Care Home: The Village (58)

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What the care home does well The staff team made efforts to make the environment as homely as possible for residents. Attention was given to meeting resident`s individual needs and to provide residents with leisure and social activities. Residents were well cared for and no complaints were made about the service to the home or the Commission since the last inspection. Relatives were satisfied with the quality of care provided. The home had a fairly stable staff team. What has improved since the last inspection? Improvements had been made to food storage. The manager had discussed the use of homely remedies with the GP. All windows checked above the ground floor had restricted openings. Two male carers were employed which gave residents a choice of being cared for by a male or female carer. There has been a period of stable management. What the care home could do better: The registered person must ensure they comply with requirements included in inspection reports or advise the Commission why this has not been done. A number of requirements have been repeated in this report for the registered person to address. The registered person must address the requirements in relation to medicine management, the environment, compliance with regulation 26 visits and provision of a quality assurance review system. The registered person must ensure records such as staff rotas, staff training records and care documentation are kept as required by regulation and are up to date. The manager must apply to register with the Commission as soon as she receives her CRB check. The Commission will monitor compliance with requirements. CARE HOME ADULTS 18-65 The Village (58) 58 The Village Charlton London SE7 8UD Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 26th May 2006 09:55 The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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 The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Village (58) Address 58 The Village Charlton London SE7 8UD 0208 854 8888 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) Greenwich Council Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: The Village is a detached Victorian house situated in a residential area close to Charlton village and the main centres of Woolwich and Greenwich. The home is part of a group of homes providing care for six residents with learning disability. The London Borough of Greenwich Social Services Department provides the care and the property is owned and maintained by Hyde Housing. The home has six single bedrooms for service users and the accommodation is arranged over three floors. A lift provides access between the ground and first floor and stairs between the first and second floor. One bedroom is located on the ground floor, which is wheelchair accessible. This bedroom has an ensuite shower and toilet and the room is suitable for a resident with a physical or mobility disability or is a designated wheelchair user. On the ground floor there is a communal dining room, a kitchen, a lounge and a laundry room. Toilets and bathing facilities are provided on all floors and all bedrooms have wash hand basins. There are garden areas to the rear and side of the house, which is wheelchair accessible, includes a large patio area and a small lawn. The garden area is attractive and secluded and is much enjoyed by the residents when weather permits. The residents pay towards food and the running of the mini bus and for all personal expenses. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 26th May 2006 over 7.5 hours. The manager participated with the inspection from late morning. All residents were out at their various activities at the start of the inspection and five residents were seen later when they returned to the home. The service was last inspected on the 28th October 2005. The inspection included a review of information held on the service file, a tour of the premises, inspection of records, talking to residents and the staff team and reviewing compliance with previous requirements. Following the inspection contact was made with relatives and other interested parties to get their views of the service. Feedback obtained from five relatives was generally positive. From the evidence provided a number of areas needed improvement. These included the environment, record keeping and quality assurance. A number of requirements made at the last inspection had not been met. However there was evidence to show that residents received the care they required. Relatives were generally satisfied with the care provided and the way staff involved them in the lives of the residents. The inspector spoke to the responsible individual following the inspection to discuss issues identified from the inspection. These included the environment, the need to have a registered manager and the lack of regulation 26 reports and a quality assurance system. She agreed to forward information to the Commission about the maintenance issues in relation to the property, to arrange for the manager to apply for registration with the Commission and to address the quality assurance issues. Improvements were needed to this service to ensure compliance with standards and regulations. What the service does well: What has improved since the last inspection? Improvements had been made to food storage. The manager had discussed the use of homely remedies with the GP. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 6 All windows checked above the ground floor had restricted openings. Two male carers were employed which gave residents a choice of being cared for by a male or female carer. There has been a period of stable management. 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 Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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 The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. No new residents had been admitted since the last inspection however systems were in place to ensure admissions were made in line with standards and regulation. EVIDENCE: No new residents had been admitted since the last inspection. A statement of purpose, service user guide and an admission procedure were provided and the manager was aware of the need to comply with this standard and its supporting regulation. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Individual care plans seen showed how assessed needs were to be met and how risks identified were to be managed. However staff must sign and date care documents to show that these are being reviewed in line with regulation. EVIDENCE: Three care plans were inspected. These included risk assessments and care plans to show how needs were to be met. None of the residents had the ability to be involved with care planning. Relatives contacted said that staff did discuss resident needs with them and most were satisfied with the way residents were cared for. One resident had a ‘befriender’ as they did not have any next of kin. This person was also contacted and was generally happy with how the resident’s needs were met. The befriender did not attend life plan meetings but received copies of these. The care plans inspected reflected the information key workers provided abut the resident’s needs and how they were met. Not all care plans and risk assessments seen were dated and signed so there was no evidence to show that these were kept under review. This issue was also discussed at the last inspection. Care plans were prepared in ‘symwrite’, which is a word and picture format to assist residents to The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 10 understand them. Daily records were kept to show that care plans were followed. Life plans were in place and had been prepared with the inclusion of the resident, relative, staff and life planner. Care plans seen included details of weekly activities for the residents. Based on staff knowledge of the resident and in discussion with relatives residents were supported to live life as independently as possible and supported to take risks based on assessment. For example residents were supported to participate in social and leisure activities outside the home, locking bedroom doors and using public transport. Requirement 1. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Residents had the opportunity to attend day centres, participate in social and leisure activities they liked and to have an annual holiday. Residents were provided with a nutritious diet and from observation and relative feedback residents were treated with respect. EVIDENCE: All residents attended day centres where they had opportunities to develop personal skills based on ability and assessment. One resident attended the centre five days a week and the others attended four days a week. On days off residents had one to one time with their key worker to take part in leisure activities of choice outside the home. Daily records showed that this happened and relatives contacted confirmed that residents did have the opportunity to do enjoy leisure time outside the home. Records showed that residents enjoyed outings such as day trips, pub visits, theatre and cinema trips, shopping, going for walks and going out for meals. Residents went on an annual holiday and plans were in place to take two residents to Malta and two to Great Yarmouth in June 2006. One relative contacted said that in their opinion residents did The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 12 not have enough activities at weekends and they spent a lot of time in front of the television. Residents were supported to maintain contact with family and friends. Relatives said they were made feel welcome when they visited the home. None of the residents were home during the early part of the inspection visit. Five of the residents returned to the home later in the day. Staff were observed interacting and communicating appropriately with the residents. All residents had their own bedrooms however one resident was making life difficult for others by disturbing them at night and frequently going into their bedrooms. The manager had identified and was addressing this issue. Relatives contacted said that staff treated residents with respect. One relative said their resident ‘had a better life in the home than the family could provide’ The kitchen was clean and tidy. Fridge and freezer temperatures were recorded and a cleaning schedule was in place. Foods with a shelf life were dated when opened and stored properly. A new fridge / freezer had been provided since the last inspection. The home had some domestic hours provided but care staff did some cleaning and the cooking and shopping. The menu was prepared as far as was possible with the involvement of the residents by using pictures. Meals provided were varied and nutritious. One evening a week residents had the choice of a take away meal, which staff said was very popular. Residents who were able assisted with laying and clearing tables. None of the residents had the ability to prepare or cook meals. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Resident’s personal and healthcare needs were being met but some improvements were needed to medicine management. EVIDENCE: As mentioned due to resident ability it was not possible to assess if residents were satisfied with how their care was delivered. Care plans seen showed how care needs were to be met and staff who spoke to the inspector displayed a good understanding of resident preferences in relation to how their personal care was provided. All residents were registered with a local GP and records seen showed they were supported to access medical services. Residents were supported to access routine NHS services such as dental, optical and chiropody services and to keep hospital appointments. An aroma therapist visited the home to treat residents on a private basis. The home had a medicine policy and procedure dated 8/98. These policies must be updated to reflect current practice in the home and to comply with the British Pharmaceutical Society guidance. This issue was identified at the last inspection and remained unchanged. A copy of the pharmaceutical guidance The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 14 was sent to the manager following the inspection. None of the residents managed their own medicines. Medicines were stored satisfactorily and records were seen for receipt, administration and disposal of medicines. Medicine records were checked for two residents and were correct. Some homely remedy medicines were in stock but there were no records kept for these. Since the last inspection the manager had obtained an agreement from the GP to use homely remedies however this was not specific about the medicines, the dosage that could be given to residents and the reasons for administration. Internal and external medicines were stored together and when staff made prescription entries on medicine administration charts these were not signed by two members of staff. Requirement 2. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Satisfactory systems were in place to manage complaints and ensure the protection of adults. EVIDENCE: The home had a complaints policy and procedure. A system was in place to record complaints and to show how these had been managed. Six complaints were recorded since the last inspection. Although the records showed details of the complaints and how they were investigated they did not show the final outcome or whether the complainant was satisfied. Residents were unable to make a complaint themselves however relatives contacted said they knew about the complaints procedure. One relative said they had reason to complain on two occasions and both of these had been managed to their satisfaction. No complaints had been made to the Commission since the last inspection. Management followed Greenwich adult protection policies and procedures. Staff who spoke to the inspector displayed a good awareness of adult protection and how to manage such a situation. No allegations or suspicions of abuse had occurred in the home since the last inspection. The manager said that staff had access to adult protection training since the last inspection. Recommendation 1. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. Although the staff had undertaken some redecoration since the last inspection the requirements made not been met. The property was not well maintained. The home was adequately clean and tidy but not well maintained. EVIDENCE: The home did not have a maintenance programme in place and requirements made at the last inspection in relation to the environment had not been met. The inspector was told that care staff had repainted the walls in the lounge, dining room and the bathroom on the first floor. Although the décor did not pose a risk to residents some maintenance issues could such as the leaking toilet pan in the shower room. A maintenance plan must be in place to ensure the property is satisfactorily maintained and provides a safe, comfortable and pleasant home for residents. Bedrooms seen varied in appearance. Two bedrooms had unpleasant odours, carpets in two bedrooms were stained, in one bedroom the curtains were not hanging properly, wash-basin tops in three bedrooms were water damaged and unsightly. Some bedroom furniture was beginning to look old and worn. All bedrooms would benefit from repainting and some bedrooms needed The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 17 repairs to cracks in walls and round windows. Most of these issues were identified at the last inspection but remained unchanged. One relative described the environment as ‘being very basic’. The stairway walls and woodwork needed repainting and the registered person must advise the Commission what action has been taken to address the large cracks in the walls and ceiling. Again this issue was identified at the last inspection but remained unchanged. The lounge was clean, tidy, bright and homely and the walls had repainted by the care staff since the last inspection. However here again there were large cracks in the ceiling coving which had not been addressed. Care staff had also painted the dining room walls since the last inspection. Although this room was used as a working area for staff it was cleared at mealtimes to allow residents to eat together at the table. In the shower room on the top floor there was a large crack in the plaster at the top of the wall behind the WC. This too was identified at the last inspection but remained unchanged. The paper on the ceiling over the shower was peeling off and the toilet pan was leaking. This leak could pose a risk to resident safety as the floor was wet and could cause anyone using the room to slip or fall. Care staff had painted the walls in the bathroom on the first floor but the woodwork needed painting. There was no evidence provided to show that the cause of the cracks in the building had been investigated or if any action was being taken to repair these. Following the inspection the inspector contacted the responsible person to raise concerns about the environment. Requirements 3, 4 and 5. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were maintained and staff were provided with supervision. Improvements were needed to records such as staff rotas, staff training and staff recruitment. EVIDENCE: The staff team comprised of a full time manager, a part time deputy manager, support workers and some domestic hours. Five of the seven care staff had achieved NVQ level 2 or above. Staff rotas seen showed adequate staffing levels were maintained. Relatives contacted said that they felt there was always enough staff on duty and were very positive about the staff team. Comments made included ‘staff do the best they can’ and ‘the manager involves me in decisions about my residents life’. A requirement made at the last inspection to ensure rotas included the full name of staff on duty had not been met. Staff personal files were not kept in the home. A record was available for each member of staff to show what information the employer had obtained. Therefore it was not possible to check whether gaps in employment had been explained or whether a reference had been obtained from the last employer if in that role the prospective employee had worked with vulnerable people. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 19 Individual training files had not been kept up to date. Staff who spoke to the inspector said they had received relevant training since the last inspection. The pre-inspection questionnaire showed that the following training had been provided for staff since the last inspection; health & safety, autism and adult protection. However there were no records seen to confirm this information. Records were seen to show staff received supervision. Requirements 6, 7 and 8. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. The home has not had a registered manager since 2002, there was no evidence to show that a quality assurance system was in place or that visits were made as required by regulation 26. More attention was needed to ensure the home was safely maintained. Policies and procedures had not been reviewed for some time. EVIDENCE: This home has not had a registered manager since the introduction of the national minimum standards. The current manager had been in post since July 2005 and has NVQ level 4 in care and management. She has experience of working with the category of residents in the home. A requirement made at the lat inspection for the manager to apply to register with the Commission was not met and has been restated in this report. This matter was discussed with the responsible person following the inspection. There was no evidence to show that a quality assurance system was in place. Resident meetings were held but no records were seen for these. The The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 21 manager said that staff communicated with relatives on a one to one basis therefore, relative meetings were not held. Regulation 26 reports were not sent to the Commission regularly and none were seen in the home. The manager completed in-house monthly health and safety audits. A selection of health and safety records were viewed. Fire safety and gas records were satisfactory. The electricity supply certificate was dated 4th December 2000 so the manager was asked to check this as the system may be overdue a re-inspection. Records showed the lift was last serviced on 21st April 2005 and therefore was overdue a service. Many of the Policies and procedures provided had not been updated for a long period. Requirement 9, 10, 11 and 12. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 22 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 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 2 25 2 26 X 27 1 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 3 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 2 X 2 X 1 X X 2 X The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person must ensure resident care plans and assessments are signed and dated to show that they are kept under review. The registered person must ensure safe systems are in place to manage medications. Policies and procedures must be updated to reflect current practice in the home by 28/07/06 • Internal and external medicines must be stored separately. • Homely remedy medicines must only be used in line with clear guidance from the GP, which must state the name and dose of the medicine, why it should be given and how many doses can be given. • Records must be kept for receipt, administration and disposal of homely remedies. • When staff transcribe prescription details on administration charts two DS0000036904.V290514.R01.S.doc Timescale for action 14/07/06 2. YA20 13 14/07/06 The Village (58) Version 5.1 Page 24 3. YA24 23 4. YA24 23 5. YA24 23 6. YA33 17 7. YA34 19 8. YA35 18 9. YA37 9 staff must sign to verify the information is correct. The registered person must ensure the premises are kept reasonably well decorated and well maintained. Repairs must be completed to the bedrooms as identified. All other repairs and redecorating must be completed to the areas identified. The home must be kept free of offensive odours. (Timescale of 05/10/05 was not met). The registered person must ensure a maintenance and refurbishment programme is in place and a copy sent to the Commission. The programme must include start and completion dates for work identified. (Timescale of 19/12/05 was not met). The registered person must undertake an audit of the environment including furniture, furnishings, carpets and fittings and send a copy of this to the Commission together with any improvement plans. The registered person must ensure staff rotas include the full name and designation of employees on duty at all times including agency staff. (Timescale of 05/12/05was not met) The registered person must ensure recruitment information kept in the home provides evidence to show staff are recruited in line with the requirements of this regulation. The registered person must ensure records are kept to show that staff receive training relevant to their role. The registered person must DS0000036904.V290514.R01.S.doc 14/07/06 14/07/06 14/07/06 14/07/06 14/07/06 14/07/06 21/07/06 Page 25 The Village (58) Version 5.1 10. YA37 Appendix 2 11. YA39 24 12. YA39 26 ensure the manager submits a completed application to register with the Commission as soon as she receives her CRB check. (Timescale of 05/12/05 was not met). The registered person must ensure policies and procedures provided are up to date and reflect current practice and legislation. The registered person must have a system in place to review, monitor and improve the quality of care provided in the home. (Timescale of 29/08/05 was not met) The registered person must ensure visits are made to the home as required by this regulation and reports of the visits sent to the Commission 01/09/06 14/07/06 14/07/06 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 YA22 Good Practice Recommendations The registered person should ensure complaint records show the final outcome of any complaint investigation. The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Village (58) DS0000036904.V290514.R01.S.doc Version 5.1 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. 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