Inspection on 26/01/06 for Vulcan Square

This inspection was carried out on 26th January 2006.

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

Other inspections for this house

Vulcan Square 23/07/08

Vulcan Square 09/01/08

Vulcan Square 07/09/06

Vulcan Square 03/08/05

Vulcan Square 22/02/05

Vulcan Square 13/07/04

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 Vulcan Square 32-33 Vulcan Square Westferry Road Isle Of Dogs London E14 3RJ Lead Inspector Lea Alexander Unannounced Inspection 26th January 2006 12:30 Vulcan Square DS0000010308.V277130.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 Vulcan Square DS0000010308.V277130.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. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Vulcan Square Address 32-33 Vulcan Square Westferry Road Isle Of Dogs London E14 3RJ 020 7537 0411 020 7987 3917 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.mencap.org.uk Royal Mencap Society Ms Dorinda Maclean Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Vulcan Square comprises of two adjoining houses set in a small square of similar residential properties. Each house comprises of a lounge, kitchen diner and a ground floor wc and hand basin. On the first floor there are three service users bedrooms in each house and a small box room that accommodates the staff sleepover room in one house and the staff office in the other. The two houses have the same layout and are connected by a shared garden. Three female service users reside in one house and three male service users in the other. The buildings are owned and maintained by East Living. The home is staffed and managed by Mencap. The home is set in the heart of Docklands on the Isle of Dogs. There are local shops and amenities nearby. Behind the development there is access to the River Thames. The home has experience some changes since the last inspection. The Manager, Deputy Manager and one support worker have been dismissed following disciplinary action and the acting manager and acting deputy manager have now been permanently appointed to these posts. A new support worker has also been appointed. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors third inspection of this home. The Inspection occurred over the course of an afternoon and was conducted by one inspector. A member of support staff and the manager were spoken to by the Inspector, as was one service user. The Inspector also sampled service users personal files, staff personnel files and other relevant documentation. The main focus of the inspection was to establish the progress made with the 39 requirements and one recommendation made at the previous inspection on the 3rd August 2005. What the service does well: What has improved since the last inspection? Since the last inspection the home has reviewed its record keeping, including the information to be kept on service users personal files, and its’ administrative practises are much improved. Each service user has an individual plan and risk assessments that are being regularly reviewed. Service users meetings have been introduced and the minutes of these suggest a lively forum where service users can participate in the day-to-day running of the home. The homes complaints procedure has been reviewed and updated and a current recruitment policy and procedure is available. All staff has received training with regard to Epilepsy and improvements in food handling and hygiene were also evidenced. Communal areas are no longer being used to store administrative papers, and many of the maintenance issues identified at previous inspections have been satisfactorily attended to. Following the conclusion of disciplinary matters, the acting manager and deputy have been permanently appointed. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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 Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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. The needs of prospective service users are assessed prior to their moving in, and the home has evidenced that it is able to meet these. EVIDENCE: The home has had one new admission since the last inspection. The Inspector sampled their personal file and found that a range of information had been obtained as part of the referral process, including an Occupational Therapy (OT) activities of daily living comprehensive assessment, and an OT individual plan outlining the service users likes and preferences. A hospital discharge summary and Psychiatrists referral letter were also available. This service user was unable to visit the home prior to their moving in, and the circumstances around this unusual situation were discussed and agreed with the Commission for Social Care Inspection at the time. The Inspector noted that a “Personal Care Plan” and risk assessments had been completed for this service user during the initial admission phase to the home and these indicated that the home are able to meet their needs. Minutes for a placement review meeting some weeks after the service user moved in evidenced a multi disciplinary view that the home is able to meet this service users needs. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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 & 10. The home has implemented an improved system to manage service users personal information. Each service user now benefits from an individual plan and risk assessment that addresses their needs. EVIDENCE: At previous inspections the homes systems for storing service users information and recording and reviewing their needs were found to significantly fall short of the standard required. The Inspector was pleased to note improvement in this area at this inspection. The Inspector sampled the personal files for three service users. Since the last inspection the homes filing system has been rationalised and reviewed. Service users individual plans and information relating to these such as medical appointments, next of kin details and general correspondence is kept in individual service user “Personal Care Plan” (PCP) folders. The Inspector did however find that there were inconsistencies between staff members regarding where information should be filed. For example, service users bank statements were found filed in several different places in their PCP file and the manager advised that these should actually be stored in a specified area in a locked filing cabinet. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 10 Some outdated service user information was being stored in a second individual service user file. The Inspector is of the opinion that it would be more appropriate to archive this material. The Inspector sampled the individual plans for three service users and noted that the format for these had been revised since the previous inspection. The plans are recorded in a format to support service users understanding and use simple words and pictures. Information included in the plan includes: Things I am good at. Special people. Things I need assistance with. How I like to be helped. One service users plan indicates that they have specific care needs with regard to hair care, and detailed information is referred to and recorded on a separate plan. The home should develop this practise to include more detailed information on how service users need support to manage their finances. At present two service users are identified as needing this support, however, their main plan identifies the support required as “help with shopping”. This should be expanded to include information such as assistance with budgeting, planning, handling cash etc. The Inspector sampled two service users personal files to establish the homes practise in reviewing individual plans. Both of the files sampled contained minutes of multi disciplinary reviews that had been held since the last inspection. One of these in particular recorded many direct quotes from the service user on their views regarding their needs and how the home meets these. The home must ensure that these reviews continue to take place on at least a six monthly basis or as service users needs change. The Inspector noted that the personal files sampled contained information that related solely to the specified service user. The Inspector viewed the minutes of service users meetings. These have occurred on a monthly basis since the last inspection. In these meetings service users have discussed and made decisions regarding redecoration of the home, a smoking policy and arrangements for visitors. The minutes are recorded in a service user accessible format with simple words supported by pictures. The Inspector viewed the homes risk assessment folder. This contains individual risk assessments for each service user for activities around the home such as using kitchen equipment, and for activities identified in the individual plan such as travelling to day services. The Inspector noted that risk Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 11 assessments were annotated as being reviewed in 2005 and a further review date had been annotated for later this year. Service users records were found to be accurate, confidential and stored in a locked staff office. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. Improved food handling practises contribute to a healthy diet for service users. EVIDENCE: The previous inspection had required the home to improve its practise with regard to the labelling of prepared and opened processed foods. The Inspector viewed the contents of both houses fridges and freezers and evidenced that this is now occurring. The previous inspection had recommended that the homes contracts with service users be amended to include information on smoking and alcohol policies. Sampling of two service users personal files evidenced that this remains outstanding. Key standards 12, 13, 15 and 16 were not inspected on this occasion. They were inspected on the 3rd August 2005 and assessed as met. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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. The home must evidence that all service users attend regular and periodic health checks. EVIDENCE: The Inspector sampled the personal files for three service users and the minutes of service users meetings. These evidenced that there has been discussions around service users choosing a “day off” from their usual weekday activities to develop individual interests and activities. One service user had decided to use this day to focus on developing their cooking skills. The previous inspection on the 3rd August 2005 had identified that two female service users had received reminders for cervical smear tests several months previously and that these had not been acted upon. The Inspector sampled both service users personal files and evidenced that one service user had been supported to complete and submit a form to the local health authority confirming that they did not wish to participate in the screening programme. The Inspector looked through the correspondence and health appointment diary sheet but was unable to evidence that the other service user had either opted out of the programme or attended for their smear. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 14 At the previous inspection a third service user was noted to have received a letter from their day service advising of a potential Tuberculosis diagnosis for a day centre service user. The Inspector spoke with the manager regarding this issue and was advised that each service user had been sent to his or her own GP for a health care check up and that no evidence of Tuberculosis infection had been found. The Inspector viewed the homes Medication Administration Record (MAR) and the medications actually available for two service users. One service user was noted to have three medications that were not recorded on the MAR, or marked as discontinued. The Inspector also noted that the service users medication pen picture and other lists of medication held in the personal file did not match the current medications listed on the MAR. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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. Service users benefit from a complaints policy that aims to listen and act upon their views. EVIDENCE: Whilst touring the premises the Inspector saw that a pictorial representation of the complaints procedure with simple words was displayed in the hallway of each house. This had been revised since the last inspection and now includes contact details for the Commission for Social Care Inspection and clearly states that the home aims to deal with complaints within 15 days. The Inspector also viewed the homes complaints log. No complaints have been made since the last inspection. The Inspector viewed the homes training records and these indicate that no staffs has received adult protection refresher training as required by the previous inspection. The manager advised that 3 members of staff have been nominated for this training, and that it is scheduled to take place in February 2006. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 16 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, 26, 28 & 30. A backlog of maintenance issues in the two houses has been satisfactorily addressed since the last inspection. EVIDENCE: Previous inspections had identified a range of maintenance issues to be addressed within the houses and garden. Whilst touring the premises the Inspector evidenced that new patio doors had been fitted in one house, and that the steps from the patio doors to the garden in both houses had been redesigned to give easier access. The rear garden had been freshly gravelled, and remnants of cement posts that presented a trip hazard had been removed. Within the home both kitchens had been redecorated with the service users colour of choice, and new lampshades had been fitted in the women’s lounge and on both landings. Inspection of the lounge in the men’s house evidenced that all administrative and office papers relating to the running of the home had been moved and are now appropriately kept in the staff office. The Inspector viewed the bedrooms of several service users. Some of these had been recently redecorated with the colour scheme chosen by the service user. The bedrooms seen were found to be clean and well maintained with the Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 17 service user having opportunities to personalise their room with mementos and other belongings. The under stairs area in both houses continues to be used for storage, and these items should either be moved to a more appropriate area, or built in storage cupboards installed. Inspection of the two bathrooms and WC’s in the home evidenced that a requirement from the previous inspection to clean and maintain these has been met. Previous inspections have identified that the chest of draws supplied for one service user are not appropriate and are constantly being broken. A viewing of this service users bedroom evidenced that these have yet to be replaced. The Inspector discussed this issue with the manager who advised that a replacement item had been identified and tried out with the service user, and that the remaining chest of draws would be replaced with these shortly. The Inspector found the home to be generally clean and free from odour and maintained to a good standard. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 18 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): 33, 34, 35 & 36. Service users are protected by the homes recruitment policy and practise. However, staff should receive regular, recorded supervision. EVIDENCE: Original recruitment documents for staff members are held at a centralised personnel office, with photocopies of these held locally. The Inspector sampled two personnel files for staff working in the home. One of these is the most recently joined member of the staff group. Sampling of this file evidenced that their original application form and interview notes had been kept. Photocopies of the relevant passport pages including proof of identity and entitlement to work had been obtained. Before taking up their post a Criminal Records Bureau (CRB) enhanced check had been applied for and a “POVA (Protection of Vulnerable Adults) first” check obtained. At the time of this inspection a current enhanced level CRB was available on file. Further documentation on the personnel file evidenced that the manager had reviewed and confirmed the staff member’s appointment after satisfactory completion of a three-month probationary period. The Inspector noted that there was no evidence of a completed induction programme for this staff member, and the manager advised that this had been completed and was currently with the manager of another home for verification and counter signature. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 19 The second personnel file examined by the Inspector was for a more established staff member. Examination of their supervision records evidenced that this had occurred on only two occasions in the current inspection year. The Inspector sampled the homes training records for each staff member and noted that all staff had received training with regard to epilepsy since the last inspection. Some staff had also received fire training and risk assessment training. The manager advised that all support staff are currently undertaking learning disability foundation training run by the London Borough of Tower Hamlets, and that successful completion of this will give credits towards NVQ level 3. All four-care staff within the home is currently undertaking NVQ level 2 studies. The Inspector viewed the minutes of staff meetings these evidenced that staff meetings have been occurring on a monthly basis since the last inspection. The Inspector noted that a copy of the organisations recruitment policy and procedure was now available on site, and that this complies with the requirements of National Minimum Standards. Key standard 32 was not inspected on this occasion. It was inspected on the 3rd August 2005 and assessed as met. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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): 37, 38, 39, 40, 41 & 42. A new management team has been appointed and service users are now benefiting from a generally well run home. EVIDENCE: Since the last inspection disciplinary procedures against the registered manager, deputy manager and a support worker have concluded. All have been dismissed from their posts. The current acting manager and deputy manager who have been working at the home for some six months have been permanently appointed, and the new manager is undertaking the registration process. This manager has previous experience of managing care homes for adults with learning disabilities and is undertaking NVQ level 4 studies. The previous inspection had identified some anxiety on the part of service users and staff with regard to the management of the home, and the conclusion of disciplinary proceedings and appointment of a new manager and deputy who are already known to the service users and staff team will minimise any further disruption. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 21 The Inspector noted that requirements addressing the need to maintain the fabric and environment of the home had been satisfactorily addressed. Discussions recorded in service users meetings minutes evidenced that they had chosen new colour schemes for the redecorated areas. Since the last inspection regular “person in charge” visits have taken place and are reported. These reports have been copied to the Commission for Social Care Inspection and were also available within the home. A full set of Mencap policies and procedures were available within the home, and staffs are able to access these. Through the sampling of service users personal files, staff personnel files and other documentation mentioned elsewhere in this report the Inspector was satisfied that the home generally maintains records required by regulation, and that these are up to date, accurate and secure. The Inspector noted that the homes records and documentation are in a much-improved condition compared to previous inspections. Sampling of the record of fridge and freezer temperatures evidenced that this is occurring on a daily basis, however, there were a number of consecutive days in January 2006 when the temperature was recorded as 8 degrees for the refrigerator, with no indication of appropriate action being taken to restore the temperature to an acceptable level. The Inspector sampled the homes accident book and noted that this had been revised since the last inspection. Guidance notes for staff on completing accident documentation were clear and concise and outlined the procedure to be followed. No entries had been made since the last inspection. The Inspector viewed the homes fire record and this evidenced that two evacuation drills had been conducted since the last inspection. The names of evacuees were recorded along with an overall timing to complete the evacuation. The homes weekly fire alarm test had been completed up until the 28th December 2005 and this indicated all alarms were in working order. No tests were recorded as having taken place since then. The Inspector asked the manager about the homes quality assurance procedure and was advised that informal feedback is obtained from service users during meetings and from day services. There is no procedure at present to formally obtain quality assurance information, to evaluate it or publish it. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 3 4 X 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 3 25 X 26 2 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 2 3 3 2 X Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 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 YA6 Regulation 15 & 17 Requirement The current service user file system should be further reviewed and rationalised. Individual plans should appropriately reflect the nature and complexity of the support required. Service users individual plans must be reviewed at least every six months or as their needs change. 2. YA7 15 Where support and tuition are needed in assisting service users to manage their own finances, the reasons for this and manner of support must be documented and recorded. This is a restated requirement. The previous target of the 30/11/05 was not met. 3. YA19 13 The registered person must ensure that the healthcare needs of service users are assessed and recognised and that procedures are in place to DS0000010308.V277130.R01.S.doc Timescale for action 31/03/06 31/03/06 31/03/06 Vulcan Square Version 5.1 Page 24 address them. This is a restated requirement. The previous target of the 30/11/05 was not met. 4. YA20 13(2) The MAR and other lists of current medication must correspond. All current medication must be listed on the MAR. These are restated requirements. The previous target of the 30/11/05 was not met. 5. YA23 13(6) Staff must receive initial and refresher training in adult protection. This is a restated requirement. The previous target of the 30/11/05 was not met. 6. YA26 16(2) The chest of draws in one service 31/03/06 users bedroom must be replaced with items suitable for the purpose. This is a restated requirement. The previous target of the 30/11/05 was not met. 7. YA28 23 Items being stored under the stairs must be moved and more appropriately stored. This is a restated requirement. The previous target of the 30/11/05 was not met. 8. YA35 18(c) The home must evidence that new members of staff complete an induction programme. 31/03/06 31/03/06 31/03/06 30/11/05 9. YA36 18 Staff must have regular, 30/06/06 recorded supervision meetings at DS0000010308.V277130.R01.S.doc Version 5.1 Page 25 Vulcan Square least six times per year. This is a restated requirement. The previous target of the 30/11/05 was not met. 10. YA39 24 The home must develop and implement a quality assurance procedure to gather the views of service users and other stakeholders. The results of this should be evaluated and made available to interested parties. Fridge and Freezer temperatures must be maintained within acceptable parameters. Fire alarm tests must occur on a weekly basis and their outcome be recorded. 30/06/06 11. YA42 12 & 23(4) 31/03/06 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 YA16 Good Practice Recommendations The contract with service users should be expanded to include information on the homes alcohol and smoking policies. This is a restated recommendation. Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 26 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 Vulcan Square DS0000010308.V277130.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!