Inspection on 12/12/05 for Woodcote Grove Road (100)

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodcote Grove Road (100) 10/02/09

Woodcote Grove Road (100) 18/02/08

Woodcote Grove Road (100) 08/05/06

Woodcote Grove Road (100) 06/09/05

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 Woodcote Grove Road (100) 100 Woodcote Grove Road Coulsdon Surrey CR5 2AF Lead Inspector James Pitts Unannounced Inspection 13:45 12 December 2005 th Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodcote Grove Road (100) Address 100 Woodcote Grove Road Coulsdon Surrey CR5 2AF 020 8763 4256 020 8763 4257 NO EMAIL 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) CareTech Community Services (No.2) Ltd Mrs Lesley Ann Lush Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Woodcote Grove Road (100) was registered in October 2003. The home offers eight single bedrooms; there are two bedrooms with en-suite bathrooms. There are two bathrooms with toilets upstairs and one bathroom with a toilet downstairs. The home is registered to provide support to eight people with learning disabilities. At present the home offers support to five service users, all of whom have been recognised as having Autistic Spectrum Disorder. The home is situated on a quiet main road in Coulsdon. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on the core standards that the Commission inspects in every inspection year and the progress on how the home keeps the service users safe from harm. The reason for updating the home’s progress on how the service users are kept safe is that there had been two incidents earlier this year where service users had come to harm. It should, however, be noted that the home has made improvements in these areas, although further efforts are required. There are now five people living at the home, three of who were at home during parts of this visit. Most of the people who live here find it very difficult to have conversations with staff or other people to let them know in detail how they are and what they need. These people can let staff know in their own individual ways that they might want something and the staff have to get to know the service users very well to recognise the ways in which each person does this. Three relatives sent back comment cards to the Commission before the previous visit and two care managers and a local GP did so before this visit. The comments that were made by relatives were referred to in the previous report, however it is useful to mention these again. One relative said that staff do appear to be caring. One said that there does not seem to be enough staff on duty, and another said that they do not know about how to make a complaint or how to see a copy of inspection reports about the home. The two care managers both made reference to the safety of service users in light of the incidents earlier this year and the GP had no comment to make. What the service does well: What has improved since the last inspection? The two en suite showers now have appropriately safe shower heads and thermostatically controlled mixing valves attached to them. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 The service users can feel confident that the home will only care for people that the home is registered to care for. The service users are told about how much it costs to live at the home and whenever this amount changes all of the people who need to know are told. EVIDENCE: There has been one new service user come to live at the home since the previous inspection visit. The file for this person was seen and it contained comprehensive referral information that was submitted by the Care Manager from this service user’s placing local authority. A copy of the home’s own assessment was also in place. There was sufficient information in place to show that the decision on this service user’s placement had been taken in light of suitable information about their care and support needs. There is a comprehensive contract in place that outlines the service that is provided and what this costs. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 The service users cannot feel confident that enough is being done to address situations that result in service users behaving in ways that might hurt themselves or others. The staff team also need to develop the methods of communication with service users to maximise their involvement in their own lives and the care that they receive. EVIDENCE: Two service user care plans, which are known as “ Individual Support Requirements “, were looked at in detail during this visit. These are written in a way that makes it look as though these are about what the service user thinks as the words that are used are things like “how staff assist me with personal care” and “how staff treat me and my communication needs”. One thing that is of concern is that two of the service users are showing regular signs of distress and are either hurting themselves or becoming angry and might hit out at other people. When things like this occur the staff write an incident report although it is unclear whether these then lead to the proper assessment and response to why and how to support service users to remain safe. Aside from the home’s manager no other staff have been trained in methods of working with people who display these types of behaviours. The Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 10 home use techniques that are geared to addressing the immediate behaviour, however, responding in the longer term in order to divert service users from, and reduce the incidence of, these behaviours is not clearly evidenced in each case. The home must write to the Commission and fully outline what happens if service users show signs of increasingly doing things that harm themselves or others. The keyworker for each of the service users is expected to spend specific time with their respective key service user in order to assess their progress and to ascertain their thoughts, feelings and goals. There is some evidence that this is happening at regular intervals. However, staff do require more training particularly when considering the needs of any service user who may have limited verbal or written communication abilities. On a slightly more positive note the care plans also include risk assessments that tell staff and other people about anything that may harm a service user and anything that the person might do that might hurt themselves. Copies of risk assessments are kept in the service users file and cover a variety of situations from accessing community activities to learning skills and activities within the home. Risk assessments are reviewed very often, however, there are concerns about some service users displaying more harmful behaviours and it is not clear whether these fully explain what staff can do to lessen the risks. There is one thing that was also of concern at the previous inspection, which was that although the risk assessments are very detailed; the staff did not know how to properly carry out safety checks of the hot water temperatures in the showers. Please see the comment made under the section “Environment”. The home has very clear procedures for staff about making sure that service users personal information remains confidential. These procedures are designed to ensure that information is not shared with anyone who does not have a right to know. Each member of the staff team signs a record to confirm that they have read, understood and will abide by the confidentiality policy. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 The service users can feel confident that they are offered choices in how to live their lives. This could, however, be expanded upon further so that service users can have increasing opportunities to be involved in community based activities and leisure pursuits. EVIDENCE: Some of the service users go to day centres or to other activities. However these activities appear to be very limited and the activity sheets indicate that most of the activities that occur are at home. There needs to be a lot more work done to ensure that service users are offered increased opportunities not only for fulfilling weekday activities but also to pursue social and leisure interests. The home has it’s own vehicle that service users be transported in although there are difficulties with the home not having many staff who can drive. The managing organisations most recent quality assurance report highlight the issue of how the staff team need to improve upon the service users having positive life experiences. The staff are, however, very good at helping each service user to keep in contact with their families and friends. Family and Friends are made very Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 12 welcome when they visit the home and many of the service users go to visit their families, often staying for a whole day or even longer at times. There are not many rules at this home. The most important one is that no one is allowed to smoke in the house, although none of the service users smoke in any case. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office if a meeting is happening. All of the service users are registered to vote, however it is unlikely that any would take a particular interest in doing so. Each of the people who live at this home is allowed to make choices about what they want to eat. The staff are good at making sure that healthy food is always on offer. If anyone puts on too much weight and this might make them unwell then the staff also help them to deal with that too so they can stay healthy. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users still cannot feel confident that all of the staff will make sure that they are always supported in the way that each of the people who live at the home really needs. A lack of diligence in following the clear policy and guidelines of the organisation continues to place service users are unacceptable risk. EVIDENCE: At the time of the previous inspection it was questioned whether a service user who was scolded whilst having a shower was being properly supported at the time. The managing organisation have now dealt with this particular occurrence, however it remains questionable whether there is sufficient diligence in keeping service users safe and appropriately supported. A more recent incident occurred where a service users was given the incorrect medication, which was in fact supposed to be given to a different service user. The deputy manager and a support worker where preparing two different service users medications at the same time and during this they were called away. On returning to the medication cabinet the wrong medication was picked up and given to a service user for whom it was not intended. Accepted good practise, and even the managing organisation’s own medication policy and procedure, clearly states that staff should focus on administering one service user’s medication at a time. It is evident that both of the staff failed to adhere Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 14 to this and as a result a service user was placed at unacceptable risk. Fortunately once the error had been spotted the right things were done and no serious harm came to the service user. However, this was clearly due to good luck rather than good care. The staff team must adhere to the policy and procedures for administering medication at all times and this must be properly overseen by the management of the home. The managing organisation must write to the commission to outline what further response and retraining is to be provided to both of the staff involved and how the home will ensure that proper and diligent care practices are observed from here on. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has clear information about how people who either live at the home or others can make a complaint. The home should still, however, make sure that everyone is given this information and in particular the relatives of the people who live here. Service users can feel confident that the staff team are now better at making sure that no-one does anything to deliberately harm them. Even though another service user has been placed at risk recently there is nothing to suggest that this was done deliberately. However, a lack of diligent care as an omission may be classed as abuse. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. One relative said in their comment card prior to the previous inspection that they do not know how to make a complaint. The home were told that they should send a reminder to all relatives to make sure that they are told how to, although this has not yet been done. No complaints have been made to either the home or to the Commission since the previous inspection. The two concerns that were raised about service users suffering harm prior to the previous inspection have now been investigated and conclusions have been reached. Although there was no indication of any deliberate intent to harm service users it must be remembered that a failure to apply good care practice may also be classed as abusive. The managing organisation must now write to the Commission to outline how it intends to ensure that service users are not placed at risk of harm by failures of diligence in providing good care. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 16 The training of the staff team about making sure that all of the service users are protected from abuse (this means that the staff at the home do everything that they can to stop any of the service users from being hurt by someone else) has improved still further. Only one of the current permanent staff team has yet to complete this training, although this is expected to be done in March 2006. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The service users can now be assured that the showers in the home have been made safe to use, although there is still some confusion about how to carry out water safety checks for the showers. Other safety checks still appear to be carried out properly and the home is kept clean and is comfortable. EVIDENCE: During the previous inspection the override to the shower control temperature settings were looked at as this had been said to be the reason that a service user had become injured when using the shower. These controls have now been replaced. Please refer to the section of this report entitled “Conduct and management of the home” for further comment about the apparent confusion that seems to exist about how hot water temperature checks should be carried out. The home is well decorated, comfortable and is kept clean and hygienic. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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): 32, 34 & 35 Service users can feel confident that there are enough people working each day in order to take care of them. They cannot, however, be assured that the company that owns the home are doing what they can to make sure that there are sufficient numbers of staff who are properly qualified. EVIDENCE: The manager of the home is still doing the NVQ level 4 qualification, the deputy manager is doing the NVQ level3, one care and support worker is doing NVQ level 2 and another has already achieved the NVQ level 2 qualification. The manager previously said that the remainder of the staff team would start their NVQ qualification course in October of this year, which has not happened. It was stated that this would now be October 2006 that is unacceptable in terms of the delay with ensuring that at least 50 of staff have the NVQ level 2 qualification. The managing organisation must write to the Commission to outline how it intends to ensure that there are sufficient numbers of appropriately qualified staff working at the home. The home has enough staff available each day to offer support to service users. At present there is a large usage of agency staff although this is expected to decrease dramatically in the New Year when 8 new staff commence employment. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 19 The managing organisation carries out checks to make sure that the people who work here are safe people to work with the service users. These checks include things like asking the police if a new member of staff has ever been found guilty of a crime, and asking people who used to employ them if their work was good and if they are the right sort of person to work with the service users and to support them. The Commission now accepts that as the home is run by a larger company that has a central personnel department that original copies of these checks can be kept there. The home does, however, still receive written confirmation that the checks have been carried out. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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, 39, & 42 The service users cannot feel confident that they are living in a home that is well managed both internally or externally. However, most of the necessary health and safety checks are properly carried out. EVIDENCE: The manager has yet to complete the NVQ level 4 qualification. The manager must endeavour to complete this without undue delay. The law says that the owner of the home, or their representative, must visit the home at least once a month to check on how well the service users are being cared for and about how well the home is run. The home must then get a copy of the report that is written about the visit. This is not happening properly as in April, July, August and October no visit was made. A report was written of a visit in November, which was said to class as the visit for October and yet no further visit happened in November in any case. A copy of each monthly report must also be sent to the Commission, which is also not Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 21 happening as required. The lack of diligence in both internal and external oversight in the management of this home is of serious concern, which is underlined by the serious incidents that have happened in the last year. The managing organisation must write to the Commission to outline how it intends to address the concerns about the failures of proper managerial oversight of the home. The managing organisation does, however, have a six monthly quality assurance programme which indicates that at least some areas are being identified as being in need of improvement. However this system would be seriously undermined if the matters, which are raised, were not addressed. An annual development plan also must be compiled. The information that is held in service user’s case files is well kept and is easy to read. Personal information that is written about each service user is kept confidential by the home. The following health and safety checks have been carried out within the last year: Fire Alarm System: 19/04/05 Gas Safety Check: 04/10/05 Legionellosis: Not applicable to this home. Portable appliances: 15/11/04 (This is now out of date and a further check must be carried out. Once completed this must be confirmed in writing with the Commission) Please refer to the section entitled “Environment” for comment about how the managing organisation must clarify how the checks of the hot water temperatures in the two en suite showers should occur. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 1 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 x 12 1 13 1 14 1 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 1 x 3 1 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodcote Grove Road (100) Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 x x 1 x DS0000065438.V269307.R01.S.doc Version 5.0 Page 23 No 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 YA6 Regulation 15 (2) Requirement The home must write to the Commission and fully outline what happens if service users show signs of increasingly doing things that harm themselves or others. The staff team require more training particularly when considering the needs of any service user who may have limited verbal or written communication abilities. There must be more work done to ensure that service users are offered increased opportunities not only for fulfilling weekday activities but also to pursue social and leisure interests. The managing organisation must address the limited opportunities for service users to engage in activity and leisure pursuits which is compounded by the limited availability of the home’s transport due to a lack of staff that drive. The managing organisation must write to the commission to outline what further response and retraining is to be provided DS0000065438.V269307.R01.S.doc Timescale for action 01/02/06 2 YA7 24 (3) 01/02/06 3 YA12YA13 16 (20 (m) & (n) 01/02/06 4 YA14 16 (2) (m) 01/02/06 5 YA20 13 (2) 01/02/06 Woodcote Grove Road (100) Version 5.0 Page 24 6 YA23 13 (6) 7 YA32YA35 18 (1) (a) 8 YA37 9 (2) (b) (i) 26 (3) 9 YA39 10 YA39 24 (1) (a) & (b) 11 12 YA39 YA42 24 (1) (b) 23 (2) (b) to both of the staff involved in failing to adhere to the policy on administering medicines and how the home will ensure that proper and diligent practices are observed from here on. The managing organisation must write to the Commission to outline how it intends to ensure that service users are not placed at risk of harm by failures of diligence in providing good care. The managing organisation must write to the Commission to outline how it intends to ensure that there are sufficient numbers of appropriately qualified staff working at the home. The manager must endeavour to complete the NVQ level 4 qualification without undue delay. Monthly visits that are required under this regulation must occur each month and a copy of each monthly report must also be sent to the Commission. The managing organisation must write to the Commission to outline how it intends to address the concerns about the failures of proper managerial oversight of the home. An annual development plan must be compiled. An updated portable appliances check must be completed and once completed this must be confirmed in writing with the Commission. 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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 YA22 Good Practice Recommendations The home should still issue a copy of the complaints procedure to the closest relatives of all service users. Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Woodcote Grove Road (100) DS0000065438.V269307.R01.S.doc Version 5.0 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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