Inspection on 05/10/06 for St Judes House

This inspection was carried out on 5th October 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 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Judes House 20/05/08

St Judes House 21/06/07

St Judes House 24/02/06

St Judes House 10/10/05

St Judes House 02/03/05

St Judes House 11/08/04

St Judes House 26/03/04

Similar services:

Ashlong House

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Delrose House Ltd

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

CARE HOME ADULTS 18-65 St Judes House 14 Canadian Avenue Catford London SE6 3AS Lead Inspector Lisa Wilde Unannounced Inspection 5 & 13 October 2006 11:00 th th St Judes House DS0000025643.V315492.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 Judes House DS0000025643.V315492.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 Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Judes House Address 14 Canadian Avenue Catford London SE6 3AS 0208 6904493 0208 690 4501 stjudes@hotmail.com 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) Elizabeth Peters Care Home Limited Mrs Priscilla Kagijo Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 10 persons aged 40 years and above with a past or present mental disorder, 2 of whom can have a physical disability service users can be over 65 years To include one named person aged 39 years, until May 2006 2. Date of last inspection 24th February 2006 Brief Description of the Service: St Judes is a large Victorian property offering care and accommodation to ten adults with past or present mental health problems, some of who may be over 65 years of age. The home is one of four owned and managed by a local provider, Elizabeth Peters Care Homes Ltd. The home is situated on a main road and is in within short walking distance of shops and facilities of Catford town centre. This provides the home with good transport links as the town centre has two train stations and is well served by buses. The house is unobtrusive and blends in with the surrounding properties. The home offers single bedroom accommodation and communal space including a large rear garden. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in October 2006. The inspector met with service users, staff and the Registered Manager was there for part of the day. The inspector toured the building, checked records and documents and asked for more information be sent on after the inspection. Service users said they were very happy at the home and they liked staff. There is a lot of good work going on at this home and most of the requirements are to do with systems and procedures rather than concerns about the care being offered by staff. What the service does well: What has improved since the last inspection? • • Staff find out more about what service users want. The manager has had an interview with the Commission. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet the needs of service users before they are offered a place at the home but they do not fully take account of what the service user thinks their needs are. Service users are given contracts when they move to the home but not all details are completed which means that they are not given all the information they need. EVIDENCE: There is new legislation in place now that came into force on 01/09/06 and other changes come into force on 01/10/06 which will require services to state exactly what fees each service user is paying and how it breaks down into different areas, in the service user guide. (See Requirement 1) Staff meet with services users and conduct an assessment of their need before someone is offered a place at the home. The referral form of the newest service user was on file but had not been fully completed as the service user’s views sections had not been filled in. (See Requirement 2) There was a previous requirement that the registered provider must ensure that all service users are issued with a service user contract including all of the St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 9 elements listed under Standard 5 of the National Minimum Standards. The contracts have been revised now but the room number (or room identification) and monthly charges had not been filled in. (See Requirement 3) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 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 the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all service users’ needs are met. Service users do not always agree with the care plans that are in place which means that they are not getting the support and care that they want and so the care plans won’t be successful. Not all the care plans are reviewed often enough which means that service users may not have their changing needs met. Risks are assessed and plans put in place to make sure that any risk are managed which means that service users are kept safe. EVIDENCE: Care plans are on file that outlined staff action to support service users and meet their needs. Some of the service users at the home are over 65 years of St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 11 age and so they must be treated as if they were in an older person’s home, which means that their care plans must be reviewed monthly. Other care plans have to be reviewed every six months and some care plans had not been reviewed this frequently. (See Requirement 4) One service user had a care plan around exercise that they had refused to sign presumably because they did not agree with it. Another service user had a care plan that said their activities needed to be regularly varied to assist with their mental health management but the records of their daily activity showed that they spent most of their days in their room. (See Requirement 5) There was a previous requirement that the registered provider must ensure that daily records fully reflect the service users actions/behaviour. This is now being done. There was a previous requirement that the registered provider must ensure that service user meeting minutes are recorded more formally to include previous meeting minutes and matters arising so that responses to issues raised can be easily tracked and the home is held more accountable. The minutes are now more detailed but there were still some occasions where service users had raised issues in one meeting but these had not been followed up in the next meeting. (See Requirement 6) There was a previous recommendation that more proactive ways be developed of supporting service users to participate more fully in service user meetings. Staff said that they post agendas in the home and record showed that most service users attend the meetings. There was a previous requirement that the registered provider must ensure that service users are consulted about where they wish to go on holiday and that their individual wishes and preferences are met as far as possible. Service user meeting minutes showed that they had been consulted but the minutes showed that they wanted to go to one place whereas the holiday has been planned for somewhere else. Risk assessments were on file along with plans to manage or minimise those risks. There was a previous recommendation that the home should produce a statement on confidentiality for partner agencies, setting out the principles for governing the sharing of information. This has not yet been done. (See Recommendation 1) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to do what they want to do and go out when they want to. Service users choose what they want to eat and staff cook for them. EVIDENCE: Staff talked about the difficulties in getting some service users to go out but that other service users regularly go out. Records showed that some service users have reasonably full weekly plans. Although this is technically a younger adults home, several of the service users are over 65 years of age and as such do not want to do as much as some younger people. Staff cook for service users and records are kept of what they eat each day. Service users said that they liked the food a lot and they get to eat what they want. Staff said that sometimes staff are not able to cook dishes that service users want as well as some other staff. (See Recommendation 2) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff support service users in different ways and service users are encouraged to attend regular appointments to make sure they stay healthy. Some medication systems are operated effectively but recording of medication in the home and of medication changes must be more accurate to make sure that service users are getting their medication properly. EVIDENCE: Staff discussed how it was difficult to get some service users to attend regular GP or other healthcare appointments. Currently evidence of health care visits and monitoring is kept in the daily records whereas it would be easier to check how often service users are or aren’t attending appointments if separate healthcare sheets were kept in the files. (See Recommendation 3) One visiting health professional said that they were very satisfied wit the service their client gets at the home. They said the home was very good value for money and staff look after the service users very well. The inspector checked the medication stocks and records and found most systems to be operated effectively except that some medication in the home St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 14 had not been recorded and one medication had been changed recently but this change had not been added into the medication administration chart. (See Requirements 7 & 8) There was a previous requirement that the registered provider must ensure that a list of homely remedies used in the home is drawn up and signed by a GP. This has now been done. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users know how to complain but their day-to-day concerns should be taken more seriously so that action can be taken to make things better for them. Service users are protected from harm by staff receiving training and understanding what to do if they think a service user is being abused. EVIDENCE: There is a complaints procedure although there have been no formal complaints since the last inspection, the last complaint being recorded in 2004. The home does not keep records of informal concerns and what is done to address these concerns as issues were raised in the minutes of the service user meetings that had not been seen as comments on the service. (See Requirement 9) Staff could describe the procedures in place to protect service users and what staff should do if they thought a service user was being abused. There was a previous requirement that the registered provider must ensure that when service users move in to the home their possessions are recorded in order to protect their interests. This is now being done. Two staff who do all the sleep-ins at the home live in a flat at the top of the house. There is no written policy that describes the procedures around these staff’s visitors to the home. (See Requirement 10) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 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 the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Service users have their own rooms that they have decorated how they choose and the communal areas are large enough. EVIDENCE: On the day of the inspection the home was clean and hygienic throughout. There is a large lounge/dining room and a separate kitchen. Service users have their own rooms that have been decorated as they choose. Service user said they were happy with their rooms. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 17 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): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of service users. Staff hold the right qualifications and get enough training which means that service users are cared for by people who know what they are doing. Recruitment procedures are not effective enough which means that the organisation is not doing enough to check up on the people who work in the home or to make sure that it is getting staff who can do the job which means that service users may be being put at some risk. Staff are not getting fully effective supervision which means that service users may be getting care from people who may not be getting enough support and advice from their managers. EVIDENCE: There are usually four staff on duty. All but two staff hold the NVQ Level 2 in Care. St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 18 There were several issues noted with the recruitment procedures in the home. The application form does not ask for a full employment history and so gaps in employment could not be investigated. Records were not maintained of all interviewers’ notes and comments on interviewees’ performances. References were not always stamped by the organisation or on headed notepaper. Although the home applies for new Criminal Records Bureau checks on all staff, it is currently using the POVAFirst check as a matter of course, which is only supposed to be used for emergencies. The home does not destroy CRB checks after six months (or when the inspector has had the opportunity to see the checks) and then keep a central record of the dates of the CRB checks. There was a previous recommendation that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. This has not yet been done. (See Requirements 11-15 and Recommendation 4) There was a previous requirement that the registered manager must ensure that the home’s induction and foundation training is in accordance with sector skills council specifications. This has now been done although the work books and training information being used by the organisation is that of TOPSS which is the organisation now called Skills For Care. This means that although the induction and foundation programme is almost in line with requirements, there will be a more up-to-date version of the guidelines that should be used. (See Requirement 16) Each member of staff has an individual training plan and these are drawn together into an overall annual training plan for the home. This plan showed that staff receive the basic training required. Although the staff team has recently had some mental health training from another manager within the organisation who is a registered nurse, there may be more opportunities for the Registered Manager to offer in-house training to staff during team meetings or to access external training. (See Recommendation 5) There was a previous requirement that the frequency of supervision must be increased to at least six times a year and cover the aspects detailed in this standard. The supervision records were not in the home as the Registered Manager had taken them home. Staff said that they get offered supervision from the Registered Manager of the deputy manager and are not allocated on supervisor. (See Requirements 17 & 18) There was a previous recommendation staff who conduct supervision should receive formal training on the matter in order that all staff receive the maximum benefit from the experience. This has not yet been done. The Registered Manager is also the Responsible Individual in this organisation and she talked about how she does not supervise her managers and isn’t sure if she is the best person to do so. She has been on supervision training but not St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 19 for some years. Discussions with the Registered Manager also showed that she would benefit from additional courses in recruitment and sickness management. (See Requirement 19 & Recommendation 6) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 20 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, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has been at the home for several years and holds or is undertaking the required qualifications, which means that she has the skills to run the home well. Although there are lots of checks in place at the home there is no systems that looks at developing the home and planning to make things better for service users each year which means that things do not change much for service users. Service users are protected from harm by the effective operation of all health and safety procedures. EVIDENCE: St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 21 There was a previous requirement that the registered provider must ensure that the manager of St Judes is registered with CSCI. This has been done. As stated earlier the Registered Manager of this home is also the Responsible Individual for the organisation and as such has to spend some time at the other services. The staff roster does not reflect when the Registered Manager is away from the home. Inspections of other service showed that the required monthly monitoring visits are not taking place as required and that other managers are not being supervised by the Responsible Individual. The inspector was concerned that when these required checks and supervisions take place the Registered Manager may not be available at this service enough to meet the needs of the service. (See Requirements 20 & 21) The required monthly unannounced visits to the home are not being conducted. This has not been happening as required. (See Requirement 22) There was a previous recommendation that surveys of the views of service users and relatives be specifically designed for each purpose. This has not been done as the survey still says that it is for relatives when it has been used with service users. The surveys do get carried out and although there is a thorough system of checks in place in the home there is not yet a system that looks forward at planning how the home will improve in the next year in order to make things better for service user and there isn’t a plan in place based on what service users want. (See Requirement 23 & Recommendation 7) All health and safety documentation and checks were in place and in order. There were no health and safety problems noted on the tour of the building. There was a previous requirement that the registered provider must ensure that window restrictors are in place unless a risk assessment indicates they are not necessary. The inspector asked for evidence of this to be sent on after the inspection but did not receive the information by the time the draft version of this report had to be sent out. (See Requirement 24) St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 22 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 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X X 3 St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 23 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&5 Requirement The Registered Individuals must ensure that the breakdown of each service users’ fees is put these in the service user guide/statement of purpose as required by the new legislation. The Registered Manager must ensure that they gather the service user’s views on their needs and the placement when they complete an assessment. If the service user does not wish to contribute to the assessment this should be stated on the form. The Registered Manager should ensure that all required details are completed in service users’ contracts. The Registered Manager must ensure that all care plans are reviewed as required i.e. at least every six months for service users under 65 years of age and at least monthly for service users over 65 years of age. The Registered Manager must ensure that all care plans are useful to service users and agreed by them and that agreed actions are carried out as DS0000025643.V315492.R01.S.doc Timescale for action 31/12/06 2. YA2 14 (1) (c) 30/11/06 3. YA5 5 30/11/06 4. YA6 15 (2) (b) 30/11/06 5. YA6 15 (2) (c) 30/11/06 St Judes House Version 5.2 Page 24 6. YA7 YA39 12 (3) 7. YA20 13 (2) 8. YA20 13 (2) 9. YA22 22 10. YA23 13 (6) 11. YA34 19 (1) & (4) 12. YA34 19 (1) & (4) 13 (6) 13. YA34 14. YA34 13 (6) identified in the care plans and risk assessments. The Registered Manager must ensure that action is taken to address all issues raised in service user meetings and that this is fed back in the next meeting and recorded in the minutes. The Registered Manager must ensure that all medication brought into the home is recorded. The Registered Manager must ensure that all changes to medication administration is recorded on the medication administration charts. The Registered Manager must ensure that all informal concerns and comments on the service are recorded along with action taken to address the issues. The Registered Manager must ensure that there is a written policy that staff are aware of, that describes the procedures and requirements for allowing staff visitors into the home (as this relates to staff who live in the flat at the top of the home). The Registered Individuals must ensure that the staff application form asks for a full employment history and that any gaps in employment are investigated with records of that investigation being kept. The Registered Individuals must ensure that records are kept of all interviewers notes and decisions. The Registered Individuals must ensure that effective measures are taken to verify the source of all staff references. The Registered Individuals must ensure that the POVAFirst check DS0000025643.V315492.R01.S.doc 30/11/06 05/10/06 05/10/06 30/11/06 30/11/06 31/01/07 31/01/07 31/01/07 31/01/07 Page 25 St Judes House Version 5.2 15. YA34 13 (6) & 17 (2) 16. YA35 18 (1 (c) (i) 17. YA36 18 (2) 18. YA36 18 (2) 19. YA36 18 (1) (c) (i) & (2) 20. YA37 17 (2) 21. YA37 18 (1) (a) is only used in emergencies and not as a matter of course. The Registered Individuals must ensure that CRB checks are destroyed after six months or when the inspectors have had the opportunity to see them and that a central record is then maintained of the CRB date and number. The Registered Individuals must ensure that the induction and foundation programme being used is the most up-to-date version of the Skills For Care (and not TOPSS) programme The Registered Manager must ensure that supervision is offered regularly and covers the aspects detailed in this standard. Records of these supervisions must be kept in the home. Previous requirement (but reworded in this report): Unmet timescales 30/07/04, 31/12/04, 31/05/05, 31/01/06 & 31/05/06 The Registered Manager must ensure that staff receive supervision from the same supervisor in order that they can build a supportive and effective supervisory relationship. The Registered Individual must ensure that all staff who offer supervision have received training and been judged as competent to do so. The Registered Manager must ensure that the staff roster accurately reflects when she is based at the home and when she is at other homes in the organisation. The Registered Manager should ensure that conducts an audit of how often she is at the home and how often she is conducting organisation business elsewhere DS0000025643.V315492.R01.S.doc 31/12/06 31/12/06 30/11/06 30/11/06 31/12/06 31/10/06 31/12/06 St Judes House Version 5.2 Page 26 22. YA39 26 (3) 23. YA39 24 24. YA42 13 (4) (a) and send this audit to the Commission. (This audit must be done when she has begun to supervise other home managers appropriately and when she conducts the other homes’ monthly monitoring visits as required.) The Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. The Registered Individual must ensure that there is an annual development plan for the home that is based on a systemic cycle of planning, action and review and reflecting aims and outcomes for service users. The registered provider must ensure that window restrictors are in place unless a risk assessment indicates they are not necessary. Previous requirement with timescales 31/12/04, 31/05/05 & 30/11/05. Evidence of this requirement was not received before the draft version of this report. 31/10/06 31/01/07 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA10 Good Practice Recommendations The home should produce a statement on confidentiality for partner agencies, setting out the principles for governing the sharing of information. Previous recommendation. The Registered Manager should ensure that staff teach each other to cook the dishes that service users like. The Registered Manager should ensure that records of health care appointments and of staff attempts to get DS0000025643.V315492.R01.S.doc Version 5.2 Page 27 2. 3. YA17 YA19 St Judes House 4. YA34 5. YA35 6. 7. YA35 YA36 YA39 service users to attend appointments are kept separate to the daily notes to make monitoring of healthcare easier. The Registered Manager should ensure that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. Previous recommendation The Registered Manager should consider ways in which inhouse training can be offered to staff around mental health issues and should look into accessing more external training for staff in this area. The Registered Manager should ensure that she attends additional training on supervision and appraisal, recruitment and sickness management. It is recommended that surveys of the views of service users and relatives be specifically designed for each purpose. Previous recommendation St Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Judes House DS0000025643.V315492.R01.S.doc Version 5.2 Page 29 - 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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