Inspection on 22/01/07 for Rowan House

This inspection was carried out on 22nd January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 24 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rowan House 11/06/07

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

CARE HOME ADULTS 18-65 Rowan House 23 Galliard Road & 56 Bury Street Edmonton London N9 7NY Lead Inspector Jane Ray Key Unannounced Inspection 22nd January 2007 10:00 Rowan House DS0000069134.V329735.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 Rowan House DS0000069134.V329735.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. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowan House Address 23 Galliard Road & 56 Bury Street Edmonton London N9 7NY 020 8482 4112 020 8482 4112 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) Connifers Care Limited Tahen Seechurn Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users. Limited to 9 adults of either gender with a mental disorder not to exceed 6 accommodated at 23 Galliard Road, Edmonton, London, N9 7NY and 3 accommodated at 56 Bury Street, Edmonton, London, N9 7JY. The home must cease to admit any new service users to the home until such time as: having regard to the size of the care home, the statement of purpose and the number and needs of service users, there are at all times suitably qualified, competent and experienced persons working in the home in such numbers as are appropriate for the health and welfare of the service users to be accommodated. 12th June 2006 2. Date of last inspection Brief Description of the Service: Rowan House is a privately owned care home for adults who have continuing mental health problems. The home is registered to provide care for nine adults between 18 and 65 years. At the time of the inspection, all the residents were male. Rowan House has just come under new management and the care provider is Conifers Care Ltd, which is a limited company. The company also manages two other registered homes in the locality and one further home is undergoing registration. The responsible person is Mr Sanjeev Soobdhan and the registered manager is Mr Tahen Seechurn. The company has three partners who are all qualified mental health nurses and have extensive management experience. The home comprises of two separate two-storey, semi-detached houses that are a few minutes walk apart. Galliard Road is the main house, which accommodates six residents, and Bury Street is where three other service users reside. This arrangement was approved when the home was originally registered. The home is situated in Edmonton, North London and is near to shops and other amenities. There are good public transport links to the home. The stated aim of the service is to “offer care and rehabilitation in a supportive and friendly environment for people recovering from mental health problems. To work towards meeting service user needs by encouraging user involvement in exercising choice and independence whilst building on key daily skills in enabling progress towards independent living in the community”. The service has a condition of registration stating that no new service users Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 5 can be admitted to the service. This condition was imposed for the previous provider as there was no registered manager and also outstanding requirements relating to staffing levels and training. Connifers Care has a manager registered for the home and is addressing outstanding staffing issues. The inspector intends to review the condition of registration in the next 6 weeks once the new provider can demonstrate that improvements are underway. At the time of the inspection there were four men living in the service. The current range of fees in the home is from £530 - £740 a week although the company is in the process of reassessing the service users and reviewing fees to bring them in line with the company fee structure. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 22 January 2007 and was announced. The inspection took three hours to complete. The inspector was able to meet with the newly registered provider and manager. The departing provider was also present at the inspection. The inspector briefly met three of the current four service users and three members of staff. The inspector looked at the downstairs communal areas of the home and also inspected the service user case notes, the staff records and other key documentation. The main aim of the inspection was to look at outstanding action from previous inspection reports and agree timescales for this work to be undertaken by the new provider. It also offered an opportunity for the provider to explain work they want to undertake to improve the physical environment. What the service does well: What has improved since the last inspection? Since the previous inspection all the service users have new individual risk assessments. The home is also keeping an accurate record of what the service users are eating. The other requirements from the previous inspection are still outstanding and timescales to undertake this work have been agreed with the new care provider. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 7 What they could do better: Twenty-four requirements are made at this inspection and the current quality judgements are poor in all areas. This reflects the outstanding work inherited from the previous care provider by Conifers Care Ltd who have just acquired the homes. The inspector is very optimistic that the new provider has the skills, experience and commitment to address all the areas concern and the inspector will work closely with the new provider to monitor their progress. This report sets out all the areas of work that are needed and it is hoped that the next report will reflect significant progress. In terms of the service users, the new care provider will need to undertake the following work: • Complete assessments of all the service users • Prepare new care plans, implement the key-working system and develop behavioural guidelines • Liaise with placing authorities to obtain minutes of review meetings • Review the service user risk assessments • Provide the service users with contracts • Support the service users to access college and other structured activities • Support the service users to access a wider range of leisure activities • Provide new menu’s • Support the service users to access primary healthcare checks In terms of the staffing, the new care provider will need to undertake the following work: • Give the staff induction training • Provide staff training in all areas of health and safety, medication, POVA, challenging behaviour, mental health and NVQ in care • Ensure recruitment checks are in place and provide new contracts of employment • Provide regular individual supervision In terms of the environment, the new care provider will need to undertake the following work: • Refurbish both the houses • Replace old and damaged crockery • Replace bedding and towels as needed In terms of policies and procedures, the new care provider will need to undertake the following work: • Review the statement of purpose and prepare a service user guide • Provide a comprehensive set of policies and procedures for the home • Implement a system of quality assurance Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 8 In terms of health and safety, the new care provider will need to undertake the following work: • Review fire safety in the home including undertaking night time fire drills, servicing the fire extinguishers, reviewing the fire safety risk assessment, preparing an emergency plan and providing the staff with fire training • Ensuring the gas landlord safety certificate is in place • Ensuring all the staff have completed mandatory health and safety training 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. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 9 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 Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Conifers Care Ltd needs to undertake an assessment of each of the service user and provide them with a service user guide and a revised contract. EVIDENCE: The new care provider has prepared a statement of purpose for Rowan House. This document covers all the necessary details and once the organisation has started to undertake the management of the home the statement of purpose can be amended to reflect the detailed practice that is taking place in the service. The new care provider needs to prepare a service user guide that is in an accessible format. The service users do not have assessments prepared by the home and the new care provider needs to undertake assessments of the four service users living in the service. The service users have contracts between themselves and the home but these need to be replaced to reflect the new service providers terms and conditions. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 11 The new care provider has prepared a policy on admissions to the home that includes supporting potential service users to visit the home to enable them to see if they want to live there. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service users need revised care plans and risk assessments to reflect their individual assessments. Staff need to be supported to implement the key working system effectively in the home. Placing authorities need to be contacted to obtain the records of recent review meetings to ensure the agreed action is completed. EVIDENCE: The case notes for the four current service users were inspected. The care plans have not changed since the previous inspection and the absence of an assessment means it is hard to judge if the service users are being supported to work on goals that are appropriate for their current needs. The new care provider has stated an intention to implement a care planning system that is being used successfully in their other services. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 13 Three of the four service users have been offered key-worker sessions since the previous inspection. The new provider will need to review key-worker allocation and ensure staff know how to undertake the role appropriately. Keyworker sessions need to take place on an ongoing basis. The four current service users have complex behaviours and since the previous inspection still do not have clear behavioural guidelines in place. The new provider will need to prepare guidelines as appropriate. The four service users have risk assessments prepared since the previous inspection. The new care provider will need to amend these documents in line with each service users assessment. All four of the service users have had review meetings with their care manager in the previous two months but only one service user had a record of this meeting. The new care provider will need to speak to the placing authorities and ask for minutes of the meeting to ensure any agreed action is carried through. The record of service user meetings was inspected. These have been taking place on a weekly basis and have mainly discussed the change in management and domestic arrangements in the home. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service users need to be supported to access meaningful activities both in the home and community. The new provider needs to prepare menus for the home and purchase new crockery. EVIDENCE: Service users were observed to be continuing to assist with domestic activities in the home such as cooking and cleaning. The departing provider said the service users were not participating in any new activities since the previous inspection. One service user said he wanted to go to college but his application form had not been submitted. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 15 The current service users all have regular contact with their relatives and have arrangements in place to see them. Service users spoken to confirmed that they had their own bedroom and front door keys available. Since the previous inspection the home has started to keep an accurate record of the food being eaten by the service users and this indicates that they are being offered a nutritious meal each day. The new care provider needs to prepare menus for the service in consultation with the service users. The previous provider has not replaced the old damaged crockery and it was agreed with the new provider that this could be implemented in the next couple of weeks. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service users need to be supported to access all the necessary healthcare checks. Staff need to be trained on the medication policies and procedures to ensure service users are supported to receive the correct medication. EVIDENCE: The inspector observed that the service users were appropriately dressed and had been supported with their personal care. The inspector looked at the healthcare records for each of the four service users. Only one had a record of attending an optical check and none had a record of having a dental check. The previous care provider explained that all the service users are registered with a GP and the records show that they are having psychiatric input and attending the clinic to receive their depot injection. The inspector examined the medication. This is kept in a secure metal box and is stored in lockable cupboard in the office. The medication is in blister packs Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 17 and a medication administration record is available and appropriately completed. A record of medication received and returned to the pharmacy is maintained and the temperature of the medication cupboard is monitored on a daily basis. The new provider explained that they will be working with the same pharmacist they use for their other homes at the end of the month. The staff training records were inspected for all the staff and only one member of staff had a record of receiving medication training. This training needs to be provided for all the staff who administer medication. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. New complaints and adult protection procedures need to be introduced in the home that reflect the new management arrangements. Staff need to receive training on adult protection and how to support people with complex behaviours. New systems need to be introduced to support the service users to manage their finances. EVIDENCE: The service has a complaint and adult protection procedures but these will need to be replaced by the new provider to reflect the arrangements in the company. The staff training records were inspected and only one member of staff out of the eight in post had a certificate to show they had received adult protection training and four had a record of training in supporting people with complex challenging behaviours. The personal monies were inspected for two service users. The previous provider explained that one service user has not been receiving his income support and hence has very little spending money. The service users all have post office accounts and their benefits are paid directly into their account or they receive their money by cheque. The post office accounts do not provide statements and so it is hard to monitor the money they receive. The new provider need to look at how to support the service users to manage their Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 19 finances and how to record their monies so there is an accurate record of income and expenditure. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Both Galliard Road and Bury Street are in very poor condition and need extensive renovation as proposed by the new providers. EVIDENCE: The new providers outlined the process for bringing both the buildings into a good state. This is an extensive piece of work. The initial work will take place at Bury Street and then the service users will move to this home while the work takes place at Galliard Road. It is anticipated that the work will take approximately six months to complete. Architects have already prepared the plans, which includes some structural changes to both buildings. The inspector asked that in the short term the new providers review bedding and towels and replace them as required. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staff will need to have all their recruitment checks in place, be offered new contracts of employment and have access to ongoing training and supervision EVIDENCE: The inspector looked at the staff rota. This indicated that there are two staff on duty throughout the day. These staffing levels need to be maintained. The three staff spoken to during the inspection were all very positive about the management changes in the home. The inspector looked at the staff records for all the eight existing care staff. All the staff had an application form and two written references. One member of staff had a CRB from another care provider that had the second page missing. This staff member needs a CRB for the current care service. One member of staff did not have the CRB record available in his staff file. Two staff did not have a record of their ID and three staff did not have evidence of permission to remain and work in the UK. The new care provider will need to ensure all the recruitment checks are in place for staff continuing to work in the service. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 22 Conifers Care Ltd will need to provide all the staff with contracts of employment. Four recently recruited staff had no record of receiving induction training. The new care provider stated their intention to induct all the staff working in the service. Five of the eight staff had been supported to have individual supervision in the last month. The new care provider will need to ensure all the staff have access to regular individual supervision. The staff training records indicated that one member of staff had an NVQ in care and one was studying for level 3 of the award. There is no ongoing training programme at present and only one member of staff had a certificate to confirm they had received training on how to support people with mental health issues. The new care provider will need to provide a programme of ongoing training to address all the shortfalls. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There is outstanding health and safety work that needs to be completed to safeguard the service users. In addition the new provider will need to carry out a quality assurance exercise. EVIDENCE: Conifers Care Ltd has registered a manager for the service who has extensive relevant care and management experience. The departing care provider has not carried out a quality assurance exercise and this will need to be addressed by Conifers Care after they have had time to address outstanding issues in the home. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 24 In terms of fire safety, the fire alarm and emergency lights have been serviced and there are records of the alarm being checked on a weekly basis. Fire drills have taken place but need to also be conducted at night. The fire extinguishers have not been serviced for over a year. The home has a fire safety risk assessment but this will need to be reviewed by the new care provider. The service also needs a fire safety emergency plan clearly stating what needs to happen in the event of a fire. Only one member of staff has a record of receiving fire safety training. The maintenance certificates were inspected and the electrical installations and portable electrical appliances had been serviced. There was no current gas landlord safety check available. Staff training records were inspected and only four of the eight staff had a record of receiving first aid training and three had food hygiene training. This needs to be given a high priority when booking the staff training. Conifers Care Ltd stated their intention to provide a comprehensive set of policies and procedures for the home. Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 25 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 1 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 3 12 1 13 1 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 3 X 2 2 X 1 X Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes but relate to previous provider 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 YA1 Regulation 5(1), 6 Requirement The registered person must review the statement of purpose and prepare a service user guide. The registered person must complete comprehensive assessments for each service user in consultation with other care professionals as needed. The registered person must provide each service user with a new contract between the home and the service user. The registered person must introduce a new system of care planning in the home. As part of this process the staff must be trained on how to use the care plans and how to support the service users in their role as a key worker. The care planning process must also identify how the service users should be supported with complex and challenging behaviours and written guidelines must be available. The registered person must contact the placing authorities and obtain minutes of the recent DS0000069134.V329735.R01.S.doc Timescale for action 16/04/07 2. YA2 14(1) 12/03/07 3. YA5 5(1)(b) 16/04/07 4. YA6 15(1)(2) 16/04/07 5. YA6 15(2) 19/02/07 Rowan House Version 5.2 Page 27 6. 7. YA9 YA12 8. YA13 9. YA17 10. YA18 11. YA20 12. YA22 13. YA23 14. YA24 15. YA26 review meetings so that any agreed action can be followed through. 13(4) The registered person must review the individual service user risk assessments. 16(2)(n) The registered person must support the service users to access college or other structured activities. 16(2)(m) The registered person must support the service users to access a wider range of community based leisure activities. 16(2)(g)(i) The registered person in consultation with the service users must introduce menu’s into the home and replace broken or damaged crockery. 13(1)(b) The registered person must support the service users to access primary healthcare checks. 13(2) The registered person must ensure that all the staff have undertaken medication training and can follow medication procedures. 22(1)(2) The registered person must introduce a new user-friendly complaints procedure with the contact details for the new care provider. 13(6) The registered provider must provide a protection of vulnerable adults procedure for the home and ensure all the staff have received POVA training. 23(2)(b) The registered provider must complete the refurbishment work at Bury Street and Galliard Road. 16(2)(c) The registered provider must replace worn bedding and towels. DS0000069134.V329735.R01.S.doc 16/04/07 12/03/07 12/03/07 12/03/07 12/03/07 16/04/07 16/04/07 16/04/07 31/07/07 19/02/07 Rowan House Version 5.2 Page 28 16. YA32 18(1)(c) 17. YA34 19(1)-(5) 18. YA35 18(1)(c) 19. YA35 18(1)(c) 20. 21. YA36 YA39 18(2) 24(1)-(3) 22. YA40 17(2) 23. YA42 23(4) 24. YA42 13(4) The registered person must ensure that the ongoing training programme includes NVQ training so that at least 50 of the team have completed or are studying for an NVQ in care. The registered person must ensure all the staff have recruitment checks in place including a CRB disclosure, ID and permission to work in the UK where needed. The registered person must prepare an ongoing programme of training. This needs to include all the mandatory health and safety training as well as training on supporting people with mental health issues and working with people who have complex challenging behaviours. The registered person must ensure all the staff complete induction training with the new company. The registered person must ensure all staff receive regular individual supervision. The registered person must ensure a quality assurance system is introduced that seeks the views of service users, relatives, other care professionals and other stakeholders. The registered person must provide a comprehensive set of policies and procedures in the home. The registered person must improve fire safety by having fire drills at night, servicing the fire extinguishers, reviewing the fire safety risk assessment and preparing a fire emergency plan. The registered person must ensure the home has a gas landlord safety check. DS0000069134.V329735.R01.S.doc 16/04/07 19/02/07 12/03/07 12/03/07 16/04/07 16/04/07 12/03/07 19/02/07 12/03/07 Rowan House Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rowan House DS0000069134.V329735.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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