Inspection on 29/11/05 for Vine, The

This inspection was carried out on 29th 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vine, The 13/02/09

Vine, The 25/02/08

Vine, The 05/05/06

Vine, The 30/06/05

Vine, The 15/03/05

Vine, The 24/09/04

Vine, The 05/02/04

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Ashlong House

Norbury Crescent (30)

Edenvale

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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 Vine, The 58-60 Rosendale Road London SE21 8DP Lead Inspector Sonia McKay Unannounced Inspection 29th November 2005 08:30 Vine, The DS0000022768.V256613.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 Vine, The DS0000022768.V256613.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. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vine, The Address 58-60 Rosendale Road London SE21 8DP 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) 0208-670-9248 L`Arche Lambeth Mrs Lal Keenan Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (1) of places Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over the age of 65 years of age. This condition will apply until the named person leaves the home. 30/06/05 Date of last inspection Brief Description of the Service: The Vine is registered to accommodate seven adults with a learning disability. All of the service users require varying degrees of support and assistance in their daily lives. The home is one of six residential care homes in Lambeth and Southwark, which are part of the local L’Arche community. The aim of the community is to create an environment that welcomes people with learning disabilities. Fundamental principles of the community are that each person has a right to friendship, a spiritual life and to live in an environment that fosters personal growth. Two houses are joined together to create one large home and back garden. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of the Vine was conducted in five hours. Recruitment records were examined on 16 November 2005 at the L’Arche head office. The inspection involved observing meal arrangements (breakfast), talking with service users and the home manager, inspecting home records and records of the care required and provided to each person. There was a tour of the premises that included the communal areas, three of the bedrooms occupied by service users and one bedroom occupied by a member of staff. What the service does well: What has improved since the last inspection? What they could do better: Records of healthcare attended and needed must be better documented to ensure continuity of ongoing and preventative healthcare. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 6 Recruitment must provide service users with a higher degree of protection, by ensuring that adequate checks are taken up for all staff. Staff training must be developed to National Vocational Standards. The home must handle valuables held in safe keeping in a more methodical and diligent manner. Additional steps must be taken to ensure environmental safety and the safety of mobility aids. Action taken in response to complaints must be recorded. 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. Vine, The DS0000022768.V256613.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 Vine, The DS0000022768.V256613.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): 1 Prospective service users have the information they need to make an informed choice about where to live. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users’ Guide’ to the home. Emphasis is placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. Vine, The DS0000022768.V256613.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, 7, 8 & 9 The changing needs and personal goals of each service user are reflected in their individual care plans. Service users are able to make decisions about their lives with assistance as needed. Emphasis is placed on service user consultation and participation. Confidential information is handled appropriately and service users are supported to take risks as part of an independent lifestyle, within a risk management framework. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set with the individual, home staff and staff from the workshops. The service user, along with family members (if the service user wishes) and home staff attend an annual review meeting. Home staff work creatively with the service user before the review to enable them to understand and contribute as much as possible to the process in ways of their individual choosing (video, photographs, spoken word, objects, music and drawings). The meeting is held in a place that is comfortable to the service user (either at home or in a formal meeting room). The meeting aims to review goals from previous planning meetings and explore how new goals can be supported. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 10 The home has links with the Lambeth community team for adults with a learning disability, who provide behaviour support and speech and language therapy as the need arises. Each service user has a ‘reference person’ in the home to act as a key worker. The key worker has special responsibility for assisting the service user with planning, maintaining personal records and day-to-day arrangements. Service users are encouraged to participate in the day to running of the home and in community planning. They can take part in weekly house meetings, ‘talking group’ meetings with the director ten times a year and community council elections. Service users are also involved in the assessment of new staff during their probationary period. Fully independent advocates are in short supply in the borough. L’Arche uses a semi-independent advocacy system with assistants from other homes or workshops who know the service user well being assigned to each service user. A recommendation is made for L’Arche to pursue the services of fully independent advocates when major decisions have to be made. (See recommendation 1). General risk assessments are in place and risk management plans developed around high-risk activity or behaviour. These written risk assessments have been reviewed, as required in the previous inspection report. The risk of service users ingesting unsuitable items they may find in unlocked staff bedrooms has been addressed by fitting a lockable area in each staff bedroom. Staff confirmed that they are aware of the need to lock away any medicine or other potentially dangerous item and also to lock their bedroom if they go away on leave. Vine, The DS0000022768.V256613.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): 11, 12, 13, 14, 15, 16 & 17. Service users have opportunities for personal development. They are able to take part in a wide range of leisure activities, and therapeutic employment. Appropriate relationships with family and friends are encouraged and supported. Service users are encouraged to be responsible in their daily lives. Meals are healthy and attractively presented and mealtimes are relaxed. Staff interact well with the service users. EVIDENCE: L’Arche is a faith-based community and offers active support to each service user to develop their faith and spiritual lives. Service users who choose not to attend religious activities of any particular denomination are offered alternative activities. All service users are offered opportunities to engage in art, music and nature. One service user attends a local authority daycentre and others attend the L’Arche workshops (weaving, stone work, gardening and candle making). One service user attends the LArche retirement group. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 12 The proximity of the other L’Arche homes provides a close community. L’Arche Lambeth has been operating for more than 25 years and has developed good relationships with local individuals and organisations. Staff live at the Vine with the service users, with the intention of building a shared community and consistent engagement between the staff and the service users. All service users are offered a minimum two weeks holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interests. Holidays taken this year include trips to France, Inverness, Preston and Dorset. One service user is planning a holiday in Portugal. Two service users are looking forward to a theatre visit to see a musical show. Personal information held in individual care files contains detailed information about family and friends, their birthdays and family history. This enables staff to support service users to maintain and develop family relationships. Observed interactions between the staff and the service users are respectful, natural and caring. The service users and assistants eat together at a large dining table in the communal lounge. Breakfast was being served as the inspection began. Service users and staff interacted well. The mealtime was relaxed and only paced with a view to getting everybody to his or her activity or workshop on time. Each service user was having the breakfast menu of their choice, and the food prepared was fresh and appetising. Records of meals eaten indicate that a range of meals has been served. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Each service user chooses and helps to prepare an evening meal to the best of their ability. One service user said that he liked the meals. Vine, The DS0000022768.V256613.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): 19 & 20 Although there is evidence that service users have access to good reactive healthcare, record keeping is poor and pro-active preventative healthcare must be better organised. EVIDENCE: Healthcare records are but are incomplete in some cases. For example, a letter from an ophthalmologist advised a follow up appointment after three months, but the follow up appointment is still outstanding nine months later. There are records of appointments offered but no record of whether the appointment has been attended or of the outcome. Annual check ups have not taken place in some cases (dentist). The visitors book records that a district nurse visited to administer flu jabs, but there is no record of this inoculation in individual health records. Although there is evidence that service users receive appropriate medical attention when they are noticeably unwell and there is regular monitoring of the psychological health of two of the service users, there is a need to plan health care effectively so that illness is prevented. There are no health care plans in place to advise staff of how often service users should attend appointments or health screenings and no effective systems to record the outcomes of appointments attended. (See requirement 1) Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 14 The home manager has recently joined a GP practice forum that is aiming to improve the health provision for service users with a learning disability and communication needs. Vine, The DS0000022768.V256613.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 The complaints policy and procedure is adequate but to be effective it must be followed when a complaint is made. This had not happened. Financial safeguards and procedures are in place but had not been followed by staff. This does not provide service users with adequate protection from financial abuse. EVIDENCE: The home has a good complaints policy. There is text version and a more accessible version for service users who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area and has colour photographs of people who can assist with a complaint, including the CSCI. Regular house meetings provide service users with an opportunity to raise concerns. A requirement was made in the previous inspection report as complaints and actions taken as a result had not been recorded as required. During this inspection the home manager conceded that this is an area of recording that has not improved. The home manager said that concerns/complaints made in regular meetings with service users and family members were addressed but not necessarily recorded. There are no recorded complaints. The previous requirement is therefore unmet. (See requirement 2) A record of visitors is available and is being used appropriately. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 16 All service users require staff support to manage their finances. A spot check of service user finances held in safe keeping by staff indicated that adequate systems are in place to protect service users from financial abuse, although these are not followed on all occasions. Foreign currency is stored (left over from recent holidays) but is not recorded on the individual financial sheets used to record the finances held in safekeeping. Bank account books and passports are held but there is no record kept of the presence of these valuable documents. Each financial transaction is recorded and receipts for items purchased are retained. The record of transactions requires that two staff sign for each expenditure. Only one member of staff has signed for some of the transactions. (See requirement 3) Vine, The DS0000022768.V256613.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, 26, 27, 28, 29 & 30. Service users live in a comfortable and homely environment. Bedrooms and bathrooms meet their individual needs and are sufficient in number. Service users have the equipment they need to maximise their independence, although failure to arrange regular checks and servicing of wheelchairs has safety implications. The rear garden is not fully accessible to service users with a mobility need. EVIDENCE: The large home is suitable for its purpose, comfortably furnished, clean and homely. Communal areas are large and include a lounge/dining room, a smaller lounge with patio doors that open on to a conservatory and the rear garden. The ramped access to the rear garden is not suitable to meet the mobility needs of all service users, as the ramp ends abruptly and does not provide level access to the grassed area. This is a requirement of the previous inspection report that is not met. The home manager said that there are plans for major redesign of the garden that will address this. (See requirement 4). Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 18 All bedrooms are single occupancy and suitable to the needs of the service users. Radiator covers are in place to prevent contact burns where needed. One service user was keen to show me her bedroom and was very happy with the room, which has many family photographs and treasured items on display. A first floor bedroom door has a privacy lock that is of a type that does not allow staff access in an emergency. This lock must be replaced. (See requirement 5) A window in a service users bedroom had been smashed for two weeks. Broken glass and jagged edges were not covered. The broken pane of glass was secured and made safe on the day of the inspection as a result of an immediate requirement. (See requirement 6) The number of toilets and bathing facilities are adequate and meet the individual mobility needs of the service users. However, the ground floor assisted communal bathroom is poorly lit and continence aids are stored openly on shelves. (See requirement 7 & recommendation 2) Two of the service users use wheelchairs. There is no record of professional checks and servicing of the wheelchairs and in-house checks are not conducted. (See requirement 8) There is a clinical waste disposal contract and clinical waste is stored appropriately before collection. Fridge and freezer temperature checks are conducted daily and the results recorded. The kitchen hand-washing basin is not working. This must be repaired swiftly to ensure good kitchen hygiene. (See requirement 9) Vine, The DS0000022768.V256613.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): 31, 32, 33, 34, 35 & 36. Staff roles and responsibilities are clear. Recruitment procedures have improved but still do not provide service users with adequate protection. Staff training has improved, although high staff turnover has reduced the effectiveness of the training plan. Staff are supervised regularly. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Staff at the Vine live on the premises and take turns to do duty. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. A L’Arche framework of policies and procedures, provides staff with guidance. There is ongoing staff support and training from the home manager, the homes co-ordinator and other long standing community staff. As assistants generally stay in the community for one to three years, the director of L’Arche has conceded that it will be hard for the organisation to meet the standard of NVQ qualification by 2005. (See requirement 10) There is a training programme for staff working at the Vine. Training is obtained from the local community team for adults with a learning disability Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 20 who operate a rolling programme for local care providers and also the LArche foundation-training programme. A number of new staff had recently arrived at the Vine. There is a high turnover of staff, which is unsettling for service users (one service user has attachment disorder). L’Arche has looked at ways to improve staff retention and a new system of working is planned for 2006. Staff duty rotas are in place and show that a sufficient number of staff are on duty at all times. Additional staff cover is provided by other LArche community staff if needed. A placing authority supplies an agency night waking staff for one elder service user who is frail. Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and is currently revising the LArche recruitment procedures. The records are still incomplete in some cases. References taken up by telephone are not all authenticated in writing. Recruitment practice is such that some staff arrive in the UK, and move into the Vine, before a satisfactory POVA first check and enhanced CRB check are obtained. At the time that recruitment records were checked (16 November 2005) twelve members of staff (working both at the Vine and elsewhere in the LArche community) did not have UK CRB checks in place or confirmation of a satisfactory POVA First check. Overseas police checks are obtained before staff arrive in the UK and all have since applied for an enhanced UK CRB check and POVA First check. This is not in accordance with vetting procedures for the protection of vulnerable adults. (See requirement 11) Staff team meetings are regular and documented. The home manager is trained in supervision and supervises each member of staff working at the Vine. Supervision meetings are held regularly and notes are kept of the topics discussed. However, the notes do not define action to be taken and timescales and are not signed by the manager or the supervisee. Supervisees should be given a copy of the notes. (See recommendation 3) Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 & 42 Service users benefit from a well run home. The manager is registered and competent and is undertaking vocational training to fully develop her skills. Systems and checks to promote the health, safety and welfare of service users must be improved. EVIDENCE: The registered home manager has been in post for five years and is undertaking an NVQ level 4 in Care and Registered Managers Award this year. Staff conduct regular in house health and safety checks. The Gas Boiler annual safety certificate is dated 13/12/04. Mains electrical circuitry was safety tested on 31/01/01. The test certificate covers a five-year period. Small electrical appliances are safety tested by one of the house assistants. The last test was carried out on 21/09/04. This test must be conducted annually. (See requirement 12) Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 22 Fire authorities inspected the premises and confirmed that precautions are adequate on 11/01/05. Environmental and fire risk assessments are conducted. Environmental health inspectors inspected the food handling arrangements in March 2005. The home manager is taking steps to ensure that all staff receive food hygiene training and use temperature probes to check hot food temperatures. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vine, The Score X 2 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000022768.V256613.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation Requirement Timescale for action 03/02/06 2 YA22 3 YA23 4 YA29 12(1) The registered persons must 17(1) ensure that the healthcare Sch3(k)(m) needs of service users are assessed and recognised and that procedures are in place to address them (heath care plans). There must also be a record of any treatment or specialist health care. 17(2) The registered persons must Sch 4(11) ensure that a record is kept of all complaints made by service users or their representatives or relatives and the action taken in respect of any such complaint. Previous timescale of 31/08/05 not met. 17(2) The registered persons must Sch4(9)(a) ensure that a record is kept of all finances (including foreign currency) and valuable documents held on behalf of service users. Previous timescale of 31/08/05 not met. 23(1)(b) The registered persons must 23(2)(n) ensure that the ramp built in the rear garden to provide level access to the garden, does so (the ramp ends abruptly and DS0000022768.V256613.R01.S.doc 03/02/06 03/02/05 31/05/06 Vine, The Version 5.0 Page 25 5 YA42YA26 12(1) 13(4) 6 YA42YA26 13(4)(a) 12(1) 12(1) 23(2)(p) 12(1) 13(4) 12(1) 13(3) 18(1)(a) 7 YA42YA27 8 YA42YA29 9 10 YA30 YA32 11 YA34 19(1) Sch 2 12 YA42 12(1) 23(2)(c) does not extend to the level of the grassed area. Previous timescale of 30/06/05 not met. The registered persons must ensure that staff can gain access to all bedrooms in an emergency (a first floor bedroom door lock must be replaced). The registered manager must make a broken pane of glass safe immediately (first floor bedroom). The registered persons must ensure that the ground floor assisted bathroom is adequately lit. The registered persons must ensure that wheelchairs and mobility aids are regularly checked and serviced. The registered persons must ensure that the kitchen hand washbasin is repaired. The registered persons must ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. The registered persons must ensure that evidence of all information and documentation required by Schedule 2 of the Care Homes Regulations 2001 (revised in July 2004) is obtained for staff before they commence work in the care home. Previous timescale of 31/08/05 not met. The registered persons must ensure that all small electrical appliances are safety tested DS0000022768.V256613.R01.S.doc 03/02/06 21/11/05 03/02/06 03/02/06 03/02/06 03/02/06 03/02/06 03/02/06 Vine, The Version 5.0 Page 26 annually. 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 YA7 YA27 YA36 Good Practice Recommendations The registered persons should pursue independant advocacy services for LArche service users when major decisions have to be made. The registered persons should store continence aids discreetly in shared bathrooms. The registered manager should implement a system for staff supervision meetings that records action points and timescales. Both the supervisor and the person being supervised should sign the notes and both parties should retain a copy. Vine, The DS0000022768.V256613.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vine, The DS0000022768.V256613.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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