Inspection on 11/05/09 for Riverside Drive

This inspection was carried out on 11th May 2009.

CQC 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 CQC 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Riverside Drive 19/06/08

Riverside Drive 24/04/07

Riverside Drive 09/06/06

Riverside Drive 01/02/06

Riverside Drive 08/08/05

Riverside Drive 14/10/04

Riverside Drive 18/05/04

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 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Riverside Drive 112 Riverside Drive Mitcham Surrey CR4 4BW Lead Inspector Emma Dove Unannounced Inspection 11th and 12th May 2009 12:15 Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riverside Drive Address 112 Riverside Drive Mitcham Surrey CR4 4BW 020 8640 8279 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) keniwenofu@merton.gov.uk www.merton.gov.uk/housingsupport London Borough of Merton Kenneth Nnamdi Iwenofu Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 19th June 2008 Date of last inspection Brief Description of the Service: 112 Riverside Drive is a care home providing personal care and accommodation for eight adults with learning disabilities, up to two of whom may have physical disabilities. The home is staffed and managed by the London Borough of Merton social services department. The premises are owned by a housing association. The home was purpose built and is located on a site set back from a residential road in Mitcham. Bedrooms are single. One bedroom has en suite facilities and tracking for a hoist. A lift provides access to the first floor. People who use the service have access to an enclosed garden. Parking is available to the front of the home. The home is close to bus and tram links. Information about the service is available in the Statement of Purpose and Service User Guide. Fees are not applicable to this service as it is an in-house service funded by the London Borough of Merton. However, people who use the service are expected to pay towards holidays. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate quality outcomes. This unannounced inspection took place over four hours on the 11th May and four and a half hours on the 12th May 2009. One regulation inspector visited, looked at records, spoke with people who use the service, staff and the manager. Questionnaires were sent to relatives of people who use the service and staff. We have received three completed questionnaires, information from these is included throughout this report. We received a completed Annual Quality Assurance Assessment (AQAA), which contained information which has been used in this report. What the service does well: What has improved since the last inspection? Progress has been made with developing care plans and goals for individuals, with scope for further work to improve the information provided. Risk assessments have been reviewed and updated to ensure people are protected from harm. Confirmation that Criminal Records Bureau checks have been completed or updated, for all but one member of staff, was made available during our second visit. These were all issues raised at the last inspection in June 2008. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Riverside Drive DS0000033994.V375725.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 Riverside Drive DS0000033994.V375725.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has developed information for prospective and new people, although it is not accessible to all the people who currently live there. Assessments are completed before someone moves in, ensuring it is ‘the right place for them’. EVIDENCE: The manager told us ‘the Statement of Purpose and Service Users Guide could benefit from modification to include pictorial descriptions that will help them be service user friendly’. He also said they will need expert professional help to achieve this, which is being sought. This has been ongoing since the inspection in April 2007. We saw some parts of the Service User Guide have been produced in pictorial format. The people who use the service have been living there for many years. The manager told us they had the information they needed to provide appropriate care and support when they first moved in. The policy for admissions includes a full social work assessment and getting details of the assistance individuals require to ensure the service can meet their needs. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans have been developed to include the care and support individuals need. Staff are generally able to communicate with the people who use the service but more could be done to help individuals make decisions about their future. Risk assessments are completed and kept up to date, although some areas were not included. EVIDENCE: We saw care plans have been developed from assessments, they are written in the first person ‘I like’ and include the support and assistance individuals need. These have improved since the last inspection with more detailed information available for staff. Old information is now stored separately, making it easier for staff to access relevant details of people’s care and support needs. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 10 The manager told us in the self assessment that they could ‘develop staff abilities in communicating with the people who use the service in more effective ways, to increase their participation in decision making’. Although the service plans to improve over the next year do not include training for staff on how to communicate better with the people who use the service. One relative said the service ‘usually’ meets the needs of the person who uses the service. Staff say they ‘always’ have up to date information to meet the needs of the people who use the service. Reviews are held every year with the placing authority and records were available. We saw records of reviews cover health, mobility and holidays. People told us they have developed goals to work towards during the year. One relative said the service ‘usually’ and ‘sometimes’ keeps them up to date. Risk assessments are completed for areas such as finance, going out in the community, using the kitchen and relationships, to protect people from harm. We saw that one person did not have a risk assessment around their behaviour the manager said this was not needed, although staff are expected to ‘calm the person down’. It would be better to have clear guidance for staff about how they should respond to the individual. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to activities and leisure facilities to meet their social needs. People receive a varied diet to meet their health, religious and cultural needs. EVIDENCE: We saw people return from day centres, shopping, having lunch out and going to college, watching television and listening to music during our visits. The manager and staff told us that most people go out to different day centres depending on their needs. One person confirmed that they go to day centre and it is what they want to do. One person told us they go to college and enjoy it. The manager told us in the self assessment that they have introduced a ‘community day’ giving each person a day in the community with a member of staff. Staff and people who use the service confirmed that they Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 12 regularly go out in the community. The manager told us one person does music therapy. There is more scope for staff to do activities in the home with people in small groups or individually. One relative said the service ‘usually’ and ‘sometimes’ helps their relative keep in touch with them. People who use the service told us they can have visitors and keep in contact with family members. We saw visitors during our visits. One relative thinks the service ‘usually’ and ‘sometimes’ helps people to live the life they choose. We saw people enjoy an evening meal. People’s comments about the food included ‘I like the food’, dinner was good’, ‘tasty’ and ‘I enjoyed it’. We saw a varied menu and a record of food individuals have eaten. We saw some details of individuals dietary requirements displayed in the kitchen, this practice should be reconsidered, to protect people’s privacy and dignity. The manager told us the people who use the service could be more involved in food preparation and they plan to develop ‘kitchen days’ to give people the opportunity to support staff with cooking. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health needs are well recorded and met, with the exception of medication recording. EVIDENCE: The manager told us they have good links with the community learning disability team to help meet people’s health needs. People have health action plans which are reviewed regularly. We saw the health plans detail any issues and support needed. People are registered with a GP and see other health professionals when needed. One person told us they feel their health needs are fully met and staff help them. One relative told us they are kept up to date with health information. Medication is appropriately stored. Medication Administration Record Sheets (MARS) were signed and up to date. Although they do not include clear details Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 14 of the medication received and any medication carried over from the previous month, making an audit of medication administration impossible for medication for two people. The count of medication for two people was correct. One cream for one person was not included on the MARS, the manager and staff said it was no longer being used, although it was still in the medication cabinet and could still have been used by staff. One person’s medication profile noted a medication which was not on the MARS, the manager said this medication was no longer being used. A full audit of medication received and administered must be carried out to ascertain whether it has been given as per instructions and ensure the health and welfare of people who use the service is maintained. All old, unused medications must be returned to the pharmacy, to reduce the risk of staff administering medication which is not required. Medication profiles must be updated to include all medications currently being used, so staff have access to up to date, correct information. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has an appropriate complaints procedure which is accessible to people who use the service and their representatives. Staff have completed training in safeguarding and are aware of their responsibilities. EVIDENCE: One relative is aware of how to make a complaint and two relatives are not, although one relative said they would probably write to someone. One relative told us the service ‘usually’ responds appropriately to concerns. Staff told us that they are aware how to respond to concerns and complaints. The complaints procedure is displayed in the home. People told us they did not have any complaints and are happy with the care and support they receive. The manger told us in the self assessment there have been four complaints in the last year, with one complaint upheld and one complaint awaiting an outcome. The complaints record had three issues although information is not stored together and was quite confusing. One complaint from a relative noted in the staff meeting minutes was not in the complaints record with no details of any actions taken or the outcome. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 16 The manager told us in the self assessment that staff have completed training in dealing with complaints and safeguarding and they plan to up date this training at regular intervals. Staff told us they are aware of how to respond to complaints and concerns and are aware of their responsibilities regarding safeguarding. Riverside Drive DS0000033994.V375725.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides a physical environment appropriate to the specific needs of the people who live there. Bedrooms are single and people are encouraged to personalise their rooms. Appropriate aids and adaptations are provided. The environment is generally clean and free from odours. EVIDENCE: Comments from people who use the service included ‘I like my room’, ‘I’ve got all I need’, ‘I sleep well’ and ‘I like my television’. We saw people have personalised their rooms to their choice with pictures, photographs and belongings. People have access to a through lounge, dining room and kitchen, which can be divided by screens. On the first floor is a small lounge, which is called the quiet room and used for staff and residents meetings. The garden is fully Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 18 accessible to people who use the service and has garden furniture and a Barbeque. The kitchen has a raise/lower work surface, making it accessible to all people who use the service. The walls in the entrance and woodwork in the lounge need repainting. Carpets in some bedrooms need cleaning or replacing, to keep the home at a good standard for the people who live there. The building is adapted for people who use a wheelchair, rails and bars are provided in bathrooms and toilets, a hoist and fully accessible bathroom is available and a lift from the ground to first floor. These aids and adaptations ensure people who use the service can access all areas of the home and garden. The general cleaning was good, although the extractor fans in bathrooms and toilets need cleaning and the door frames need dusting/cleaning on a regular basis to keep the environment clean. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are sufficient to meet the needs of the people who use the service. Staff have access to appropriate training to help them carry out their role. Staff recruitment is generally good, although not all records are readily available to show that all the checks have been completed. EVIDENCE: The staff rota showed three or four members of staff on duty during the day, the fourth staff being available to accommodate activities/outings. One member of staff is awake and one member of staff asleep but on call at the home at night. These staff levels were seen to be sufficient to meet the needs of the people who use the service. Staff said there is ‘sometimes’ enough staff to meet the individual needs of the people who use the service. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 20 People who use the service said they did the things they want and were not prevented from doing things due to lack of staff. We saw some good interactions between staff and people who use the service. We saw staff spending time with individuals, giving information and advice, discussing recent events and talking with people about their day and what they want to do. We feel staff missed some opportunities for communicating with people who use the service and could have involved people in the day to day running of the home. Two relatives told us ‘staff usually have the right skills and experience to look after people properly’. The manager said there are no vacancies, although they are ‘looking at recruiting another member of staff to cover sickness and other absences better’. Staff told us they had the appropriate checks before they started work. We saw some records of staff recruitment kept at the home, although they were not all together and not easily accessible. The manager said most staff recruitment records are held at the organisations head office. The manager told us he has not seen the records for a temporary member of staff employed by another service managed by the organisation. A full list of the staff recruitment checks completed must be kept at the home for inspection, to show that people who use the service are protected from harm. The manager told us they plan to look at ways of involving the people who use the service in staff recruitment in the next year. Staff said they have appropriate training to help them do their job. The manager said most staff have completed NVQ training. The organisation has a training and development programme which is accessible to all staff. Future training should include more specialist training on communicating with people who use the service, to ensure staff are able to communicate with them fully. The manager told us in the self assessment that all staff receive supervision and appraisals. Staff confirmed that they see their manager regularly. The manager told us in the self assessment that staff meetings are held every two weeks. Records showed these meetings have been held monthly. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is qualified to run the home. The views of people who use the service are sought, although more innovative ways to communicate with individuals could be tried. Health and safety checks are generally up to date, maintaining the health and welfare of the people who use the service, visitors and staff. EVIDENCE: The manager has the relevant qualifications and experience to run the service. Further work is required on the monitoring of systems in place to check medication, both administration and returns. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 22 The manager told us in the self assessment that they have regular residents meetings every month. People who use the service confirmed that they have regular meetings. Further work could be done to make these meetings more relevant to everyone who currently uses the service. A representative from the organisation visits the home every month and speaks with people who use the service and staff, looks at care plans, menus and financial records. A report is written with any actions for the manager noted. The manager said they sent surveys in March 2009 to one person who uses the service and relatives and representatives of other people who use the service. Comments received have been generally positive, although not all responses are back and the manager is yet to collate information and write a report. This information should be used to formulate the annual development plan for the service. The manager told us he had completed training in the deprivation of liberties and will be passing the information on to the staff team. No referrals have been made under the Deprivation of Liberties Safeguarding. Checks have been made at the appropriate times on the electrical supply, gas safety, fire alarm system and the hoists. The portable electrical appliances were tested in March 2008, they should be tested every year, to ensure the health and safety of the people who use the service, visitors and staff. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 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 2 X 3 X 2 X X 3 X Version 5.2 Page 24 Riverside Drive DS0000033994.V375725.R01.S.doc Are there any outstanding requirements from the last inspection? YES 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 YA7 Regulation 12 (3) & (4) Requirement To ensure case files are up to date and contain correct information, checks must be made that the religion noted for individuals is correct. Timescale for action 25/06/09 2. YA7 24/08/09 12(2)(3)(4) Staff must be trained in alternative forms of communication, to ensure that they are fully able to meet the needs of the people who use the service. Timescales of 15/07/07 and 01/01/09 not met. Failure to comply with this requirement may lead to enforcement action being taken. 3. YA9 13 (4) b & c 4. YA22 22 (4) To protect people who use the service from harm and ensure staff provide appropriate support, clear written guidelines must be available for how to manage and respond to individuals behaviour. Information about complaints must be easily accessible and clearly indicate the complaint, any actions taken and the DS0000033994.V375725.R01.S.doc 24/08/09 24/08/09 Riverside Drive Version 5.2 Page 25 outcome. 5. YA30 23 (2) d To keep the environment at a good standard, the extractor fans in bathrooms and toilets must be cleaned and the door frames and high dusting should be done on a regular basis. The walls in the entrance and woodwork in the lounge need repainting. Carpets in some bedrooms need cleaning or replacing, to keep the home at a good standard for the people who live there. 6. YA20 13 (2) To ensure the health and welfare of the people who use the service, clear records must be kept of medication received and carried over every month, this will allow audits to take place to check medication has been administered as prescribed. The portable electrical appliances must be checked every year to ensure people who use the service are safe. A display screen assessment and must be completed to ensure staff work in a safe environment. 24/08/09 24/08/09 7 YA42 13 (4) 24/08/09 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 YA1 Good Practice Recommendations The information provided to people who use the service, including what they can expect from the service, should be reviewed. Consideration should be given to providing this DS0000033994.V375725.R01.S.doc Version 5.2 Page 26 Riverside Drive information in formats suitable for individuals currently living there. 2. 3. YA10 YA39 To ensure peoples privacy and dignity is maintained any information about food allergies and support required should not be displayed in communal areas. To ensure that the views of people who use the service underpin the development of the service an annual review of the support provided should be carried out. This review should include seeking the views of people who use the service and other stakeholders, which should form the basis of an annual development plan. The views of people who use the service should be published and made available to any interested parties. Riverside Drive DS0000033994.V375725.R01.S.doc Version 5.2 Page 27 Care Quality Commission South East The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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