Care Home: 39 Townend

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What the care home does well There are good procedures are in place for assessing the needs of a person prior to admission to the home. Care plans are in place for all individuals and these are regularly reviewed in consultation with the person and any other relevant person. Comprehensive risk assessments are also in place and agreed with the resident. The home promotes residents rights to choice and dignity, and friendships with family and friends are encouraged and maintained. Recruitment practices are robust and protect the residents. The management of the home offers the people who live at the service a safe and secure home in which they can live with dignity and respect. A health care professional stated that the registered manager is "quite remarkable" in ensuring the levels of care at Townend. What has improved since the last inspection? The home has met the requirements recommendations made by the Commission for Social Care Inspection in the previouse report dated 08/02/2007 to improve practice at the home. The manager and the staff group are constantly introducing new or alternative opportunities to the people who live in the home. The manager is continuing with an ongoing remedial maintance programme through out the home. What the care home could do better: No requirements were made during this site visit. CARE HOME ADULTS 18-65 Townend Townend 39 Townend Caterham Surrey CR3 5UJ Lead Inspector Kenneth Dunn Unannounced Inspection 24th January 2008 09:15 Townend DS0000013814.V356070.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 Townend DS0000013814.V356070.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. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Townend Address Townend 39 Townend Caterham Surrey CR3 5UJ 01883 383827 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) Surrey and Borders Partnership NHS Trust Mrs Tracy Tonczynski Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (4), Physical disability (1) of places Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2007 Brief Description of the Service: Townend is registered with the CSCI (Commission for Social Care Inspection) to provide accommodation and care for nine people with learning disabilities, the majority of whom are under the age of 65 years. Townend is a large detached family styled house is in a residential street in Caterham-on-the-Hill. The service is close to shops, public amenities and transport in addition the service has its own transport to enable the service users to enjoy a flexible service. The service users are supported to live as independently as possible with the help of staff and the wider network of community health care professionals. The accommodation is arranged over two floors of the house. On the ground floor two large communal lounges, assisted bathroom, toilet and 4 bedrooms. The first floor has 5 good-sized bedrooms and a further bathroom. There is a moderately sized garden at the rear of the property, and a limited amount of off street parking for cars at the front of the house. The service does not have a lift. The service is owned and operated by Surrey and Borders NHS Partnership. Current weekly fee charge £1,273.90. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. The registered manager represented the service. The inspector arrived at the service at 09.15 and was in the home for four and a half hours. It was a look at how well the home is doing. It took into account detailed information provided by the home’s manager, and any information that Commission for Social Care Inspection has received about the service since the last inspection. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the care/person centred plans, daily records and risk assessments, medication procedures, staff recruitment folders, staff training records, and health and safety records. The home has submitted the Annual Quality Assurance Assessment prior to the inspection, some details of which have been added to the report. The Commission for Social Care Inspection recived a total of twelve completed questionairs from Relatives, Carers and Advocates, Health Professionals, and Staff members. The Commission for Social Care Inspection has included information contained in the completed questionairs within the body of the report. No complainant has contacted the Commission for Social Care Inspection with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the residents in the home and the staff for their time, assistance and hospitality during this inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Townend DS0000013814.V356070.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 Townend DS0000013814.V356070.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): Standards 1 & 2 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of this serviced will benefit from quantity and quality of information about the home. The homes admission and assessment procedures ensure that the needs of the people who use this service are appropriately identified and met. EVIDENCE: The statement of purpose and the residents guide was well designed and informative. Prospective people who would like to live at the service would be able to make a clear and informed choice about the home from the description of the home and the ethos behind it. Both documents were last updated in January 2007. The inspector was advised that there have been no admissions to the home since the last inspection. The manager demonstrated the knowledge and ability to ensure that the homes admission and assessment procedure would be implemented for a person who wanted to move to the home to determine that the care home could meet the needs of the individual. Townend DS0000013814.V356070.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 were assessed during this visit. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use this service are provided with an individual care plan, which records their individual needs and goals. They are supported to make decisions about their lives with assistance. Individuals are fully supported by staff. EVIDENCE: A review of individual Person Centred Plans provided detailed information that the people how use this service are fully supported and enabled to have appropriate control over their lives. The manager and the key workers have compiled a detailed communication profile within the Person Centred Plan, which highlights individuals likes and dislikes, and the level of support required by each person. The individual needs and personal goals of the people who use this service were clearly recorded within their personal Person Centred Plans. The information provided has been developed in consultation with the person living in the home their families and other stake holders/professionals. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 10 A statement in one of the returned Health Professionals surveys outlined the individual approach to care offered at the service they described the home as offering a “beautifully tailored approach to care” and one particular action was described as “an example of excellent quality care”. The returned Annual Quality Assurance Assessment stated that “each individual and key worker were encouraged to be involved in formulating” their own Person Centred Plan, in addition the “documents are live documents and are reviewed at least 6 monthly or more as required”. Review meetings are regularly undertaken and actioned for all of the individuals living at the service. The Annual Quality Assurance Assessment stated that “Annually care management reviews have taken place, these are with a care manager, the individual and home staff. A review of needs takes place to ensure that the placement remains suitable for the individuals needs”. The manager stated that all the people who live at “Townend have communication difficulties” and “despite this all of them are able to let you know if they like or dislike something using there own methods of communication”. This information is fully and comprehensively documented within Person Centred Plans. Where necessary individuals also have guidelines for behavioural management and as required medication. The behavioural guidelines were drawn up with the support of a Psychologist. Each individual has risk assessments in place these are pertinent to their needs, they are read and signed by all staff to ensure continuity of care and to provide a safe environment. The Annual Quality Assurance Assessment states, “when risk assessments are put in place every effort is made to not restrict an individuals choice but to ensure they are safe”. Townend DS0000013814.V356070.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 were assessed during this visit. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use this service benefit from a range of appropriate activities and engage in a range of leisure activities. Individuals are supported to participate in the local community. The rights and responsibilities of the people who use this service are respected and advanced. Meals are well balanced and nutritious. EVIDENCE: The service offers the people who live there a wide range of activities. There is sufficient evidence within individual Person Centred Plan’s, that activities were tailored to suit individual needs and preferences. A detailed activity plan was available for each individual. The Annual Quality Assurance Assessment stated that “all individuals at the home attended a day centre where they participate in activities, they are asked if they wish to go if they decline this is respected, generally all like to attend”. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 12 A sample of daily notes demonstrated that individuals are encouraged to participate in at home activities. The manager stated that some like to help cooking, others take a more passive role but participate in cleaning their rooms by holding items and just generally watching. One person who lives at the service has a keen “interest in memorabilia of past years”, with Poppy day being one of his specific favourites. The service was able to arrange from him to visit a poppy making factory with the possibility of him being able to do voluntary work in the future if he was able to undertake the work. The people who use the service benefits from this use of an estate car and minibus, and relatively easy access to local buses and trains for outings and trips. The manager stated that “by using local facilities/venues we are offering individuals the opportunity to meet new people and make new friends”. There is well documented evidence that family members are always welcome, and that there are no restrictions on when people can visit the home and that everyone has his or her own rooms to entertain visitors. The homes policy is to ask all visitors to sign the visitors book and where appropreat to complete a Quality Assurance Questionnaires to support the home in improving the service they are currently offering. The Annual Quality Assurance Assessment states that the “home does not have any strict routines or restrictions on movement within the home unless it has an effect on safety of individuals or others within the home, if this was the case it would be covered by a risk assessment”. Staff endeavour to promote the independence of the people who use the service by offering them individual support in whatever they are doing. The ethos is to promote support rather than doing for somebody. The people who use the service are respected and the staff ensure that they are offered privacy treated with dignity when being supported in their personal care. The staff team were seen knocking on doors before entering rooms and respecting that individuals need their own space and time. Meal are offered three times a day with snacks in between. “Meal times are morning lunch and evening, the meal is offered at regular, although it was stated that this is not rigid, if individuals choose to eat then they do, if not they are offered something later” and a log is manitained to ensure that the person is safe. The menu plans are checked for nutritional value by the Trusts dietician the last check was completed in November 2007. The menues have been developed with nutrition, likes, and season in mind. The policy of the home is that if an individual dislikes what is offered an alternative is offered. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 13 The people who use the service are encouraged to assist in meal preparations and table laying. Townend DS0000013814.V356070.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): Standards 18,19 & 20 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that the people who use the service health care, wellbeing and welfare are fully supported. The homes medication procedures are robust to ensure the safety and wellbeing of the people living in the home. EVIDENCE: The care plans demonstrated that the personal support needs were well documented and had been agreed with the resident, families, advocate and care professionals. The manager stated that the time for getting up and going to bed in the home is flexible. A review of individual Person Centred Plan’s indicated that all residents are registered with a local general practitioner (GP). It was documented in the individual Person Centred Plan’s that the people who use the service have access to a dentist, chiropodist and optician. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 15 The manager informed the inspector that it is the “good observation of the staff that helps in the quick identification of the changing needs of the individuals, this enables us to request specialist in-put for their assessments”. All medication is stored in a locked cupboard and there is documentation to indicate that the medication is reviewed and audited regularly. The homes Medication administration practices were examined. Procedures were in place including a copy of the Royal Society Pharmaceutical Guidelines. Protocols were in place for service users receiving “As required” medication. Townend DS0000013814.V356070.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): Standards 22 & 23 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use this service benefit from the knowledge that any complaints or concerns will be listened to and they are protected from abuse. EVIDENCE: The complaint procedure had been produced in a pictorial format. There is a pictorial poster available to keep people aware of what is abuse and where and how it may occur. Records sampled indicated that there have been no complaints made since the last inspection. The Commission for Social Care Inspection have not been informed of any issue or complaint since the previous inspection visit 08/02/2007. There is a clearly written safeguarding adults procedure and a copy of the local authority safeguarding adults from abuse policy was available. The contact details for the local authority Social Care Team was also displayed. All staff have attended in the Safe guarding adults training. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the home enables the people who use the service to live in a safe environment. The home is clean, pleasant and hygienic throughout. EVIDENCE: The home has undertaken a series of upgrades and refurbisments the interior of the house has been decorated, bedrooms have had new curtains, bedding and decoration, a new kitchen has been fitted, laminate floor to dining room and kitchen, new carpets in hallways and lounge. The manager stated in the Annual Quality Assurance Assessment that the home was in the process of ordering a new assited bath for one of the ground floor bathrooms. The people who live at Townend have their own individual bedroom this was described as being “personal to them with there own possessions”. The service undertakes a three monthly audit of the home, this is carried out to ensure that the home continues to offer a safe environment. The manager Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 18 stated that the enviromental audit is undertaken “by a member of staff walking through the house and recording and acting upon what they see”. The home was clean and free of mal odours. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff group are skilled and in sufficient numbers to provide 24-hour care within the home. The systems for recruitment and training are designed to be robust and therefore should protect the people who use the service. EVIDENCE: Townend has 11 permanent staff all of who have a variety of skills and experience that is shared amongst the team. The manager stated that all staff at the home have undertaken a full induction programme and the records confirmed this. The manager provided copies of duty rotas to the inspector, which indicated that adequate staffing levels are maintained in the service. During the inspection the manager was working supernummary with three other members of staff on duty. Each member of staff has their own training record in place and it was evident that staff have received mandatory training in safeguarding adults, fire, food handling, food hygiene manual handling, health and safety, first aid and Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 20 managing medication. The service has two Qualified Deputy Managers in post they are both , Registered Mental Health Nurses and are qualified National Vocational Qualification Assessors. The manager stated that three Senior Support Workers have gained their National Vocational Qualification Level 2 in care and one further member of staff is awaiting a start date to comence their National Vocational Qualification. Four employment folders were sampled and contained all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. During the review of the staff files is was apparent that in three of the files there was gaps in the individuals educational and employment history. In all three case the staff member had been in post for some considerable time and there was evidence of some background checks being undertaken but these were not recorded within their files. A recommendation has been made to ensure that all relevant information regarding anomalies found on application forms is correctly recorded on the individual’s personal file. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 were assessed during this visit. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use the service benefit from a well run home and can be confident their views are taken into account. The health, safety and welfare of individual within the home are promoted and there are appropriate risk assessments in place. EVIDENCE: The registered manager is a qualified nurse in learning Disabilities and has worked within this area since 1981. The manager hold a National Vocational Qualification level 4 in Mangfement and is a qualified National Vocational Qualification Assessor. The manager has also gained a Registered Managers Award. The manager was described as being “open in her approach to the staff and the people who use the service” and that the manager has introduced systems to aid good communication within the home. “Staff and individuals in the Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 22 home are encouraged to voice their opinions” and manager stated “I aim to make myself available to listen”. A statement in one of the returned Health Professionals surveys that the in their opinion the registered manager is “quite remarkable” in ensuring the levels of care at Townend. The manager stated in the completed Annual Quality Assurance Assessment that “The home management encompasses the principles of the Social Care Code of conduct, treating people as individuals, respecting and promoting views of individuals, acknowledge rights and choice, respect privacy and dignity, promote equal opportunities and to respect diversity and different cultures”. A random review of documents upheld this statement. The home has conducted a Quality Assurance a questionnaire was offered to visitors, the people who live at the home and relatives. The manager stated that, “this information aids us in improving our service” and that “individuals in the home are supported to express their views, to the best of their ability on an every day basis, during care reviews, service user meetings, health action and person centred planning. Relatives and friends are encouraged to also be involved for those who are not able to communicate their needs”. A sample of the returned questionnaires clearly demonstrated that comments are welcomed and where they could benefit the home and the people who use the service they are introduced. The service holds monthly meetings for the people who live there and the minutes are documented and action plans drawn up if necessary. Regulation 26 visits take place every month by the Responsible Individual and these are saved in the home and available during inspection. The health and welfare of the people who live and work in the home are seen is a priority in the service and records observed on the day of the inspection were found to be well documented and kept up to date. This included certificates for the testing of Legionella, electrical, fire prevention records, fridge and water temperatures. The Annual Quality Assurance Assessment demonstrated the health and safety checks had taken place also. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA1 YA34 Good Practice Recommendations The registered person should ensure that the statement of purpose and the residents guide are audited and regularly reviewed. The registered person should ensure that where gaps and omissions on staff application forms have been discussed a record should be kept to safeguard the people who use the service. Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Close Hermitage Lane Maidstone, Kent 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 Townend DS0000013814.V356070.R01.S.doc Version 5.2 Page 26 - 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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