Inspection on 10/11/05 for St Matthews Avenue, 1

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Matthews Avenue, 1 05/10/07

St Matthews Avenue, 1 20/06/06

St Matthews Avenue, 1 19/07/05

St Matthews Avenue, 1 05/10/04

St Matthews Avenue, 1 11/05/04

St Matthews Avenue, 1 29/12/03

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 Matthews Avenue, 1 Surbiton Surrey KT6 6JJ Lead Inspector Michael Stapley Unannounced Inspection 10th November 2005 09:30 St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 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 Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 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 Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Matthews Avenue, 1 Address Surbiton Surrey KT6 6JJ 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) 020 8390 3734 020 8390 3734 Home Farm Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 7 is undersized at 9.19 sqm - due to inclusion of insulation to the outer wall. To be reviewed annually. 190705 Date of last inspection Brief Description of the Service: 1, St Matthews Avenue is a registered care home for eight adults with learning disabilities. Seven service users are currently residing at the home. The home is owned and managed by Home Farm Trust Limited, an organization with another care home in the local area. The home is situated in a residential rod in Surbiton, close to local shops and amenities with good transport links. The home is not identifiable as a care home and is in keeping with neighbouring houses. The home is staffed twenty-four hours a day. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 10th November 2005. There has been a change in management at the home since the last inspection. The home is now managed by Stewart Noble who is a qualified and experienced manager who has managed a home similar to that of St Matthews Avenue. Unfortunately the manager was not available during the course of this inspection as he was attending a conference with a number of service users. Given the inspector had serious concerns regarding staffing records a follow up visit was made to the home on 18th November 2005. The manager is supported by Tracy Lazell who is the Area Manager of Home Farm Trust. She too is very experienced and well qualified to support the manager in his day to day management of the home. Records examined included service user plans; care manager’s community care assessments, risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the manager and senior support worker. What the service does well: Service users are very much the centre of attention in the home, service users have been very complimentary about staff and have been generally happy with how the home is being run, service users have also commented positively about activities, food and their opportunities to be involved in running the home during the two inspections of 2005-06. Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of a local pharmacist for advice on medication. Staff members have access to a range of training courses to build on their skills to ensure that they are able to meet the service users assessed needs, although this programme of training needs to be developed further. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The new manager of the home, Stewart Noble commenced his duties in September and has begun to address a number of issues that have been outstanding for some considerable time. Unfortunately some of these issues were not addressed by the previous manager and, as a consequence matters of an urgent nature have still to be addressed. The manager’s post is crucial for the home to continue its programme of development and have a clear vision for the future. While the home is now using Personal Care Plans these need to be further developed in conjunction with service users and relatives/friends. Contracts for service users did not contain all the information required under standard five. There were a number of outstanding requirements that had still not been complied with. Given some of these requirements have been outstanding for at least the last three inspections the managing company must address them within laid down timescales. The home has not developed a quality assurance system or sought the views of service users and other stakeholders by means of surveys and has not carried out an annual audit. Requirements have therefore been made in respect of this standard. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 7 In addition the managing company must review the number of permanent staff that the home has. At the time of the inspection there were two vacancies and an over dependency on bank/agency staff. 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 Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 8 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 Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 9 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, 3 and 5. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users do not contain all the information required under standard five potentially reducing the rights of the residents of St Matthews Avenue. Staff at the home has access to a wide range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. An assessment for the homes most recent service user was seen on the service users file. The assessment was completed by a care manager and included additional assessments from other professionals. The home has an excellent training programme including NVQ training. The managing company has a training coordinator. The training programme includes mental health, epilepsy, medication, working with symbols and makaton training. All staff have an annual development plan and a monthly training matrix was evidenced during the course of the inspection in July 2005. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 10 There has been some progress in improving contracts between the home and the service users. However contracts still did not state that all residents would have a three month ‘settling in’ period of residence at the home. In addition contracts inspected did not contain all the information as required under standard 5.2. The home must accordingly amended service users contracts as at present there is the potential for their rights to be reduced. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 11 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 and 9. Service user care plans contain all the information required as per standard six. Staff at the home have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker although the home must ensure care notes contain evidence of key working. The home has become far more service user focused. Service users are encouraged to become far more involved in the home. House meetings have recently started and staff at the home receive specialist training from a consultant in how to engage and communicate with particular service users. The home uses St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 12 Person Centred Plans where ownership of the plan is given to the individual service user. Staff at the home has undertaken appropriate training in order to facilitate the care plans. Service users files sampled at random all had individual risk assessments and risk management strategies. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. The home seeks to empower service users through group meetings and key working. The home has a consultant who works with the staff and offers support and guidance in how to engage with particular service users. It is hoped that such training will enable service users to become more involved in the decision making process. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 13 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, and 17. The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The home is supporting service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, local leisure facilities and shops. In addition to swimming, gym and library. The staff team are available to support service users while accessing community resources. Service users spoken to during the course of the two inspections during 2005/06 stated that they enjoyed the activities on offer at the home. In addition all of the service user’s have had an annual holiday with some travelling to Spain with support from staff. The home has an annual “open day” where family, friends and parents are invited to the home. In addition the area manager attends parents meetings at the home. These being used as a St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 14 communication tool. Service users have access to computers and software is appropriate and accessible. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. One service user said that he enjoyed what he had to eat at the home. While the inspector acknowledged the choice and variety of food it was noted that some foodstuffs were passed their ‘use by’ date while other food, notably cereals were not in sealed containers. The home has its own mini-bus and the use of two cars St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 15 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 and 20. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. EVIDENCE: Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home now keep a central record of incidents as well as an individual record on service users files. Staff members monitor service user’s health and maintain up to date records. Some of the staff team including the night staff have undertaken epilepsy and medication training. The pharmacist last inspection was on 11th May 2005 and all requirements from that inspection have been completed save for the development of a Homely remedies policy. The home is in the process of changing its pharmacist and it is suggested that an inspection is arranged to ensure continuation of safe practices. All medication records were complete at the time of the inspection. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 16 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 There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Support Worker said that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. Most of the staff has received appropriate training in Vulnerable Adult Abuse although there is a need to update this training on a regular basis. The staff team are aware of the action they must take if they need to report an incident. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: The home is a two story building in a quiet residential road. It is situated in Surbiton and is close to local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The furniture is domestic, flame retardant, and of good quality. There has been some improvements in the décor of the home since the last inspection although some areas look shabby and in need of decoration. The area manager stated at the last inspection of July 2005 that a programme of redecoration is due to be implemented. In addition new furnishing, fixtures and fittings are to be purchased as required. Unfortunately this work had not commenced at the time of this inspection although one of the senior support workers confirmed that work would be starting during the course of November 2005. There is also a pleasant garden at the rear of the home. Bedrooms viewed provided sufficient and suitable furniture. All areas of the premises viewed were clean and free from offensive odours. There are appropriate laundry St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 18 facilities. Systems are in place for controlling the spread of infection. This includes staff training in this area. The home has one ‘high low’ bath situated on the first floor. The home has thermostatic valves fitted to each of the baths to avoid any scalding accidents. The temperature of the water is taken and recorded on a chart in the office. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 and 35 The staff team at the home have a range of skills and abilities, which appear to meet the needs of the service users. Staffing Records within the home did not contain all the documents required as per regulation. CRB checks were not available for inspection thus posing the potential for service users to be placed at risk. EVIDENCE: The home offers training opportunities to staff at all levels within the home. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. Staff Personal Files inspected did not contain all the documents required as per regulation. The inspector noted on one file there were no references, birth certificate or copy of passport, contract of employment or evidence of CRB check. A print out of all staff who are employed by Home Farm Trust was seen by the inspector, notwithstanding not all staff currently working at St Matthews Avenue were on this list. The manager and the registered provider must ensure all staffing documents as laid down under schedule 2 of the Care Home Regulations are available for inspection at all times without further delay. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 20 The home has had a change in management since the last inspection. Stewart Noble is the new manager of St Matthews Road who commenced his duties in September 2005. The new manager will, in due course need to make an application to the Commission for Social Care Inspection to be the registered manager of the home. The home does not have a deputy manager but has senior support workers who act as shift leaders. They are currently responsible for the supervision of junior staff which is in line with the standard. The inspector has some concern regarding the number of permanent staff employed by the Home Farm Trust at St Matthews Avenue. There is a very small core group of permanent staff and at the time of the inspection there were two vacancies. In addition the home uses bank/agency staff. Inspection of rotas confirmed a dependency on agency/bank staff. Such staff should only be used as a back up to cover shortfalls such as holidays, training and sickness. This issue must be addressed without further delay by the manager and Home Farm Trust. The inspector was advised that staff meetings usually take place every fortnight. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are three staff members on duty on each shift. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: The managing company has recently appointed a new manager to the home. The inspector was advised that regional changes had proved positive. There were good support mechanisms in place and the area manager meets with the directors of the trust to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The annual development plan and business plan for 2005-06 were not available for inspection at the home during the course of this inspection. Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are now up to date and a fire risk assessment has now been completed, St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 22 although Fire Training needs to be updated for all new and existing staff. In addition the manager and Home Farm Trust must ensure all records required for Health and Safety are available for inspection at all times. These include The Landlords Gas Safety Certificate, Legionella Certificate, Five Yearly Electrical Certificate and the results of PAT testing. The residents are beginning to see the benefits of a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties is reasonable although the quality assurance system should include service user, relatives, staff and outside professional questionnaires. In addition there was no evidence of an annual audit. St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 2 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 2 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 1 1 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Matthews Avenue, 1 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 2 DS0000013389.V264199.R01.S.doc Version 5.0 Page 24 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 5 Requirement The Registered Provider must ensure that the home produces a Service Users Guide, gives a copy to all service users and stakeholders as appropriate. (Requirement almost met as of 101105) The Registered Provider must ensure that the admissions policy is reviewed to include a minimum three month settling in period of residence is offered for long-term placements, followed by a review with the service user of the trial placement, during which existing users are consulted about the compatibility of the prospective new service user. (Requirement not met as of 30/09/05) The Registered Provider must ensure that the contract/statement of terms and conditions includes the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of the Service Users Plan, and makes clear the ninety day trial DS0000013389.V264199.R01.S.doc Timescale for action 31/12/05 2. YA4 14 31/12/05 3. YA5 5 31/12/05 St Matthews Avenue, 1 Version 5.0 Page 25 4. YA17 16 5. YA20 12 13 6. 7. YA23 YA24 13 23 8. YA27 23 9. YA29 12 10. YA33 12 period. (Requirement not met as of 30/09/05) The registered person must ensure that storage boxes are supplied in sufficient quantity to allow secure storage of all foodstuffs thus minimising the risk of contamanation/infiltration and the registered person must ensure all ‘out of date’ foodstuffs are disposed of. The registered person must make appropriate arrangements for the pharmicist to undertake an inspection of all medication issues. The registered person must ensure all staff undertake Adult Protection Training. The registered person must send to the CSCI, local office an ongoing maintenance and development programme regarding the renewal of the fabric and decoration of the home both internally and externally. The Registered Provider must ensure that the carpet is protected from water damage from the shower room. (Requirement not met as of 30/09/05) The registered person must ensure an assessment of the home for aids and adaptations is undertaken by an Occupational Therapist or other suitably qualified specialist. The Registered Provider must review staffing levels at the home to ensure the needs of the service user’s are being met and ensure that the home employ sufficient permanent staff as opposed to continual use of agency/bank staff. Rotas must be submitted to the Commission DS0000013389.V264199.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 St Matthews Avenue, 1 Version 5.0 Page 26 11. YA34 17 and 4 12. YA35.4 12 13. YA37 9 14. YA39 24 15. YA42 12 for Social Care Inspection (CSCI) to ensure compliance with this regulation.(Similar requirement not met as of 30/09/05) Records to be kept in a care home to include a record of all persons employed, name, address, date of birth, qualifications and experience; copies of the birth certificate and passport, each reference; dates on which they commenced and ceased to be employed; position and hours worked; correspondence, reports, records of disciplinary action, CRB Checks and any other records in relation to their employment. (Requirement not met as of 30/09/05) The registered person must ensure that all staff undertake disability equality training, race equality and anti-racism training The registered person must appoint a permanant manager to manage the care home and give notice to CSCI of the name of the person so appointed and ensure that the person so appointed comples the appropriate application form for registration purposes. A quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and the home must implement a professionally recognised quality assurance or join up their own quality assurance tools into a cyclic quality assurance system. (Partially met as of 30/09/05) The registered provider must ensure all certificates appertaining to Health and Safety are available for DS0000013389.V264199.R01.S.doc 10/11/05 31/12/05 10/12/05 31/12/05 31/12/05 St Matthews Avenue, 1 Version 5.0 Page 27 16. YA42 23(4) 17. YA43 25 inspection at all times. These certificates include Landlord’s Gas Certificate, Five Yearly Electrical Certificate and Certificate in respect of tests for Legionella. The registered person must ensure that all staff undertake fire awareness training by a competent person. The Registered Provider must ensure that a budget financial plan is provided to the Commission for Social Care Inspection (CSCI), demonstrating Financial planning and the effectiveness, financial viability and accountability of the home. (Requirement not met as of 30/09/05) 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 Page 28 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 Matthews Avenue, 1 DS0000013389.V264199.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!