Inspection on 23/05/05 for Sampson Avenue

This inspection was carried out on 23rd May 2005.

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

Other inspections for this house

Sampson Avenue 13/08/07

Sampson Avenue 04/09/06

Sampson Avenue 08/12/05

Sampson Avenue 04/01/05

Sampson Avenue 30/09/04

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Norbury Crescent (30)

Edenvale

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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 27 SAMPSON AVENUE Barnet Hertfordshire EN5 2RN Lead Inspector Anthony Lewis Announced 23rd May 2005 at 09.00am 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 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 Stationary 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. 27 SAMPSON AVENUE Version 1.10 Page 3 SERVICE INFORMATION Name of service 27 Sampson Avenue Address 27 Sampson Avenue, Barnet, Hertfordshire EN5 2RN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8449 0142 Cedric Frederick for PentaHact Jackie Driscoll PC Care Home only 6 Category(ies) of LD Learning Disability registration, with number PD Physical Disability of places 27 SAMPSON AVENUE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Limited to 6 adults who have a learning disability (LD) and who may also have a physical disability (PD). Date of last inspection 4 January 2005 Brief Description of the Service: 27 Samson Avenue is a purpose built care home registered for six adult males and females with learning and physical disabilities. The home was opened in 1993 and is run by PentaHact, an organisation based in Barnet, specialising in operating care homes and supported living projects for people with learning disabilities. Metropolitan Housing Association own the building and it is maintained jointly by Metropolitan Housing Association and PentaHact. The home is situated on a relatively new housing estate in Barnet. Shops and local aminities are a short walk from the home. To the front of the home is a large garden with shrubs and plants and off street parking. To the rear is a large garden with two sheds and garden furniture. 27 SAMPSON AVENUE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on Monday 23rd May 2005 at 9am and was completed at 4.30pm. The registered manager and assistant manager were available throughout the inspection and were very helpful and accommodating. Only one resident’s was spoken to briefly. One of the residents was out all day and the other four were not able to fully participate verbally due to their communication difficulties. Four members of the staff team were spoken to individually and in private in the office. To gather further information for this report, a tour of the home was conducted with the registered manger. Comment cards were viewed from, two general practitioners, three relatives and three from residents. The pre-inspection questionnaire was also used to gather information. The inspector also attended the staff team meeting. What the service does well: What has improved since the last inspection? The registered manager and the assistant manager have made many positive changes to the home since they took up posts nearly a year ago. A new service user plan format has been devised, bedroom three and six have been redecorated, the external door to the utility room has been replaced, the old furniture outside in the garden has been removed, the light cover in the kitchen has been cleaned, staff files contain a photograph of them and there is an absent without leave policy in place. The staff have ensured that the chest of drawers in bedroom four have been replaced and a pressure care risk assessment has been carried out. All trip 27 SAMPSON AVENUE Version 1.10 Page 6 hazards in the lounge have been removed and bedroom six now has a self closing “door guard”. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 27 SAMPSON AVENUE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection 27 SAMPSON AVENUE Version 1.10 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 standard(s) 1, 3 and 4. Prospective residents to the home are given misleading information and are therefore not able to make an informed choice as to whether to move into the home or not. EVIDENCE: Although the home has a statement of purpose and a service users guide, on viewing them, they were both found to be inaccurate. Both the statement of purpose and service users guide had the name of National Care Standards Commission instead of Commission for Social Care Inspection and the address of the Commission needs to be included. The home has had a new manager for a year and there are new staff working in the home and some staff have left in the past year. A requirement is made that the registered persons ensure that the statement of purpose and service user guides are updated to reflect the present situation in the home and that a copy of the statement of purpose is sent to the Commission. Five of the residents have physical disabilities and are supported by specialised equipment such as two hoists and a specially adapted bath. The home also has a lift. Staff files were viewed and seen to contain certificates on training courses relevant to the residents that they support such as manual handling, health and safety and risk assessments. 27 SAMPSON AVENUE Version 1.10 Page 9 The home has a PentaHact moving in policy and procedure file, which includes information for prospective residents to the home on; nominations for the vacancy, when one occurs, the procedures for visiting the home and the procedures for moving into the home. 27 SAMPSON AVENUE Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10. The staff team are ensuring that they are able to meet all of the resident’s individual care needs and support them with the choices that they make and that residents will be supported in taking reasonable assessed risks. EVIDENCE: At the previous inspection, a requirement was made that the registered manager review all of the resident’s care plans to meet the required standards by 01 April 2005. This has been done and the registered manager has produced a comprehensive care plan format in February 2005, which includes detailed information on the care provided by the home. A written agreement between PentaHact and each resident was seen as per a requirement from the previous inspection regarding the decision process for resident’s Disability Living Allowance (DLA), being used to pay for the hire of a vehicle. According to the registered manager, the agreement was made in May 2004 at a meeting attended by the operations manager, the registered manager and a care manager. Another care manager and resident’s family were spoken to on individual occasions. The decision was made that in order to support residents who use wheelchairs and need specially adapted transport, a mini bus would be the most practicable cost effective method of travelling due to the expense of tacking mini cabs and the unreliability of taxis and the lack 27 SAMPSON AVENUE Version 1.10 Page 11 of space. The monthly cost for the mini bus is £650, which has been divided between the six residents. A copy of the risk assessment on residents at risk of developing pressure sores was carried out on 07 April 2005 and a copy retained in each resident’s file. Various other risk assessments were seen in resident’s files relating to bathing and mobility. There is a policy and procedure on confidentiality in the home. The home also has a policy on access to resident’s files. The registered manager said that the residents or their family are allowed to view the files. All residents have their own filing drawer, which holds confidential information on them and is locked when not in use. 27 SAMPSON AVENUE Version 1.10 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 16 and 17. Residents are confident that the staff team will support them in developing their social skills and ensure that they are a valued part of their community and are able to participate in community and house activities. EVIDENCE: Staff ensure that the residents participate in various activities. An activities chart was seen on the office wall with resident’s activities throughout the week. There was also information in resident’s care plans regarding their hobbies and interests. One resident said that he enjoys going to the gym once a week. The registered manager said that residents go out shopping for food and clothes and staff ensure that residents who wish to go to church are supported to do so. On the day of the inspection, one resident was out at a day centre and another one went out to a day centre later on. The registered manager said that residents go to the pub and out to restaurants and out to do their own personal shopping with staff support, this was seen on resident’s care plans. 27 SAMPSON AVENUE Version 1.10 Page 13 Staff were observed knocking on resident’s bedroom and bathroom doors and asking their permission to enter. All but one of the residents uses a wheelchair to move about the home. One resident was seen moving about the home freely, without restrictions and with staff support when necessary. Another residents moved about freely in his wheelchair. The home has a gate at the top of the stairs. When asked about this, the registered manager stated that there is one resident who might fall down the stairs in his wheelchair and at times he crawls about on the floor in his bedroom and in the passage. There was no information regarding this in his care plan. A requirement is made that the registered providers ensure that where residents are restricted from moving about the home freely, that the reasons are agreed with the resident or their representative and recorded in their care plans. The home’s menu was seen and contained a variety of wholesome and nourishing meals. Two residents were asked if they liked the meals prepared, both said that they enjoyed the meals. The registered manager said that at the weekly house meeting, residents have the opportunity to discuss the menu for the week ahead. The lunchtime meal was taken with the residents in the dining room and was tasty and nourishing. Staff were supportive of residents who have difficulty eating and ensured that residents were given the choice of drinks. The atmosphere at lunch was congenial and unrushed. 27 SAMPSON AVENUE Version 1.10 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. Residents are confident that the staff team have the necessary training and advice to support them with their physical disabilities and that the home is adapted to meet their physical needs. EVIDENCE: The home has two hoists for lifting and transferring most of the residents. Staff files viewed, were seen to contain their certificates in moving and handling. In resident’s files, there was information on their likes and dislikes such as how they wish to be treated by staff. Staff spoken to said that resident go to bed and get up when they are ready. The staff team have been working closely with an Occupational Therapist to ensure that the home has the appropriate equipment and advice to support residents and to ensure that staff are aware of and trained to support residents with physical disabilities. Records kept in the home for accidents and incidents showed that three residents have been taken to accident and emergency in the past twelve months, none for any major injury. One resident has a pressure sore. The registered manager stated that the district nurse comes in regularly to treat it and staff monitor it daily. 27 SAMPSON AVENUE Version 1.10 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 standard(s) 22 and 23. Staff are not able to fully support residents who report allegations of abuse due to lack of training and complaints may be overlooked and not recorded due to the home not having a complaints book. EVIDENCE: The home has a policy and procedure manual on how to make a complaint. There is also information in the statement of purpose regarding making a complaint and information was seen regarding complaints on the notice board in the office. At the previous inspection, the staff were not able to locate the complaints book. At this inspection, the registered manager said that there has not been any complaint in the past twelve months and that the home does not have a complaints book. A requirement is made that the registered persons ensure that the home has a complaints book. The home has a policy and procedure file on adult protection. Staff spoken to said that they are aware of the whistle blowing procedure. No staff have been referred for inclusion on the POVA list. On speaking to the registered manager and looking through staff’s files, a number of staff have not as yet had protection of vulnerable adults training. A requirement is made that the registered persons ensure that all staff receive training in adult protection. 27 SAMPSON AVENUE Version 1.10 Page 16 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 standard(s) 24, 26, 27, 29 and 30. Metropolitan Housing Association and PentaHact are not taking seriously the resident’s care needs. Staff are supporting residents in an undignified manner due to the inadequate specialist equipment provided in the home. Although previously identified at inspections, parts of the home are still shabby and in desperate need of repair. EVIDENCE: On a tour of the building, there were a number of maintenance and health and safety issues that were identified. Some of the issues identified at the previous inspection have been met such as the garden is more secure with high fencing to prevent intruders from entering and the broken furniture in the garden has been disposed of. The external door of the utility room and the ironing board, have been replaced. The light cover in the kitchen has been cleaned. The stained carpets in the office, lounge, hall and corridors identified at the previous inspection, as needing replacing has not been met. A requirement is made that the carpets in the office, lounge, hall and corridors be replaced. This requirement is restated. 27 SAMPSON AVENUE Version 1.10 Page 17 The home has a lift for transporting residents from one floor to another. However, the home does not have guidelines in place and staff have not been trained in what action to take in the event of the lift breaking down with passengers in it. A requirement is made that the registered persons ensure that the home has guidelines in place, as to what action is to take in the event of the lift breaking down with passengers’ inside. A requirement that the broken chest of drawers in bedroom four be removed has been met. On a tour of the home, it was noticed that the downstairs toilet and utility room had not been redecorated. A requirement was made that the previous inspection that they be redecorated by 01 February 2005, this requirement has not been met and is restated. A requirement was made at the previous inspection that bedrooms three and six be redecorated by 01 April 2005. Neither of the bedrooms has been decorated. This requirement is restated. All bedrooms have been furnished to meet the needs and personality of the residents who occupy them. All bedrooms have wash hand basins. The broken chest of draws in bedroom four identified at the previous inspection, have been replaced. The bathrooms and the shower room were viewed on a tour of the building. In the upstairs bathroom a number of tiles were missing from the walls. A requirement is made that the missing tiles in the upstairs bathroom be replaced. A requirement was made at the previous inspection that the facilities in the bathrooms and shower room were unsatisfactory for the residents in the home. It was recommended by an Occupational Therapist that the downstairs bathroom and the shower room be renovated and the upstairs bathroom be changed to a shower room with a ceiling track hoist. In all the Occupational Therapist made nineteen recommendations in her report. A requirement was made that PentaHact respond to the Commission in writing informing them of their actions to attend to the recommendations. The timescale of 01 March 2005 was not met. At this inspection, the registered manager said that she has been liaising closely with the Occupational Therapist, who is compiling an action plan and that a copy will be sent to the Commission. This requirement is restated. 27 SAMPSON AVENUE Version 1.10 Page 18 All areas of the home were found to be clean and free from offensive odours. The home has an infection control procedure manual and information on infectious diseases and the risk to people in the home. The registered manager stated that a cleaner is being employed on a part time basis in the near future. 27 SAMPSON AVENUE Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 36. Resident’s quality of care is being compromised because staff’s personal development is not being taken seriously due to the lack of supervision and staff training in order to ensure that staff are competent and suitably qualified to NVQ2 level. EVIDENCE: Three support workers were spoken to separately and in private and although all have a good understanding of their roles and responsibilities none has yet started the NVQ2 in care, as was a requirement at the previous inspection. The registered manager stated that PentaHact has appointed an NVQ assessor and that three staff will be registered soon. At present, only the registered manager and the assistant manager have level NVQ3. A requirement is made that the registered persons ensure that at least 50 percent of staff, achieve a care NVQ2 qualification by 2005. This requirement is restated. The registered manger stated that a review of the staffing levels will soon be taking place with a view to increasing the staff at peak times in the home to support residents. At present there are three staff on the early and late shifts and two night staff. The staff have team meetings every two weeks. On the day of the inspection, a team meeting was scheduled for 1pm, which went 27 SAMPSON AVENUE Version 1.10 Page 20 ahead and lasted for approximately one and a half hours. A member of staff took the minutes. On viewing four staff files, there were minutes of supervisions although on looking further, it was noticed that supervisions have been irregular. One member of staff’s supervision record showed that her last supervision was in July 2004. A requirement is made that all staff must have a minimum of six supervisions a year and that a record is kept in the staff’s file. 27 SAMPSON AVENUE Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40 and 42. Resident’s are confident in the knowledge that the home is being run by an experienced and manager and that their safety and welfare is taken seriously. In order for all of the staff team to feel confident with the management approach, concerns must be dealt with immediately when they come to light. EVIDENCE: The registered manager said that she has a NVQ3 in care and that she has been an acting manager at another home for two year. She had a good knowledge of the residents and the issues regarding staffing and staff skills and competences. The registered manager has been in post for the past twelve months. According to two staff that were spoken to, there have been many positive changes to the way in which the home is managed. However, another member of staff stated that she was not happy with the way in which the registered manager communicates with her at times and was not comfortable meeting 27 SAMPSON AVENUE Version 1.10 Page 22 with the registered manager so has spoken to the assistant deputy instead. When mentioned to the registered manager and the assistant manager, both said that they were aware of the staff’s concerns and are dealing with them. A requirement is made that the registered manager ensures that all staff concerns are responded to and recorded. All policies and procedures were seen to be on display on shelves in the office where staff and residents have easy access to them. An absent without leave policy was seen, which was a requirement from the previous inspection. On a tour of the building, all areas were seen to be safe for residents. The electrical leads highlighted at the previous inspection was moved and tucked away safely and the door to bedroom six was not seen to be propped open with a chair and has now been fitted with a self closing “door guard”. Certificates of safety and fire drills will be inspected at the next inspection. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 27 SAMPSON AVENUE Version 1.10 Page 23 CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 2 x 1 3 Standard No 11 12 13 14 15 16 17 3 3 x x x 2 x Standard No 31 32 33 34 35 36 Score x 2 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x 3 x 27 SAMPSON AVENUE Version 1.10 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 YA1 Regulation 4 (2), Schedule 1. 15 (2) (b) (d) Requirement The registered persons must ensure that the statement of purpose and service user guide is updated to reflect the present situation in the home and that a copy of the statement of purpose is sent to the Commission. The registered persons must ensure that any restrictions of movement to residents are agreed with the resident and recorded in their care plan. The registered persons must ensure that the home has a complaints book for recording any complaints. The registered persons must ensure that all staff receive training in adult protection (Timescale of 01/02/05 not met). The registered persons must ensure that the stained carpets in the office, lounge, hall and corridors are replaced (Timescale of 01/04/05 not met) The registered persons must ensure that the downstairs toilet and utility room be redecorated. (Timescale of 01/02/05 not met). Version 1.10 Timescale for action 03/06/05 2. YA16 15 (1) (c) 03/06/05 3. YA22 22 (1) 03/06/05 4. YA23 18 (1) (c) (i) 29/07/05 5. YA24 23 (2) (d) 17/06/05 6. YA24 23 (b) (d) 29/07/05 27 SAMPSON AVENUE Page 25 7. YA24 18 (1) (c) (i) 8. YA27 23 (2) (b) 9. YA29 23 (2) (n) 10. YA32 18 (1) (c) (i) (ii) 11. YA36 18 (2) 12. 13. YA38 21 (2) The registered persons must ensure that there are guidelines in place in the event of the lift breaking down with passengers inside. The registered persons must ensure that the missing tiles in the upstairs bathroom are replaced. The registered persons must ensure that an action plan is forwarded to the Commission setting out what action is being taken to comply with the recommendations made by the Occupational Therapist regarding the bathrooms and shower room. This requirement is revised and restated. (Timescale of 01/03/05 was not met). The registered persons must ensure that at least 50 of staff, achieve their NVQ2 in care by 2005. (Timescale of 01/02/05 not met). The registered persons must ensure that all staff have a minimum of six supervisions per year and that a record is kept in the staff’s file. The registered persons must ensure that all staff concerns are responded to and recorded. 24/06/05 24/06/05 10/06/05 30/09/05 17/06/05 03/06/05 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. 2. Refer to Standard Good Practice Recommendations 27 SAMPSON AVENUE Version 1.10 Page 26 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 27 SAMPSON AVENUE Version 1.10 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. 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