CARE HOME ADULTS 18-65
Vale Road (1b) 1b Vale Road Forest Gate London E7 Lead Inspector
Sharon Lewis Unannounced Inspection 5th January 2006 12:30 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 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 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 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. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Vale Road (1b) Address 1b Vale Road Forest Gate London E7 020 8471 3545 020 8471 3545 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) www.heritagecare.co.uk Heritage Care Post Vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: 1B Vale Road is a registered care home, which provides 24-hour residential care for 6 people with learning disabilities. The registered provider is Heritage Care, and the property is owned by London & Quadrant, who also provide housing services. 1B Vale Road is a ground floor property, which is specially designed to accommodate people with mobility difficulties. Most of the areas within the home are wheelchair accessible. All service users have single bedrooms with washbasin facilities. The home has a communal lounge and a kitchen/dining area. The lounge overlooks the garden. The garden has a patio area, with garden furniture and a lawn area with flowerbeds. 1B Vale Road is situated off Upton Lane, in Forest Gate. Buses 25 and 86 run along the Romford Road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of culturally diverse shops, services and amenities are situated on Upton Lane, Romford Road and Woodgrange Road. At the time of the Inspection there were no placement vacancies. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken on a Thursday afternoon and lasted four and a quarter hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. In addition to checking the home’s compliance with the legal requirements made at the last Inspection. The Inspector spoke to all service users currently living at the home. Individual discussions were also held with the Senior Support Worker and the Acting Manager. Service users daily logs, medication and medication administration records, fire safety records and other relevant documentation were examined. A tour of the premises was also undertaken. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well:
All service users were comfortable in their surroundings and indicated that they were happy living at the home. Service users benefit from residing in a warm, family atmosphere where their individuality and independence is promoted. Service users had built up good relationships with staff. Service users benefit from a stable, competent staff team. The organisation has managed to recruit to the majority of vacant positions. Continuity of care has been achieved through bank staff being recruited to permanent positions. Service users are able to take part in age, peer and culturally appropriate activities. The home demonstrated that service users engage positively in their local community and are attending relevant classes and social groups. This included visiting their local pub, café, hairdresser, pensioner’s group, sauna, swimming and accessing a range of local amenities. During the Inspection one service user went out to the pub.
Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 6 Service users have opportunities for personal development within the home. Service users are able to attend a Women’s Group and music therapy. Spiritual needs were addressed through regular church attendance. Independent living skills are actively encouraged. Service users assist with gardening, meal preparation, clearing the table, shopping, housework and their laundry. Each bedroom was individualised with its own colour scheme and washbasin facilities. Service users bedrooms had a range of personalised items that reflected their individuality, hobbies and interests. What has improved since the last inspection? What they could do better: Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 7 During this Inspection nine legal requirements and three recommendations were highlighted. The Statement of Purpose and Service User Guide must be further developed. The Statement of Purpose must be updated to include the Acting Manager’s qualifications and experience. The Statement of Purpose and the Service User’s Guide must also include the Commission for Social Care Inspection details in regards to complaints. This requirement is repeated from the previous Inspection. Service users and their relatives must have adequate upto-date information regarding the home. Written evaluations must be available to evidence service users consultation. The home must demonstrate that service users are consulted on, and participate in all aspects of the home. A referral must be made to the Occupational Therapist in reference to the service user who experiences frequent falls. The continence needs for service users must also be monitored. Service users health needs must be fully met. Service users respective wishes should be noted in the event of death. Service users should be confident that in the event of death, matters will be managed in a respectful and sensitive manner. The home must obtain a copy of Newham’s Adult Protection procedure, in order to better protect service users from abuse, neglect or self-harm. Examination of newly appointed staff evidenced no evidence of the staff induction. Written evidence of the staff induction must be on file. Service users must be protected by more robust recruitment and employment practices. The fire safety records must be more robust. The home must ensure the name of all service users involved in each drill is recorded. Service users must be protected by the home’s fire safety practices. Both the supervisor and staff member should consistently sign supervision records. The home should fully evidence that accountable staff support service users. Accident records must be fully completed. A referral must be made to the Occupational Therapist in reference to the service user who experiences frequent falls. The health and safety of service users must be promoted and protected. General maintenance must be further addressed. The radiator must be repaired and dusted in GM’s room. The chest of drawers handles must also be replaced in BB’s bedroom. These requirements are repeated from the previous Inspection. Service users must reside in a well-maintained, homely environment.
Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 8 In addition the light covering in the hallway entrance must be replaced. The lights in the front bathroom and on the overhead washbasin in DP’s room must be replaced. Service users must benefit from well-lit facilities. 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. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 9 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 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 10 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): 1, 2 & 4 Vale Road demonstrated the ability to meet service users individual needs. Documentation must be further developed to inform service users choice and promote their rights. EVIDENCE: The Statement of Purpose and Service User Guide must be further developed. The Statement of Purpose must be updated to include the Acting Manager’s qualifications and experience. The Statement of Purpose and the Service User’s Guide must also include the Commission for Social Care Inspection details in regards to complaints. This requirement is repeated from the previous Inspection. Service users and their relatives must have adequate upto-date information regarding the home. The home has not admitted any new service users since the last Inspection. The home was able to evidence that they are able to meet the assessed needs of individuals. All service users were comfortable in their surroundings and indicated that they were happy living at the home, and had no complaints. The home has a warm, family atmosphere and service users interacted amiably like siblings. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 11 The home has eligibility criteria and service users are only admitted into the home, if their needs can be met. This Inspection evidenced and all service users felt their needs were being met. Prospective service users have the opportunity to visit the home and stay on a trial basis. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Service users individual needs and choices are generally promoted at Vale Road. Evidence of service user consultation must be further developed. EVIDENCE: Person centered planning is at the centre of the home’s philosophy. Quality of care is service user led. The home focuses on service users unique histories, individual needs and personal preferences. Personal activity and care plans are then developed which reflects their individuality. Observation, discussion and examination of documentation, evidenced that service users exercised choice in their daily lives. Service users were observed engaging in different activities and choose whether to be alone or socialise with others. The Acting Manager explained that the majority of service users communicate non-verbally. The home has therefore devised a creative system to achieve service users consultation through the use of parties. These parties are videoed and action taken to address service comments and interactions. Written evaluations of these parties must be available to evidence service
Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 13 users consultation. The home must demonstrate that service users are consulted on, and participate in all aspects of the home. Service users are supported to take risks as part of an independent lifestyle. Risk assessments have been developed for all service users. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 14 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): 11, 12, 13, 16 & 17 Service users lifestyle needs are individually promoted at Vale Road. EVIDENCE: Service users are able to take part in age, peer and culturally appropriate activities. The home demonstrated that service users engage positively in their local community and are attending relevant classes and social groups. This included visiting their local pub, café, hairdresser, pensioner’s group, sauna, swimming and accessing a range of local amenities. Service users have benefited from attending a range of birthday parties, Christmas and New Years parties. During the Inspection one service user went out to the pub. Service users have opportunities for personal development within the home. Service users are able to attend a Women’s Group and music therapy. Spiritual needs were addressed through regular church attendance. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 15 Independent living skills are actively encouraged. Service users assist with gardening, meal preparation, clearing the table, shopping, housework and their laundry. The home promotes a healthy lifestyle through exercise. A service users was noted to have their own exercise bike. Menus were examined and found to be nutritious, balanced and reflecting various cultures. These included traditional British, Italian and African. Examination of the kitchen evidenced the home had an abundant supply of food and fresh fruit was available. Service users additionally eat out on a regular basis. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 16 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): 19, 20 & 21 Service users personal and health needs must be further promoted at Vale Road. EVIDENCE: Service users are supported to access NHS healthcare facilities in the locality. Documentation evidenced that generally service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Evidence was seen that service users have been referred to a speech and language therapist, clinical psychologist and specialist check-ups. Service users benefit from regular optician, chiropodist, dentist, psychiatric and district nurse support. It was noted that there is a service users who experiences frequent falls. A referral must be made to the Occupational Therapist in reference to this service user. Examination of daily logs evidenced that the majority of service users have continence needs. The continence needs for service users must be monitored as specialist equipment and services may be needed in relation to infection control. Service users health needs must be fully met.
Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 17 The organisation has a policy, which addresses the ageing, illness and death of a service user. Service users respective wishes should be noted in the event of death. Service users should be confident that in the event of death, matters will be managed in a respectful and sensitive manner. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 18 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 developments are needed to ensure service users safety and welfare is promoted, to minimise risk and safeguard them from abuse or harm. EVIDENCE: The home has produced a complaints policy. The complaints book was examined; there have been no service user complaints since 2001. Adult Protection procedures have been produced. The home had an adult protection flow chart displayed in the main office, which listed steps to take in reporting any incident of adult protection. Discussions with staff evidenced their awareness of the adult protection procedure and appropriate training. The home has obtained a copy of the ‘No Secrets’ document issued by the Department Of Health. The home must also obtain a copy of Newham’s Adult Protection procedure; this requirement is repeated from the last Inspection. Service users welfare must be safeguarded by the home’s overall adult protection procedures. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 19 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, 26, 27, 29 & 30 Vale Road provides service users with a homely environment. General maintenance however must be further addressed. EVIDENCE: 1B Vale Road is situated on the ground floor and is specially designed to accommodate people with mobility difficulties; with most areas being fully wheelchair accessible. All service users have single bedrooms with washbasin facilities. The home has a communal lounge and kitchen/dining areas. The lounge overlooks the garden that includes a patio area with garden furniture, lawn area with flowerbeds and a sensory garden. Vale Road is situated off Upton Lane, in Forest Gate. Buses 25 and 86 run along the Romford Road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of culturally diverse shops, services and amenities are situated on Upton Lane, Romford Road and Woodgrange Road. Service users benefit from an increased security system, daily patrols by the local Police and management liaison with the community team and council
Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 20 departments. The home has CCTV surveillance for the external areas and there are confirmed plans to install a security gate. All service user bedrooms were inspected. Bedrooms were clean, tidy and had sufficient space for personal items. Service users can bring their own furniture and can decorate and personalise their rooms subject to fire and safety requirements. Each bedroom was individualised with its own colour scheme and washbasin facilities. Service users bedrooms had a range of personalised items, these included televisions, music system, personal artwork, pictures and an exercise bike. All bedrooms reflected each service users individuality, hobbies and interests. Toilets and bathrooms provide sufficient privacy to meet individual needs. A new bathroom with new flooring has been fitted. There is a choice of two bathrooms, both with shower facilities. The home was clean and free from offensive odours. A utility room is available with laundry facilities. A refurbishment and maintenance programme is in progress. The hallway has been redecorated and the damp/plastering damage in the hallway has been addressed. Other maintenance issues have additionally been actioned. General maintenance however must be further addressed. The Acting Manager explained the problems the home had with their landlord London and Quadrant Housing Association, in relation to maintenance of the property. The radiator must be repaired and dusted in GM’s room. The chest of drawers handles must also be replaced in BB’s bedroom. These requirements are repeated from the previous Inspection. Service users must reside in a well-maintained, homely environment. In addition the light covering in the hallway entrance must be replaced. The lights in the front bathroom and on the overhead washbasin in DP’s room must be replaced. Service users must benefit from well-lit facilities. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 - 36 Vale Road has adequate staffing and service users benefit from an effective staff team. Shortfalls in relation to staff inductions must be addressed. EVIDENCE: Service users had built up good relationships with staff. Service users benefit from a stable, competent staff team. The organisation has managed to recruit to the majority of vacant positions. Continuity of care has been achieved through bank staff being recruited to permanent positions. Observation, service user and staff discussions evidenced that competent staff supported service users. Staff discussions and observations demonstrated that staff respect service users and have attitudes and characteristics that are important to them. In addition to having the necessary skills and experience. Examination of the staffing rota and observations evidenced that the home was sufficiently staffed to meet the individual and collective needs of service users. A Senior support worker has been appointed. The Senior post assists with management of the home and staff supervision to ensure service users benefit from a well run home. An on-call system is in operation in the event of an emergency. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 22 Service users now benefit from well-supported and supervised staff. Staff now receive regular supervision and supervision contracts are in place. Both the supervisor and staff member should consistently sign supervision records. The organisation has a central human resources department. Examination of newly appointed staff evidenced no evidence of the staff induction. Written evidence of the staff induction must be on file. Service users must be protected by more robust recruitment and employment practices. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40, 41, 42 & 43 Vale Road is adequately managed however service users welfare, health and safety must be better promoted. EVIDENCE: The Acting Manager has applied for registration with the Commission for Social Care Inspection. The Acting Manager has worked for Heritage Care since 1997 and has managed the home since December 2004. The Acting Manager demonstrated the necessary skills and qualities for the role. The Acting Manager had a good rapport with service users and staff and was committed to improving the service to achieve the best outcomes for service users. The Acting Manager related they had attended various relevant training courses and is currently enrolled on a Level 4 National Vocational Qualification (NVQ) in Management and Care. The organisation has produced policies and procedures in accordance with Appendix 3, National Minimum Standards for Younger Adults. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 24 Service users daily logs were examined. Records were found to be up-to-date and adequately maintained. Improvements however could be made in the recording practices. Staff should focus on recording the outcomes for service users and endeavour to make their lives meaningful. Vale Road has the necessary health and safety certificates in place. The employers liability insurance expires on 30/03/06. Health and safety records were also examined. Shortfalls were noted in the fire safety and accident records. The fire safety records must be more robust. The home must ensure the name of all service users involved in each drill is recorded. Accident records must be fully completed. The health and safety of service users must be promoted and protected. The service development was examined. This plan relates to the year 2004/2005. The Acting Manager was aware of the need to update the service plan for the forthcoming year. The home’s financial budget was also examined. The Acting Manager confirmed there were regular overspends in relation to gardening, food, maintenance/replacements and activities. The Acting Manager stated this was not an issue, as the organisation had sufficient funds to meet the needs of service users. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 25 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 2 2 3 3 X 4 3 5 X 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 2 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 3 3 3 X X 3 2 2 3 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 26 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 4 (c) Requirement The Statement of Purpose must be updated to include the Acting Managers qualifications and experience. The Statement of Purpose must also be amended to include the Commission for Social Care Inspection details in regards to complaints. Timescale of 01/12/05 not met. 2. YA1 5 (1) The Service Users Guide must be amended to include the Commission for Social Care Inspection details in regards to complaints. Timescale of 01/12/05 not met. 3. YA8 12(2)& (3) Written evaluations must be available to evidence service users consultation. 01/04/06 01/04/06 Timescale for action 01/04/06 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 27 4. YA19 13 (1) (b) A referral must be made to the Occupational Therapist in reference to the service user who experiences frequent falls. The continence needs for service users must be monitored. 01/03/06 5. YA23 13(6) A copy of Newhams Adult Protection procedure must be obtained. Timescale of 01/12/05 not met. 01/04/06 6. YA24 23(2)(c), (d)&(m) The radiator must be repaired and dusted in GM’s bedroom. The chest of drawers handles must also be replaced BB’s bedroom. Timescale of 01/12/05 not met. 01/12/05 7. YA35 18 (1) (a) & (c) Written evidence of the staff induction must be on file. Accident records must be fully completed. The home must record the name of all service users involved in each fire drill. 01/04/06 8. 9. YA41 YA42 17 (2) 23 (4) 01/02/06 01/02/06 Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 28 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. Refer to Standard YA21 YA36 YA41 Good Practice Recommendations Service users respective wishes should be noted in the event of death. Both the supervisor and staff member should consistently sign supervision records. In daily recordings staff should focus on recording the outcomes for service users and endeavour to make their lives meaningful. Vale Road (1b) DS0000022851.V275525.R01.S.doc Version 5.1 Page 29 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
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