Inspection on 05/06/07 for Wardley Street

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wardley Street 11/07/06

Wardley Street 07/09/05

Wardley Street 24/05/05

Wardley Street 25/01/05

Wardley Street 31/08/04

Wardley Street 24/02/04

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 Wardley Street 2 Wardley Street London SW18 4LU Lead Inspector Sharon Newman Unannounced Inspection 5th June 2007 10:00 Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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 Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wardley Street Address 2 Wardley Street London SW18 4LU 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) 020 8875 1293 /1336 www.odyssey-csft.org Odyssey Care Solutions for Today Ms Comfort Bonti Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Physical disability (2), of places Physical disability over 65 years of age (0) Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: The home is located in Wandsworth, in a small cul-de-sac off the main road from Wandsworth to Tooting. It is situated across the main road from a day service run by The London Borough of Wandsworth, close to local shops, post office, public transport, pubs, and other amenities. Thames Housing Association owns the building and Odyssey Care Solutions for Today, a charitable organisation manage the home. It is registered to provide care for up to seven service users with learning disabilities. The home is a purpose-built three-storey building. There is no passenger lift. All bedrooms are single including two of which are wheelchair accessible and these are on the ground floor, both with en-suite facilities. The home has an open plan lounge/dining room and a patio garden to the rear. Fees range from between £776.23 per to 983.00 per week. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector conducted this unannounced inspection on 5th June 2007. The manager was present during the inspection and was open and welcoming. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety records. A tour was also taken of the premises. The manager also completed an Annual Quality Assurance Assessment (AQAA) which is a self assessment of the service. Surveys were left for all residents to complete if they wished. Surveys were also left at the home to be given to relatives and staff. Two were returned from staff and one from a relative before the completion of this report. Three residents seen on the day of inspection indicated they were happy at the home. One reported that they ‘liked living at the home’. The manager and the staff on duty were helpful, open and welcoming throughout the inspection visit. What the service does well: What has improved since the last inspection? Staff training in mandatory areas such as first aid, food hygiene and moving and handling has improved and there is a regular rolling programme of these courses for staff to attend. This helps to ensure the health and safety of residents and staff. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 6 The manager reported that a new thermostat has been installed and hot water temperatures are now maintained within safe limits. 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. The summary of this inspection report can be made available in other formats on request. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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 Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents have had a review of their needs and this could have an impact on whether their ongoing needs can be met. EVIDENCE: The Service User’s Guide has been reviewed and is now available in a format that is easier for the residents to follow. It contains colour photos and large print and the wording has been kept to a minimum. A discussion took place with the manager as there are photographs of the residents in this document. The manager reported that it would remain within the home and not be made public so that the residents’ confidentiality would be respected. There was evidence in the residents’ files that they were assessed prior to coming to the home to help ensure that the home can meet their needs. However, it was discussed with the manager that reviews of all the residents need to take place to ensure that that their needs are reassessed. The manager reported that it is very difficult for social workers to attend reviews at the home as she believed their services are ‘very stretched’. She said that she has been organising reviews and then inviting the social workers who are usually unable to attend. She reported that social workers were offering to carry out telephone reviews of the residents. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 9 Evidence showed that reviews have taken place for three residents. Two were held by staff at the home, one was a telephone review held by a social worker. There was no evidence of recent reviews for the remaining three residents. The manager reported that she valued the presence of social workers at the reviews especially as there have been some instances of challenging behaviour between two of the residents. She reported that she felt input from social services may help. A relative wrote that they are not kept up-to-date with the progress of their family member and they are given very little information from the home. They also reported that they had not been invited to attend any recent review meetings or been informed who the allocated social worker is. Contracts were seen to have been signed by the residents or a relative and countersigned by the manager. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans are not person centred and they still need to be more userfriendly as they contain a lot of information which can be confusing for the reader. Some of the information is disorganised. Documentation needs to be archived as which would make the information more accessible and be of benefit to staff and service users. Residents’ choice is respected and they are supported by staff to participate in community activities. Residents are supported to take risks and maintain their independence. EVIDENCE: Issues still remain outstanding with the residents’ care plans. Although they contain a lot of information it was difficult to find relevant information as there was too much documentation in place. A lot of this information still needs to be Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 11 archived and the care plans need to be reorganised. This is so that the most relevant and up-to-date information about the residents is easily available. The ‘handover file’ was particularly disorganised and it did not give a clear picture of the residents or their needs, likes and dislikes in much detail. This information is important to ensure that residents needs can be met and also so that new staff members or locum staff can see immediately the care that residents require and their preferred routines. Also, the care plans need to be more person centred and there was little evidence to suggest that residents are involved in their formulation and contribute to them on a regular basis. The inspector was informed that more person-centred documentation is being introduced. However this was not in place at the time of inspection. A risk assessment was not in place for one resident with specific health needs and the manager reported that she would address this. It was noted that many risk assessments have not been fully reviewed and re- written and this was discussed with the manager during the inspection visit. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Links with the community continue to be good which helps to support and enrich resident’s social and educational opportunities. The home provides a good environment for residents to develop their social skills. Staff continue to encourage and support them to be as independent as possible. Residents families are involved in their care. EVIDENCE: Residents are offered a range of activities and day placements. Three residents were out participating in day activities at local day centres at the time of inspection and three residents were at home. One of these had chosen not to attend their day placement and this decision was respected by the staff. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 13 Another resident was seen to go out with their community care worker in the morning, they indicated that they had enjoyed this very much. Activities enjoyed by residents include: going to the pub, bingo, for walks, to local cafes and shopping. Some residents take part in a full range of activities. One goes swimming weekly and to the library and sports centre. The manager reported that the home tries to ensure that it supports residents cultural and religious beliefs. She reported that they are assisted to take part in religious worship if they wish. One resident regularly attends a place of worship. There is a television, music centre and video for the use of residents in the lounge/dining area. Residents are encouraged to be independent and the manager reported that they are supported by staff in learning to travel independently. Travel training programmes were seen in residents files looked at during this inspection. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff take the health needs of the residents seriously and residents have access to a range of community healthcare facilities. Medication is stored and administered appropriately. However omissions in the recording in the medication administration records could place residents at risk. EVIDENCE: Residents were observed to be supported by staff in a caring and respectful manner. There was evidence in the resident’s files of input from a range of health and social care professionals. The residents can also access the services of the local community specialist services. One resident’s file contained information and instructions to be followed from physiotherapists and occupational therapists following their discharge from hospital. Appropriate risk assessments were in place for this individual. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 15 The manager discussed current concerns regarding one of the residents. There was information in their file showing that a range of health and social care professionals had been contacted including their GP, a dietician and social services. The manager reported that both the GP and the dietician have visited the home. The manager was clearly concerned about this resident and contacted the GP surgery during the inspection. There was evidence to demonstrate that staff receive medication training and this helps to ensure that residents are not placed at risk from unsafe practice. The medication cupboard was locked securely at the time of inspection. The allergies section on the medication administration record records (MAR) was fully completed and where no allergies are known this is recorded. However two entries had been left blank in one of the MAR sheets. Administration or non-administration of all medication must be recorded and signed for. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service has a clear complaints procedure which is available in a format which is easier for the residents to understand. There is not enough evidence at the home to show that all staff are up-to-date with training in abuse awareness. EVIDENCE: The home follows the London Borough of Wandsworth’s Protection of Vulnerable Adults procedures however a copy of the new procedures was not available at the home and must be obtained. An organisational abuse policy is in place. There was insufficient evidence at the time of inspection to show that that staff are up-to-date with training in abuse awareness and protection of vulnerable adults. A complaints procedure is in place and there have been no formal complaints at this home since the last inspection visit. The complaints policy is available in pictorial format to help residents understand it more easily. Residents meetings are held to encourage them to air their views and bring up any issues. The minutes were available at the time of inspection. It was discussed with the manager that more frequent meetings may be of benefit to the residents. She reported that she was addressing this. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The premises do not look homely and they need to be redecorated. Maintenance and redecoration are not given a high priority by the organisation. Attention needs to be paid to cleanliness to help ensure this home is a pleasant place for residents to live. EVIDENCE: Areas within the home including the hallways and bathrooms still require redecoration, as there are many areas of scuffed and marked paintwork in the corridors, stairwells and bathrooms. The flooring in the bathrooms needs to be replaced as it is marked and stained. There are cracks in the plaster work on the top floor landing. Much of the woodwork is chipped and needs redecoration. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 18 In the lounge area black marks were seen above the radiator, areas of wallpaper are peeling away from the wall and there are unsightly scuff marks on the walls. Re- decoration of the home must be carried out, as the environment does not present as homely or attractive. It was discussed with the manager that more attention needs to be paid to maintaining levels of cleanliness at the home. An extractor fan in one of the bathrooms was covered in dust. Stains from spilt fluids were seen on the walls in the stairwell and in the lounge area both on one of the walls and on one of the radiators. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff training has improved and this helps to ensure the safety of residents and staff. Staff meetings take place regularly however not all staff are receiving regular one-to-one supervision to ensure that they have the support and direction they need. EVIDENCE: Staff were observed to have a good rapport with the residents and to treat them with respect. They offered them choices with regard to the activities they wanted to do and lunch choices. One resident chose not to go to their day placement and this was respected by staff. A relative commented that they were concerned about staffing ratios at the home. They also commented that some (agency) staff sit down to ‘chat to each other’ and ‘watch TV’. Sufficient staffing levels were observed on the day of inspection. The manager reported that there is one vacancy at the home and these hours are being covered by using locum staff. The home needs to ensure Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 20 that there are sufficient members of permanent staff to meet the needs of the residents. Training logs indicated that most staff are up-to-date with mandatory training such as first aid, moving and handling and food hygiene. However it was discussed with the manger that this information needs to be more clear as it was quite difficult to see that all staff were receiving this training due to all the separate training log information which appeared disorganised. It would be easier to follow if the information was all contained within one log. One-to-one staff supervision is not yet taking place regularly for all staff. The frequency of this supervision needs to increase to help ensure that staff receive the support and direction they need to carry out their roles. Although forms have been put in place to indicate that staff have had recruitment and criminal record bureau checks the manager had signed to verify these forms. However she said that she had not seen the information that she had signed for. They have not been signed or dated by a nominated representative (for example from Human Resources) who has seen all the preemployment checks to confirm that the details are correct. This must be addressed. Regular staff meetings take place so that staff can discuss any issues. Recent matters discussed include: the residents, health and safety and training. These meetings enable staff to remain up-to-date with organisational changes and to raise any issues. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is experienced and has a caring attitude towards tohe residents. Health and safety issues including those relating to fire safety need to be addressed to ensure that residents and staff are not placed at risk. EVIDENCE: The manager is experienced and was observed to have a very good rapport with the residents. She was helpful and open throughout the inspection. residents were seen to be very fond of her and she displayed a genuinely caring attitude to them. A quality assurance programme has been implemented by the organisation to help make sure that the views of residents are taken into consideration Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 22 regarding the running of the home. Regular monitoring meetings and business plan meetings are also held. A relative raised concerns about staff communication with them and suggested that a newsletter may be useful to update them about events at the home. As stated in the previous inspection report the Commission for Social care Inspection has also not received recent copies of the Registered Providers monthly audit visits to the home. These must be forwarded to the CSCI. Some incidents affecting the welfare of residents were seen to be recorded in their files. The CSCI had not been notified. All incidents affecting the health and welfare of the residents must be reported to the CSCI. A soap dispenser was seen in one of the bathrooms and this is an improvement. However a bar of soap had been provided in the another bathroom. It was discussed with the manager that this is not good hygiene practice and soap should not be left out for communal use. Adequate hand washing facilities must be in place to promote good hygiene practice and to prevent the spread of infection. The gas safety certificate was out-of-date and an electrical installations certificate was not available. These certificates need to be obtained to help ensure the safety of the residents and staff. Other records relating to health and safety such as first aid box checks, portable appliance testing and legionella were in order. There was no evidence that a fire drill had been undertaken this year. It was discussed with the manager the importance of holding regular fire drills so that staff, visitors and residents know what action to take in the event of a fire. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 2 3 X 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X x 2 2 Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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 YA2 Regulation 14 (1) (2) Requirement Reviews of need must be carried out to help ensure that residents ongoing social and health needs are reassessed and that the home can meet these needs The care plans need to demonstrate a more person centred approach and the involvement of the residents. Information in the residents files must be archived any inappropriate documentation removed. (Previous timescales of 01/11/05 and 01/08/06 not met) The Registered Person must ensure that appropriate risk assessments are in place and are kept under review. Previous timescale of 01/11/06 not met. Medication administration records must be fully completed for all residents. Evidence must be available at the home to demonstrate that all staff are trained in recognising and reporting abuse. A copy of the most up-to-date Wandsworth Protection of DS0000010236.V340936.R01.S.doc Timescale for action 01/09/07 2 YA6 12 (2) (3) 01/07/07 3 YA6 15 (1) (2) 01/08/07 4 YA9 13 (4) (6) 01/07/07 5 6 YA20 YA23 13 (2) 13 (4) 05/06/07 01/07/07 7 YA23 13 (6) 01/07/07 Wardley Street Version 5.2 Page 25 8 YA24 23(2)(b) & (d) 9 10 YA30 YA33 23 (d) 18 (1) (a) (b) 11 YA34 19Sch. 2 12 YA36 18 (2) (a) 13 14 YA42 YA42 13 (4) 13 (4) 15 YA42 13 (4)37 16 YA42 13 (4) 17 YA42 23 (4) Vulnerable Adult Guidelines must be obtained. All staff must read these procedures. This will help to ensure that staff are aware of the correct procedures to follow. All maintenance issues outlined in Standard 24 of this report are addressed. Previous timescales of 01/09/06 and 01/02/07 not met. The home must ensure that attention is paid to maintaining the cleanliness of the home. The organisation must ensure that there are sufficient numbers of qualified permanent staff to ensure consistency for the residents A representative from Human Resources must sign the information available at the home demonstrating that staff files contain all the necessary checks. All staff must receive one-to-one supervision at least six times a year (pro-rata for part time staff) and this must be fully recorded. An up-to-date gas safety certificate must be obtained. The five yearly electrical installations check must be carried out and a certificate kept at the home. All incidents which affect the well being of the residents must be reported to the CSCI. Previous timescales of 11/07/06 and 11/10/06 not met. Appropriate hand washing facilities must be provided in all toilets and bathrooms. Previous timescales of 01/08/06 and 01/11/06 not met. Regular fire drills must take place and be fully recorded. All staff must be aware of what DS0000010236.V340936.R01.S.doc 01/09/07 01/07/07 01/07/07 01/07/07 01/08/07 01/07/07 01/07/07 05/06/07 01/07/07 01/07/07 Wardley Street Version 5.2 Page 26 18 YA43 26 action to take in case of a fire this is to ensure the safety of residents, visitors and staff. Copies of the reports from the provider’s monthly visits to the home must be available for inspection. 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the care planning system in place be reviewed to ensure that it is an effective working document for staff to use in conjunction with the service user. Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wardley Street DS0000010236.V340936.R01.S.doc Version 5.2 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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