Care Home: Samuel Close (1, 2 & 3)

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What the care home does well Residents are only admitted to the home following a comprehensive assessment of their needs. Staff ensure that a detailed risk assessment is in place for each resident to promote independence and safety. Staff support residents to participate in a range of social and recreational activities in the local community. Residents are provided with a varied nutritious diet. Staff ensure residents have access to appropriate health care professionals. Residents and their advocates are provided with clear information regarding the organisations complaints procedure. What has improved since the last inspection? The home continues to benefit from the programme of refurbishment and redecoration. A requirement made stating the provider must provide written information regarding the circumstances under which service users are expected to purchase standard furnishings for their bedroom. This has been addressed in the organisations new contract. It was evident that staff have worked hard to improve the standard and quality of care plans since the last inspection. Since the last inspection the manager has introduced a "tracking record" which highlights the range of activities residents have participated in.Since the last inspection the provider has updated their Protecting Vulnerable Adults Policy. Since the last inspection the provider has undertaken a recruitment drive and this has resulted in staff vacancies being filled. CARE HOME ADULTS 18-65 Samuel Close (1, 2 & 3) Samuel St Woolwich London SE18 5LR Lead Inspector Lorraine Pumford Key Unannounced Inspection 28th September 2007 11.00a Samuel Close (1, 2 & 3) DS0000006770.V346398.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 Samuel Close (1, 2 & 3) DS0000006770.V346398.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. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Samuel Close (1, 2 & 3) Address Samuel St Woolwich London SE18 5LR 020 8855 0332 020 8855 6261 staff@milbury4.freeserve.co.uk londonroad@tiscali.co.uk Milbury Care Services Ltd 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) Mr Jimmy Lendor Care Home 17 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (1) of places Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2006 Brief Description of the Service: Numbers 1, 2 and 3 Samuel Close are three bungalows situated in a residential close in Woolwich. Each house provides board and nursing care for between five and seven adults with learning disabilities. The three houses provide services for different needs. House one is for people with learning disabilities who have challenging behaviour, house two for people with physical disabilities as well as learning disabilities and house 3 for people with learning disabilities who may also have other needs. Each house functions as a distinct group with its own front door, house leader, staff group, and communal facilities. Service users in each house eat together and share a communal lounge. There is an overall registered manager for the three houses. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over two afternoons and early evenings. During that time the residents, manager and staff were spoken with. Records pertaining to three residents were examined in relation to their health, care and activities and a number of the providers policies and procedures were reviewed. A tour of houses one and two was also undertaken. The fees at the time of the visit £1,245.55p What the service does well: What has improved since the last inspection? The home continues to benefit from the programme of refurbishment and redecoration. A requirement made stating the provider must provide written information regarding the circumstances under which service users are expected to purchase standard furnishings for their bedroom. This has been addressed in the organisations new contract. It was evident that staff have worked hard to improve the standard and quality of care plans since the last inspection. Since the last inspection the manager has introduced a tracking record which highlights the range of activities residents have participated in. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 6 Since the last inspection the provider has updated their Protecting Vulnerable Adults Policy. Since the last inspection the provider has undertaken a recruitment drive and this has resulted in staff vacancies being filled. 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. Samuel Close (1, 2 & 3) DS0000006770.V346398.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 Samuel Close (1, 2 & 3) DS0000006770.V346398.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): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider has systems in place to ensure that prospective residents have a comprehensive assessment regarding their health and care needs prior to admission. Residents and their advocates are provided with a contract highlighting both partys rights and responsibilities. EVIDENCE: The manager stated that the resident group has remained the same since the last inspection and their have been no new admissions to the home however in the event of the new resident being admitted the provider has a comprehensive assessment procedure both relevant social and health care professionals would be included in the process. A requirement was made at the time of the last inspection stating that the provider must detail in the homes Statement of Purpose circumstances under which service users are expected to purchase standard furnishings for their bedrooms. The manager stated that this issue had been addressed in the organisations new contract. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 9 This states Your room is a single/double/en-suite furnished room. include: A bed A Wardrobe A Chair A Table Lamp/wall light Bed Linen (1 Full set) Towels (1 Bath, 1 Hand, 1 Face Cloth). [delete as appropriate] This will Any replacements or / additions to the above list is your responsibility. Therefore this requirement has been met. However from discussion with the manager it is apparent that none of the residents residing in Samuel close are able to make decisions about purchasing the above items for themselves. Decisions about purchasing furniture and furnishings are made by staff members and the provider should look at this issue taking into account their responsibility to the residents under the Mental Capacity Act 2005 and where neccary advocates should be sought to act on behalf of residents. Samuel Close (1, 2 & 3) DS0000006770.V346398.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. Detailed care plans enable staff to provide the care residents have been assessed as requiring. Risk assessments promote independence and safety. EVIDENCE: It was apparent that staff have worked hard to improve the standard and quality of care plans since the last inspection. A sample of two care plans in house one and two were examined. All care plans were found to be comprehensive and provided clear guidance for staff on how to meet the assessed needs of residents. The majority of residents are unable to verbally express their views and feelings staff have recorded residents actions, expressions and demeanour to help new staff understand what residents are trying to communicate to them. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 11 Much of the care plan is in a pictorial format to enable those residents who are able to understand what is recorded about them. Staff record information regarding residents health, activities and demeanour in individual daily logs, records seen were comprehensive and it was possible to attain a clear picture of residents routines health and well-being from the documents seen. Risk assessments were seen to be in place, which promote independence and safety; for example, these had been completed for residents in relation to use of equipment in the home and transport and activities outside of the home. Staff stated that a key worker system operates. Staff spoken with were able to provide very clear evidence of the way in which they both support and promote residents independence on a daily basis. There was evidence that care plans are reviewed on a regular basis and include the resident, their advocate and relevant health and social care professionals. It was evident that staff endeavour to promote residents individual choice and decision-making for example staff were seen to offer residents a choice of refreshments, whether they preferred the TV or radio on and if they wanted to be in the lounge or bedroom when they returned home from day centres. Staff stated that all residents residing in the home needed some support in managing their finances and personal allowance. Residents benefits are paid directly into individual named personal accounts. Residents personal allowances are held in individually in named envelopes, the sample examined indicated that residents personal allowance tallied with the house records. The provider ensures regular audits of the system take place. Samuel Close (1, 2 & 3) DS0000006770.V346398.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a varied nutritious diet and provided with opportunities to participate in appropriate meaningful activities. EVIDENCE: None of the current resident group are able to participate in employment or formal education, however all attend day centres on a regular basis. A requirement was made at the time of the last inspection that the provider must be able to provide written evidence that appropriate social activities are arranged for residents. Since then the manager has introduced a tracking record which highlights the range of activities residents have participated in. Documentation seen indicates that residents are provided with appropriate activities. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 13 Residents benefit from the home having its own transport which enables them to access community resources and local events. The manager stated that staff were planning to increase residents opportunities to participate in local community activities over forthcoming months. From discussion with staff and record seen is apparent that residents are enabled to maintain links with relatives. Residents who are able are free to move around the bungalow as they wish and also visit residents living in other bungalows on site. On both occasions staff were preparing and cooking the evening meal for residents. This was served appropriately for each resident depending on their needs and ability. A number of residents require assistance from staff with eating and staff provided help in a calm unrushed manner. Samuel Close (1, 2 & 3) DS0000006770.V346398.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. Residents receive good health care support. Sound medication procedures protect the health and safety of residents and staff. EVIDENCE: The storage, recording and administration of medication were examined in detail for four residents and no errors were found. Medication is stored in a locked cupboard. A record is kept of all medication brought into the home and taken from the home for safe disposal. It was good to see that staff have already developed protocols for the administration of medication to people who are unable to verbally express they are in pain in order to comply with new Royal Society Pharmaceutical guidelines. The manager was also advised to introduce a medicine profile for each resident with evidence of regular medicine reviews are taken place. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 15 Discussion also took place regarding the need for staff responsible for medicine management to be reassessed annually as competent to do so. Records seen indicated that residents receive appropriate health care when required. Staff have established links with the local Community Learning Disability Team, the local Speech and Language Therapists and Occupational Therapists who support them to meet the needs of the residents. Good interaction was seen between staff and residents. People requiring help with personal care were seen to be assisted by staff in a calm and appropriate manner. All residents were wearing clean appropriate clothing. It was apparent that staff support residents to attain an individual and personal identity. Residents appeared relaxed and comfortable in their surroundings. Samuel Close (1, 2 & 3) DS0000006770.V346398.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. Residents are protected by the organisations Safeguarding Adults Policy and training. There is a comprehensive complaints procedure in place. EVIDENCE: The provider has a clear complaints procedure which is in a user-friendly format for residents. In addition the manager keeps a record of any complaint or concern made and the action taken to address the issue. Since the last inspection there has been one complaint regarding the heating and action was taken to address this within the providers timeframe for response. To date the CSCI has received no complaints with regard to the service. Since the last inspection the provider has updated their Protecting Vulnerable Adults Policy. Staff spoken with stated they had received training regarding this and whistleblowing as part of their NVQ training and additionally have attended training courses arranged by the provider. Staff spoken with had a clear understanding of the term whistleblowing and stated they would raise any concerns they may have with the manager or senior staff in the home. There is also a notice regarding the procedure displayed in the office. Since the last inspection the manager has reported one incident in accordance with the local authority Adult Protection Procedure which was investigated by them and found to be unsubstantiated. Samuel Close (1, 2 & 3) DS0000006770.V346398.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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean, comfortable and well maintained environment. EVIDENCE: A tour of houses one and two was undertaken, both houses were clean and comfortably and appropriately furnished. At the time of the last inspection there was an outstanding requirement regarding the need for the paved area to the rear of the houses to be levelled to ensure the safety of residents. Action has now been taken to address this. However on the day of this visit the cover to the top of the soak away was missing and this needs to be replaced. The manager stated that he would ask the member of staff responsible for maintenance to replace it as soon as possible. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 18 At the time of the last inspection house three was experiencing problems with heating and water supply and the requirement was made regarding the need to ensure that a supply of hot water was available to prevent the spread of infection. The manager stated that remedial work was undertaken at the time and there have been no further problems in this area. A requirement was made regarding the need for risk assessments to be implemented regarding the use of additional electrical heaters which had been purchased. Record seen indicated that action has been taken to address this issue and additional radiators have been installed in the hallways to house two and three. A recommendation was made at the time of the last inspection regarding the need to replace the fridge seals in house three which had perished and staff stated that these had been replaced. In general all three bungalows continued to benefit from the ongoing refurbishment and redecoration programme. A number of bedrooms in house one have been repainted and appear much more cheerful. However the environment could be improved further by cutting back shrubs growing over bedroom windows to the rear of the building making these rooms particularly dark. The manager has identified further areas for improvement and action will be taken to address these over the forthcoming months. Residents bedrooms are individually personalised, however a number seen were smaller than the current minimum room size requirement and it is not possible to equip all bedrooms to comply with the National Minimum Standard. Staff stated this continues to be a problem when trying to provide personal care to some residents. Staff stated that the laundry equipment was fully functional and the machines provided meet the current needs of the residents accommodated. Samuel Close (1, 2 & 3) DS0000006770.V346398.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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are cared for by appropriately qualified staff. The provider must be able to provide evidence that sound recruitment procedures have been followed to protect people living in the home. EVIDENCE: A requirement was made at the time of the last inspection regarding the need for staffing levels to be revived to reflect the increasing needs of the residents accommodated and to enable adequate staffing levels to support residents to participate in more activities in the community. The manager stated that since the last inspection the provider has undertaken a recruitment drive and this has resulted in staff vacancies being filled. In addition there is a dedicated bank of staff that works specifically to Samuel close. Files were examined in relation to four members of staff. It was good to see the records were kept of each persons interview with part of the process Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 20 written to enable the interviewers to assess the individuals written and numeracy skills. Staff have been provided with a job description and a contract of employment. A requirement was made at the time of the last inspection regarding the need for the provider to provide written evidence that staff working in the home have completed a satisfactory POVA check as part of the recruitment process. Since then there has been an agreement between the provider and the CSCI that a record will be kept in the home confirming that the provider has undertaking appropriate employment checks in relation to the recruitment of new staff. However the template had not yet been introduced into the home and it remained impossible to clarify that POVA checks had been undertaken. In addition one file did not contain a photograph of the member of staff working in the home. Staff spoken with stated they had undertaken a period of induction when they commenced employment with the provider. The manager stated that the provider had invested in Elbox which provides induction for staff in an interactive computer format. Staff have to work their way through the system and progress is monitored and assessed on a regular basis before they are deemed to be competent to perform a task. Samuel close is registered to provide nursing care and there is always an appropriately qualified nurse in charge in each of the houses. In addition over 50 of the care staff hold a minimum of an NVQ 2 qualification in care. Two members of staff spoken with stated that they had been given the opportunity of applying for an NVQ 3 in the near future. Staff spoke highly of the provider in terms of training and felt they were provided with appropriate training opportunities to meet the needs of the residents accommodated. Staff stated that in addition to mandatory statutory training they had been provided with training regarding the additional needs of residents, for example in relation to understanding epilepsy and communicating with residents who have limited verbal ability. Staff spoken with stated they receive regular supervision to monitor their practice and training and development needs. Samuel Close (1, 2 & 3) DS0000006770.V346398.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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Regular safety and maintenance checks are carried out to ensure residents and staff are in a safe environment. There are sound quality assurance mechanisms in place that seek to monitor and improve the service. EVIDENCE: The manager holds a relevant qualification in care and management and has considerable experience of working with adults with a learning disability. It was good to see the manager works regular shifts outside office hours which enables him to monitor the care and service provided by care staff working in the home seven days a week. Staff spoken with stated they had received moving and handling training, first aid and health and safety training. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 22 Record seen indicate that regular maintenance and safety checks are undertaken to equipment such as hoists being used in the home. The Operations Manager visits the home regularly and undertakes a monthly audit on behalf of the registered provider in accordance with regulation 26 of the Care Standards Act 2000. A copy of this report is forwarded to the CSCI. Records seen indicate that there are regular checks to the fire detection system within the home and staff are provided with regular fire safety training. The record regarding fire drills was examined and the manager was advised to indicate the time the drill took place to indicate that all staff including those working nights have been included in this training. Samuel Close (1, 2 & 3) DS0000006770.V346398.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 X 2 3 3 X 4 X 5 3 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 2 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 X 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 Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19(4) Requirement The responsible individual must be able to provide written evidence that staff working in the home have had a satisfactory POVA check completed as part of the recruitment process. Timescale 30/03/07 not met The responsible individual must ensure that the recruitment procedure includes obtaining a photograph of the employee, which is kept in the home and available for inspection. Timescale for action 04/01/08 2 YA34 19(4) 04/01/08 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 2 Refer to Standard YA7 YA20 Good Practice Recommendations Advocates should be sought for residents who are unable to make decisions for themselves. Staff are advised to maintain a medication profile for each resident and ensure that staff responsible for administering medication are reassessed as competent to perform the DS0000006770.V346398.R01.S.doc Version 5.2 Page 25 Samuel Close (1, 2 & 3) task on an annual basis. 3 4 YA24 YA42 The overgrown shrubs to the rear of house one restricts the natural light to the bedrooms and action should be taken to address this. The manager was advised to record the time fire drills take place to evidence that all staff including night staff are involved in this training process. Samuel Close (1, 2 & 3) DS0000006770.V346398.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Samuel Close (1, 2 & 3) DS0000006770.V346398.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. 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