Inspection on 12/06/07 for The Beeches

This inspection was carried out on 12th June 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Beeches 01/03/06

The Beeches 19/09/05

The Beeches 16/02/05

The Beeches 19/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Beeches (The) 28 Shell Beach Road Canvey Island Essex SS8 7NU Lead Inspector Pauline Marshall Unannounced Inspection 12th June 2007 9:15 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 Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beeches (The) Address 28 Shell Beach Road Canvey Island Essex SS8 7NU 01268 515441 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) kingswood@donna-higby.freeserve.co.uk Kingswood Care Services Limited Michael Frederick Bedford Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Personal care to be provided to not more than 4 adults with a learning disability. Mr Michael Frederick Bedford to complete an approved course in Protection of Vulnerable Adults (POVA) within three months of registration. 1st March 2006 Date of last inspection Brief Description of the Service: The Beeches is a two storey detached property set in a quite residential area in Canvey Island. The home is situated close to the beach, buses, pubs and clubs and within a mile of the town centre. The home offers one lounge, one dining room/ kitchenette and four single bedrooms, three with en suite facilities with additional bathroom and downstairs WC. The grounds and garden are well maintained and accessible offering both lawn and decking area for residents. Residents within the home access a range of day care and participate in a range of leisure pursuits/work based programmes within the local community. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. The costs of a bed space range from £1190.77 to £1948.59 per week and residents contributions range from £51.65 to £63.95 per week. Additional charges are made for toiletries and evening and weekend transport, including taxis. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for six hours and fifteen minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with staff, the manager, and deputy manager. As part of this inspection surveys were sent to four residents four relatives’ four health and social care professionals and seven care workers to obtain their views on the service the home provides. At the time of writing this report three residents surveys, one relative survey, one health care professionals survey and five care workers surveys were returned and most were positive in their responses. Comments included “the standard of care is outstanding”, “the home provides good activities and staff communicate well with residents”. One of the care workers surveys identified that recruitment practice was not good and that basic checks had not been carried out. The same survey stated that the staff at the home feels supported by the house manager but unsupported by “the management at head office”. A letter of serious concerns has been sent to the provider with regard to the safety issues identified in this report. Twenty-five of the forty-three standards were inspected. What the service does well: The homes Statement of Purpose and Service User Guide is regularly reviewed and improved upon to make it easier to understand. The admission procedure includes a thorough pre-admission assessment and as many visits to the home as the prospective resident wants to help decide if the home is suitable. Care plans are very informative and help staff to understand the level of assistance residents’ want. The home provides good activities and staff accompany residents on their holidays each year as well as on regular day trips and visits to local shops and pubs. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 6 The Beeches provides good food and homely accommodation that is clean and tidy. The homes use of picture boards for activities and meals is good and assists residents in making their own choices. Staff are well trained and supported by a competent and efficient registered manager. What has improved since the last inspection? What they could do better: The home should ensure that any changes to fees payable are supported in writing and a copy kept with the contract. The complaints procedure should be reviewed to ensure that it is clear on the level of the CSCI involvement. The Protection of Vulnerable Adults procedure must include the need to refer all suspected abuse to the Local Authority. The homes recruitment practices must be more robust and include all of the checks that are required under the Care Homes Regulations. Staff supervision should take place at least six times per year as laid out in the National Minimum Standards. The home should undertake annual reviews of the quality of care provided at the home and supply a written report of its findings to the CSCI and all other relevant people. All health and safety issues, such as repairs to doors must be carried out swiftly and the home must act swiftly on any areas of risk identified at their fire inspection. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 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 Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with sufficient up to date information and a full assessment of need is undertaken prior to admission. EVIDENCE: The homes Statement of Purpose and Service User Guide were reviewed in April 2007. The Service User Guide is being developed further and now includes information that is easier to read and includes pictures, makaton and photographs. There have been no admissions to The Beeches since the last inspection, however all of the current residents care files examined contained fully completed comprehensive pre-admission assessments. Each resident has a contract of their terms and conditions with the home but the fees shown on the contract are at the point of admission. There was no evidence of any increases to residents fees or their contributions. Residents contracts did not include up to date information on the fees payable. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents know that their needs are reflected in the care plan and are assisted and encouraged to make decisions about their lives. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: The care files examined contained thorough detailed information and clearly set out the level of staff intervention. Relatives’ surveys stated that the standard of care is outstanding and the home communicates well. It was clear from the care plans and after speaking with residents that they are very much involved with all aspects of life in the care home. Residents spoken with confirmed that they choose their daily activities and that they Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 11 make their own decisions with support from their families and the homes staff. Regular residents meetings take place and the manager is in the process of arranging relatives meetings. The home has pictorial boards for menus, activities and chores to assist residents with making their choices. The daily notes confirmed that residents participate in every day household chores including their personal laundry and bedroom cleaning. All four of the residents care files were examined and they all contained good clear risk assessments that included plans on how identified risks were to be managed. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents participate in appropriate activities and are part of the local community. Residents are supported in their personal friendships and relationships and recognise their rights and responsibilities. The Beeches offers a range of healthy foods that are chosen by the residents, which they enjoy in a pleasant environment. EVIDENCE: Residents spoken with confirmed that they participated in many activities both inside and outside of the home; they said they frequently visit local cafes and pubs and that they are due to go on holiday to the Isle of Wight later this year. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 13 Residents spoken with shared details of how they were supported by staff in their personal relationships and that the home encourages visits from their family and friends. The Beeches daily routine varies to meet the needs of the individuals living in the home. Residents spoken with confirmed that staff respects their privacy. Staff was observed to interact well with residents and with each other. Care workers surveys stated that the staff team are very close and they implement new ideas that assist the residents understanding, for example pictorial menus and activity boards. Care plans are clear on residents’ responsibilities for household chores. The home offers its residents a four-week rotating menu that is changed at residents’ requests. Mealtimes are flexible and although the menu offers a choice of two main meals the nutrition records confirmed that residents were able to have alternatives if they required. The dining area is spacious and residents spoken with said that they enjoyed their meals and sometimes helped to cook them. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive personal support in their preferred way and their physical and emotional health needs are met. Medication policy and practice is good. EVIDENCE: Residents spoken with said that they were able to go to bed and get up when they wanted. The care files examined contained good clear information on the support that each individual resident required. There was evidence of residents receiving specialist advice and information as needed from physicologists, occupational therapists and speech therapists. Health care records were examined for all four residents and evidenced that their health needs were being fully met and that regular monitoring appointments take place. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 15 Medication is administered for all four residents and the homes medication and administration records were examined and were satisfactory. The home records all errors in administration and details any actions taken. There is a list of signatures for all staff administering medication and a list of any homely remedies used. The home has PRN (as and when) protocols for all of the medication prescribed for use as and when required. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are confident that their views will be listened to and acted upon. The homes policy on the Protection of Vulnerable Adults needs reviewing to comply with the Local Authorities procedures. EVIDENCE: The homes complaints procedure stated that if a complaint was not sucessfully resolved it would be passed to the CSCI. The complaints procedure needs to be reviewed as the CSCI is a regulatory body and has no statutory powers to investigate complaints. The CSCI can use its powers of inspection to undertake enquiries so that judgements can be made as to whether the provider is complying with the regulations. The last complaint received by the home was on 8/09/05 and the records showed that this was dealt with appropriately. The staff files examined contained evidence that staff had received the Protection of Vulnerable Adults training and staff spoken with were aware of the actions they needed to take if abuse was suspected. The homes procedure did not state that all allegations of abuse must be reported to the local authority. The home has a copy of the Essex Vulnerable Adults Protection Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 17 Committees training materials and copies of the guidance documents but did not have a copy of their procedure (Blue Book). The manager said that he had tried to obtain information on his own internet but had found it difficult to locate. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment that is clean and hygienic. EVIDENCE: All of the rooms at The Beeches are spacious and have their own adjacent or en-suite bath or shower and WC. There is one bedroom on the ground floor that leads off of the main lounge area. The home is decorated to a good standard and all rooms have a range of fitted wardrobes and adequate storage facilities. Residents spoken with proudly showed me around their rooms and said how comfortable and homely the home is. The old laundry room is currently being converted to a staff meeting room, to enable private meetings to take place. Private meetings are currently held Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 19 either in the office or in the dining room when residents are out on activities. The garage has now been converted to a laundry room. The garden is small but well laid out and includes a quiet decking area with seating; this can be accessed through either the lounge patio doors or the office door. The homes vehicle is parked on the drive and the manager said that work is in progress to clear more of the front garden to allow for extra parking. There is ample on street parking outside of the home. Residents work together with staff to ensure that their home is kept clean and tidy and on the day of the inspection the home was bright, cheerful, clean and hygienic. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Well-trained, competent and qualified staff supports residents, however the company’s recruitment practice is poor and does not support and protect its residents. Staff supervision does take place but is irregular. EVIDENCE: The Beeches offers staff training in food hygiene, first aid, health and safety, moving and handling, fire safety, administration of medication, POVA and service specific training on epilepsy, effective communication, autistic spectrum disorder, challenging behaviour and makaton. The staff files examined contained evidence of staff having completed most of the above courses. The manager said that training needs are identified through supervision sessions and staff are booked on the next available course. Four of the twelve staff employed at the home have an NVQ qualification and the manager said that further staff are enrolled on an NVQ programme. Staff surveys undertaken by the CSCI varied in their comments and included good Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 21 care and interaction with residents, good communication and activities and staff are well treated and good support from house manager but no support from upper management. The manager said that he is not always involved in the interviewing of staff for The Beeches and that the company owns other homes and sometimes staff are interviewed by managers of one of the other homes and he is then given contact details to make arrangements for staff to start work. The manager said that one staff member is due to start work on 29th June 2007 (a waking night shift) and the only information he has on this person is their christian name and that he has not been provided with any documents for them. Two of the three staff files examined contained evidence of induction, written references and proof of identity; application forms did not require a full employment history. There was no evidence of fitness on the staff files examined. There was no written documentation available for the three most recently employed staff; the manager said that the application forms were returned to head office and they compiled the staff files and forwarded them to him once they were complete. A discussion took place around the importance of the registered manager having evidence that staff are safe to work with a very vulnerable client group and the manager confirmed that he had not had sight of criminal record bureau checks or references for any of the three newest employed staff. Two of the three staff have been working at the home since 12/3/07 and the third began work on 1/5/07. An immediate requirement to obtain the relevant documents for the staff currently working at the home was issued. The staff files examined contained evidence that supervision does take place, however both staff files showed that formal supervision had taken place once a year only. The manager explained that due to staff shortages and him having to work on shift this had caused some difficulties with administration tasks and that supervision was a task that he had already identified needed to be improved upon. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ views are sought on a daily basis but the home has not maintained its quality assurance system. The health and safety of residents is not always protected and reported faults remain in disrepair for long periods of time EVIDENCE: The registered manager has completed the NVQ4 Registered Managers Award but has not yet undertaken an award in Care (NVQ 4 in Care). The manager is very competent and has plans to improve the service provided at The Beeches. The manager said that now there are more staff working at the home he will be able to delegate tasks more effectively and that he will have Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 23 more time to monitor and supervise staff. The manager said that he often works on a shift, escorting residents in the community and on holidays and that this limits the time available for management tasks. The manager should ensure that he has adequate time to fulfil his management duties. There was evidence of two Regulation 26 visits being made by the provider in the past year, the last one being on 15/03/07. One bedroom door was identified at the homes fire inspection as presenting a serious risk to the occupant. The section of the Regulation 26 form dated 15/03/07 reporting on the condition of the fire doors stated that there were no problems and in brackets stated that one door still needs action. The original fire risk was identified by the fire brigade at the homes fire inspection on 26/09/05 and the work was still outstanding on the day of the inspection. The manager said that this had been brought to the providers attention on many occassions. An immediate requirement was left at the home for this door to be either replaced or the gap filled as it poses a serious fire risk to the occupant of the room and should not have been left outstanding for so long. The home had a letter on file that was addressed to the CSCI regarding Regulation 26 visits and the letter stated that a service manager visited the home weekly and were monitoring it on a day to day basis. Staff spoken with said that weekly visits did not take place and the visitors book supported this view. The service manager of Kingswood Care Services Ltd said in his letter to the CSCI that he agreed to complete Regulation 26 visit reports on a three monthly basis and keep them on file at the home for inspection. This agreement has not been adhered to. There was a wardrobe door hanging on by only one of its hinges, making it unsafe; the manager said that this must have happened this morning as it was not reported on the repairs sheet. A discussion took place around safety issues being reported immediately as a staff member was present with the resident throughout the morning and had left the building without reporting any faults. There was evidence that faulty fire doors had been reported to the head office on three occassions over the past month and were still waiting for repair on the day of the inspection. All safety repairs must be carried out immediately to prevent an unnecessary risk to residents. An immediate requirement was left at the home for the faulty fire doors to be repaired. All safety certificates were in place and up to date. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 1 X Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 (b) Requirement The registered person shall produce a written guide that includes the amount and method of payment of fees. Timescale for action 31/08/07 2. YA23 13 (6) This refers to the need to provide residents with written up to date information on the fees payable. The registered person shall make 31/08/07 arrangements to prevent residents being placed at risk of harm or abuse. This refers to the need to review the homes policies and procedures to ensure that all suspected abuse is referred to the Local Authority. The registered person shall not employ a person to work at the care home unless he obtains all the information and documentation required under Schedule 2. This refers to the lack of staff files, the lack of evidence of fitness and employing staff without any of the required 3. YA34 19 (1) (i) 31/08/07 Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 26 information available. An immediate requirement was left for this issue. Where the registered provider is not in day to day charge of the home, he shall visit the care home unannounced at least once a month and prepare a written report on the conduct of the care home and supply a copy to the CSCI. The registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from avoidable risks. This refers to the need to effect repairs swiftly and to act upon any fire safety inspectors instructions (the gap on a residents bedroom door that was identified as a risk in 2005). An immediate requirement was left for this issue. 4. YA39 26 31/08/07 5. YA42 13 (4) (a) 31/08/07 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. Refer to Standard YA22 YA36 Good Practice Recommendations The complaints procedure should be reviewed to ensure that it is clear on the level of the CSCI involvement. All staff should receive supervision at least six times each year. Beeches (The) DS0000047171.V339384.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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