there is a staff member who sleeps in the project to offer support as needed to residents during the night. There is also an on-call service to support the staff member during the night. There is an overlap of staff on duty between 1:30 and 4:30 to allow sufficient time to handover key information and to provide one-to-one time with residents. Communication between staff is good with handover sheets being used to outline contact with residents and their whereabouts and to document key activities or concerns. One of the staff commented, “we have regular detailed hand over during the beginning of every shift. Also we make good use of our message book to pass on info at all times – and it works well” Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 19 Seventy five per cent of the staff team are either qualified to NVQ level 2 or above/equivalent or are currently working towards this qualification. The Registered Manager has the NVQ assessor’s award and is able to train staff up to NVQ level 3. Training opportunities are available for staff through the organisation and they are able to access Westminster City Council’s training programme also. Staff commented that they felt they receive training that is relevant to their role, helps understand and meet individual needs of residents and keeps them up-to-date with new ways of working. Example of some of the courses undertaken within the last 12 months includes, Core skills for working with drug and alcohol users; Human Rights legislation; Hearing Voices awareness; Mental Capacity Act and Recovery approach and well-being. A staff commented “I am currently undertaking my NVQ level 3 in care at the moment. My Manager likes to register me with other relevant training when available.” The frequency of refresher training for staff in safe working practices has been reviewed as per the requirement of the last inspection report. A staff commented “my organisation is quite good and on top of ensuring we get relevant training. Refresher courses are also run all the year round”. The Manager however must make sure that individual staff training records are upto-date to reflect the training undertaken. Newly recruited staff, undergo the skills for care induction programme. The personal files of two staff that had recently joined the staff team were checked during the inspection. The organisation’s regional office is responsible for the recruitment of new staff. Staff at the regional office complete all preemployment checks, which include Criminal Records Bureau check (CRB) and checks against the Protection of Vulnerable Adults list (POVA), health checks and references. A CRB was on both of the files checked. There was evidence on the files that residents were involved in the interviewing of applicants. Staff commented that they meet with their manager regularly or often for support and discuss how they are working. A staff commented “supervision is a thing that goes on regularly and work practice is usually discussed”. The records checked demonstrated that the staff whose files were checked had received recent and formal supervision. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well-run by a qualified and competed person who has a clear understanding of the key principles and focus of the service. Residents’ views are listened to but there are shortfalls in the support and monitoring provided on behalf of the registered provider. The health, safety and welfare of residents are promoted and protected as far as is possible. EVIDENCE: The home has a Registered Manager in post, and was present during the inspection. The Manager has a degree in Sociology and Social Policy. She has been studying the NVQ level 4 Registered Manager’s Award and is due to complete this in December 2007. The Manager also holds the NVQ assessors award to assess staff up to level 3. The Manager is an experienced person with over 10 years experience in working with people with mental health disorders and learning disabilities. The manager is person centred in her approach, and was open and accommodating throughout the inspection process. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 21 Residents’ views are sought through weekly residents’ meetings and household votes on decisions that need to be made. Residents are invited to participate in the selection of staff employed in the home. Annual satisfaction questionnaires are circulated to residents, staff, health professionals and referrers. Results of service user questionnaires are compiled and published in the service’s annual plan. Quarterly audits are undertaken on the service users’ files to ensure all information is up-to-date. The monthly visits on behalf of the registered provider are not currently taking place regularly and as per the regulations. The documentation in the home demonstrated that visits on behalf of the registered provider have not been taking place and quality review reports are not been produced. It remains a requirement of this report that the home’s quality assurance procedure must include visits on behalf of the registered provider, where the person assesses the overall quality of the service. During these visits, the person carrying out the visit should interview, with their consent and in private, residents and their representatives and staff working in the home. The person carrying out the visit should also inspect the premises and check records including complaint records. Health and safety records were checked during the inspection. Daily health and safety checks of the building are undertaken to observe for any hazards and include daily fridge and freezer temperature checks and daily food temperature checks. Water temperatures are measured weekly to check that the thermostatic mixer valves are working and delivering water at safe temperatures. Fire alarm tests and quarterly fire drills are performed and the fire fighting equipment had been tested as required. Health and safety risk assessments are in place, which covers fire risk assessment. The home’s permanent staff have completed the first aid course to ensure that a qualified first aider is on duty at all times. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 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 YA35 Regulation 17, 18 Requirement The Manager must ensure that the staff training records are kept up to date. Timescale for action 01/01/08 2. YA39 26 1 2 3 4 The visits on behalf of the 01/01/08 registered provider must be undertaken monthly and unannounced by a person that is not directly involved with the project as per the regulations. Original timescale of 01/03/07 not met, this is a repeat requirement. 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 YA6 Good Practice Recommendations Weekly key working sessions should be offered as outlined in the statement of purpose/service user’s guide. Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Randolph Avenue, 248 DS0000010866.V349203.R01.S.doc Version 5.2 Page 25 - 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. 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