Inspection on 10/10/06 for Salisbury Road

This inspection was carried out on 10th 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Road 15/01/09

Salisbury Road 15/01/08

Salisbury Road 25/02/06

Salisbury Road 07/02/05

Salisbury Road 25/11/04

Salisbury Road 22/03/04

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 Salisbury Road 22-23 Salisbury Road Leyton London E10 5RG Lead Inspector Yemi Adegbite Unannounced Inspection 10th October 2006 10:05 Salisbury Road DS0000007264.V314886.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 Salisbury Road DS0000007264.V314886.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. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salisbury Road Address 22-23 Salisbury Road Leyton London E10 5RG 020 8556 8147 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) r.tucker@mcch.org.uk perrymans@mcch.org.uk Maidstone Community Care Housing Society Limited (MCCH) Mr Richard Tucker Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th February 2006 Brief Description of the Service: 23 Salisbury Road is registered to provide personal care and support to up to seven residents of either sex. The home is now operated by MCCH, having been taken over in 2002. The home is located in a residential area of Leyton, North East London. It is close to shops, community facilities and is well served by public transport. All residents have complex needs and require a high level of support and supervision. Residents are encouraged to maintain family relationships and some have regular visits home, including for overnight/ weekend stays. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by one inspector over the course of a day. The main focus of this inspection was to review progress made with requirements made at a previous inspection and to inspect key National Minimum Standards. During the course of the inspection the Inspector sampled service users files, toured the premises, met with the registered manager, deputy manager, and two care staff. There were no personal or professional visitors at the time of this inspection. Verbal feedback was given to the registered manager and the deputy manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home have addressed a number of requirements identified by previous inspections. However it was disappointing to note that some requirements were not met and would therefore be repeated again in this inspection report. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Salisbury Road DS0000007264.V314886.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 Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. There has been no admission since the last inspection. EVIDENCE: Although there has been no admission since the last inspection, the registered manager was able to discuss how the admission process would be managed for a prospective service user. Policies and procedures relating to admission process were inspected and deemed to be appropriate in relation to the National Minimum Standards (NMS). Evidence was seen of the service users contracts together with the statement of terms and conditions, which meets with the requirements in place. This was a requirement from the previous inspection, which has now been met. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, & 9 The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. The home develops an individual plan for each service user. However, these must be reviewed at least six monthly and be subject to a risk assessment. The home is now working towards ‘person centred planning’. EVIDENCE: The registered manager stated that the home is now working towards ‘person centred planning’ which will hopefully be implemented and reflected in the service users care plans and daily living. Three members of staff are currently undergoing the ‘person centred planning’ training, which, will be rolled out to other members of staff in due course. The inspector sampled two care plans which evidence that the home develops individual plan for each service users, and that this addressed their health, social and personal support needs. The inspector saw evidence that the care plan is drawn up with the involvement of the service user together with their families and relevant Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 10 professionals. The registered manager further stated that service users families are very much involved in their needs and undertake all advocacy services. The care plans in place evidence that the home enables service users to take responsible risks with appropriate risk assessment undertaken ensuring the safety and wellbeing of service users. Detailed risk assessments for activities such as: handling sharp objects, accessing the local community, holiday etc. was comprehensive. However, examination of these care plans showed that some sections had not been completed; that regular reviews of care are not held in line with the NMS, as there was no evidence available to demonstrate that a review had been held since 2004. The inspector also saw old records in a care plan, which was not reflecting the service users current changing needs. The emphasis of ensuring that current information relating to service users changing needs was discussed with the registered manager. However he stated that the home is now in the process of archiving old records. This was a requirement from the previous inspection report, which will be repeated in this report. Evidence of individual activity weekly planner printed in a pictorial format was seen which shows what service users are engaged in for the week. However it was unfortunate to note that this was not updated to reflect the service user current changing needs. The weekly planner seen by the inspector was last updated in June 2005. The registered manager stated that service users are supported to make decisions about their lives with assistance as needed. All staff had undertaken Makaton training, which has greatly improved communication with non-verbal service users. Great improvement has been noted in a particular service user with challenging behaviour. Service users are able to attend community meetings and have 1-1 meetings with their key workers. The inspector saw evidence that documentation promoting service users independence are printed in pictorial format e.g. weekly menu and staff rota. Due to their care characteristics, service users have limited ability to participate in the day to day running of the home but are encouraged to do so when appropriate. All service users finance is adequately managed and appropriately signed for by the registered manager. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Service users are encouraged and supported to engage in a range of educational and local activities. They are also supported to maintain appropriate contact with their families. EVIDENCE: Cross tracking of files and discussion with the registered manager indicates that service users are supported to attend college and other day service activities, which includes: Berkeley Farm (an autism friendly screenings theatre) and local leisure activities. Care plans inspected indicated that service users have a weekly activity planner, which shows activities for the day, but unfortunately this was not updated or filled in to reflect the change of activity in the case of one service user. However it was positively noted that the activity of the day, which was Aromatherapy, was clearly written on the board with a particular service user eagerly awaiting the arrival of the therapist. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 12 The registered manager stated that staff respect service users privacy and dignity. Discussion with staff and cross tracking of daily record files indicates that service users are been offered choice in what they do and where they spend their time. Service users were observed to have free access and movement around the home. Positive interaction was also noted between members of staff and service users. Two service users have support worker who works with them on a 1-1 basis. The registered manager stated that this additional input has greatly improved the behaviour and understanding of a service user with behaviour that challenges. On the day of the inspection there were three service users at the home, two attending day centre and one service user was at college. Service users are supported to maintain family links and friendships outside of the home. A service user was on home visit on the day of the inspection. Families are also kept up to date and involved with issues affecting service users. The deputy manager stated that the home is looking into re-introducing the relative meetings. Responsibility for preparing and cooking meals is shared amongst the staff group. The inspector viewed the menu and noted that a range of nutritious and varied meals is offered. The meals reflected the cultural and individual preferences of the service users. The inspector noted that the food cupboards were empty; however, the registered manager stated that the weekly food shopping is usually done late Tuesday or Wednesday. The registered manager was advised of the importance of ensuring that the home maintains sufficient quantities of suitable, wholesome and nutritious foodstuff as specified in the NMS. The manager stated that service users are all registered on the electoral role but have never voted. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home promotes service users physical wellbeing and its medication practices protect them. EVIDENCE: Nursing care is not provided at the home. Personal care is not generally provided at the home but prompting and support is offered when required. The home aims to meet individual service users needs, and times for getting up, going to bed, meals and other activities are therefore flexible and tailored to the service users individual plan. Staff on duty demonstrated a good knowledge of service users healthcare needs. Rotas were checked and showed that the ratio of male and female staff on duty is well balanced to cater for the needs of service users. During the visit, the inspector observed positive example of same/preferred gender care provision. e.g. a male service user receiving personal care from a male member of staff. The inspector was satisfied that members of staff are fully aware of service users needs and make appropriate referrals when required. For example, cross-tracking of service users personal files contained documented medical appointments to GP, dentist and out patients appointments. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 14 The home has an appropriate medication policy, which gives guidance to staff on the ordering, receiving and disposal of medication. Medication is stored in a locked cupboard in the office. Medication administration records were inspected and were deemed to be satisfactory. Medication is dispensed in blister packs by the local chemist. Inspection of the MAR sheet together with the actual medication available corresponded with the MAR sheet appropriately signed. The registered manager stated that staff would be attending refresher medication training in December. The inspector saw evidence that appropriate action was taken by the registered manager in regards to an incident of the mis-administration of medication. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home had an adult protection procedure in place, which ensures that service users views are listened to and protected from abuse. Staff had received appropriate adult protection training. However the responsible person must further ensure that staff are made aware of the whistle blowing policy. EVIDENCE: The deputy manager advised the inspector that no adult protection concerns had been reported since the previous inspection. The home is part of MCCH and has adopted the complaints and adult protection policies of the organisation. This includes types of abuse service users can experience and makes appropriate references to local adult protection guidelines. The policy also contains guidance for staff on the steps to follow should they have any adult protection concerns. The home also has a copy of the local authority adult protection policy. Complaints are generally made on behalf of residents by their relatives. The inspector saw evidence that complaints are responded to in an appropriate manner and that action is taken to resolve any issues raised. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 16 An easy pictorial version of the complaints procedure with contact details for the Commission for Social Care Inspection is in place and well displayed within the complaints record. However the inspector noted that this document has not been updated to reflect the current management changes within the organisation. The deputy manager stated that there is a separate whistle blowing policy in place. Staff spoken to by the inspector at the time of the inspection had some general knowledge of adult protection issues. However the staff further stated that they would benefit from having a refresher course in adult protection issues and was also not aware of the whistle blowing policy. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Service users benefit from a generally well maintained and comfortable home. EVIDENCE: The home comprises two converted houses in a residential area of Leytonstone. The house is indistinguishable from others in the street and is closes to local shops, amenities and public transport. The house is not accessible for wheelchair users. The home has undertaken a re-decoration program over the past few months. The two requirements issued in the previous inspection report in regards to the communal areas of the home to be made more homely and basic hygiene standard were found to have been satisfactorily met. It was positively noted by the inspector that service users pictures were hung in the communal area giving it a warm and homely feel. The home has also incorporated a ‘daily cleaning rota’ which ensure that all shared facilities are inspected and cleaned every hour when necessary. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 18 The deputy manager also stated service users had input with the recent decoration around the home, which was discussed during service users meeting. He expressed that this was partly achieved by showing the service users colour chats. All service users have a single bedroom and shared use of the home’s lounge, quiet room, dining room, kitchen and bathroom facilities. The service users bedroom inspected contained the required facilities and equipment in line with the National Minimum Standards. The bedrooms were noted to be generally well maintained with personal furniture. The inspector noted that the home was generally clean, hygienic and free from offensive odours. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. The home is part of the MCCH group and uses employment policies and procedure of that organisation. However, the home must ensure that all support staff are supervised at least six times a year. The home must also ensure that the control sheet in regards to staff personal details must be adequately filled and available for inspection. EVIDENCE: In addition to the registered manager, the home employs a deputy, one senior support worker, twelve support staff and two casual workers. MCCH operates a central human resources department that retains all personal records. A local file is held at the home that includes a control sheet detailing the pre employment checks completed prior to the support worker taking up their post. Through discussion with staff and the management team, the inspector was satisfied that staff are aware of their roles and responsibilities. The inspector Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 20 observed that staff interacted well with service users and are fully aware of their needs. Inspection of the rota indicates that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. There is a minimum of three members of staff on duty throughout the day and one waking night plus a sleep-in staff. Rota seen at the time of the inspection accurately reflected the staff on duty. There is an on call emergency procedure in place. It was disappointing to note that the control sheet did not contain all the relevant information required in regards to Schedule 2 as stated in the Regulations. There was no evidence to indicate that some members of staff had two references (copies not attached to the control sheet) and CRB section was not appropriately filled in. This was a requirement from the previous inspection report, which will again be repeated in this report. Staff meetings are held regularly; the inspector saw evidence of a staff meeting taking place during the course of this inspection. Evidence of training certificates was seen on staff files, which included courses, attended such as: manual handling, basic food hygiene and adult protection. However staff spoken to during the inspection stated that they would benefit from an in-depth refresher course in adult protection and the whistle blowing policy. Evidence of the NVQ certificates at the time of the inspection indicates that the home is below the required standard as stated in the NMS which specifies that at least 50 of the work force should have undertaken either NVQ level 2 or 3 in care by 2005. Inspection of staff records indicated that staff are not adequately supervised in line with the NMS. All members of staff must receive six supervision sessions per year and records maintained to evidence this. Salisbury Road DS0000007264.V314886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. Service users benefit from a generally well run home. However the home must ensure that quality assurance is developed to include the views of service users and their relatives. EVIDENCE: The inspector was satisfied through discussions and observations that the registered manager who has considerable experience in management and working with people with learning disabilities is aware of his role and responsibilities to run the care home in line with its stated purpose. A requirement issued in regards to the food safety and general hygiene has now been met. The registered manager stated that staff had training in regards to food and hygiene and the inspector saw a ‘safe food better business’ manual, which all staff are expected to read. Cleaning duties and responsibilities is also discussed during handover. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 22 Positive interaction was noticed between members of staff and service users were friendly, open and appeared comfortable within the home. Staff spoken to during the inspection felt that the atmosphere within the home is generally good and felt able to raise concern with the management team should they need to. Records seen during the inspection in relation to Schedule 4 of the Care Standard Act were generally of good standard. However, as previously stated the control sheet did not contain the required information ensuring the safety and wellbeing of service users. The inspector saw evidence that portable electrical appliances and fire alarm system were appropriately tested and recorded. Other health and safety checks, which includes water temperature, fire drill, and gas check have been satisfactorily maintained. However it was noted that the fridge/freezer temperature had not been adequately maintained as specified in the home’s guideline sheet. The inspector discussed with the deputy manager the importance of ensuring the home develop quality assurance process which should include feedback from service users, their relatives and other professionals. It was stated by the deputy manager that the home is looking into re-introducing the relative meeting. Salisbury Road DS0000007264.V314886.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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 3 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 2 3 Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The responsible person must ensure that the care needs of service users is regularly reviewed and changing needs/ aspirations met. Repeated Requirement The responsible person must ensure that old records no longer in use must be removed from care files to avoid confusion in delivery of care. Repeated Requirement The responsible person must ensure that the complaint procedure is updated to reflect the current management team. The responsible person must ensure that staff are aware and have understanding of the whistle blowing policy. The responsible person must ensure that the control sheet contains the entire relevant requirements as specified in Schedule 2 of the Care Standards Act. Repeated Requirement The responsible person must ensure that at least 50 of staff are NVQ level 2 or 3 qualified. DS0000007264.V314886.R01.S.doc Timescale for action 31/01/07 2. YA6 15 31/01/07 3. YA22 22 31/01/07 4. YA23 21 31/01/07 5. YA34 17 18/12/06 6. YA35 18. (1)(a) 31/01/07 Salisbury Road Version 5.2 Page 25 7. 8. YA36 YA39 18. (2) 24 9. YA42 16 The responsible person must ensure that staff are supervised six times a year. The responsible person must ensure that quality assurance process is developed to include the views of service users, relatives and professionals. The responsible person must ensure that the fridge temperature is maintained within acceptable limit. 31/01/07 31/01/07 28/12/06 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 YA35 Good Practice Recommendations The responsible person must ensure that all members of staff are provided with refresher training course in regards to adult protection. Salisbury Road DS0000007264.V314886.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Salisbury Road DS0000007264.V314886.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!