Inspection on 19/07/05 for St Matthews Avenue, 1

This inspection was carried out on 19th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 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 10/11/05

St Matthews Avenue, 1 05/10/04

St Matthews Avenue, 1 11/05/04

St Matthews Avenue, 1 29/12/03

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Edenvale

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Chatsworth Care - Tudor Lodge

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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 Announced 19 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Matthews Avenue, 1 Address Surbiton Surrey KT6 6JJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Bedroom 7 is undersized at 9.19 sqm - due to inclusion of insulation to the outer wall. To be reviewed annually. Date of last inspection 021105 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 19th June 2005. There has been a change in management at the home in the last year. The home is currently without a manager although one is due to commence duties shortly. Currently the home is managed by Tracy Lazell who is the Area Manager of Home Farm Trust. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the acting manager and registered persons. What the service does well: What has improved since the last inspection? St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 6 The senior staff are now using the staff meetings at the home to improve communication amongst the team and discuss basic care values. Staff members have improved their skills and knowledge by attending a number of training courses. Care plans have been reviewed in consultation with service users although they need fine tuning to include all the elements of standard six. In addition Person Centred care plans have been introduced for all service users and staff has received appropriate training in order to facilitate such plans. The home has a complaints procedure both in written and pictorial form. There have been improvements in the environment with refurbishment and redecoration shortly to take place. The home now has a sensory room for service users and is very focused on Information Technology. Service users have access to a range of IT programmes which are both appropriate and accessible. The managing company has improved its systems of communication and there are good support mechanisms within the organization. What they could do better: The registered providers have recently appointed a permanent manager to manage the home. The new manager will need to register with CSCI. This is a crucial post 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 two inspections the managing company must address them within laid down timescales. While it was evident that key working was taking place with the service users there was no written record. 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. In addition the managing company must review the homes vulnerable adults’ procedure and ensure that a senior member of staff is on duty at all times. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 7 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 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 potentially reducing the rights of the residents of Acorn Lodge. Staff at the home have 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, makaton St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 10 training. All staff have an annual development plan and a monthly training matrix was evidenced. There has been some progress in improving contracts between the home and the service users. However contracts 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 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 to 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 area manager St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 12 explained that the home has moved towards Person Centred Plans where ownership of the plan is given to the individual service user. Staff at the home have 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 area manager informed the inspector that “Home Farm Trust” had commissioned a consultant to work with the home and offer 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 standard(s) 12, 13, 14, 15 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 stated that they enjoyed the activities on offer at the home. The home has a 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 communication tool. Service users have access to computers and software is appropriate and accessible. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 14 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. The home has its own mini-bus and the use of two cars St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 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. All medication records were complete at the time of the inspection. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 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 Area Manager 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. The area manager stated that the staff team are due to complete a refresher course on adult protection issues. The staff team are aware of the action they must take if they need to report an incident. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 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 that a programme of redecoration is due to be implemented. In addition new furnishing, fixtures and fittings are to be purchased as required. 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: The home offers training opportunities to staff at all levels within the home. St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 20 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. Criminal Records Checks are completed before a new member of staff can begin work in a home. The home has had a change in management in the last year. Nick Young has left his post as manager of St Matthews Road and a new manager is shortly to commence duties at the home. 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 area manager 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 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 area manager stated 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. 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 St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 22 are now up to date although a fire risk assessment had not been completed. In addition The Landlords Gas Safety Certificate and Legionella Certificate could not be found. 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 x 2 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 2 3 3 3 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Matthews Avenue, 1 Score 3 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 2 x x 2 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 and 12 Requirement Timescale for action 30/09/05 2. YA1 5 3. YA5 5 4. YA21 12 The Registered Provider must ensure that the Statement of Purpose includes a description of how the experience of staff members meets the needs of service users, and describes the age range of the existing service users, and for what specific age range the service is intended and The Registered Provider must ensure that the Service Users Guide maximises the independence of service users. The Registered Provider must 30/09/05 ensure that the home produces a Service Users Guide, gives a copy to all service users and stakeholders as appropriate. The Registered Provider must 30/09/05 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 period. The Registered Provider must 30/09/05 ensure that the Version 1.30 St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Page 25 5. YA4 14 6. YA16 12 7. YA27 23 8. YA33 12 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 period. 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. The Registered Provider must ensure that service users are offered a key (or suitable locking device) to their own bedroom/bathroom, which can be locked from inside and outside, and a key to the front door of the home. This must be recorded, and where it is declined or assessed unsafe recorded. The Registered Provider must ensure that the carpet is protected from water damage from the shower room. The Registered Provider must ensure that staff left in charge of the home are clearly assessed as competent to do so, and that staffing at the home is reviewed against the needs of service users described, evidence of the calculation of staffing against the number of needs of service users supplied to the Commission for Social Care Inspection (CSCI) with examples of revised rotas. G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc 30/09/05 30/09/05 30/09/05 30/09/05 St Matthews Avenue, 1 Version 1.30 Page 26 9. YA34 17 and 4 10. YA39 24 11. YA40 12 and 24 12. YA12 42 13. YA42 23 14. YA43 25 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. 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. The Registered Provider must ensure that all policies and procedures are kept under review, to include ‘missing service user’, protection of vulnerable adults, and procedure and policy regarding quality assurance. The registered provider must send to the CSCI, local office a copy of the current legionella certificate, five yearly electrical certificate and a current landlords gas certificate of safety. The registered person must ensure the home has a fire risk assessment. (Timescale of 19/07/04 not met) The Registered Provider must ensure that a budget financial plan is provided to the Commission for Social Care Inspection (CSCI), 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 Page 27 demonstrating Financial planning and the effectiveness, financial viability and accountability of the home 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 Good Practice Recommendations St Matthews Avenue, 1 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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 G53-G53 S13389 StMatthewsAvenue(1) V178266 190705 Stage 0.doc Version 1.30 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. 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