Care Home: 24 Surrenden Road

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What the care home does well 24 Surrenden Road is an established, generally well-managed and wellmaintained service that provides good quality care and support for the young people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the commitment within the staff team and the open and inclusive management style. What has improved since the last inspection? Service users are protected from potential abuse by appropriate staff training and relevant and up to date policies and procedures that have been developed and implemented since the previous inspection. The quality monitoring systems have been improved by the recent introduction of satisfaction questionnaires seeking the views of service users` relatives and other stakeholders in the community. Since the last inspection, as recommended, the kitchen has been redecorated and totally refurbished, with good quality replacement units, work surfaces, tiles and a new floor covering. Radiators throughout the building have also been repainted or upgraded, and where necessary, following risk assessments, covers have been fitted. CARE HOME ADULTS 18-65 24 Surrenden Road Brighton East Sussex BN1 6PP Lead Inspector Nigel Thompson Unannounced Inspection 8th July 2008 09:30 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24 Surrenden Road Address Brighton East Sussex BN1 6PP 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) 01273 504344 01273 552626 Brenda@rogate.org Hallcreed Limited Julia Brooks Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 7th August 2007 Brief Description of the Service: 24 Surrenden Rd is registered with the Commission for Social Care Inspection (CSCI) to provide residential care and support for up to three people with learning disabilities. The home is situated in a pleasant residential area of Brighton, close to local parks, shops and pubs. It is convenient for bus services into the city centre and other areas, and is close to Preston Park station. The home does not provide nursing care. The building is a two-storey house with accommodation on both floors. It is not suitable for people with mobility problems. There is a garden to the rear of the property. The current service users, who have lived in the home for many years, have the use of the lounge and a large kitchen/diner and also the hydrotherapy pool located in one of the other properties owned by Hallcreed Limited. Information about the service, including the recently updated Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at 24 Surrenden Road, as of 31 July 2007, is £88.50 - £98.85 per day. Additional charges are made for hairdressing, certain activities, magazines, toiletries and holidays. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection took place over five hours in July 2008. All of the key National Minimum Standards were assessed and found to have been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to monitor care practices at the home and the focus was on the quality of life and outcomes for people who live at the home. On the day of the inspection there were three service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with two service users, the Care Consultant, the Training Officer and one member of staff. Information received in the Annual Quality Assurance Assessment (AQAA) and responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the service does well: 24 Surrenden Road is an established, generally well-managed and wellmaintained service that provides good quality care and support for the young people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the commitment within the staff team and the open and inclusive management style. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Although the Care Consultant confirmed that there have been no admissions to the home for over fifteen years, it was noted that there is a clear admission policy and procedure in place. Comprehensive information is made available to all prospective service users and the quality and accessibility of the home’s ‘Statement of Purpose ‘ and the ‘Service User Guide’ is further enhanced by effective use of illustrations. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 9 However it was noted that neither of these documents have been reviewed and amended since the previous inspection to reflect the managerial changes that have taken place. Following a referral to the home, the manager will visit the prospective service user and carry out a pre-admission needs assessment, including any personal care needs, mobility issues, social and cultural needs and family involvement. In addition to establishing whether the individual’s care and support needs can be met within the home, the Care Consultant also stressed the importance of ensuring compatibility with existing service users. For individuals referred through Care Management arrangements, the manager confirmed the need for a completed Social Care Assessment being provided. All prospective service users have the opportunity to visit the home to look around and meet with existing residents and staff before moving in. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of service users in a structured and consistent manner. Systems for consultation and participation are generally satisfactory. Service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: ‘Person centred’ care and support plans have been developed and implemented for each service user. Individual plans that were examined contained personal risk assessments and details of their physical and emotional support needs and were found to be accurate, up to date and generally well maintained. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 11 Service users’ care plans also showed evidence of annual community reviews and of interim six monthly ‘in-house’ reviews. Since the previous inspection, as recommended there is also a record maintained of who is present at the review meeting. Independence and individuality continues to be encouraged and promoted within the home. The Shift Leader confirmed that service users are consulted regarding many aspects of their day-to-day living, including choosing colour schemes for their room and communal areas, menu planning, recreational and leisure activities and holidays. This was supported through discussions with service users, spoken with during the inspection. The Care Consultant emphasised the importance of staff developing close working relationships with individual service users. Despite the limited verbal communication of one service user, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of service users being supported in a professional, sensitive and respectful manner. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish. However, inadequate staffing levels limit opportunities for recreational activities and menus, reflecting service users’ individual likes and preferences, are not always adhered to. EVIDENCE: The recreational and leisure interests of service users are identified and documented in their individual care plan, as part of the initial and ongoing assessment process. Although recorded activities, including various day services, college courses, visiting garden centres and friends and shopping, reflect these interests, it is 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 13 evident that the current staffing levels restrict and limit individual opportunities to undertake such activities. Community participation evidently remains a focus in the home and staff confirmed that, in addition to structured day services, service users are encouraged and supported to visit the cinema, theatre, local shops and other amenities. However, opportunity for individuals to go out is significantly restricted as a result of the minimum staffing levels that continue to operate in the home. The Care Consultant confirmed that visiting at the home is unrestricted and service users may see their friends or relatives in the lounge or in the privacy of their own room. Where appropriate, links with family and friends are encouraged and supported. Menus examined were found to be varied and balanced and are evidently based on service users’ identified likes and preferences. An alternative to the main meal is always available and the ‘flexible’ four-week menu is regularly discussed with service users. Service users are not generally involved in meal preparation. However from discussion with staff and service users it is evident that menus are not always adhered to and meals are sometimes prepared, possibly for convenience, from whatever is more readily available at the time. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with service users in a professional and respectful manner. Documentary evidence was in place to demonstrate that the health and emotional care needs are continuing to be met within the home. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 15 All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. The Care Consultant confirmed that close and effective working relationships between service users and their key worker ensured that any subtle change in an individual’s mood or behaviour could be picked up on and addressed at an early stage. Policies and procedures, relating to the storage, control and administration of medication, are in place and were found to be accurate, well maintained and up to date. The Care Consultant confirmed that staff directly involved in these procedures receive appropriate training. This was confirmed through discussions with staff and supported by training records examined. The home operates a ‘Monitored Dosage System’ (MDS) and regular monitoring of procedures as well as guidance and advice is provided by a local pharmacist. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users and staff feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through relevant staff training and policies and procedures relating to abuse and safeguarding vulnerable adults. EVIDENCE: Close working relationships, effective and ongoing communication and consultation with service users provide adequate opportunity for any concerns to be raised and discussed, before they become complaints. Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. For the benefit of service users living in the home, a simple illustrated complaints procedure has been developed, with the use of symbols. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 17 The Care Consultant confirmed that due to the variable levels of mental capacity among the service users, it is unclear, particularly in respect of one service user, as to their awareness or understanding of the process. It was noted that no complaints have been received by the home since the previous inspection. The organisation has produced detailed policies and procedures relating to adult protection and abuse, including a whistle blowing policy. The Care Consultant confirmed that staff have undertaken specific adult protection training, in accordance with the recently implemented multi agency guidelines for safeguarding vulnerable adults. This was supported through discussion with the Training Officer and a member of staff during the inspection and evidenced through individual training records. She also confirmed that staff are made aware of relevant policies and procedures relating to abuse and adult protection through their induction training. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and reasonably clean and remains suitable for its stated purpose. Service users benefit from pleasant accommodation that is comfortable, generally well maintained and furnished and decorated to a reasonable standard. EVIDENCE: It is evident that, with the exception of the kitchen, there has been little change in the physical environment at 24 Surrenden Road since the previous inspection and standards remain generally satisfactory throughout. The premises, including the lounge, conservatory, kitchen, dining area and large garden are accessible, safe and continue to meet their stated purpose. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 19 During my ‘guided tour’ of the premises, by one of the service users, it was evident that the reasonably well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. One service user, spoken with during the inspection, was clearly very happy with his new bedroom, which evidently had been redecorated and refurbished prior to him moving in: ‘I’m very pleased with my new room. It’s nice and big. I chose the colours and I did a lot of shopping for it’. Also since the previous inspection, as recommended, the kitchen has been redecorated and totally refurbished, with good quality replacement units, work surfaces, tiles and a new floor covering. However it was noted that a badly stained carpet in the dining area has not yet been replaced. Many radiators throughout the building have also been repainted or upgraded, and where necessary, following risk assessments, covers have been fitted. The Care Consultant confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. She also was able to confirm that, a walk in shower cubicle is shortly to be installed in one service user’s ground floor room, as he has mobility issues and is unable to safely manage the stairs to access the first floor bathroom. It was noted that infection control policies and procedures are in place and clearly adhered to. A daily cleaning rota is evidently in place for individual rooms, which staff are expected to sign off when the work is completed. Levels of cleanliness remain satisfactory throughout. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is not always sufficient trained and competent staff on duty to meet the assessed needs of the service users. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: As with other services in the group, and as previously documented, there are ongoing concerns regarding the minimal staffing levels currently operating within the home and the potential impact this has on the care and support of service users, as well as the inevitable affect on their social and recreational opportunities. It is on record that there is often only one member of staff on duty, both mornings and evenings, as well as at weekends. At peak times of the day, with the sole member of staff working closely with one service user with relatively high personal care needs, there is an inevitable impact on the level of care and support provided to the remaining service users in the home. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 21 The Care Consultant confirmed that, in line with other homes within the group, the matter is being addressed. Following a difficult and unsettling time, some welcome stability is now returning and additional staff are currently being recruited, through the organisation’s head office. The possible introduction of a second member of staff during the day at weekends, was discussed, to provide increased opportunities for social and recreational activities and more flexibility for individual outings. The situation when service users are out at college or day centres remains the same and the home is often left un-staffed during the day. However the Care Consultant described the ‘on call’ system that is in place, with staff from another home being available if needed between 9.00am and 5.00pm. Management level ‘on call’ cover is provided outside of ‘office hours’ and is detailed on the rota. In accordance with company policy, the Care Consultant confirmed that formal supervision is provided for all care staff on a regular basis. Staff recruitment records, although not held in the home, were made available at the head office. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. Their best interests are safeguarded by adequate quality monitoring systems. EVIDENCE: The experienced ‘unit manager’ has been in her current position since March 2006 and is registered with the CSCI. She is clearly competent to run the service and has achieved NVQ level 4, in Management and Care. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 23 The home continues to use a pictorial satisfaction feedback chart for service users to demonstrate how they are feeling about the service they receive. Since the previous inspection, as recommended, surveys for service users’ relatives and stakeholders in the community have been developed and implemented. Feedback from recent responses has been positive and indicates a generally high level of satisfaction with the home and the care and support services provided: ‘As always I think ………. is in very good hands. Many thanks.’ The Care Consultant confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. She added that training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. This was supported through discussions with the Training Officer and staff and evidenced in staff training records that were examined. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 (1) (a) Requirement It is required that sufficient qualified and competent care staff are on duty at all times to meet the assessed needs of service users. (Previous timescale of 30.11.2006 and 31.10.2007 not met.) Timescale for action 30/09/08 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 YA1 Good Practice Recommendations It is recommended that information made available to existing and prospective service users, including the Statement of Purpose and Service user Guide, be kept under review to ensure it accurately reflects the current situation within the home. It is recommended that the badly stained carpet in the dining area be replaced. 2. YA24 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 24 Surrenden Road DS0000014123.V366934.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!