Inspection on 04/07/06 for St Edwards (6).

This inspection was carried out on 4th July 2006.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Edwards (6). 16/07/07

St Edwards (6). 23/09/05

St Edwards (6). 25/05/05

St Edwards (6). 22/11/04

St Edwards (6). 21/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Edwards (6) 6 St Edward`s Close New Addington Croydon Surrey CR0 0EL Lead Inspector Peter Stanley Key Unannounced Inspection 4th July 2006 9:30am St Edwards (6) DS0000025839.V300163.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 St Edwards (6) DS0000025839.V300163.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. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edwards (6) Address 6 St Edward`s Close New Addington Croydon Surrey CR0 0EL 01689 800 960 01689 800 861 croydon@nas.org.uk Vanessahalfacre@nas.org.uk National Autistic Society 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) Care Home 12 Category(ies) of Learning disability (12) registration, with number of places St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2005 Brief Description of the Service: St Edwards is situated in a quiet close in New Addington near to local shops and trams. The National Autistic Society leases the building from Croydon Churches Housing Association. All service users have been identified as having an autistic disorder. The service provides residential care for twelve residents in two houses, which are separated by an attractive garden area. One of the houses is for male residents only, the other is shared between male and female service users. All residents have a single room; all contain a wash hand basin although some are not in use. This is due to the particular needs of the person occupying those rooms and has been agreed with the registration authority as being in their best interests. The furniture in some bedrooms has also been specially adapted where necessary. In addition to the bedrooms there is a communal lounge, dining room, a kitchen, toilets and bathroom in each house. Each house has its own staff team, with one waking member of staff allocated to each and one member of staff sleeping in. Residents attend Coney Hall Day Centre in West Wickham from Monday to Friday. This is housed in the same building as many of the National Autistic Societys regional administrative functions such as personnel, and was seen during the course of this announced inspection. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. St Edwards is a purpose-built home for adults who have autism or aspergers syndrome. There are two houses within the home with a gender divide, each accommodating six residents. Female residents are accommodated in The Willows while male residents are accommodated in The Conifers. This unannounced inspection was conducted over one day. Following the departure of the previous manager in March 2006, the area manager is currently managing the home, with the assistance of a recently appointed deputy manager. Given her other duties this arrangement is not ideal, but it was confirmed (by the area manager) that it is hoped that a new registered manager will be appointed in the near future. Given the vulnerability of this service user group, and the relative managerial inexperience of the recently appointed deputy manager, the inspector is concerned that there is not any undue delay in appointing a new registered manager. This unannounced inspection was conducted over six hours, during which the inspector examined policies, procedures, service user, staff and service user records, and other documentation relating to the management and running of the home. This involved visiting both the home and the NAS (National Autistic Society) Day Centre at Coney Hall where staff records are kept, and where he met a number of day care staff and service users. The inspector also spoke to a senior support worker at the home. Feedback from both residential and day care staff was generally very positive, with staff feeling valued, and being given the necessary support with which to effectively carry out their duties. The inspector was, however, concerned to note that staff supervision has not been taking place as regularly as it should, and expects to see an improvement in this area. While the inspector was unable to engage verbally with those service users that he met, he was, through a process of non-verbal interaction and observation, able to ascertain that service users feel settled and well supported in their daily environment, and are being enabled to develop their social, communication and living skills. The inspector was, once again, generally impressed with the standard of care and support provided to service users, and with the commitment shown by the home’s management and staff in creating an enabling and inclusive home environment. As a result of this inspection there are nine new requirements and six recommendations. The inspector would like to thank the area manager and staff for their cooperation throughout this inspection. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 6 What the service does well: The home is able to demonstrate that the range of needs presented by service users are being properly assessed. The home has a thorough and ongoing process of assessment and review in place. Staff are provided with the training, support and knowledge base required with which to meet the needs of this service user group. Each service user is provided with a service agreement. This is written in a format, which is appropriate to the communication needs of the service users. Service users are having their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. Service users are assisted to participate fully in the day-to-day life and routines of the home, and are supported in making decisions for themselves in their daily activities. Staff work with service users in an enabling and clientcentred way, with service users being consulted regarding matters which affect them and their lives within the home. Service users are thoroughly assessed regarding potential risks to their health and safety, and are positively enabled to take responsible risks wherever possible. Service users know that information about them is handled appropriately. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 7 Service users are provided with opportunities for participating in a varied range of day care activities and for developing their interests and abilities. The home actively encourages service users to maintain family links and friendships, to visit relatives/friends, and to receive visitors. The home provides guidance and support in enabling service users to develop appropriate peer relationships. The rights and responsibilities of service users are respected and recognised in their daily lives. Service users are provided with a healthy and nutritious diet in pleasant and homely surroundings. Individuals are consulted and enabled to make an informed choice regarding the available menu options. Mealtimes are flexible and take account of service users’ activity schedules. Service users’ personal support, physical and emotional health care needs are being well met in this home, with support being planned and tailored according to the individual needs presented. Service users are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. An up-to-date pharmacy inspection is, however, required. Whilst, generally, service users’ wishes regarding the eventuality of their ageing, illness and death are being respected, there is a need for staff to receive bereavement training so as to better support relatives and other service users when a death occurs. There is also a need to involve service users and their relatives in planning ahead for their future care as older adults. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available in an appropriate format for service users. Service users are being protected from abuse by the home’s adult protection practice, policies and procedures. The home has a rolling programme of training, which is ensuring that all staff undertake adult protection training. Service users live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Service users’ rooms present as safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Generally, the home presents as having the necessary aids and adaptations in place with which to meet the collective needs of the home’s service users. An OT assessment of the home would, however, assist in identifying any scope for further improvements. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 8 Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Service users are having their needs well met by an appropriately trained and qualified staff group. Service users are being supported and protected by the home’s recruitment policy and procedures. What has improved since the last inspection? What they could do better: Prospective service users are being provided with the information they require, and the opportunity to visit and stay overnight, before deciding whether the home is likely to meet their needs. However, both the Statement of Purpose and the Service User Guide must be reviewed annually so as to ensure that the information given is up-to-date. Whilst, generally, service users’ wishes regarding the eventuality of their ageing, illness and death are being respected, there is a need for staff to receive bereavement training so as to better support relatives and other service users when a death occurs. There is also a need to involve service users and their relatives in planning ahead for their future care as older adults. Generally, the home presents as clean, pleasant and hygienic. Staff training in infection control is, however, required if standards of hygiene are to be maintained and improved. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 9 Whilst, generally, staff are being supported in meeting service users’ best interests, the home has not been providing staff with sufficiently regular supervision in recent months. While the home is generally being managed in the best interests of the home’s service users, the home is presently lacking the leadership of a full-time registered manager. Service users can generally be confident that their views underpin selfmonitoring by the home. The home needs, however, to further extend its consultation processes, and evidence its performance by producing a quality assurance audit and development plan. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. Fire drills should, however be held on at least a monthly basis. 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. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 10 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 St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 11 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 to 5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users are being provided with the information they require, and the opportunity to visit and stay overnight, before deciding whether the home is likely to meet their needs. However, both the Statement of Purpose and the Service User Guide must be reviewed annually so as to ensure that the information given is up-to-date. The home is able to demonstrate that the range of needs presented by service users are being properly assessed. The home has a thorough and ongoing process of assessment and review in place. Staff are provided with the training, support and knowledge base required with which to meet the needs of this service user group. Each service user is provided with a service agreement. This is written in a format which is appropriate to the communication needs of the service user. EVIDENCE: The home has compiled a statement of purpose. This outlines the aims and objectives of the home, and the facilities and services it provides. The Statement of Purpose includes all the information detailed in Schedule 1 of the St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 12 Care Homes Regulations (2001). The home has developed a service user’s guide which is called a ‘Welcome Pack’, and is written in a format/language suitable for the service users. This contains all the elements of regulation 5(1)(2)(3). The inspector found that neither the Statement of Purpose or the Service User Guide had been reviewed within the last 12 months; this is essential for up-todate information to be made available. A requirement applies. The home also has a Welcome Pack which includes information that service users are expected to be involved in. This includes the upkeep of their room, their laundry and to contribute to the communal household tasks. It also gives general information in reasonably simple statements about the running of the service. There have not been any admissions within the last 12 months. Decisions about admissions are taken by a panel from St Edwards. This includes senior staff and a range of other professionals who know the service user. Staff from St Edwards carry out thorough and detailed assessments, with assessment visits being made to the service user and family. A comprehensive history is obtained. This includes a history of behaviours and medical diagnosis. Prospective service users visit the home, usually with family members, when a placement is being considered. The initial visit takes place when other users are not present. The prospective service user is then invited to an evening meal with other service users. Overnight stays may be arranged but this depends on the needs of the individual. Service users are offered a six-month trial period with a review after three months. This is to allow for a full assessment and is normal professional practice within the NAS (National Autistic Society). The home aims to meet the specialist needs of people diagnosed with autism and asperger syndrome. All service users have communication difficulties, and some present challenging behaviour. Individuals’ cultural and religious needs are met in consultation with family members. While some users possess varying degrees of verbal understanding and ability to communicate, others are unable to do so and use Makaton or other systems for communicating. The inspector was able to observe, on the day of inspection, both residential and day care staff (at the NAS Coney Hall day centre) interacting with service users. This evidenced that staff use various means to engage with service users, and have acquired relevant communication and social skills with which to interact in a patient, caring and skilled way. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 13 The NAS has a comprehensive and ongoing programme of staff training, which includes autism awareness training and training in specialist teaching techniques. Training in how to manage challenging behaviour is also provided. The home’s approach is to try and identify triggers and take preventative action if possible, using the least intrusive method of control if this is required. The inspector spent some time observing a small number of service users at the home and at the Society’s Coney Hall day centre. Through observation and engagement with staff and service users, he felt satisfied that service users’ support needs are being appropriately addressed and that service users present as settled and well supported. There is an emphasis on one-to-one working, with a keyworker being allocated for each service user. Day care staff include workers with specific skills, including social skills, art, dance and drama therapy. Two assistant psychologists are available for assessment and support sessions with service users, with access to consultation from a clinical psychologist. From the feedback given by staff, service users and relatives, and the information provided regarding staff support and training (standards 31 to 36), the specialist needs of this group are evidenced as being well met. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 14 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 to 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are having their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. Service users are assisted to participate fully in the day-to-day life and routines of the home, and are supported in making decisions for themselves in their daily activities. Staff work with service users in an enabling and clientcentred way, with service users being consulted regarding matters which affect them and their lives within the home. Service users are thoroughly assessed regarding potential risks to their health and safety, and are positively enabled to take responsible risks wherever possible. Service users know that information about them is handled appropriately. EVIDENCE: St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 15 The inspector examined a small sample of service users’ files. These detail a range of individualised health and social needs with guidelines on necessary interventions for each user. The home’s approach is to try and identify triggers and take preventative action if possible and use the least intrusive method of control if this is required. There is a detailed care plan and individual learning plan for each service user, together with individual risk assessments, a health check and medication profile. Service users’ care plans provide information relating to users’ support needs and short term goals throughout the year. These are signed and dated, and are being reviewed on a regular basis. There is also an annual formal review to which the service user’s keyworker, care manager, nearest relative(s), friend or advocate, and any involved professionals, are invited to attend. These were all evidenced to have taken place for those files that were sampled. Service users are assisted to make decisions about admission to the home and which activities interest them. Each service user has a key worker who provides individualised support, assists day-to-day decision-making, and provides support at reviews. Independent advocates are used, whenever possible, in drawing up and reviewing the individual care plan. The inspector inspected the minutes of service users’ meetings, and has spoken to both staff members, and relatives of service users. Engaging with service users directly was problematic due to very restricted communication abilities. Feedback and observation indicated, however, that service users are being realistically involved in making choices and decisions for themselves regarding their day to day routines and activities, and that their views and feelings are being respected. Service users are being consulted regarding their support and care needs, their interests and activities, their likes and dislikes, preferred choice of food, and wishes regarding holidays away with relatives, friends or staff. Service users are also involved in staff recruitment. Short listed candidates are invited to the home prior to the final offer of appointment and service user reactions taken into account. The finance officer of Croydon NAS (National Autistic Society) acts as appointee for some service users, while others are represented by their families. Financial records are appropriately maintained. Service users are actively encouraged to manage small amounts of money where possible. Where support is needed, the reason for, and manner, of support is documented in care plans and regularly reviewed. All the home’s service users have Bank accounts. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 16 Service user meetings are held on a weekly basis, and service users are also involved in a committee at the ‘Transitions Project’. The inspector was concerned to note that copies of minutes of recent service user meetings were not found on site, and not available in the files maintained for this purpose within each of the two units, Willows and Conifers. A requirement applies. Service user questionnaires, written in an appropriate format, cover all aspects of day to day living and activities, also provide a means for ascertaining service users’ wishes and choices. The home has a policy of encouraging positive risk taking. Each activity undertaken is risk assessed. Service users’ files inspected included a range of risk assessments covering a range of identifiable risks, together with risk management strategies. These indicated that service users potential for developing independence is encouraged and enabled wherever possible, subject to safe strategies for managing risks being in place. Files contain service user details and photos. Service users are supported to use local shops independently and to undertake small monetary transactions. There is training with view to enabling individuals to access public transport and travel independently. All service users are given ID cards to carry with them when going to places they are not familiar with. Staff have mobile phones when supporting service users in the community. A Missing Persons Policy is in place. The home has a confidentiality policy in respect of personal information held in relation to service users. The policy states that service users have the right to access personal information held about them by the home. The NAS is a registered organization under the Data Protection Act. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 17 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): 11 to 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with opportunities for participating in a varied range of day care activities and for developing their interests and abilities. The home actively encourages service users to maintain family links and friendships, to visit relatives/friends, and to receive visitors. The home provides guidance and support in enabling service users to develop appropriate peer relationships. The rights and responsibilities of service users are respected and recognised in their daily lives. Service users are provided with a healthy and nutritious diet in pleasant and homely surroundings. Individuals are consulted and enabled to make an informed choice regarding the available menu options. Mealtimes are flexible and take account of service users’ activity schedules. EVIDENCE: St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 18 Documentation such as the ‘Welcome Pack’ sets out the aims of the home, which include providing individuals with opportunities for development. The large majority of service users regularly attend the NAS day centres, one of which, ‘Transitions’, in Croydon, is primarily for those who have higher functioning Aspergers Syndrome and Autism. The Coney Hall day centre, which a larger group of service users from the home attends, provides specialist day care for service users with autism, and includes both residents from St Edwards and users who live in the community. Staff from St Edward’s accompany and support service users to each of the two day centres where there are also trained day centre staff. The inspector visited the day centre, based in Coney Hall. The centre provides a structured programme of activities, which is tailored according to the needs of each service user. Activities include art, woodwork, drama, computer use, writing skills, and communication sessions. A sensory room is also available. The inspector met with both service users and staff. Whilst it was not possible to engage verbally with most of the service users, the inspector was able to ascertain that service users were purposefully engaged in day care activities, and ably supported by staff (with one-to-one working) in encouraging their participation and developing their skills and interests. The inspector was impressed with the knowledge, skills and commitment evidenced by the staff present, and with the positive interactions observed between staff and service users. Lunch, snacks and drinks are provided at the centre, pictorial symbols being used to denote the choices on offer. Staff maintain records relating to the daily routines and progress of service users. These are well maintained and evidence an ongoing record of each service user’s attendance, activities and development. The activity programmes of service users are reviewed at six-monthly intervals with both service users and relatives being consulted regarding any changes that they would like to see introduced or altered. The Transitions Day Centre, based in West Croydon, offers a specialised day care service for service users with Aspbergers Syndrome. Care staff from the home accompany residents to the centre where they complement the input of specialised day care staff. The centre provides a varied range of activities, which includes painting, drawing, writing, drama and computer use. There are a number of small rooms for differing recreational and developmental activities. Service users are assisted to develop daily living skills through participation in daily routines at the home. Close working relationships with the day service staff enables service users to benefit from continuity of care and behavioural management. There are Behavioural Management guidelines for individual St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 19 residents, with staff having access to specialist advice from psychiatrists and psychologists. The philosophy of the home is a positive one, encouraging and assisting service users to realise their full potential and to participate as fully as possible in the wider community. Care Plans and Activity timetable boards inspected in the home, confirm that service users are offered choices regarding daily activities. All service users have a yearly holiday, which can be taken with relatives or individually/small groups, with key workers escorting them. The cost of this holiday is included in the basic contract price. At the time of the inspection two service users were on a week’s holiday, staying at a holiday cottage in Dorset with their respective key workers. There is a wide and varied range of community-based activities offered at the home. These include canoeing, trampolining, horse riding, ten-pin bowling, cycling, pottery and swimming. One service user goes water skiing once a week at a water sports centre near Staines, while four service users attend trampolining sessions at a local sports centre. There is a regular weekly swimming session at local swimming baths, attended by four service users, and a weekly visit to the gym by two others. Service users are able to attend Further Education classes at Sandown F.E College where subjects offered include English, mathematics, cookery, assertiveness and crafts. Some service users have been able to train for accredited qualifications while others have been able to gain work experience through taking part in employment projects. Many service users have extensive contact with relatives and visit them at weekends. Telephone contact is maintained with some relatives who live abroad. Relatives are able to visit at any reasonable time. From comments previously received by relatives, the home provides a very homely and welcoming environment, there being a close involvement with the home’s operation and activities. As part of this involvement, a Partnership Day, to which relatives and friends are invited, is held every three months, where relevant issues are discussed and a buffet provided. Family barbecues are also held from time to time in the summer months and a party organised at Christmas. The evidence provided in both key information documents, such as the Service User Guide, and in the home’s policies and procedures, emphasises the need to promote independence and develop individual abilities and potential. Respect for service users’ rights is characterised in both the philosophy of the home, and in the wealth of detail, contained in care plans and activity programmes, relating to service users’ day to day living, routines and activities. There is extensive one-to-one support from key workers in assisting and enabling service users to make decisions for themselves, and regular consultation through service user house meetings. Service users are also assisted to St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 20 develop daily living skills through guidance/support with participating in daily routines within the home, and are encouraged to access shopping, leisure and educational facilities in the local community, within a risk management framework. There is a pleasant dining area in each of the two houses, where service users can take their meals. Meals are provided at the day centre at lunchtime and at the home at breakfast and in the evening. Mealtimes are relaxed and flexible to suit individual work and activity schedules. Service users are encouraged to assist with food preparation, if they wish, and are able to prepare snacks and drinks between meals. The NAS has a corporate food policy. This states a commitment to healthy eating. A rotating menu, developed by the University of Sunderland, aims to ensure a nutritious and well balanced diet. The menu for the week includes pictures of the meal options for which service users take it in turn to make a choice for the main option each day. A random sample of menus indicates that a wide variety of different food options are available in the home. Where the published menu option is not desired on the day alternatives are provided as service users wish, and a detailed record is kept of the food actually provided. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 21 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 to 21 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ personal support, physical and emotional health care needs are being well met in this home, with support being planned and tailored according to the individual needs presented. Service users are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. An up-to-date pharmacy inspection is, however, required. Whilst, generally, service users’ wishes regarding the eventuality of their ageing, illness and death are being respected, there is a need for staff to receive bereavement training so as to better support relatives and other service users when a death occurs. There is also a need to involve service users and their relatives in planning ahead for their future care as older adults. EVIDENCE: The inspector observed staff, both at the home and at the day centre, to be interacting in a positive and respectful way with service users, and to be enabling in their support. Each service user is allocated a key worker whose St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 22 responsibility it is to provide personal support. Several service users, who have high level needs, receive 1:1 support throughout the day. This allows a flexible person centred approach to service delivery. From the inspector’s observations, his interaction with service users, and his conversations with staff, he found service users to reassured by the assistance provided, and to be individually supported in an enabling and flexible way. Staff on duty demonstrated a receptivity and awareness in responding to individual expressions of need and the range of behaviours presented by users. Guidelines are in place to assist staff, in their interaction with residents, with objects of reference for those who require help with knowing which activity is about to take place. A number of service users’ care plans were inspected. These were found to be detailed and comprehensive, and to have been updated on a regular basis so as to reflect changes in individually expressed needs and preferences regarding their daily support needs. The healthcare needs of service users are being well monitored with detailed health records being in place together with monitoring and referral procedures. Service users are registered with one of two GP practices. Records checked indicate that GP’s and other community based medical/health care professionals are contacted as and when required. These include dentists, opticians, audiologists, chiropodists, and specialist nurses. The inspector was informed that two assistant psychologists are employed to provide advice and consultation, and to undertake support sessions with service users, with external professional support being provided by a clinical psychologist. Service users receive regular annual health checks from a GP. Potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. Records of all medical/health appointment/visits are recorded. Weekly weight charts are maintained for all service users. For one service user who has experienced a lot of recent weight gain, referral has been made to a dietician. The acting manager advised that there have not been any recent episodes of any serious illness within the home. The home has an appropriate medication policy and procedures in place. Both Boots and Opus pharmacies provide accredited medication training to staff on a rolling basis. A pharmacist from Boots inspects the handling of medication, the last visit having taken place in January 2006. Another inspection is slightly overdue and needs to be arranged without any further delay. A recommendation applies. The inspector examined the medication records of two service users and found these to be in good order. No service users are responsible for the St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 23 administration of their own medication. The home has a ‘Homely Remedies Policy’ GPs state in writing what Home Remedies each service users can have administered, this is reviewed on a regular basis and a record of what is administered to each service user is kept on their medication chart. The medication policy also states that medicines should be retained for 7 days following the death of a service user. The inspector was advised that there are no service users currently using controlled drugs. The wishes of service users and their relatives concerning the eventuality of their death are recorded and placed on their files. The inspector was advised that a questionnaire is sent out to relatives to request clarification of their wishes in the event of their own death or, subject to the service user’s agreement, their wishes in the event of his/her death. On the last inspection, the inspector discussed the issues of ageing and bereavement. The previous manager had indicated that with two service users in their late fifties there was a growing realisation within the NAS of the need to plan ahead for their future care as older adults. The inspector addressed this issue again, with the acting (area) manager, and understands that this is currently being reviewed by the NAS, with view possibly, to developing some specific housing provision within the NAS for older adults. The need for staff to undertake training in the area of bereavement and loss has not, as yet, taken place. The inspector was advised, however, that it is hoped to arrange training at a later date. A recommendation applies. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 24 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 and 23 Quality in this outcome area is good. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available in an appropriate format for service users. Service users are being protected from abuse by the home’s adult protection practice, policies and procedures. The home has a rolling programme of training, which is ensuring that all staff undertake adult protection training. EVIDENCE: The home has a complaints procedure that has been given to all the homes service users and/or carers. The home’s complaints procedure is available in an appropriate language/format for each service user and/or their carer. This includes a version in makaton. Information about the complaints procedure is also included in the statement of purpose. A simplified copy of the complaints procedure is on display in both homes, using large print and makaton symbols for the benefit of service users. The inspector checked the complaints record and found that there have been no complaints since the last inspection. The record of complaints is appropriately maintained. This includes details of any investigation, its outcome, and action taken. All complaints are responded to within twentyeight days after the date on which the complaint was made. A concerns and St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 25 compliments log is kept in the reception area, so as to provide a channel for both criticism/concern and positive feedback from relatives and other visitors. The home has an Adult Protection procedure, which is in line with Croydon’s multi-agency vulnerable adult procedures. The home also has an appropriate whistle blowing procedure. Physical and verbal aggression by a service user is understood and dealt with appropriately, in accordance with the homes physical intervention policy. All staff have undertaken restraint and breakaway techniques training in accordance with Department of Health guidelines. The home has a rolling programme to ensure that all staff undertakes adult protection training. Two staff, who had not previously completed this training at the time of the last inspection, have now done so. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 26 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 to 30 Quality in this outcome area is good. Service users live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Service users’ rooms present as safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Generally, the home presents as having the necessary aids and adaptations in place with which to meet the collective needs of the home’s service users. An OT assessment of the home would, however, assist in identifying any scope for further improvements. Generally, the home presents as clean, pleasant and hygienic. Staff training in infection control is, however, required if standards of hygiene are to be maintained and improved. EVIDENCE: St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 27 St. Edwards was purpose built for people with disabilities. The home is well laid out and meets the needs of the service users. The garden is well laid out and maintained. There is a ramp to the front door but no lift. In style it blends in well with the local community. The premises were inspected and found to be homely, comfortable and safe. Fittings, adaptations and equipment are of good quality, and domestic in scale. The home is divided into two separate houses, each of which has six resident service users, with six single rooms in each house. Some rooms have individualised symbols on the door, indicating whose room it is. The inspector looked at a number of rooms. On inspection, these presented as being pleasantly arranged and decorated, reflecting individuals’ personalities and tastes. These are suited to the needs of the present service users, but are not suitable for people who use wheelchairs. Furnishings and fittings are adapted to meet the needs of individual residents. All rooms have washbasins. Some of these are not in use as residents are not able to use these appropriately. This is indicated in the individuals’ care plans as not being appropriate. The home is decorated to a reasonably high standard throughout and presents as being pleasant and comfortable. There is consultation with service users regarding any redecoration of rooms that takes place, and a planned programme of maintenance for the redecoration of the home. Three service users rooms (1 in Willows, 2 in Conifers) have been redecorated since the last inspection, and one other (in Willows) being redecorated at the time of inspection. An audit of all service users’ bedrooms has been undertaken, so as to ensure that all are maintained to a good state of decoration and repair. There are four toilets and two bathrooms in each house. One of the toilets is on the ground floor where there is also a shower. All afford privacy to users. The two houses share a pleasant, reasonable sized garden area with covered seating. Each house has a separate lounge and domestic style kitchen and dining room. These are homely, with comfortable furniture and pictures. There is a small room in each house, which can be used as a quiet room. The medication is also stored here as is the white board with information about shift plans. Generally, the home presents as having the necessary aids and adaptations in place with which to safely meet the needs of the present service users. Equipment such as bedroom furniture is adapted to meet specific needs. A ramp leads into the building. The inspector understands, however, that there has not, in recent years, been any assessment of the home by a qualified occupational therapist, to assess what further aids or adaptations could be put in place for meeting the collective needs of the residents. A recommendation applies. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 28 Three health and safety concerns have been addressed since the last inspection, with the home presenting as safe and in a good state of repair. The home presents as generally clean and hygienic in most areas, though there was evidence of unpleasant odours from a pile of unwashed clothing lying in the laundry area of the Conifers. The houses have separate laundry areas, which are domestic in scale. The home’s laundry facilities are suitably positioned to ensure that any soiled articles/foul laundry is never carried through areas where food is stored, prepared or eaten. The homes washing machine is capable of thoroughly cleaning foul laundry at appropriate temperatures (minimum of 65 Degrees Celsius). The homes policies/procedures manual contains various policies for the prevention and control of infection including dealing with spillages, HIV and Hepatitis B. The inspector understands that while in-house training is provided, staff have not, as yet, had the opportunity of attending accredited infection control training. This is necessary in order to raise staff’s awareness of good practice in maintaining hygiene, and in preventing any risk of infection within the home. Following discussion with the area manager, it was agreed to include this as a requirement. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 29 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): 31 to 36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Service users are having their needs well met by an appropriately trained and qualified staff group. Service users are being supported and protected by the home’s recruitment policy and procedures. Service users are having their needs well met by an appropriately trained and qualified staff group. The home has achieved 50 of care staff with a minimum of NVQ Level 3, and is aiming to increase this further. Whilst, generally, staff are being supported in meeting service users’ best interests, the home has not been providing staff with sufficiently regular supervision in recent months. EVIDENCE: There is clarity of staff roles and responsibilities, with clearly defined job descriptions having been developed. A key worker system is in place, with each key worker having a clear responsibility for developing a one-to-one St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 30 relationship with an allocated service user, providing both a supportive and enabling role. Keyworkers escort service users to a wide range of communitybased activities, and accompany them to their day care service, where they work alongside specialist day care staff. This is viewed by the provider as encouraging a consistent approach to programming and care. The home does not currently work with volunteers and/or students although the home has a policy and procedure in place to cover this. The inspector examined the staff rota and evidenced that there are sufficient numbers of staff on duty at all times- this confirmed that the home has 3 staff on duty in each house at all times during the day, providing a staffing ratio of 2:1. In addition to this several service users receive 1:1 support at key times during the day. Each house has 1 waking night staff and a sleep in member of staff is shared between the two houses. The home’s acting manager is on-call during weekdays from Monday to Friday, and covers alternate weekends in tandem with the recently appointed deputy manager. There is also an on-call Out of Hours Service provided within the organisation for providing cover for any emergencies that may arise. Service users are evidenced to have their needs well met by an appropriately trained and qualified staff group. Staff possess relevant qualifications and experience and are assisted to obtain their NVQ qualifications. The acting manager advised that of twenty-one care staff, eleven (including the deputy manager and four shift leaders) have now achieved a minimum of NVQ Level 3, with one other staff member currently studying for an NVQ Level 2. The NAS provides extensive specialised in-house training both locally and at its national training centre, and staff at the home are able to access both these and other relevant external training courses. All new staff undertake a six-week induction programme, followed by sixmonths of foundation training, when they commence employment. The induction programme starts with two weeks of training, which includes ‘autism awareness’ and introduces staff to the aims and objectives of the service, policy and procedures. Weeks 3 to 5 are spent observing practice and procedures while week 6 is spent shadowing an experienced staff member. The home offers a 3-day induction programme for bank staff and specialist autism training is provided for all staff who work at the home. Staff records provide documentary evidence of qualifications obtained by staff. This includes statutory training in adult protection, basic food hygiene, first aid, health and safety, fire safety, medication, equality, diversity and rights, person centred planning and epilepsy training. All staff attend training on autism awareness, and on how to manage challenging behaviour. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 31 No new staff have been appointed since the last inspection though one is presently being processed, awaiting the receipt of references and a satisfactory CRB (Criminal Records Bureau) check. The inspector examined the file and found that all other employment checks have been completed. The area manager is currently providing supervision to the recently appointed deputy manager, and by the deputy manager to the shift leaders. The shift leaders provide supervision for the care and support workers. The inspector examined some supervision records, which indicated that staff are not currently being supervised on a sufficiently regular basis. Three staff files evidenced long gaps of 3 or more months between supervision sessions. This is concerning and must be addressed as a priority, with all staff receiving supervision, as previously evidenced, on a six to eight weekly basis. A requirement applies. The supervision format ‘Management support and Development record’ provides a structured format for recording practice, training and performance issues. Annual appraisals are undertaken to review staff performance against job descriptions and agree career development plans. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 32 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. While the home is generally being managed in the best interests of the home’s service users, the home is presently lacking the leadership of a full-time registered manager. Service users can generally be confident that their views underpin selfmonitoring by the home. The home needs, however, to further extend its consultation processes, and evidence its performance by producing a quality assurance audit and development plan. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. Fire drills should, however be held on at least a monthly basis. EVIDENCE: St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 33 Following the departure of the previous manager, the area manager is currently managing the home, with the assistance of a recently appointed deputy manager. Given her other duties this arrangement is not ideal, but it was confirmed (by the area manager) that it is hoped that a new registered manager will be appointed in the near future. At present, the area manager is working at the home approximately 3 days a week, being available at other times when required. Given the vulnerability of this service user group and the relative inexperience of the recently appointed deputy manager, the inspector is concerned that there is not any undue delay in appointing a new manager; a requirement applies. With the very recent appointment of a shift leader to the position of deputy manager, the inspector recommends that he is provided with the opportunity of studying for an NVQ Level 4 and an appropriate management qualification, once a new manager is in post. The home has a robust and innovative approach to Quality Assurance using an accepted tool ‘Accreditation for People with Autism.’ This includes an evaluation over a period of 2-3 days carried out by a panel of 4-5 people, which includes a layperson. The last inspection under the accredited scheme was in August 2005. There is also a Service Support Committee, which consists of the landlord, Housing Association, relatives, staff and a community representative. This committee also carries out unannounced visits at the home, reports of which are produced. There is active involvement by some parents and relatives in the support of St Edwards, and their views regarding the home are sought and taken into account. There is a strong ethos in the home towards fully involving service users in decisions affecting their day-to-day lives and the running of the home. This is evidenced in the detailed individual care and learning plans, and in the feedback received from service users and relatives. The minutes of service user meetings indicate that service users views are regularly canvassed as to their views, with discussion of such topics as forthcoming choice of activities, the upkeep of the home, their daily routines, and food choices for the week ahead. The home sends out questionnaires to relatives and friends, and an annual assessment questionnaire is completed with service users, with these being produced in an appropriately comprehensible format, using widget symbols. A questionnaire should also be developed for care managers, professionals and other workers so as to provide feedback regarding their views of the home and the services provided; a recommendation applies. The home must aim to produce a quality assurance audit report and development plan, so as to evidence the feedback received from surveys and St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 34 other sources, and to detail the plans and priorities for the year ahead. A requirement applies. A sample of policies and procedures were seen during the inspection. These were generally in good order and tailored to the specific needs of the client group. All staff have access to the homes’ policies and procedures, which are brought to their attention during the induction period. The home’s policies and procedures were, however, found to have been last reviewed in June 2005, just over a year ago. The home must ensure that these are all reviewed at least twelve monthly. The inspector recommends that a Policies and Procedures checklist is included at the front of the manual, to include the date when each of these was last reviewed, and the signature and position of the person completing the review. The health and safety of service users is generally being well protected in this home. All health and safety checks, (apart from Legionella, last completed in May 2005) were evidenced to have been completed and up to date, though evidence of some of these was not present on site, but at the Coney Hall NAS offices; a requirement applies. The home has in place a rolling programme of training, which includes manual handling, food hygiene, first aid and medication. Infection control training needs, however, to be extended to all staff (see requirement). Hazardous substances are being appropriately stored in a locked COSHH cupboard. A fire inspection (23/6/06) and fire awareness training for staff (29/3/06) were evidenced. Fire drills had been recorded as having taken place on 10/5/06 and 1/7/06. Given the potential vulnerability of the service user group, it was agreed with the area manager that the home would henceforth hold fire drills on a regular monthly basis. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 35 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 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 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 2 3 2 2 x St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 36 Are there any outstanding requirements from the last inspection? None 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 6(a)&(b) Requirement The Statement of Purpose and Service User Guide must be annually reviewed, and be signed and dated. The minutes of all Service users meetings must be evidenced on site, and a copy of these kept in the respective residential units. Timescale for action 30/09/06 2 YA7 12(2)&(3) 31/07/06 3 YA30 13(4)(a)&(c), All staff must receive 18(1)(c) accredited infection control training. 18(2) 31/10/06 4 YA36 All staff must receive regular 31/07/06 supervision at least once every 8 weeks. A new registered manager must be appointed to manage the home. Quality assurance feedback regarding the home should be obtained from relevant professionals and care managers. A questionnaire should be compiled for this purpose. DS0000025839.V300163.R01.S.doc 5 YA37 8(1)&(2) 30/09/06 6 YA39 24(1) 31/10/06 St Edwards (6) Version 5.2 Page 37 7 YA39 24(1)&(2) The home must produce a quality assurance audit report and development plan, so as to evidence the feedback received from surveys and other sources, and to detail the plans and priorities for the year ahead. A requirement applies. All health and safety checks must be evidenced on site. An up-to-date Legionella inspection is required. 31/12/06 8 9 YA42 YA42 13(4)(a)&(c) 13(4)(a)&(c) 31/07/06 31/08/06 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 2 3 Refer to Standard YA20 YA21 YA24 Good Practice Recommendations An up to date pharmacy inspection should be arranged. This should take place on at least a six-monthly basis. The inspector recommends that staff undertake training in the area of bereavement and loss. The inspector recommends an audit of the home’s lighting with view to identifying any areas where lighting could be improved or made more domestic in character. The home should arrange for an assessment of the home by a qualified occupational therapist, to assess what further aids or adaptations could be put in place. The inspector recommends that the recently promoted deputy manager is provided with the opportunity of studying for an NVQ Level 4 and an appropriate management qualification. A questionnaire should be developed for care managers, professionals and other workers, so as to provide feedback DS0000025839.V300163.R01.S.doc Version 5.2 Page 38 4 YA29 5 YA37 6 YA39 St Edwards (6) regarding their views of the home and the services provided. 6 YA40 The inspector recommends that a Policies and Procedures checklist is included at the front of the manual, to include the date when each of these was last reviewed and the signature/position of the person undertaking the review. All policies and procedures must be reviewed at least 12 monthly. 7 YA42 All incidents and accidents should be logged in a logbook, so as to provide a running record of all incidents and accidents. This should provide brief details of the information recorded on the incident sheets. St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 St Edwards (6) DS0000025839.V300163.R01.S.doc Version 5.2 Page 40 - 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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