Inspection on 20/11/05 for Trumpington Road 130

This inspection was carried out on 20th November 2005.

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

The inspector found 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trumpington Road 130 05/05/09

Trumpington Road 130 06/05/08

Trumpington Road 130 14/06/07

Trumpington Road 130 29/07/06

Trumpington Road 130 11/08/05

Trumpington Road 130 15/02/05

Trumpington Road 130 02/11/04

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 Trumpington Road 130 130 Trumpington Road Forest Gate London E7 9EQ Lead Inspector Robert Sobotka Unannounced Inspection 20th November 2005 10:30 Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trumpington Road 130 Address 130 Trumpington Road Forest Gate London E7 9EQ 020 8496 1440 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) London Borough of Waltham Forest Mrs Irene Luton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1.The home may provide accommodation and personal care for up to 15 persons of either gender who are between the ages of 18-65 who have a Learning Disability. 2.The provider must undertake a programme of measures that will achieve full compliance with the National Minimum Standards for Younger Adults Standards 24 to 30 Environment, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) By April 1st 2006. 3.In order to promote the health and safety needs of service users living in Trumpington Road, the provider must ensure that the home complies with all requirements contained in the relevant Health and Safety legislation on an ongoing basis and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Younger Adults - Standard 42 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - By April 1st 2005. 11th August 2005 3. Date of last inspection Brief Description of the Service: Trumpington Road is a purpose built 15-bed respite unit managed by the London Borough of Waltham Forest. The design of the building is different from others in the locality and sets users apart from neighbours in adjacent domestic properties. The home is divided into four units. One of the units can accommodate people with learning disabilities. At present there are still some service users that have been staying in the home for an extended period whilst attempts are made to find appropriate alternative accommodation. The service caters for people with a wide range of learning disabilities and a wide range of support needs. The length of stay also varies. The establishment does not provide nursing services. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 1 day (on Sunday) and included speaking to the service users staying at the respite service, some of the staff and the deputy manager. The inspector also conducted a tour of the premises and viewed various records. During this visit, the inspector also investigated an anonymous complaint about the home, which was received by the Commission on 07/11/05. The aim of this visit was to check the home’s progress towards full compliance with the legislation, as well as to investigate the complaint about the home. What the service does well: What has improved since the last inspection? Very limited progress has been made in ensuring that all previous requirements and recommendations have been met. Although it was noted that some work has been done to ensure that all service user using the service have appropriate and up-to-date care plans and risk assessments in place, further work in required in order to meet the requirements fully. Since the last inspection, the cleanliness of the place has been improved. Staff have introduced a system of checking First Aid Boxes. Service users have also received individual contracts including terms and conditions. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5. No progress has been made to improve the home’s admission procedure to ensure that there is a proper assessment carried out prior to people moving into the home. Without it there is no assurance that care needs will be met. EVIDENCE: As part of this inspection visit, the inspector reviewed six individual service users’ files. Not all care plans viewed contained up-to-date assessments to ensure that the project would be able to meet the assessed needs of its service users. The requirement in relation to assessment process has therefore been repeated and must be met without delay. As documentation in respect of service users was in some cases incomplete and kept under review, the inspector was unable to assess whether the needs of all service users were being met. The issue of care plans and risk assessment has been of ongoing concern, as a result the Commission will be taking an enforcement action to ensure that the home complies with its repeated requirements and recommendation in relation to the care planning process and risk management. Service user’s files viewed showed that each person has been given a contract of terms and conditions. This requirement has now been met. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 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 the following standard(s): 6, 9. Little progress has been made on improving arrangements to ensure that the needs and goals of residents are identified and met. These shortfalls could have a potential to place those who use the service at risk. EVIDENCE: Six care plans of service users who were being accommodated at the time of this visit were checked by the inspector. The quality of documentation reviewed varied. One person, who has received services from the project for at least 9 times did not have care plan and risk assessments in place. Care plan of another service users was found half-completed and risk assessment form was blank. It was not singed or dated. Another care plan viewed did not include information as to how the home was going to meet cultural and religious needs of that service user. In addition, it was noted that not all actions identified in care plans were being carried out. For example, care plan of one service user stated that she her weight was meant to be monitored on a weekly basis, however no weight records were in place. As part of this inspection, the inspector asked for a risk assessment in respect of one service user, who had recently required attending emergency services, Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 10 due to an accident that took place in the home. Staff on duty were unable to show the risk assessment to the inspector, which would show that appropriate action has been taken to prevent further accidents. As previously mentioned, due to ongoing concerns, the Commission will be taking enforcement action to ensure that each service user has an up-to-date and comprehensive care plan and risk assessment in place and that those are reviewed on regular basis. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 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 the following standard(s): 17. No progress has been made that food kept in the home is stored safely. This could have a potential to place those who use the service at risk. EVIDENCE: As Trumpington Road is a respite unit, the main responsibility for finding employment and education foes not lie with the project. Throughout the inspection, there was evidence that staff engaged and encouraged service users to take in indoor and outdoor activities. In case of those service users who have lived in the home for prolonged period of time, there was evidence that the home offered appropriate support in promoting leisure activities. The inspector shared Sunday roast lunch with service users on one the units. Food offered was appetising and nutritious. Service users said that they liked the food offered to them. Following lunch, the inspector conducted tour of the premises and checked fridges on individual units and the main kitchen. There has been no progress made by the home in ensuring that food is appropriately labelled once opened. Whilst during the last inspection it was identified that food was not being labelled on individual units, this inspection visit showed Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 12 that some items were also not labelled in the main kitchen. In addition, food samples were not kept, as required by the environmental health team. The requirement in relation to food storage has therefore been repeated and must be met without any further delay. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Limited progress has been made in ensuring that personal and healthcare needs of the service users were being met. Medication systems required improvement. EVIDENCE: The requirement relating to detailed individual preferences in relation to receiving personal care to be recorded on the service user’s file remains unmet and must be met without further delay. As mentioned before, because Trumpington Road is a respite unit, the main responsibility for meeting healthcare needs of the service users remains with their primary carers (parents/relatives). Those service users who have been staying in the project for longer periods were registered with the General Practitioner. One of the service users using the service has challenging needs and their health action plan stated that their episodes of physical aggression and/or verbal abuse should be recorded, however no detailed record was maintained by the home. The registered manager must ensure that staff follow instructions within individual service users’ health action plans and maintain appropriate records where required/agreed. Another service user was supposed to be weighed on a weekly basis. Member of staff on duty stated that this person was refusing to be weighed. No record indicating refusal from the service user was available. It is required that service users are weighed on Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 14 regular basis. Where it is not possible to monitor weight (due to refusals from a service user), this must also be recorded. Medication systems continue to require improvement. Individual guidelines/protocols to be in place for the administration of “as required” medication have not been introduced. In addition, several medication administration sheets contained gaps, and it was unclear whether medication was administered to those service users. Records of medication were found incorrect. Staff in charge of the home of the day of the inspection was unable to explain the inaccuracy. Due to ongoing concerns with the medication systems in the project, the Commission for Social Care Inspection will be taking an enforcement action for the home to achieve compliance with the regulations. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Further work was required to ensure that record of finances kept on behalf of service users were accurate. Recording of incidents/accidents also required improvement. EVIDENCE: The home had appropriate complaints procedure in place. Records of complaints made to the home were examined and they showed that appropriate action was taken to investigate complaints made to the home. There was one complaint that was being investigated remained unresolved and was being dealt with by the manager. The home had a copy of the CSCI adult protection protocol and staff have received adult protection training. During this inspection, it transpired that all not incidents were being recorded and subsequently reported to the Commission for Social Care Inspection, as required by law. The registered manager that comprehensive record of each incident/accident in the home is kept. It is also required that all notifiable incidents listed in Regulation 37 of the Care Homes Regulations are reported to the Commission without delay. Records kept in the home on behalf of service users were also randomly checked. Finances in relation to one of the service users appeared to be £2.07 short. One record viewed showed that this money was kept in the home for the service user, whilst another sheet showed the balance of £0. This highlighted that more scrutiny and tighter systems were required to ensure that financial systems are not open to abuse. The home’s policy relating to holding finances of behalf of service users stated that money should be checked on Mondays, Wednesdays and Saturdays, however there was no evidence that this practice was taking place. The registered manager must ensure that financial records Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 16 relating to money kept on behalf of service users are up-to-date and that the home’s policy on dealing with the finances kept in the home is adhered to. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30. The premises were meeting the needs of the service users, however some areas required tidying up. EVIDENCE: The home was purpose built 13 years ago and is different in design from other properties on the same street. The home is close to local shops, amenities and transport. There are four separate units each with lounge, dining room and small kitchen areas. The home is accessible for people with physical disabilities and one unit has specialised bathing facilities. The premises appeared to be clean and hygienic at the time of the inspection, however some areas, such as one of the courtyards and rubbish by the front gate required clearing. The offensive odour in one of the bedrooms has now been eliminated, as required during last inspection. The registered manager must ensure that communal courtyards and area outside of the front gate are cleared from clutter. Twelve of the bedrooms are approximately 7 square meters in size. The three bedrooms in the unit designed for people with physical disabilities are approximately 10 square meters. The rooms are all small and therefore the amount of furniture provided is limited, as is the space for service users to move around their rooms. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 18 Some of the rooms were viewed. They were generally clean and hygienic and service user said that they were happy with the rooms they occupied. Each unit has a bathroom and a shower room and there are appropriate facilities to meet the needs of people with physical disabilities. As stated in the previous inspection reports, although attempts have been made to make bathrooms more homely, they are in general institutional and unwelcoming. The recommendation that all bathrooms and shower units are made less institutional and more in keeping with the homely environment therefore remains outstanding. Appropriate laundry facilities were in place, although at the time of this inspection there appeared to be excessive amounts of laundry kept in the laundry room. Person in charge stated that this was due to the laundry person being off on leave. She also stated that the backlog would be by the end of the next night shift. One of the elements of the anonymous complaint included concerns from the complainant about staff smoking in the courtyard. The inspector checked the area and it contained appropriate ashtrays. The home’s smoking policy stated that staff were permitted to use this area during their breaks. This element of the complaint was therefore not substantiated. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34. Staff recruitment and prompt response to staff training needs required improvement. EVIDENCE: These standards could be fully assessed, as the person holding the key to the office where staff personnel files are kept was off on the day of this inspection. The requirement in relation to the recruitment practices has therefore been repeated. During discussion with a person in charge, it transpired that it has been identified that one member of staff in particular required training in dealing with service users who may have challenging needs. The inspector was informed that no training has been arranged till date. The registered manager must ensure that where identified that staff require training in working with service users with challenging needs, this is provided to staff without delay. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 40, 41, 42. Limited progress has been made to ensure that the service users’ needs were being met. These shortfalls have a potential to place residents at risk. EVIDENCE: The manager’s post is currently filled by the person on secondment from another Local Authority (Redbrigde). At the time of this inspection, the manager was on annual leave, the standard could not therefore be tested fully. The anonymous complaint, received by the Commission, included some concerns about the home manager’s and one of the deputy’s management styles. It was noted that there has been some low staff morale in the home and increased sickness levels. This was also confirmed by the service manager. when the inspector provided feedback from this inspection visit. The inspector viewed a random selection of the home’s policies and procedures and these were now to be in place, however, as previously mentioned, staff Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 21 must ensure that they are familiar with the home’s policies and procedures and adhere to them at all times. Some of the records kept in the home required improvement. These included: admission assessments, care plans, risk assessments, medication administration records, records of incidents/accidents, record relating to monitoring service users behaviour and weight and staff personnel files. The majority of those shortcomings have been identified during previous inspection visits and must be met without any further delay. The home has now got a satisfactory system for checking and restocking First Aid Boxes, as required during the last inspection visit. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 2 X 3 Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 3 X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trumpington Road 130 Score 2 2 1 X Standard No 37 38 39 40 41 42 43 Score X 2 X 2 2 3 X DS0000036677.V266854.R01.S.doc Version 5.0 Page 23 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 YA3 Regulation 14 Requirement Timescale for action 15/11/05 2 YA6 15 3 YA9 13 4 YA18 12, 13 The registered provider must demonstrate how residents’ assessed needs are met. (Previous timescales of 30/01/04, 30/06/04, 31/01/05, 30, 04 and 15/11/05 were not met.) Care plans must be more 15/11/05 detailed and include clear objectives and must cover all appropriate areas to meet individual assessed needs. (Previous timescales of 30/01/04, 30/06/04, 31/01/05, 30/04/05 and 15/11/05 were not met.) Comprehensive risk assessments 01/11/05 must be undertaken for all residents and strategies put in place to minimise identified risks. (Previous timescales of 31/10/03, 30/06/04, 31/01/05, 30/04/05 and 01/10/05 were not met.) Each service user’s preference 31/01/06 about how they are guided, moved, supported and transferred must be explained and recorded. (Previous timescales of 22/10/03, DS0000036677.V266854.R01.S.doc Version 5.0 Trumpington Road 130 Page 24 5 YA41 17 6 YA20 13(2) 7 YA17 16(2) 8 YA20 13(2) 9 YA34 7, 9, 19 Sch 2 10 11 YA37 YA18 9(2)(b)(i) 12(1)(a) 12 YA40 Appendix 3 30/06/04, 31/01/05, 30/04/05 and 15/10/05 were not met.) An up-to-date photograph of each service user must be kept on their files. (Previous timescales of 31/10/03, 31/05/04, 31/01/05, 30/04/05 and 15/11/05 were not met.) Individual protocols must be in place for the administration of “as required” medication. (Previous timescales of 31/05/04, 31/12/04, 31/03/05 and 01/10/05 were not met. The registered manager must ensure that all food is labelled when opened. (Previous timescale of 15/09/05 was not met.) The registered manager must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Previous timescale of 15/09/05 was not met.) The responsible person must be able to demonstrate that appropriate checks ate undertaken on all staff prior to commencing employment in the home. (Previous timescale of 01/10/05 was not met.) The registered manager must obtain relevant qualification in management. The registered manager must ensure that staff follow instructions within individual service users’ health action plans and maintain appropriate records where required/agreed. All policies and procedures identified in Appendix 3 of the National Minimum Standards must be made available in the home. They must be up-to-date DS0000036677.V266854.R01.S.doc 31/01/06 01/10/05 15/12/05 15/09/05 31/12/05 31/12/05 31/12/05 15/01/06 Trumpington Road 130 Version 5.0 Page 25 13 YA18 14 YA23 15 YA23 16 YA40YA23 17 YA30 18 YA32 and readily available. All staff should be familiar with these polices and procedures. (Previous timescales of 31/11/03, 31/07/04, 28/02/05 and 15/11/05 were not met.) 17(2) It is required that service users are weighed on regular basis. Where it is not possible to monitor weight (due to refusals from a service user), this must also be recorded. 17(2) Sch The registered manager that 4.12 comprehensive record of each incident/accident in the home is kept. 37 It is required that all notifiable incidents listed in Regulation 37 of the Care Homes Regulations are reported to the Commission without delay. 17(2) Sch The registered manager must 4.9 ensure that financial records relating to money kept on behalf of service users are up-to-date and that the home’s policy on dealing with the finances kept in the home is adhered to. 23(2)(o) The registered manager must ensure that communal courtyards and area outside of the front gate are cleared from clutter. 18(1)(c)(i) The registered manager must ensure that where identified that staff require training in working with service users with challenging needs, this is provided to staff without delay. 31/12/05 31/12/05 31/12/05 31/12/05 15/12/05 15/01/06 Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 26 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 YA27 Good Practice Recommendations It is strongly recommended that all bathrooms and shower rooms are made less institutional in keeping with the homely environment. Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Trumpington Road 130 DS0000036677.V266854.R01.S.doc Version 5.0 Page 28 - 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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