Inspection on 20/07/05 for Woodham 2

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodham 2 09/07/08

Woodham 2 10/07/07

Woodham 2 24/01/07

Woodham 2 16/01/06

Woodham 2 21/01/05

Woodham 2 08/09/04

Woodham 2 04/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Woodham 2 33 Newlands Park London SE26 5PN Lead Inspector Lorraine Pumford Unannounced 20th July 2005 14.30 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 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 Stationary 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. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodham 2 Address 33 Newlands Park, London, SE26 5PN Telephone number Fax number Email 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 8778 1850 Woodham ENT Ltd Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21/01/05 Brief Description of the Service: Woodham 2 is a large, detached Victorian residence on a main road in Sydenham, within a short walk from shops and rail or bus transport. It provides care, board and accommodation for up to eight service users with mental illness and forensic histories. The care home aims to support service users who are aged 18-65 and have been discharged from psychiatric inpatient facilities, medium-secure units or special hospitals. Service users may be resident at the home for up to three years, during which time they are encouraged towards independent living in the community. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector who was in the home for approximately 4 hours. On the day of the inspection the majority of service users were away on holiday or out for the day, therefore it was only possible to ascertain the views of one service user. During the course of the inspection staff on duty were spoken with, some records examined and parts of the premises inspected. All Registered Care Homes receive a minimum of two inspections within a 12 months period As this inspection may not have covered all the “National Minimum Standards” on this occasion if further information is required it is recommended that a copy of the last inspection report also be obtained. What the service does well: What has improved since the last inspection? Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 6 Since the last inspection a damaged shower door, which could have been potentially hazardous, has received remedial work. The care home provider has now taken action to ensure that the employer’s liability insurance certificate is displayed in the home. 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. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5 Insufficient information is included in the Statement of Purpose to enable prospective service users and their representatives to make an informed choice about the home’s ability to fulfil their care needs and if they wish to live in the home. All service users must receive a letter stating that following an initial assessment the home is able to meet their needs before they are admitted. EVIDENCE: Staff were unable to locate a copy of the home’s Statement of Purpose, however, they were confident a copy of an amended document had been sent to the CSCI following the last inspection. At this time it was highlighted that this document did not meet Regulation 4.1 or Schedule 1 of the Care Standards Act 2000. In short, the most up-to-date copy of the Statement of Purpose sent to the CSCI is incomplete and also does not include the last word of each line. The document itself does not comply with schedule 1, as it does not include the following information: 1. The name of the registered manager. (The person listed in the current document is no longer in post) 2. The relevant qualifications and experience of the registered provider and any registered manager. 3. The number, relevant qualifications and experience of the staff working in the care home. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 9 4. The organisational structure of the care home. 7. Whether nursing is to be provided or not. 12. The arrangements made for the service users to attend religious services of their choice. 15. The arrangements made to dealing with reviews of the service users plan referred to in regulation (15)(1). 17. Details of any specific therapeutic techniques used in the care home and arrangements made for their supervision. Records indicate that each service user is provided with a contract of residency and conditions of residency stating the terms and the service users’ responsibilities. The contract seen had been signed by the service user and not counter-signed by a representative of the provider. Staff stated that prospective service users are given the opportunity to visit the home prior to admission; generally the opportunity to stay for short periods of time can be arranged, before being offered a place on a formal trial basis. One pre-admission assessment was examined, staff stated that in the first instance a service user would be visited in hospital and relevant health and social care professionals would be asked to provide information regarding the service users mental health and any other needs. The copy of the assessment on file had not been signed by the member of staff who had completed the assessment. Staff stated that to date they have not sent a letter to prospective service users or their representatives stating that following an assessment the home can meet the needs of the prospective service user, this is required in order to comply with Regulation 14 of the CSA 2000. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 6,7,9,10 Care plans, which include individual risk assessments, provide staff with written guidance about service users needs. Service users have opportunities to participate in the decision-making that effects their daily lives. EVIDENCE: Staff stated that each service user has a detailed care plan. Two care plans were examined; the samples seen had not been signed by the member of staff at the time the document had been formulated. Staff stated that the most upto-date care plans were held on the computer, however, this was not working at the time of the inspection and these documents could not be viewed. Individual risk assessments formed part of the care plan, however, these had not been signed or dated at the time of completion. There was a detailed daily record regarding each service users general well-being, health and activities. Information regarding service users was seen to be stored in a secure place, staff stated that service users are aware that information is held in relation to them and they are involved in updating care plans pertaining to themselves. Staff maintain a detailed record regarding any incidences or occurrences that have affected service users lives over and above their daily norm. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 11 The home’s Statement of Purpose indicates that regular house meetings take place. Staff stated that service users are expected to attend these meetings to discuss day-to-day issues that affect their lives whilst living in the home. Staff stated that it was frequently difficult to motivate service users to attend these meetings on a regular basis. Records indicated that staff play a significant role in monitoring service users’ finances. In some instances this includes holding cash cards. Staff stated this was to prevent service users from spending their money on inappropriate substances. Records need to be maintained to ensure that this decision is by mutual agreement between the service users, the care manager and the home and included in the service users individual care plan. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 16,17 The daily routine and house rules promote independence, choice and freedom of movement. EVIDENCE: The service users’ contract indicates that visitors are welcome up until 10 pm at night. A notice displayed on the notice board in the hall stated that visiting time had been restricted to a two-hour period. Staff stated that this has occurred as a result of inappropriate and abusive behaviour by friends of one of the service users. The fact that service users may have access to personal visitors restricted should be clearly documented in the Service User Guide and discussed with care managers and commissions of the service as this affected one service user only. All documentation regarding the home and the service users’ contract indicates the expectation that people living in the home will contribute to daily domestic routines in both communal areas and their own bedrooms. Service users have the key to their own bedroom door and are able to move around the home freely. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 13 Service users were seen to enter the kitchen and access refreshments as and when they wished to. Due to the diagnosis and specific needs of service users, detailed restrictions regarding smoking, alcohol and drugs are clearly spelt out in the homes Service User Guide and contract of residency. Discussion took place regarding meals provided to service users. Staff stated that service users prepare their own breakfast as and when they wish. There is an either/or menu for service users to choose from for the main meal once a day, and staff stated a lighter meal is also provided for lunch. A number of issues arose in relation to the recording of food provided. There is no menu plan to provide guidance for staff on purchasing food for service users meals. A menu for the day is displayed on a wipe board in the kitchen, and staff record the main meal service users have had each day, however there was no record that service users are provided with a desert following the main meal. Further their is no record kept of what other food service users have eaten when at home during the day other than the main meal, without these records there is no written evidence that service users are receiving a varied nutritional diet, this needs to be addressed. There was a small stock of tinned and frozen provisions, (although the majority of service users were away at the time of the inspection). A vegetable rack of potatoes was seen in the kitchen, although staff stated these have recently been purchased, the majority of potatoes were green and sprouting roots. The fact that these potatoes were potentially hazardous if eaten was discussed with staff. There was a large bag of frozen chicken pieces in the freezer, a member of staff stated these have been purchased fresh and then frozen, the bag was torn, unsealed and had not been dated. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 19,20 Service users mental and physical health needs are being met. The current procedures for recording and storing medication are inadequate and do not safeguard service users. EVIDENCE: From record seen it is apparent that the service users receive considerable psychological support to maintain their health and well-being. Staff stated the home has good relations with local health care professionals who respond appropriately to service users needs on a regular basis. A number of issues arose in relation to current medication practices. At present staff are decanting medication from the packaging it has been administered in, into dosette boxes for individual service users, these dosette boxes were not marked with the service users name or name of the tablets. This practice necessitates the need for staff to sign the record twice, once to indicate the transfer of medication from the original box to the dosette and a second time to indicate the medication has been given to the service user at the point of administration. At present the MAR sheet is only signed by staff when administering medication to service users. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 15 Staff are handwriting service users’ medication details on to the MAR sheet. Not only is this practice time-consuming, but also requires the signature of two members of staff to reduce the possibility of an error being recorded by the person handwriting the document. At present only one member of staff is signing the document. Discussion took place around the need to consult with the homes pharmacist, to establish an appropriate and safe way of dispensing medication with pre recorded MAR sheets in order to reduce the possibility of error. The staff stated that a record is kept of all medication received by the home and returned to the pharmacist for safe disposal. Staff stated that all people responsible for administering medication have attended appropriate training courses at a local college and certificates of competency have been issued upon completion of the course, these will be inspected during the next visit. Staff stated that there are a sufficient number of care staff that hold a first aid certificate to enable one appropriately trained person to be on duty each shift. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 22 Service users and their representatives are provided with information regarding the homes Complaints procedure. EVIDENCE: Service users are provided with the homes complaints procedure and information regarding the contact details of the CSCI. Records indicated appropriate action is taken by staff to address any matters brought to their attention. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 standard(s) 24,26,27,28,29,30 Service users are able to personalise their own rooms. Action is required to create a more homelike environment for the number of service users the home is registered to accommodate. EVIDENCE: All service users have a single bedroom. Seven of the rooms have ensuite facilities and the remaining bedroom has bathroom facilities situated on the second floor and solely for the use of this rooms occupant. At the time of the inspection only one service user was in residence, he invited the inspector to view his room, this was individually personalised with his own effects and with adequate space for his music system and other electronic appliances. The service user stated he liked his room and had everything that he needed. There is a separate WC situated on the ground floor for staff and visitors to the home. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 18 The laundry facilities in the home are domestic in scale; staff stated they meet the needs of the current service user group. The home does not have a visitors’ room, which means the only space service users have to meet with guests privately is in their bedrooms. Staff stated that generally when a service user has visitors other residents retire to their bedrooms, which is an intrusion into the lives of the other service users living in the home. Although the home is registered to accommodate eight service users there are insufficient dining chairs and inadequate space to seat eight service users at the dining table, further there is an insufficient number of comfortable chairs provided in the lounge for the number of service users accommodated. The dining room is positioned between the lounge and kitchen and has restricted natural light, the room would benefit from additional domestic lighting to enhance a more homelike environment. There is a large garden to the rear of the property and tables and chairs are provided. On the day of the inspection all areas seen were clean and well maintained. None of the current service users accommodated has a disability, which would require the need of any specialised equipment or adaptations to the building. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Sound staffing procedures need to be in place to ensure the safety of both staff and service users. EVIDENCE: The staff rota displayed in the office was not an accurate reflection of the staff on duty. At the commencement of the inspection one member of staff was on duty alone with one service user. This member of staff stated a colleague would be returning shortly. When the second member of staff arrived her name was not recorded on the duty rota for that day. The duty rota is required to include the names of all staff on duty and the hours they will be working. Staff stated that another member of staff would be coming from Woodham House to commence a shift later that afternoon and this also was not recorded on the rota. A risk assessment must be completed with regard the practice of one member of staff being left alone in the home with service users, to ensure the safety of the member of staff and that the service user knows the actions to be taken in the event of an accident or emergency. There must be at least two members of staff on duty for health and safety reasons. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 20 Staff stated that the acting manager was the sole person holding keys to records pertaining to staff working in the home and that the homeowner did not have access to this information in the managers absence. The acting manager of Woodham 2 had taken some of the service users from the house away on holiday jointly with service users living in Woodhams House. In the absence of the acting manager there must be an appropriately experienced person to fulfil the day-to-day management and running of a home. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 At present the home is being managed by a person who has not been registered with the CSCI as being a suitably qualified and competent person to manage the home on a day-to-day basis. The care home provider is still failing to comply with CSA 2000 Reg 26 visits and reporting procedures, and subsequently the CSCI have not received any written evidence that the care home provider is safeguarding service users by monitoring the care and service provided in the home. EVIDENCE: Staff stated that the current acting manager of the home is PR. However the CSCI records show an application was received to register a different person, AP, as the manager from the beginning of this year. To date the Commission has not been informed that the registration of AP would not be going ahead and that an alternative manager has been employed. Further an application is required in relation to PR as the home has now been operating without a registered manager for a period of approximately 6 months. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 22 Discussion took place in relation to the companies quality assurance mechanisms. Staffs provided copies of brief questionnaires that service users and other stakeholders are asked to complete periodically throughout the year. Staff stated that the care home provider attends the home on a regular basis. CSCI records indicate the care home provider or his representative have failed to submit a report to the CSCI on a monthly basis regarding the monthly unannounced visit they are required to make to comply with Regulation 26 of the Care Standards Act 2000. This is a requirement the care home provider has been asked to address in previous inspections. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 x N/A 3 Standard No 11 12 13 14 15 16 17 x x x x x 3 2 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodham 2 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 1 x 2 x x x x G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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 1.1 Regulation 4.1 Requirement Timescale for action 30.09.05 2. 1.1 6(a)(b) 3. 3 14(1)(d) The responsible individual must ensure that the Statement of Purpose is an accurate reflection of the care services provided in the home and complies with the schedule 1 of the Care Standards Act 2000. The registered person must keep 30.09.05 under review and, where appropriate, revise the Statement of Purpose and Service User Guide and notify the Commission and service users of any such revision within 28 days. The registered person shall not 30.08.05 provide accommodation to service user at the care home unless, in so far as it shall be practicable to do so the registered person has confirmed in writing to the service user that having regard to their assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 25 4. 17 17(2) Schedule4 13 5. 28 6. 24 7. 33 8. 37 9. 39 Records of food provided to the service users in sufficient detail to enable any person inspecting the records to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets provided for individual servers users. 23(2)(i) Suitable facilities are provided for service users to meet with visitors in communal accommodation, and in private accommodation which is separate from the service users own private rooms. 23(2)(g) The registered person shall having regard to the number and needs of the service users ensure that there is adequate seating, recreational and dining space provided separately from the service uses private accommodation Regulation Maintain an accurate duty roster 17(2) of persons working in the care home, and record, whether the Schedule 4 7. roster was actually worked. 8(2) Where the registered provider appoints a person to manage the care home he shall forthwith give notice to the commission of(a) the name of the person so appointed and(b) the date on which the appointment is to take effect. 26 The responsible individual has not complied with previous requirements to undertake a monthly inspection of the home and provide the CSCI with this report.The Registered Provider must undertake an unannounced inspection each month and provide a copy of his findings to the CSCI. 30.08.05 Action Plan 30.10.05 30.10.05 With immediate effect 30.08.05 30.09.04 New timescale 30.09.05 Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 26 10. 6 17(3)(b) The registered person shall ensure that records,(in this instance the service users care plans) are at all times available for inspection in the care home by any person authorised by the commission to enter and inspect the care home. 30.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 20 33 Good Practice Recommendations Restrictions placed on service users accessing their own money at any time should be included in their individual care plan and agreed by both parties. The responsible individual consults a pharmacist to update the current practice of hand writing MAR to reduce the risk of error. Ensure a risk assessment is carried out in relation to staff working alone in the home with a service user/s Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH 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 Woodham 2 G51-G01 s44288 Woodham 2 UI v232004 200705 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!