Care Home: Kimberley Road (44)

What the care home does well There is currently only one staff member {the deputy manager} and also the manager at this home. As the staff member has a NVQ4 this currently exceeds the 50% of staff required to have a NVQ2 2 in percentage and level. The staff qualification standard is therefore currently exceeded. This is a small home {a maximum of 3 service users}, which allows the staff and service users to know each other well and provides consistency of staffing for the service user. One resident present said they were very happy here, and has said this on a number of occasions. What has improved since the last inspection? The statement of purpose now clearly specifies the levels of supervision required for residents. This was needed as 24 hour care is not currently provided by this home and including this information in the statement of purpose informs potential new residents and placing care managers of the level of support to expect in this service. Care plans now contain a reference to cultural and religious needs. This ensures that these needs are known and given equal value to other needs in the care plan. Criminal Record Bureau checks are now specific to the setting. This ensures that the right vetting checks are carried out on staff. Copies of two forms of photographic identification are now on staff files to confirm their identity. The registered manager has now completed the NVQ Level 4 in Management and Care. This ensures that a suitably qualified manager is employed at this home. The portable appliance testing results are now available for inspection. This improves the safety of electrical appliances and devises. CARE HOME ADULTS 18-65 Kimberley Road (44) 44 Kimberley Road Croydon Surrey CR0 2PU Lead Inspector Barry Khabbazi Unannounced Inspection 7th July 2008 9:00 Kimberley Road (44) DS0000028141.V366974.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 Kimberley Road (44) DS0000028141.V366974.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. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kimberley Road (44) Address 44 Kimberley Road Croydon Surrey CR0 2PU 020 8684 4188 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) kgoolaub@yahoo.co.uk Mrs Kavita Goolaub Mrs Kavita Goolaub Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 1st May 2007 Date of last inspection Brief Description of the Service: Kimberley Road is a 3 bedded home for adults with a past or present mental illness. It is situated in a residential area, well placed for travel into the centre of Croydon with its wide selection of community facilities. The house forms part of a terrace, and is indistinguishable from any other house in the road. The home is not adapted for and is not suitable for people with physical impairments significantly affecting mobility. The stated philosophy of the home is to ‘provide a secure, stable and comfortable environment where individuality of care and maintenance of dignity is paramount’. The homes Statement of Purpose currently states that the service users can be left unsupervised in the home if agreed as appropriate with the care manager. This means that 24 hour supervision is currently not provided by this service. Fees for placements currently range from £500 to £600 per week. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating of the service is 2 star. This means the people who use this service generally experience Good outcomes. As this home was previously a 1 star home the inspection was brought forwards. The manager’s latest self-assessment {AQAA} had therefore only just been received by the manager and so was not ready to be used to support findings in this inspection. This self-assessment will however be included in the next inspection report. The key Standards identified throughout this report were assessed at this inspection. At this inspection we also focused on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. At the time of this inspection there were two out of a possible three people residing at this home. During this inspection the provider was interviewed. Records, policies and care plans and the building were examined. The people who use this service refer to themselves as residents. The residents told us about recent community activities and that they were considering attending church in the near future. One resident said they liked the food. Staff were seen to be supportive and responsive to residents’ needs. No areas of serious concern were identified at this inspection. What the service does well: There is currently only one staff member {the deputy manager} and also the manager at this home. As the staff member has a NVQ4 this currently exceeds the 50 of staff required to have a NVQ2 2 in percentage and level. The staff qualification standard is therefore currently exceeded. This is a small home {a maximum of 3 service users}, which allows the staff and service users to know each other well and provides consistency of staffing for the service user. One resident present said they were very happy here, and has said this on a number of occasions. Kimberley Road (44) DS0000028141.V366974.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. Kimberley Road (44) DS0000028141.V366974.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 Kimberley Road (44) DS0000028141.V366974.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): Standard 1 and 2: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Prospective residents and placing authorities are provided with the information they need to make an informed decision about whether this home can meet their needs. Prospective residents’ aspirations and needs are assessed before admission to ensure that the home knows these needs so that they can be met. EVIDENCE: One placing authority raised with us that the home’s level of supervision of residents was not clear. To address this the last inspection report contained the following requirement: The statement of purpose must specify the levels of supervision of service users provided by this home clearly. This had been updated by the time of this inspection and the fact that the home does not provide 24 supervision of the residents if agreed with the care manager was clarified to read The statement of purpose now clarifies that the home does not provide 24 hour supervision with respect to agreement with the care manager. The statement of purpose now clearly specifies the levels of supervision required for residents This requirement is therefore currently met. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 9 The last inspection report contained the following requirement: The home must not accept any placement without a copy of the assessment, care plan, and contract. The resident concerned has since left and this information was available for the remaining two residents. This requirement is therefore also currently met. There had been no new residents placed since the last inspection. Kimberley Road (44) DS0000028141.V366974.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): Standards: 6, 7, and, 9. People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs, and how the home meets these needs are all fully recorded but changing needs are not always recorded. This could affect the home’s ability to meet and show how it has met all a resident’s changing needs. Residents make decisions about their lives with support where needed. The residents are safely supported to take risks as a part of independent living. EVIDENCE: Files were sampled and care plans were available for all residents. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 11 These had improved greatly and reflect all the elements required. Internal reviews were examined and found to be occuring at least 6- monthly for those under 65, and monthly for those over 65 years old. However, one newly identified need to support a resident to make culturally appropriate food as a part of independent living training had not been carried over to the care plan. The following new requirement is now set to address this shortfall: When a review occurs the care plan must be updated with the changes identified in the review. In this instance the need for support to prepare cultural meals. This is needed to ensure that changing needs are known to all staff. The residents are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through regular house meetings and individual discussions with their key workers. The current residents make their needs and wishes known, and they are encouraged to make their own decisions about their day-to-day activities, and their lives in general. This is regularly demonstrated in discussions with resident who regularly raises a number of these issues during conversations. Resident’s have been consistent in describing how satisfied they are with the placement – there was nothing they would like to change, they said they were happy at this home on a number of occasions and said there was nothing else they needed. All residents look after their own financial affairs. Advocacy information is available in the home. All residents have a range of external professionals from whom they can gain support. Residents are supported to make and maintain appropriate relationships. Risk is assessed prior to admission and continually updated. There are currently no restrictions of liberty practiced which are required for the protection of the residents. The manager is aware that { if necessary} choices should only limited through involving the resident and always through a risk assessment process and recorded in the resident’s file. The registered manager has completed risk assessments including an assessment of risk to residents while outside the home as required in previous inspections. The current risks are assessed to be low. Discussion with the Registered Provider evidenced that she is well versed in the process for monitoring residents and of further engaging them with services should they become unwell. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 12 Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 13 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, and 17. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents are part of the local community and are able to take part in appropriate activities to facilitate a fulfilling life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised. The daily routines and house rules promote residents’ rights, to ensure equality and that all rights are enjoyed by all residents. Residents are encouraged to have a healthy diet and support is provided where required. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 14 EVIDENCE: The residents access the community independently and engage in activities of their choice. Where required residents are supported to attend community activities that they have shown an interest in. Information about local community resources is available and known to the home. residents have told us that they attend clubs, and have the opportunity to participate in activities of their choosing. Resident’s had attended evening classes previously. They were also positive about the choice of activities that were available. One resident has talked about going out to the theatre, meals out, clubs, and using the library. Examination of care plans showed that the other resident also had access to activities. Residents are supported to attend cultural or religious events when wanted. Residents are well supported to maintain contact with friends and family and have had a wide range of friends and family who have been made welcome in the home. One previous resident had a boyfriend with whom they regularly visited. No restrictions on having visitors were noted during the inspection. The daily routines do promote independence. All residents are offered keys to the front door and their rooms. Residents can choose when to be alone or when to be in company. The residents have full unrestricted access to all communal parts of the home. Independence skills are promoted as a part of the care plan where required. A joint decision between the resident and staff resulted in the home being a smoke free zone. One resident smokes, and is happy to go outside to a covered area for this purpose. The menu of the home was available for inspection and is recorded along with a record of food actually consumed. The residents are consulted as to their meal preferences and while a menu is drawn up it may frequently change. The residents have confirmed this, and said they still liked the food at the home. A wide range of food is offered, this is usually a cooked lunch with a lighter meal for the evening. Residents are supported to prepare one meal a day as a part of their independence programme. Where required support from dieticians was seen to have been sought by the home. A range of fresh fruit is also available. The home monitors weight as needed. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 15 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, and 20. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents’ personal support needs and emotional health needs are generally met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents currently self medicate with support from staff to ensure maximised good health. EVIDENCE: There are no residents currently requiring aids and adaptations although this need continues to be monitored. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 16 Inspection of the residents’ files confirmed that all are registered with a G.P. and all have been supported to gain access to NHS resources as required. Regular health checks are also offered and specific referrals are made when identified as needed. Residents attend their health appointments independently and manage their own medication. The Registered Provider maintains a list of all current medication. All residents have their own keys to their bedrooms so that they can keep their medication safely. A British National Formulary is available for guidance for staff. All staff who administer medication have had accredited training and additional in-house training. In addition, the manager is a registered nurse. Appropriate records are kept of medication. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 17 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, and 23. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well so that service users feel their views are listened to and acted upon where appropriate. The home’s policies and procedures relevant to this Standard generally facilitate protecting residents from abuse, neglect and self harm. EVIDENCE: No complaints have been made since the previous inspection. Discussion with the residents confirmed that they are familiar with how to make a complaint. The home has a complaints procedure in place, which clearly states how complaints will be investigated, recorded and redressed. This procedure contained all the elements required, including a 28 day response time and details of how to contact the Commission. Records are kept of all complaints. The home has all the required protection policies. The home has a copy of Croydon’s Vulnerable Adults Policy. Training in adult protection facilitated by Croydon Council has occurred and an appropriate in house policy has been written. The home has a Whistle Blowing Policy, a Gifts Policy and the Wills Policy does preclude staff from being involved in the making of, or benefiting from residents’ wills. Kimberley Road (44) DS0000028141.V366974.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): Standards; 24, and 30. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The environment is homely, comfortable and generally safe, and the environment does promote the residents’ well being. The home is generally hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: Kimberley Road is situated in a residential area, well placed for travel into the centre of Croydon with its wide selection of community facilities. The house forms part of a terrace, and is indistinguishable from any other house in the road. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 19 One resident said that the extension to the lounge was the area he preferred to frequent, other than when they are spending time relaxing in his room. This area has been seen to be frequently used by residents. The home’s premises are accessible to the current residents, in keeping with the local community, and are suitable for their purpose. The premises were generally well maintained. Records are maintained of all decoration and renewal. There was suitable domestic lighting and ventilation. At the time of the inspection the premises were furnished in an appropriate style. The building was clean and tidy and was free of offensive odours. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Laundry facilities have easily cleanable floors and easily cleanable walls. Kimberley Road (44) DS0000028141.V366974.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): Standards; 32, 34, and 35. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The residents are supported by a staff group where 50 or more have the required qualifications. This raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures are generally good but need to be tightened up to better protect the residents. To put this in context there are currently no staff employed at this home and shortfalls identified refer to a member of staff that will not be used until or if there is another placement made. Staff receive induction and foundation training to ensure that they are appropriately trained. EVIDENCE: There is currently only one staff member {the deputy manager} and also the manager at this home. As the staff member has a NVQ4 this currently exceeds the 50 of staff required to have a NVQ2 2 in percentage and level. The staff qualification standard is therefore currently exceeded. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 21 The last inspection report contained the following requirement: Criminal Record Bureau checks must be specific to the setting to be valid. This had been acquired for the staff member concerned and this requirement is now met. It is noted that this staff member is currently not working at the home. The last inspection report also contained the following requirement: Copies of two forms of preferably photographic identification must be on staff files to confirm their identity. This had also been acquired for the staff member concerned and this requirement is now met. It is noted that this staff member is currently not working at the home. One new shortfall was identified in the recrutment procedures. For the same staff member, application forms were not kept on file. As this member of staff is currently not working at the home, to be proportional, a requirement will not be made at this time. However, as the member of staff may be used in the future the following recommendation will be set: Application forms should be kept on file so. {This instance referred to a member of staff that is not currently working at the home and so a recommendation only is currently set}. Previous inspections have shown that staff receive induction and foundation training to national training organisation’s specifications and targets to ensure that they are appropriately trained. Kimberley Road (44) DS0000028141.V366974.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): Standards; 37, 39, and 42. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well run home with a manager who has the required qualifications. The home’s quality assurance system involves the residents, and provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. The home promotes the health and safety of the residents. Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 23 EVIDENCE: There was a clear line of accountability within the home and the owner/manager has demonstrated a good knowledge of residents. The owner/manager has managed this home since 2000. She is a Registered Nurse. The last inspection report recorded the following requirement: The registered manager should complete the NVQ Level 4 in Management and Care to ensure that a suitably qualified manager is employed at this home. This has now occurred and in addition the deputy manager also has this qualification. The home’s quality assurance system involves the residents, and provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. All of the health and safety policies and procedures relevant to this Standard were seen to be present. Control Of Substances Hazardous to Health policies are in place and these substances were all locked away. Risk assessments covering safe working practices were present. All of the procedures and testing of systems required in Standard 42 were also present, including portable appliance testing results, gas testing and the bacterial analysis results for the water supply. The last inspection report recorded the following requirement: The portable appliance testing results must be sent into the Commission. This has occurred and this requirement is met. Kimberley Road (44) DS0000028141.V366974.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 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 4 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement When a review occurs the care plan must be updated with the changes identified in the review. In this instance the need for support to prepare cultural meals. This is needed to ensure that changing needs are known to all staff. Timescale for action 08/08/08 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 YA34 Good Practice Recommendations Application forms should be kept on file. {This instance referred to a member of staff that is not currently working at the home and so a recommendation only is currently set} Kimberley Road (44) DS0000028141.V366974.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Kimberley Road (44) DS0000028141.V366974.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. 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