Inspection on 02/05/06 for 116 Ashurst Road

This inspection was carried out on 2nd May 2006.

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

Other inspections for this house

116 Ashurst Road 16/02/09

116 Ashurst Road 30/08/05

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 Willow Holdings (UK) Ltd t/a Willow Care Homes 116 Ashurst Road North Finchley London N12 9AB Lead Inspector Anthony Lewis Key Unannounced Inspection 2nd May 2006 09:25 Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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 Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Holdings (UK) Ltd t/a Willow Care Homes Address 116 Ashurst Road North Finchley London N12 9AB 020 8492 0363 020 8492 0363 willowcarehomes@aol.com 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) Willow Care Homes Ltd Mr Paul Clancy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: 116 Ashurst Road is an extended detached home registered for six adults aged 18 - 65 with learning difficulties, who may have some additional health needs. The home is situated close to shopping areas of North Finchley and Friern Barnet with easy access to buses and tubes and links to central London. The home was opened in May 2005 and is owned and operated by Willow Care Homes Limited. The home consists of four bedrooms, each with their own en-suite facilities. There is a bathroom on the ground floor. Each bedroom is decorated to the individual taste of the resident. There is a staff room on the first floor, with an en-suite toilet. There is a well equipped laundry room. The office is to the ground floor. There is a communal lounge, dining room, laundry room and large kitchen. To the front exterior of the home, there is off street parking for several vehicles. To the rear of the home is a large well kept garden. The Statement of Purpose states that the aim is to provide a service for adults with learning difficulties who may have some additional health or behaviour needs and may have relatively high levels of dependency. The fee for residents living in the home is £1,309 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Tuesday 2nd May 2006 at 9:25am and was completed at 4:20pm. The registered manager was away on annual leave and the acting deputy manager was on a rest day but kindly came in at 10am and was available throughout the inspection process. The acting deputy manager and support staff were very helpful and accommodating. The home has been extended to provide accommodation for a further two residents, increasing the residency in the home from four to six. All of the residents are known to each other from a service were they all previously lived. To gather evidence for this inspection, three residents were spoken to. Due to their communication difficulties, conversations were quite brief. Four staff were spoken to individually and in private. Evidence was also gathered for this inspection from viewing all of the residents’ files and five staff files. The home’s fire, health and safety files and records as well as various other documents, files and certificates were also viewed. Prior to the inspection, the service history and various other documents and were used to gather information about the service. An extensive internal and external tour of the home was conducted with a support worker. What the service does well: What has improved since the last inspection? Of the six requirements made at the previous inspection, the staff have ensured that three of them have been met. They have ensured that: risk assessments are more thorough and comprehensive. Colour code mops and buckets are being used for specific areas of the home to reduce the possibility of cross contamination or infections occurring. A Portable Appliances Test (PAT) was carried out on 18th October 2005. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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 Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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): 1, 2, 4 and 5. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The staff have ensured that comprehensive information is available regarding the home and prospective resident are able to visit the home to make an informed choice. Although the home has detailed assessments on each resident, staff are not ensuring that residents are involved when drawing them up. Staff are also not ensuring that all residents sign their contract. EVIDENCE: The home has a detailed statement of purpose, which contains information on the aims of the service including, the accommodations provided, the support provided by the staff team, residents support plans and charges for living in the home. The acting deputy manager stated that the registered manager carries out assessments on prospective residents to the home. The assessment records for the two most recent residents were viewed and although they were detailed in that they contained information on their background, general information, current situation and their independent living skills, there was no evidence to show that the residents were involved in drawing up their assessment. A requirement is made in relation to this. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 9 The assessments of the two most recent residents to the home showed that they were able to visit and “test drive” the home prior to deciding whether to move in or not. The assessment stated that the residents were able to stay for lunch and get involved in social activities. All residents have a contract called “statement of services”, which contains information on the aims of the service and what residents can expect from the service. However, none of the contracts were signed by the resident or their representative. A requirement is made in relation to this. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although residents have comprehensive care plans, staff are not ensuring that the residents are involved in drawing them up. The staff are ensuring that residents are supported to take informed risks and make individual decisions and choices and participate in the day-to-day running of the home. EVIDENCE: Care plans for individual residents are comprehensive in that they contain information on each resident’s emotional needs, activities that the resident is involved in, support with meals, personal care and support with their finances. However, there is no evidence to show that residents are involved in drawing up their care plans. This was a requirement at the previous inspection and is restated. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 11 Each resident has a “Client Support Guideline” that clearly states the choices and support needs of the resident. One resident’s guidelines contains the resident’s choice of shampoo and the reasons for using it. Another resident states in her guidelines that she may not choose to eat pork at times due to her religious beliefs. Residents’ choices regarding meals are reflected in their care plans and on the menu, which is discussed every Sunday and recorded. According to the acting deputy manager, individual residents meet with a member of staff to discuss their choice of activities. This is recorded in residents’ files. Recorded in another resident’s file was a statement that the resident wants to visit her family. Records show that regular residents’ meeting occur in the home. The minutes of the last meeting held on 15th March 2006 include the existing residents welcoming the two new residents to the home, what residents wished to do for Easter and where they wish to go for their annual holiday. Resident’s files contained information on various risks to the them, the risks involved in particular activities, the benefit to the resident and others and the action taken to reduce or eliminate the risk. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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): 12, 13. 14, 15, 16 and 17. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Staff are ensuring that residents are able to access all facilities and appropriate activities within their community and are supported to maintain relationships with family and friends. Staff are also ensuring that residents are respected and are able to exercise their views and choices with regards to meals in the home. EVIDENCE: On the wall in the office the staff have produced a “Weekly day service plan.” The acting deputy manager explained that residents are involved in a range of appropriate day care activities such as gardening, cooking, information technology, sports, delivering leaflets in their local community and one resident attends a day service where she receives training to support him in finding employment. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 13 The weekly day service plan shows that residents are active in their community and engage in many activities. Care plans viewed show some of the activities that residents are involved in. A resident spoken to said, “I liked going to the pub.” When asked another resident said, “Staff take me out for meals and for a walk.” The home has a diverse mix of residents from various religions and cultures. When looked at, their care plans contained information on the support that staff will give them to ensure that their religious and cultural care needs are met, such as engaging in religious festivals and celebrations and cultural foods that residents like. The registered manager stated that all residents have contact with their family or friends and that one resident has a close relationship with a resident from another home. The residents’ care plan contained information on the support that the resident requires from the staff. Three members of staff were spoken to individually and in private about how residents’ rights and dignity are respected. One member of staff said, “I always knock on resident’s bedroom door and wait before I go in.” Another staff member described how she supports residents with their personal care, ensuring that the resident’s wishes are paramount. Throughout the day, staff were observed supporting residents in a courteous and patient manner and residents moved about the home freely or with staff support when required. The menu for the past few weeks was viewed and contained a variety of meals, such as lasagne and garlic bread, beef stew and rice, stir fry and traditional Sunday roast. According to staff, the menu is planned every Sunday with the residents who choose what they wish to eat for the week. The acting deputy manager said that residents have a choice of what they have for lunch. Resident’s care plans contained information on meals that they like and dislike. One resident’s care plan includes how staff are to support her when serving her meal. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Staff are ensuring that residents’ health and personal care needs are being met. Staff are not ensuring that all of the wishes of residents are being met. This practice may cause misunderstandings regarding residents’ wishes in certain instances if not rectified. EVIDENCE: The care plans of each resident contained information on the support they require with their personal care. A staff member spoken to described how she supports residents and ensures that the residents make the choices as to when to get up, what they wish to wear or whether they would prefer a bath or a shower. The care plans of all of the residents were viewed and all contained detailed information on their health care needs, including information on visits to their GP, dentist, chiropodist and physiotherapist. The care plans also contained information on the reason for the visit, the outcome and any changes that may have been made to their medication. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 15 At the previous inspection the registered manager, who is not qualified, was training staff to administer medication. A requirement was made that only a person deemed competent or who has been trained to carry out medication training does so. Information received from the registered manager shows that medication training is being carried out by a training organisation. Although the staff have produced a form to record residents’ wishes in the event of them becoming terminally ill and dying, not all of the residents or their representatives have filled in the forms. It was a requirement at the previous inspection that staff ensure that all residents’ wishes are recorded. This requirement is restated. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The staff team are ensuring that concerns and complaints are treated seriously and acted upon. However, staff are not receiving adult protection training to ensure that residents are protected from abuse. EVIDENCE: The home has a comprehensive complaints policies and procedures, which contains details of how residents can make a complaint. One complaint was made since the previous inspection. The details of the complaint, the action taken and the outcome were all recorded. A resident was spoken to briefly about the complaints policies and procedures. The resident stated, “I don’t make complaints, I’m ok.” The home has the London Borough of Barnet’s Multi Agency Adult Protection file and their own policies and procedures on adult protection. Since the previous inspection one investigation has taken place. The registered manager ensured that the relevant parties, including the Commission, where informed and a full investigation was conducted. Two staff were spoken to about the “whistle blowing” procedure and were able to describe the procedure in detail. However, although the manager has completed a “train the trainer” course in adult protection, which enables him to train others, staff files did not contain certificates or evidence that they have received adult protection training. A requirement is made in relation to this. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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 and 30. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. The staff team have ensured that the home is clean and tidy and that the atmosphere and environment is homely while at the same time ensuring that residents’ personal needs are met. EVIDENCE: The home is located in a quiet and pleasant residential area, a short walk from a large park and shops. Within the home all areas are homely, comfortable and safe. The lounge contained leather sofas, a TV, DVD/Video player and a HI FI system. There was also a fish bowl with goldfish inside, which according to the acting deputy manager, belongs to a resident. All bedrooms are comfortable and contain the resident’s personal possessions such as: photographs of their family and friends, ornaments, pictures and various items of their hobbies or interests. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 18 Whilst touring the home, all areas were found to be clean and tidy and free from any offensive odours. At the previous inspection, a requirement was made that the home must have adequate colour coded mops and buckets to prevent cross contamination or infections. This requirement has been met by staff ensuring that there are sufficient mops and buckets and that they are used only in the appropriate area of the home. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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): 33, 34, 35 and 36. Qualities in these outcome areas are good. This judgement has been made from evidence gathered both during and before the visit to this service. Robust recruitment procedures are being followed to ensure that residents are protected. In addition, residents are being supported by a reasonably trained and supervised staff team in sufficient numbers to be able to meet the needs of all of the residents. EVIDENCE: When spoken to about staffing levels, two staff stated that there are enough staff on shift to meet the needs of the residents. Staff were observed throughout the day working as a team and meeting the needs of the residents without difficulty. Records show that regular staff meetings occurring where topics are discussed, such as staffing in the home and staff supporting the residents. Five staff files were viewed and the information contained indicate that a thorough recruitment system is in place. Files contained two references, an application form, a recent photograph, interview notes, their Criminal Records Bureau (CRB) check and a copy of the staff’s passport. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 20 All staff files viewed contained a variety of training certificates such as moving and handling, food hygiene and health and safety. Some of the staff have completed their National Vocational Qualification (NVQ) level 2 and other staff have started the training. Of the five staff files viewed, all contained records of their supervisions. Records show that staff have been receiving supervision on average every seven weeks. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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, 39 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The home is being managed by a competent and experienced manager who is ensuring the safety of service users, staff and visitors. The staff are not ensuring that an adequate means of measuring the quality of service delivery is in place. EVIDENCE: The registered manager has a National Vocational Qualification (NVQ) in management and has managerial experience since 1995. He also has undertaken the “Train the trainer” course in adult protection and will be providing training to staff. Staff spoken to were very complementary about the way in which the home is being managed. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 22 The home does not have a quality monitoring system in place to measure the quality of service delivery to the residents and to ensure that the home is meeting its stated aims and objectives. A requirement is made that the home must have an effective quality assurance monitoring system in place. The staff are ensuring that all health and safety checks are carried out regularly. Fire drills and tests have been occurring regularly and all safety certificates such as gas, lift, water, London Fire and Emergency Planning Authority (LFEPA) and Portable Appliances Test (PAT) were seen and were up to date and in order. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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 3 2 2 3 x 4 3 5 3 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 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 3 2 3 X 2 X X 3 x Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 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) (c) Requirement The registered persons must ensure that residents or their representative are involved in drawing up their assessment. The registered persons must ensure that residents or their representative are involved in drawing up their care plan. (Timescale of 16/12/05 not met). This requirement is restated. The registered persons must ensure that residents’ wishes in the event of them becoming terminally ill and dying is recorded in their file. (Timescale of 16/12/05 not met). This requirement is restated. The registered persons must ensure that all staff receive adult protection training. The registered persons must ensure that there is an effective quality assurance monitoring system in place. Timescale for action 28/07/06 2. YA6 15(1) (2) 28/07/06 3. YA21 12 (3) 29/08/06 4 YA23 18 (1) (c) (i) 29/08/06 5. YA39 24 (1) (2) (3) 29/09/06 Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 25 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 YA5 Good Practice Recommendations It is recommended that the registered persons ensure that residents or their representative sign their contract. Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Willow Holdings Ltd t/a Willow Care Homes DS0000062932.V289774.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. 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