Inspection on 08/07/05 for Strathleven Road, 94

This inspection was carried out on 8th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Strathleven Road, 94 23/08/07

Strathleven Road, 94 15/05/06

Strathleven Road, 94 22/11/05

Strathleven Road, 94 02/03/05

Strathleven Road, 94 19/11/04

Strathleven Road, 94 06/03/04

Strathleven Road, 94 12/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 94 Strathleven Road Brixton London SE2 5LF Lead Inspector Rehema Russell Unannounced 8th July 2005 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. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 94 Strathleven Road Address Brixton, London SW2 5JF 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) 0207 738 4004 strathleven@southside.org.uk Southside Partnership CRH Care Home 6 Category(ies) of PC Care home only registration, with number of places 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 6 places - one of which is used for respite care Date of last inspection 2nd March 2005 Brief Description of the Service: The home is purpose built, fully wheelchair accessible and is situated in a residential road off Acre Lane between Brixton and Clapham. It is managed by a voluntary organisation called Southside Partnership. The home is close to local shops and buses, and is a short walk from a large shopping centre with full community and public transport facilities. There is on street parking around the home. There is a paved area at the front of the house and a good-sized garden at the rear of the property. The accommodation is all on the ground floor with six single bedrooms each with an en suite toilet and wash hand basin. One of the bedrooms is used by two clients on a shared care basis for different days of the week. At the time of inspection there were no resident vacancies at the home. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 5 hours on the afternoon of 8 July. All the residents were in the home as it was half-term and colleges were closed. All residents have severe challenging behaviours and very limited or no verbal communication. The inspector toured the premises, spoke with the acting deputy manager, spoke with two support workers, observed residents activities and behaviours, and looked at documentation and records. The inspector had also spoken with the relatives of two service users prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Following a period of management instability of the home, which is not yet resolved, record keeping and documentation is generally poor. Although some of the previous requirements had been implemented, some remained outstanding. Of particular concern was the outstanding requirement regarding sufficient staffing numbers to ensure residents’ choice in regard to individual activities and to ensure safe working practices. The replacement of the kitchen also remains outstanding, although this is within the remit of the Housing Association which owns the property. The systems already in place in regard to documentation and records must be re-started and maintained, several maintenance and repairs issues are outstanding, and much more care must be taken to ensure that care plans, reviews, equipment and aids, are updated and maintained to ensure the optimum quality of life for residents. Please contact the provider for advice of actions taken in response to this 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 There is no current Statement of Purpose at the home. A range of appropriate care and health specialists are used to ensure residents’ physical and mental care needs are met but residents’ do not currently benefit from independent advocacy services. EVIDENCE: The previous report required that the Statement of Purpose for the home be updated to incorporate necessary amendments. Although the Registered Provider’s response indicated that this had been done, on the day of inspection staff could not locate a copy of the Statement of Purpose at the home. An up to date copy of the Statement of Purpose must always be available at the home, and each current resident should have a copy in their rooms as is the good practice in other Southside Partnership homes. Information from care files and verbal information from keyworkers indicated that the home accesses a range of appropriate health and social care specialists in order to have residents’ needs assessed and met. However, no evidence of independent advocacy involvement was found. To ensure that the home meets residents’ choices and aspirations, an independent advocate should be sought for all residents. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Care plans ensure that residents’ assessed needs are met but their changing needs are not documented by way of regular and annual reviews. Staff take appropriate action to minimise risks but risk assessments do not fully reflect this and have not been reviewed and updated. EVIDENCE: Two care plans were examined, one of a permanent resident and one belonging to one of the shared-care residents. The format of care plans was good and several areas such as initial assessment, care plans, working guidelines and specialist care and health actions plans were well written and detailed. Recent keyworker meeting minutes were present, although previous months’ minutes could not be found. However, risk assessments had not been reviewed (for over 1 –2 years), there was no evidence of regular or annual care plan reviews, and the handover notes for the shared-care resident were sparse and not sufficiently informative. The standard of handover notes for other residents were patchy, sometimes with only one entry for the day (instead of three) and one day’s (5th July) completely missing. Both care files were disorganised, with sections missing or mis-filed, as were two other care plans that were briefly checked in this regard. The acting deputy manager had begun the process of updating and reorganising care files but as this is such an important part of care provision, the Registered Provider must ensure that this 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 10 is done as a matter of urgency. The Registered Provider should consider increasing staffing levels so that the acting deputy manager and acting manager have the opportunity to prioritise this work (see Staffing section below). Care plans and risk assessments must be reviewed, with new risk assessments written as necessary, and handover notes must give sufficient detail for residents’ wellbeing to be monitored. Staff were observed to interpret residents’ behaviours in order to ascertain their moods, needs and choices and appropriate guidelines were seen. However, as noted in the previous section of the report, the home should make sustained efforts to obtain independent advocates for residents so that there is an external and independent input regarding choices and decisions about their lives. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14, 15, 16 an 17. Residents are given the opportunity to fulfil social, emotional and spiritual needs and to take part in appropriate educational and leisure activities. Appropriate family relationships are encouraged and supported. The opportunity for spontaneous activities and outings is currently restricted by staffing levels. Menu records are poorly kept. EVIDENCE: Observation and verbal evidence from staff indicated that residents are supported to mix socially at clubs/outings once per month, with one resident escorted to the pub once a week, and to fulfil spiritual needs by regular church attendance if they wish. However, although one resident is able to attend church on Saturdays, there was evidence that current staffing levels were restricting the opportunity for another resident to attend church each Sunday. This will be discussed in the Staffing section below. The five permanent residents all attend college during the week, where they undertake a range of activities including creative expression, cookery, music, yoga, aromatherapy, art and gardening. Residents all have activities equipment in their rooms which is appropriate to their individual needs and choices – for example television, 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 12 music, computers, light and sensory ornamentation etc. Staff keep routines as flexible as possible but staff confirmed that at times when all residents are in the home, staffing levels would only permit the accompaniment out of one resident at a time for a walk, visit to the shop etc. This therefore restricts residents’ choice, especially during college half -terms and holidays, and will be addressed in the Staffing section below. Staff support residents to keep in regular contact with family and relatives and all except one resident have regular family visits. Staff explained an on-going situation where measures had been put in place to ensure that one resident’s family visit was appropriate, which had been agreed on a multi-disciplinary basis and ensured that the resident was safe and protected. Holidays away from the home have been planned for the five permanent residents, and staff have ensured that these holidays are appropriate to the needs and cultures of individuals. Day trips have been planned for the sharedcare residents. The evening meal was observed and was consistent with that on the menu (fish with mashed potatoes and vegetables). It was attractively presented and very tasty and was observed to be enjoyed by all residents. However, menu records were not fully filled in, and it was not possible to tell which meals were being given on a daily basis and therefore whether a varied and nutritious diet was being supplied generally. The Registered Provider must ensure that accurate daily menu records are maintained at all times. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 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 standard(s) 18 & 20 Staff provide sensitive and flexible personal support. Medication is kept and administered appropriately. Specialist support and advice is sought and aids and adaptations used. These have not been re-assessed recently to check that they are still safe and suitable to individual needs. EVIDENCE: Staff were observed to treat residents with respect and dignity. All residents were age-appropriately dressed and had good personal hygiene. Documentation seen provided evidence that specialist advice, reports and actions plans for residents had been obtained on an individual basis in the past. Medication administration, recording and storage were checked and no problems were found. The four requirements arising from the previous report had all been implemented and the home now carries out weekly medication stock checks. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 14 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 The home has a complaints procedure. The complaints process is being further developed to better enable residents, relatives and interest parties to express their views and suggestions. EVIDENCE: Following a requirement in the previous report, a form has been devised that gives the resident/key-worker/parent/advocate a means of recording suggestions, issues or complaints. This form contains a date and action column for tracking and will be kept in care plans so that it can inform the care process. The complaints file showed that there had been no formal complaints received by the home since 2003. The home must keep a central complaints book, so that any complaints received can be recorded and preserved in date order (with reference to where full details of the complaint and action taken will be kept). 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29 and 30 Residents live in a homely, comfortable and safe environment, with bedrooms that suit their needs and lifestyles. The home is generally clean and hygienic but there are several maintenance and re-decoration issues and the kitchen is in need of refurbishment. EVIDENCE: All rooms in the home were seen. All bedrooms were personalised and of good décor, with the two bedrooms that had recently been redecorated of a particularly good standard. However, there were several outstanding maintenance issues that must be resolved. In the third bedroom the doors need to be made good in regard to paintwork. In the fourth bedroom en-suite the walls must be cemented adequately so that the support bar can be refitted and the functioning of the ventilation checked. In the fifth bedroom the bathroom should be redecorated and the bedroom carpet replaced (it is still very stained and dirty despite an industrial clean two months previously). There is a large main lounge, leading out to the garden, with television, DVD, music and ornamentation, but the whole room, including the ceiling, needs to be redecorated, the carpet industrially cleaned and a new coffee table obtained. The two bathrooms are adequately equipped and decorated but the 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 16 ventilation of the second bathroom should be checked to ensure it is working correctly. Two previous inspection reports have required that the kitchen be refurbished and the home and Registered Provider have made strong efforts to ensure the Housing Association agreed to this. The Housing Association had agreed to refit the kitchen by the end of May 2005. However the furnishings offered were so unsubstantial that the home refused to accept them. This is reasonable as all fittings and fixtures in the home necessarily receive heavy wear and tear. However, it leaves this requirement still outstanding. Furthermore, the kitchen floor requires a deep clean/renewal, the walls and paintwork require redecoration, and both the fridge (water at the base) and the freezer (top door inside missing) must be serviced. The home was found to be generally clean and hygienic with no offensive odours. However, as the whole home receives heavy wear and tear, and as staffing levels appear to be low at the moment, it is recommended that a spring clean of the whole home is undertaken by an external company. Residents had appropriate technical aids and equipment but several of these were old and dated. Therefore a comprehensive re-assessment of all aids and equipment at the home must be undertaken by a suitable specialist to ensure that they continue to meet residents’ needs and ensure maximum independence. A requirement has been made for the Registered Provider to obtain a specialist assessment of the environmental adaptations and disability equipment provided at the home to ensure it meets the assessed needs of all residents. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Although the staff team is trained and experienced, numbers are not sufficient to maintain documentation and records and to give residents choice in regard to daily activities when they are at home. EVIDENCE: Excluding the 1:1 staffing provided for the shared-care residents, staffing rotas showed that there are usually three support workers during the early shift and two during the late shift. As three residents are wheelchair users, and all residents have very challenging behaviours, this does not appear to be sufficient staffing to ensure safe working practices nor to allow residents the choice to undertake individual day or evening activities. This therefore adversely affects the quality of life that can be provided at the home and has been made subject of requirement in previous reports. The Registered Provider held talks with the purchasing authority during the previous financial year and must now update CSCI as to whether any progress has been made. Another previous requirement was for the Registered Provider to split the eleven hour 1:1 Sunday shift at the home or provide staff undertaking this shift with a significant break away from the resident. The inspector was told that although the 1:1 shift is undertaken by a different support worker each Sunday it remains an eleven hour shift with no significant break. This requirement therefore remains unmet. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 18 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 and 41 The home is in a period of management instability and records and documentation do not currently meet the required standards. EVIDENCE: The previous long-serving manager left the home at the beginning 2005 but had been undertaking a dual management role within the parent organisation prior to this. An experienced manager from another of the parent organisation’s homes then took up the post but left after a month. Currently the deputy manager is acting up into the role of manager, and a support worker is acting up into the role of deputy manager. Due to the fairly lengthy period of management instability at the home, the Registered Provider must ensure that there is an experienced and permanent manager in post as soon as possible. Documentation systems at the home are good but they have not been maintained recently due to poor record keeping. This may be due to the 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 19 lengthy period of management instability and the low staffing levels at the home. The acting deputy manager has made considerable efforts to improve the situation, creating a new system in the office, a new shift plan file, a new health & safety file, re-starting monthly keyworker meetings and sorting out the files and systems in the manager’s office. However, there is much more work to be done before the home meets the required standard in regard to documentation and records (for example, all care plans need to be reviewed, all care files need to be sorted out, handover and daily notes need to be improved and kept, required records need to be well kept and accessible, etc.) and it is unlikely that the required time will be available given the current low staffing levels. A requirement has therefore been made for the Registered Provider to provide temporary extra staffing or otherwise ensure that sufficient time can be spent by the manager and deputy manager to bring all documentation and records to the required standard, and ensure that staff fill in and maintain records appropriately. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 20 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 1 x 2 x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 2 2 2 1 Standard No 11 12 13 14 15 16 17 3 3 x 2 3 3 2 Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 94 Strathleven Road Score 2 x 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 x x G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 21 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 1 Regulation 4&6 Requirement The Registered Provider must ensure that an updated copy of the Statement of Purpose is available at the home. The previous timescale of 31 May 2005 was not met. The Registered Provider must ensure that all care plans are regularly reviewed, including muliti-disciplinary annual reviews. All care plans must be organised and well kept. The Registered Provider must ensure that all risk assessments are present and that existing ones are reviewed. The Registered Provider must ensure that handover notes are sufficiently informative.The previous timescale of 31 May 2005 was not met. The Registered Provider must ensure that accurate daily menu records are kept. The Registered Provider must ensure that a central complaints book is kept at the home. The Registered Provider must ensure that the third bedroom doors are painted, the fourth bedroom en-suite walls are Timescale for action 30th September 2005 2. 6 15 (1) & 15 (2)(b) 31st October 2005 3. 9 13(4) 31st October 2005 30th September 2005 31st August 2005 30th September 2005 31st October 2005 Page 22 4. 6 15(1) 5. 6. 7. 17 22 24,26,27 16(2)(i) Sch.4 11 23 (2)(b) & 23 (2)(d) 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 8. 29 23(2) (c) & (n) 9. 28 23 (2)(b) & 16 (2) (g)&(h) 10. 33 18(1)(a) 11. 33 18(1)(a) 12. 37 CSA 13. 41 Sch 3 & made good and the support bar re-fitted, the fourth bedroom ensuite ventilation is working adequately, the fifth bedroom bathroom is redecorated and the bedroom carpet replaced, the main lounge room and ceiling is decorated, the main lounge carpet is industrially cleaned and a new coffee table obtained and that the second bathroom ventilation is working adequately. The Registered Provider must ensure that all environmental adaptations and disability equipment provided at the home is up to date and meets the currently assessed needs of all residents. The Registered Provider must ensure that all furniture and fittings in the kitchen are made good or replaced. The previously revised target date of 31.7.05 has not yet expired. The Registered Provider must review staffing levels to ensure that there is always sufficient staffing at the home to implement safe working practices and appropriate flexibility. A copy of the report must be sent to CSCI. The previous timescale of 31 \May 2005 was not met. The Registered Provider must ensure that the eleven hour 1:1 shift is split or that staff undertaking the shift can have a significant break away from the resident. The previous timescale of 30 June 2005 was not met. The Registered Provider must ensure that there is an experienced and permanent manager in post. Registered Provider must provide 31st January 2005 31st July 2005 31st August 2005 31st August 2005 31st October 2005 30th Page 23 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Sch 4 temporary extra staffing or otherwise ensure that sufficient time can be spent by the manager and deputy manager to bring all documentation and records up to the required standard. September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 3 30 Good Practice Recommendations The Registered Person should try to ensure that residents benefit from the services of an independant advocate. The Registered Person should ensure that a spring clean of the whole home by external cleaners is undertaken. 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor, 46 Loman Street Southwark London 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 94 Strathleven Road G52-G02 S22759 Strathleven Rd V238089 080705 Stage 4.doc Version 1.40 Page 25 - 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!