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Inspection on 19/08/08 for Great Western Road, Flat 4, 22-24

Also see our care home review for Great Western Road, Flat 4, 22-24 for more information

This is the latest available inspection report for this service, carried out on 19th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents` needs and personal goals are outlined within individualised care plans. Staff involve residents in planning their care. Risk assessments are in place to enable residents to be supported to take responsible risks. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The service is committed to the principles of inclusion. The home is well-managed, and the staff team are very caring and compassionate and work well together. Staff are well qualified and receive appropriate training for meeting the needs of the residents.

What has improved since the last inspection?

Tracking hosts have been installed throughout the flat to support residents who require assistance with their mobility. The Statement of Purpose and service user`s guide has been updated to provide residents with up-to-date information about the home and staff.Risk taking policies have been reviewed and updated where necessary to reflect residents` current support needs.

What the care home could do better:

Visits on behalf of the Registered Provider must take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. The Society should undertake an annual quality assurance audit of the standards in the home.

CARE HOME ADULTS 18-65 Great Western Road, Flat 4, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Ffion Simmons Key Unannounced Inspection 19th August 2008 11:15 Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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 Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 4, 22-24 Address 22-24 Great Western Road London W9 3NN 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) 020 7289 4752 020 8964 5507 The Westminster Society for People with Learning Disabilities Miss Michelle Hart Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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 - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 29th May 2007 Date of last inspection Brief Description of the Service: Flat 4 is a purpose built, wheelchair accessible, second floor flat that is registered to provide care for 6 people with learning disabilities. At the time of this visit, 4 women and 2 men were living in the home and there were no vacancies. The property is owned by Paddington Churches Housing Association and the care is provided by the Westminster Society for People with a Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Grove, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has their own bedroom. Communal areas, bathrooms and toilets are shared. The current fee for the service is £1,211.78 per week with no additional charges. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The unannounced key inspection was carried out on the 19th August 2008 and lasted a total of 7 ½ hours. During the inspection, we spoke with residents and staff and observed care practices. We tracked the care of two residents, and in doing so we checked their personal records. A number of other records and documentation was checked during the inspection, including medication administration records, staff files, health and safety documentation, the home’s complaint records and quality assurance documentation. Questionnaires were sent to residents and professionals and staff to comment on the service. We received eight completed questionnaires. Some of the comments within these have been included in this report. The Registered Manager took time to complete and return the Annual Quality Assurance Assessment (AQAA), which has been used as evidence to inform this report. What the service does well: What has improved since the last inspection? Tracking hosts have been installed throughout the flat to support residents who require assistance with their mobility. The Statement of Purpose and service user’s guide has been updated to provide residents with up-to-date information about the home and staff. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 6 Risk taking policies have been reviewed and updated where necessary to reflect residents’ current support needs. 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. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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 Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a clear statement of purpose, which provides up-to-date information on the services that the home provides. Referral and admission procedures are in place, ensuring that the residents’ needs are well known prior to moving in. EVIDENCE: The home’s statement of purpose and service user’s guide was checked during the inspection. It was noted that this has been updated as per the requirements of the last inspection report to reflect the current situation at the home. There have been no new admissions to the home since our last key inspection, which took place on the 29th May 2007 and there are no vacancies currently. The latest admission to the home was in September 2005. Policies and guidelines are in place for assessing the needs of residents prior to them moving into the home. The Registered Manager confirmed within the AQAA that “the organisation has a clear transition plan which incorporates assessment, visits, risk analysis, agreement of support hours and review points.” We tracked the care of two residents during the inspection and noted that the plan is adhered to as each had detailed needs assessments on their files. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs and personal goals are outlined within individualised care plans. Staff involve residents in planning their care. Risk assessments are in place to enable residents to be supported to take responsible risks. EVIDENCE: The care of two residents was tracked during this inspection. As part of the case tracking process we checked their individual care plans and spoke with residents and staff. The home is in the process of re-organising the personal files to include more pictures which when completed will make the documentation more accessible. One of the care plans already made good use of pictures. The Registered Manager confirmed within the AQAA that the care plans are reviewed every six months or when there are significant changes in the needs of the residents. Both care plans seen had recently been updated and provided good information on the individual needs of residents living at the home, Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 10 including information in relation to equalities and diversity. evidence of residents’ involvement in the planning of their care. There was Both files checked included detailed risk assessments, which covered a range of potential risks, including bathing, falls, personal and health care and fire safety. The risk assessments had recently been updated and included clear guidance for staff on how to enable residents to take responsible risks and to minimise unnecessary risks. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The service is committed to the principles of inclusion. EVIDENCE: All residents living at the home are supported to attend day services and each resident has an individual programme. One of the residents told us about the opportunities that they and other residents have to go on outings with the day service. The Manager told us within the AQAA that “in the last 12 months two people were supported to apply for a college course with Kensington and Chelsea around painting which was specifically catering for people with learning disabilities.” Residents’ interests and preferences for social activities are clearly documented within their personal records. Checking the daily records and activity records Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 12 in the home provided the evidence that residents are supported to take part in activities of their choice during the week, in the evenings and at week-ends. These records also provided the evidence that resident are well supported to access the local community. Some of the activities that residents have been supported to take part in have included going shopping and meals out. Residents’ needs in relation to their religious and cultural needs are also outlined within their support plans. The Manager confirmed within the AQAA that “people are supported to attend Church services, listen to hymn CD’s and watch Songs of Praise at home if they wish to.” Residents are supported to keep in touch with family and friends, who are able to visit the home. A friend commented “I feel that the residents are treated with respect and affection, and I am made to feel welcome when I telephone and visit”. Residents are supported to maintain independence and choice in the home, for example are supported to answer the telephone and the door. A friend commented “the residents’ wishes in every aspect of their life are respected wherever possible and I am impressed by this.” A copy of the weekly menu was on display in the kitchen area, which showed that residents are given a choice of nutritious meals. The mealtimes were observed to be flexible. Residents have access to dieticians for specialist advice. On display in the dinning area was residents’ preferences and needs in relation to eating and drinking. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 21. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have good support from the staff team to access care from the multi-disciplinary team. Residents are protected by the home’s medication policy and practices. EVIDENCE: Both resident case tracked had a detailed support plan in place outlining their needs and preferences in relation to personal care and health care. The Westminster Society’s policy is to offer residents the option of same gender support wherever possible. Registered Manager confirmed that residents’ wishes in this area would be respected where possible. The Registered Manager confirmed within the AQA that “everyone is supported to attend regular health appointments. If there is any change in health needs or any concerns with regards to health people are supported to access their GP or any other necessary health professionals.” During the inspection, we observed staff acting to involve the GP when they had concerns over the health of one of the residents. Staff were compassionate in their approach to residents. Care is also taken to involve the rapid response team so that unnecessary admissions to hospital can be avoided as far as possible. Both Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 14 residents had a Health Action Plan on their files but these were in need of updating following recent health care visits. From checking residents’ health care records and the AQAA, we found that residents have access to GP, dentist, opticians, podiatrist, district nurses, speech and language therapists, Macmillan Nurses, psychologist, psychiatrist and dieticians. We confirmed through checking the AQAA that the home has policies and procedures in place for the safe management of medication, which outlined that only trained staff are responsible for the administration of medication. We checked the home’s management of medication. The home uses the Boots Monitored Dosage System. There was evidence of regular audits of all medication being undertaken to check that the quantity of medication is correct. The Medication Administration Records for all six residents were checked during the inspection. These were found to be well completed and without gaps in the recording. When medication had not been administered the reason for this was clearly defined through the use of codes. The home has reported three errors in the administration of medication within the last six months, but steps have been taken by the Registered Manager and the staff team to address these issues and the standard of the home’s management of medication is now considered to be good. The medication was secure stored at the time of the inspection. The home currently has controlled drugs in use and these were being recorded in a bound book. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure that is accessible to people living in the home. Procedures are in place for protecting residents from abuse. EVIDENCE: The Manager confirmed within the AQAA that the home has received two formal complaints since the last key inspection. Complaints, compliments and concerns are recorded on an electronic system, which can be accessed by the Society’s senior Managers. The home’s complaints records were checked during the inspection and were well recorded. The home’s complaints policy makes good use of pictures and symbols to make the information more accessible to residents. The Manager confirmed within the AQAA that “people are supported and encouraged to express any complaints they may have with the support team, their link-worker or with the manager.” Residents are able to raise complaints also during house meetings. A resident commented that they would complain to the staff if they had any issues. The Manager confirmed within the AQAA that since the last inspection there have been no Adult Protection investigations involving people who use the service. Policies and procedures are in place for protecting residents from abuse, neglect and discrimination. Staff training records showed that staff attend training in the protection of vulnerable adults during their induction training and also receive periodic updates to update and refresh their knowledge in this area. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 16 As part of the inspection, the financial records of two of the residents case tracked were checked. The records were well completed and receipts were in place for the transactions undertaken on behalf of the residents. We noted that staff undertake regular audits to check that the balances of monies kept for residents are correct and that the records are accurate. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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, 27, 28 & 30. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is suitable for the needs of current residents and provides a homely, comfortable and accessible environment in which to live. EVIDENCE: Flat 4 is a purpose built, wheelchair accessible flat, located in a residential area of Westbourne Grove, close to shops and transport links. There is a lift access to flat 4. The home is part of a small residential block that includes a second registered care home. Residents have their own bedrooms and share a lounge, kitchen/dinning area and bathrooms. One of the residents commented, “my bedroom’s nice and clean, sometimes I clean it”. Since the last inspection, tracking hoists have been installed throughout the flat to support residents who require assistance with their mobility. The number of wheelchair accessible toilets and assisted bath/shower rooms are sufficient to meet the residents’ needs. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 18 There is a separate laundry room in within the flat, equipped with machines, which have the required settings for washing clothes at correct temperatures. The home was clean, fresh and hygienic at the time of our visit. The Manager told us within the AQAA that “the service has a daily, weekly and monthly cleaning rota in place which the team follow consistently” and “the manager arranges for the carpets to be cleaned professionally on a regular basis”. Training records demonstrated that staff have received training on the prevention of infection and management of infection control. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff work well together and receive the appropriate training to meet the needs of the residents. The home’s recruitment procedures are robust and involve residents in the selection process. EVIDENCE: Rotas were checked during the inspection, which demonstrated that there are a minimum of two members of staff on duty at all times. Shifts are arranged around residents’ appointments and activities, which were clearly outlined on the rota. Each night there is a permanent waking night staff working in the home, who is supported if required by an on-call support worker who sleeps in the home. The interactions between residents and staff were positive with staff approaching residents with care and compassion. Residents commented that “the staff are nice” and “they’re kind”. Staff commented “the Manager and team members work together as a team to support most of the individual needs of the service users”. A professional commented “upon my visits all the staff have been respectful”. A relative commented “I would like to say, I find the staff members I know always are informative about my relative’s care, and Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 20 I know my relative thinks an awful lot about these people. I have always found when I have spoken to any of these staff, which is quite often, they have put my mind at ease. Its good to be able to praise people for the work they do.” The recruitment of new staff, and the necessary pre-employment checks, are carried out by the Society’s Human Resources department. The preemployment checks include checks against the Protection of Vulnerable Adults list and a Criminal Record Bureau (CRB) check. The Manager confirmed within the AQAA that the recruitment procedures are based on equal opportunities and people who use the service are supported to participate in the process of interviewing and meeting potential team members. Information provided within the AQAA provided the evidence that 50 of the staff team have achieved the National Vocational Qualification (NVQ) at level 2 or above, with a further 30 of the current staff team currently working towards this qualification. This is an improvement on the figures of the last key inspection. The training records of three members of the team were checked during the inspection. The records demonstrated that staff have received essential training and are up-to-date in their training in safe working practices. Staff also have access to good training opportunities relevant to meeting the needs of the residents. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.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. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is managed, by a qualified, experienced and competent person. The health and safety of residents is protected by the home’s policies and procedures. EVIDENCE: The home has an experienced Manager in post, who has a very good understanding of the needs of the residents who live there. The Manager holds the National Vocational Qualification at level 4 and has obtained the Registered Managers Award through the organisation. The Manager also attends periodic training to update skills and knowledge. Checking the training files provided the evidence that some of the training courses undertaken include management training, Mental Capacity Act training and equalities and diversity training. The Manager has a clear understanding of the ethos of the home and works hard to maintain standards. The Assistant Manager’s post was vacant at our last inspection and the Manager is still without the support of an assistant. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 22 The Registered Manager told us within the AQAA that residents were supported to participate in a service user survey on their thoughts on their housing preferences. We checked the records of visits undertaken on behalf of the Registered Provider. No report was available for December 2007, January 2008 and April 2008. Steps must be taken to make sure that these visits take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. The Society has not undertaken the annual quality assurance audit within the last twelve months and so is overdue. We checked the home’s health and safety documentation during the inspection and toured the building to check for any risks. No urgent health and safety issues were identified during this visits. Staff training records demonstrated that they receive core health and safety training, including first aid and manual handling. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 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 X 3 3 X 2 X X 3 X Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 24 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 YA39 Regulation 26 Timescale for action Steps must be taken to make 01/10/08 sure that visits on behalf of the Registered Provider take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. Requirement 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 YA39 Good Practice Recommendations The Society should undertake an annual quality assurance audit of the standards in the home. Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 25 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 Great Western Road, Flat 4, 22-24 DS0000010878.V370822.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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