Inspection on 26/10/06 for Sach Road (31)

This inspection was carried out on 26th October 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sach Road (31) 26/07/07

Sach Road (31) 27/02/06

Sach Road (31) 08/12/04

Sach Road (31) 08/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Sach Road (31) 31 Sach Road Hackney London E5 9LJ Lead Inspector Yemi Adegbite Unannounced Inspection 26th October 2006 10:00 Sach Road (31) DS0000010285.V316898.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 Sach Road (31) DS0000010285.V316898.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. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sach Road (31) Address 31 Sach Road Hackney London E5 9LJ 020 8442 4253 020 8350 6723 sachroad@hotmail.co.uk 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) Mr Nonoy G Capina Mrs Mina Joy A Capina Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: 31 Sach Road is a residential care home for five people with learning disabilities. The home is culturally diverse and care is currently provided to service users from African/Caribbean, Chinese and White British origins. The home comprises a two storey Victorian end of terrace property in a residential area in Clapton. The home is within walking distance from Lower Clapton Road, which has a parade of shops. Mare Street and Dalston shopping areas are accessible by transport links. The home has its own minibus and unrestricted on street parking is available for visitors. The home aims to provide a caring environment, which is flexible enough to meet the differing needs of individuals for support whilst maximising their potential for independence and integration in ordinary settings. The home is privately owned and generally family run and provides care in a homely setting. At the time of the inspection there were no service user vacancies. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and commenced at 10.20am. The purpose of the inspection was to review progress made with requirements at the previous inspection and to assess the service against key elements of the National Minimum Standards. During the course of the inspection the inspector sampled service users files, toured the premises, met with the acting manager, a staff member on duty and spoke with the registered provider. The overall quality of care was very good and the home was found to be well managed providing a service, which meets the needs of the service users. Verbal feedback was given to the acting manager at the end of the inspection. The inspector wishes to thank the members of staff for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: The home has been assessed as exceeding National Minimum Standards in the positive work it continues to carry out in regards to quality assurance and cultural diversity. The home develops care plans with the involvement of service users where possible a plan that details their personal, social and healthcare needs. Identifiable risks have been comprehensively assessed for individual service users. The home accommodates service users from diverse cultural backgrounds and has undertaken positive work to ensure that the needs of all service users are met. A range of varied and nutritious meals is provided. Individual service users have varied times for getting up, baths and meals according to their individual plan and activities. The home maintains a record of all healthcare appointments and their outcomes for each service user. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Sach Road (31) DS0000010285.V316898.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 Sach Road (31) DS0000010285.V316898.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&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the necessary information required to make an informed decision about where to live. These documents are produced in pictorial format for suitability and understanding of all service users. EVIDENCE: There has been no new admission to the home for a considerable length of time. Policies and procedures relating to admission process were inspected and deemed to be appropriate in relation to the National Minimum Standards. Evidence was seen of the service users contracts together with the statement of terms and conditions, which meets with the requirements in place. The acting manager was able to discuss how the admission process would be managed for a prospective service user ensuring the involvement of family members and the local placing authority with a full assessment carried out detailing care needs. Documentation relating to admission process including the Service Users Guide and the Statement of Purpose were inspected and deemed appropriate. Sach Road (31) DS0000010285.V316898.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans reflect service users needs and preferences. Service users receive support to make decisions about their lives and are consulted about issues that affect them. Service users are supported to engage in activities, which may include some risk with appropriate actions in place to minimise risk. Confidential information is stored and handled appropriately. EVIDENCE: The inspector read three care plans. These care plans were found to be up to date, containing relevant information and satisfactorily written. The care plans contained information about the service users daily routines, personal care and daily living issues. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 10 The home is working within the ‘person centre planning’, which was evident in the care plans inspected. It was positive to note that these care plans were well organised with information filed for easy assess and understanding. In addition each service user had a health action plan and health book, which is produced in pictorial format. The acting manager stated that a member of staff had attended a course in Multimedia Advocacy with evidence of certificate seen. This was reflected in the service users health book detailing health issue and other relevant matters. This has been filled in by key workers, the health facilitator (community nurse) and with the involvement of the service user. The inspector would like to commend the home for undertaking this positive work, which would empower and encourage service users independence. The inspector saw evidence that some service users have signed their care plans indicating involvement depending on their capability and understanding. In situations when this is not possible, views of relatives/advocates were sought. The home organises weekly meetings for service users to participate in the running of the home. The inspector sampled recent minutes for these meetings and evidence that matters such as activities; holiday and menus have been discussed. Records are held in a lockable cabinet in the office and staff spoken to during the inspection displayed awareness and understanding of the need to maintain confidentiality. Sach Road (31) DS0000010285.V316898.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): 12, 13, 14, 15, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff takes into account the preference of service users when planning the menu and a varied well balanced diet is provided. Service users receive support to access their local community and to take part in activities of their choice. They receive good support to maintain and develop friendships and to remain in contact with their relativities. EVIDENCE: The home accommodates service users from diverse cultural backgrounds. Four out of the five service users were out attending various day centres during the inspection. The acting manager stated no service users are in paid employment due to their level of disability. However service users are encouraged and supported to attend a wide range of activities both indoors and outdoors, which includes: Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 12 sailing, attending leisure centres and gardening. A service user has undertaken college courses including performing art and drama; the inspector saw copies of certificates displayed on the office wall. The acting manager stated that service users are supported to become part of the local community in accordance with assessed needs. It was positively noted that the home has undertaken a lot of work ensuring that the cultural diversity of the service users are promoted with evidence of this seen in individual care plans. Some service users belong to groups, which are culturally diverse. These groups include: the users and carers group and the Anika Patrice Project group for people from ethnic minorities. Staff encourages and support service users to practice their faith. On a day to day basis the home address cultural needs through means such as menu planning, where a range of foods that is reflective of service users cultural backgrounds and requirements are offered. The inspector saw evidence of the daily menu, which indicates that service users are offered choice of meals, which are varied and nutritious. Service users are supported to maintain family links and friendships outside of the home. Personal files evidence that some service users have overnight visits to relatives. The acting manager stated that relatives are invited to care planning review meetings with some relatives involved in the managing of service users finances. Advocate services are provided for service users who are less able to make decisions, which might have an impact on their daily living. The acting manager stated all service users are registered on the electoral roll and are actively encouraged to vote. Sach Road (31) DS0000010285.V316898.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support according to their needs and wishes. This includes support to access both general and specialist health service. There are policies and procedures in place for management of medication and for safe handling and administration. EVIDENCE: The acting manager stated that service users require a range of support and assistance with personal care. He further stated that members of staff have a good understanding of how to promote service users dignity and respect whilst providing personal care. The home aims to meet individual service users needs and time for getting up, going to bed, baths, meals and other activities are flexible. Service users are given the opportunity to choose their own clothing on a daily basis with help offered to service users who might be unable to make decisions due to their level of disabilities. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 14 The acting manager and the registered provider who is also a staff member were observed to interact well with the service users present during the inspection. The inspector was satisfied that the acting manager and staff are fully aware of service users needs and make appropriate referrals when required. For example, tracking of service users personal files contained documented medical appointments to GP, dentist, and optician and outpatient’s appointments. The staff spoken to during the inspection demonstrated a good knowledge of service users healthcare needs. It was positively noted that the requirement issued in the previous inspection report in regards to medication received into the home has now been met. The inspector saw evidence that medication received by the home are now signed for. No service users are able to manage their own medication. There is an organisational policy and procedure, which covers all aspects of medication handling and administration. Medications were appropriately stored in a locked cupboard in the office. The inspector found evidence that the medications available corresponded with those listed on the MAR sheet. Staff spoken to during the inspection were knowledgeable about correct medication practices and had received appropriate training. The acting manager stated that the home has is in the process of ensuring that the wishes of service users and their relatives are obtained and documented in regard to the issue of illness and death. The acting manager was advised to ensure that the home undertakes the process of ensuring that service users together with relatives and advocate are involved in planning for and dealing with growing older, terminal illness and death with evidence of this process documented in the individual plan. Sach Road (31) DS0000010285.V316898.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. 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. Training and guidance is provided to staff in the recognition, prevention and reporting of abuse. Satisfactory written information about how to make a complaint was provided. Service users views are listened to and they are protected from abuse. EVIDENCE: The acting manager advised the inspector that no adult protection concerns had been reported since the last inspection. It was noted that some of the service users might not be able to raise complaints directly due to the level of their disabilities. However the acting manager stated that some relatives are actively involved with service users care and advocacy service would be provided when required. The home possessed an up to date copy of the local Social Service Adult Protection procedure. The acting manager stated that staff had all undertaken the Adult Protection training and are aware of the Whistle Blowing Policy. The inspector saw evidence that the Adult Protection Manager from Hackney Council visited the home in April to give a talk in regards to the adult protection policy and a member of staff is on the Safeguarding Adult strategy committee. Issues discussed are cascaded to other members of staff ensuring awareness and understanding of adult protection issues. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 16 The care staff spoken to by the inspector stated that they were aware of the complaint procedure and knew how and who to complain to if necessary. The complaint procedure is also outlined in the service users guide in a pictorial format. The care staff further demonstrated a good knowledge and understanding of their responsibilities to report any adult protection concerns. The acting manager stated that staff awareness in regards to adult protection issues are enhanced by continuous training and regular discussion in staff meetings and supervision; evidence of this was noted on supervision records and minutes of staff meetings. Sach Road (31) DS0000010285.V316898.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, 25, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the premises are suitable for the stated purpose and it is accessible to service users. Service users benefit from a generally well maintained and comfortable home. EVIDENCE: The home is located in a two storey Victorian terraced house in a quiet residential road in Hackney and is kept to a very high standard both internally and externally with numerous homely touches evident throughout the building. The inspector viewed all bedrooms in the home, which were noted to be generally well maintained with personal furniture and service users mementos. The acting manager stated that four service users bedrooms had been redecorated since the last inspection. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 18 There is a large patioed garden at the rear of the house, which was been well cared for by service users and staff as stated by the acting manager. The inspector noted that the home was generally clean, hygienic and free from offensive odours. Sach Road (31) DS0000010285.V316898.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff receive adequate training however the home must ensure that all members of staff working in the home must be CRB checked before commencing employment so as not to potentially put service users are risk. The registered manager must ensure that all support staff are supervised at least six times a year. EVIDENCE: The home has a consistent workforce who has worked in the home for a number of years; agency staff are not used by the home. The home was appropriately staffed at the time of the visit. There were two members of staff on duty at the time of the inspection; one was the acting manager and the other was the proprietor who also works as a support worker at the home. The inspector noted positive interaction between the members of staff on duty and the service user present during the inspection who at times requires a high level of supervision due to her disabilities. Staff were very familiar with the Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 20 needs of the service user and care was delivered in a caring and understanding manner. The staff spoken to during the inspection confirmed that they receive regular training and are aware of the policies and procedure of the organisation ensuring the protection of service users. She further stated that staff felt well supported by the management team. Rotas indicate that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. There are two members of staff on duty throughout the day with one sleep-in staff at night times. The rota seen at the time of the inspection accurately reflected the staff on duty. The acting manager stated that there is an on call emergency procedure in place. The inspector saw evidence that the most recently employed member of staff had undergone induction training. Staff personnel files also contained relevant training certificates. However it was disappointing to note that some files did not contain all the required identity documents before staff commence employment. One file did not contain any relevant checks including an enhanced Criminal Records Bureau check. The acting manager was advised to ensure that the home operates a thorough recruitment procedure so as not to potentially put service users are risk. Staff supervision level was inadequate with some members of staff only receiving two to three sessions of supervision per year. The acting manager was advised to ensure that service users benefit from well supported and supervised staff. Therefore the home must ensure that all members of staff receive regular, recorded supervision meetings at least six times a year. The home is not meeting its target by ensuring that at least 50 of its workforce is NVQ qualified by the year 2005. However the acting manager stated that the home has taken positive steps to ensure that this requirement is met by the next inspection date. The acting manager advised the inspector that of the six members of staff, two are undertaking the Registered Manager Award, one staff is nearing completion of the NVQ level 2 and one member of staff would be starting their NVQ course in the next few months. Staff files contained copies of signed declaration of confidentiality. Sach Road (31) DS0000010285.V316898.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, & 40 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home. EVIDENCE: The home has an appointed registered manager who is also one of the registered providers. She is a qualified nurse specialising in learning disabilities with over 30 years experience. However she was not present during this inspection due to long-term sickness. The acting manager has been in post since May 2005 covering the management responsibilities of the home on a day-to-day basis. The acting manager stated to the inspector that the proprietors would be making a Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 22 decision in the next few months in regards to him becoming the registered manager; the Commission would be informed of any changes. He is a qualified registered nurse and presently undertaking his NVQ level 4 Registered Managers Award. He demonstrated a good knowledge of the service users needs and was aware of his role and responsibilities in running and managing the care home. The member of staff spoken to during the inspection stated that the atmosphere within the staff team was generally good and said that they felt able to raise concerns with the management team should they need to. The acting manager and members of staff must be commended for the continued positive work undertaken in and around quality assurance, which was evident and reflected in care plans assessed during the inspection. The home has ensured that the equality and cultural diversity of each service user is implemented in the individual care plans ensuring the delivery of high standard of care. Areas covered include: life style, cultural identity and health life style. The inspector was satisfied that there had been consultation with service users with regards to issues such as the standard of food, activities and the general care provided. In addition there was evidence of service users meetings being held on a rolling programme and views of relatives are sought. Health and safety records reviewed during the inspection were of good standard. Certificates were in place indicating that appropriate checks were carried out on a regular basis. Records seen during the inspection in relation to Schedule 4 of the Care Homes Regulations were generally of good standard and adequately kept, staff members ensure that service users confidentially is maintained. The inspector noted that the homes policies and procedures are easily accessible and available at all times. Sach Road (31) DS0000010285.V316898.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 3 2 X 3 X 4 X 5 3 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 1 3 3 3 4 X X X Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA21 Regulation 15. (1) Requirement Timescale for action 28/03/07 2. YA32 15(5) 3. YA36 18 4. YA34 19(1)((b) The responsible person must ensure that service users or their relatives wishes are clearly recorded and documented in regards to illness and death in each individual plans. The responsible person must 28/03/07 ensure that at least 50 of the care staff achieve care NVQ 2 qualification by the year 2005. The responsible person must 28/03/07 ensure that members of staff receive regular, recorded supervision sessions at least six times a year. The responsible person must 28/03/07 ensure that all documents required in regards to Schedule 2 of the Care Standards Act is obtained before staff commence employment and made available for inspection. Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 25 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 Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Sach Road (31) DS0000010285.V316898.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!