Inspection on 13/11/07 for Marriott Road 18

This is the latest available inspection report for this service, carried out on 13th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marriott Road 18 20/09/05

Marriott Road 18 28/04/05

Marriott Road 18 05/10/04

Marriott Road 18 05/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Marriott Road 18 Barnet Hertfordshire EN5 4NJ Lead Inspector Tom McKervey Key Unannounced Inspection 13th November 2007 10:30 Marriott Road 18 DS0000010529.V350945.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 Marriott Road 18 DS0000010529.V350945.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. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marriott Road 18 Address Barnet Hertfordshire EN5 4NJ 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 8449 9493 020 8449 9493 marriottroad@btinternet.com Hoffmann Foundation for Autism Mr Delroy Gordon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2006 Brief Description of the Service: Marriot Road is a care home registered to provide care and support for six younger adults who have a learning disability, and who also have autism. The Hoffman Foundation for Autism is a registered charity and manages this home, and other similar homes in the U.K. The home opened in 1989. The property comprises a three-storey townhouse, situated in a pleasant residential area of High Barnet. It is close to shops and leisure amenities and there are good public transport links. There are three bedrooms on the first and three on the second floor. The manager’s office is also located on the first floor. The kitchen/diner, laundry and office for staff, are located on the ground floor, and there is an attractive garden to the rear of the property. The fees for the service are £1197 per person per week. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of five and a half hours and was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. Prior to the inspection, the manager submitted an Annual Quality Assurance Audit, (AQAA) to the Commission. This document is a self-assessment which is required to be carried out each year. The AQAA monitors how the home is performing against the National Minimum Standards and identifies where the home needs to improve. I discussed this document with the manager and pointed out where the information could be improved. The registered manager was present throughout the inspection and fully cooperated in the process. At the time of the inspection, there were six service users living at the home and there were no vacancies. The inspection process involved visiting all areas of the home, including residents’ communal areas and bedrooms. Residents’ care records and staff files were examined, and three staff were interviewed. All the residents were present towards the end of the inspection, five of whom had attended their various day centres. The other resident went out for planned activities, supported by a one-to-one care worker. None of the residents are able to verbalise, but I was able to assess their care and wellbeing by examining their records and observing how staff interacted with them. There were no visitors to the home during the inspection. What the service does well: There is a core group of staff that has worked at the home for a long time and they know the residents well and are able to communicate with them effectively. The residents and their representatives have good information about the service to enable them to make informed decisions and they are able to visit the home before moving in. Each resident has a care plan that sets out their health, social and personal care needs in a way that respects their wishes. The residents have a good quality of life through attendance at activity centres and they have full access to leisure facilities in the community. Activity programmes are tailored to meet the particular interests of the individual. The meals are well-balanced and nutritious and ensure that residents receive a healthy diet. Staff are sensitive to and respect, the residents’ dignity, and their health is maintained by the full range of healthcare professionals. Medication is administered safely, which safeguards residents’ wellbeing. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 6 The home takes concerns and complaints seriously and deals with them promptly. The ethos and practices in the home protect the residents from abuse. The standard of décor and cleanliness in the home is generally good and provides a safe and comfortable environment for residents and staff. There is an excellent staff recruitment procedure that involves residents in the process and staff receive training that is tailored to meet the residents’ needs. The manager gives clear leadership and staff are well supervised. There is a strong emphasis on integrating with the local and wider community and relatives are very involved in the running of the home through their peer group. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marriott Road 18 DS0000010529.V350945.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 Marriott Road 18 DS0000010529.V350945.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, 3, 4 & 5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence in residents’ case files. The residents and their representatives have good information about the service to enable them to make informed decisions and they are able to visit the home before moving in. The staff are appropriately trained to support the needs of people who have autism. EVIDENCE: The Statement of Purpose and Service Users Guide provide comprehensive information about the service. The documents are written in appropriate, easy to understand language. No new service users had been admitted since the last inspection. The residents’ files contained detailed information for staff about how to communicate with residents who are non-verbal. This included Makaton, and interpretation of behaviour and gestures. This information is used to enable understanding of the individual resident’s wishes. Staff undergo training in all aspects of supporting people with Autism. Residents’ case records showed that they and their relatives had visited the home prior to moving in. The residents have tenancy agreements and the manager told me that the local authority is going to issue new service contracts in the near future to move from the current block contract to “spot purchasing” contracts. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 9 Marriott Road 18 DS0000010529.V350945.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, 8 & 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including observation and reading residents’ records. Each resident has a care plan that sets out their health, social and personal care needs in a way that respects their wishes. The staff are able to understand and support residents to make decisions about their lives who are not able to articulate their wishes. EVIDENCE: I sampled three residents’ care plans. The care plans are becoming more “person-centred”, which is an approach to care planning that involves the resident and others who play a significant part in their lives. The plans showed that assessments had been carried out of the persons’ needs and guidelines were drawn up about how to meet those needs. The care plans are reviewed monthly by the key worker and annual care reviews are also carried out, which include relatives and staff from the resident’s day centre. Each resident has a “summary” care plan so that agency Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 11 staff, for example, who may be unfamiliar with the residents, can quickly obtain the most important and relevant information needed to support the residents appropriately. Residents’ daily records support the care plans by describing how they spent their day, and risk assessments were documented about activities within the home and in the community. Most of the residents are non-verbal. However, there are very good guidelines for staff about how to ascertain and understand residents’ wishes. Relatives provided much of this information at the time of admission. In addition, staff are able to communicate with the residents by interpreting their gestures and through objects of reference. The staff also use Makaton sign language. I observed staff interacting with the residents in a competent and caring manner, where they demonstrated their ability to understand the residents and to support them appropriately. Marriott Road 18 DS0000010529.V350945.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including discussions with staff and looking at case records and other documents. The residents have a good quality of life through attendance at activity centres and full access to leisure facilities in the community. Activity programmes are tailored to meet the particular interests of the individual. The meals are wellbalanced and nutritious to ensure that residents receive a healthy diet. EVIDENCE: Each resident has an individually tailored activity programme for each day. Five of the residents attend a day centre or college. One resident is funded by the local authority for one-to-one day care, whereby a member of staff supports them on various outings, often using public transport to visit places of interest. The daily records I saw showed a good variety of leisure pursuits, for example swimming and music sessions. Picture charts are used to enable residents to Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 13 understand what activities are planned each day. There is an activities room in the home that is used for games and music sessions. The visitors book showed that several residents have frequent visits from relatives and one person often spends weekends at the family home. The manager stated that it is not feasible to hold meetings with residents because of their limited verbal ability, but relatives play a significant role in representing residents through three-monthly “Friends of Marriott Road” meetings, which he manager attends. None of the residents attend religious services in accordance with families’ wishes. I witnessed a discussion between the manager and staff about the arrangements for a resident to attend the funeral of a parent who had just died. This was being planned with great sensitivity with the best interests of the resident and their relatives in mind. The menus showed a variety of well-balanced meals and fresh fruit was available. There was a record of the food actually eaten by the residents to ensure that they ate nutritious meals. Food in the fridge was labelled and stored correctly. Marriott Road 18 DS0000010529.V350945.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including health records and medication records. The residents’ personal care is supported by staff who are sensitive to the person’s dignity and their health is maintained by the full range of healthcare professionals. Medication is administered safely, which safeguards residents’ wellbeing. EVIDENCE: Each resident has a “Health Action Plan”, which provides a full medical history. This document goes with the resident when they visit the G.P. Staff fill in the appropriate information following the appointment. There is a good standard of health appointments with other professionals, including the psychiatrist, optician etc. At the time of the inspection, all the residents were in good health. All residents are weighed monthly and one person was on a weight reducing diet and a walking regime on the advice of the dietician. There are guidelines for staff in individual residents’ records about how they prefer to be supported in their personal care. For example, “A.. prefers to have a bath at a time when he wants to”. The staff rotas show that there is always a Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 15 male and female staff on duty so that residents of either gender can have appropriate personal care with dignity and respect. The home is equipped with baths and showers, which provides the residents with a choice. The accident book showed that accidents/incidents were properly recorded and were up to date. I examined the medication standards. The records for the administration of medicines showed no gaps in staff signatures. The medication was stored securely and returns of unused medication were documented and signed for by the pharmacist. Staff had received training in the administration of medicines. None of the residents are able to self-medicate. Marriott Road 18 DS0000010529.V350945.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including inspection of the complaints log and discussion with staff. Concerns and complaints are taken seriously and acted upon and the residents are protected from abuse through staff training and the ethos and practices in the home. EVIDENCE: The complaint log showed that two complaints had been made about the service since the last inspection. Both complaints were from a neighbour who complained about a resident throwing shoes into their garden. The manager met the neighbour to apologise and dealt with this satisfactorily. There were records to show that staff had attended training on adult protection. In discussion with staff, I was satisfied that they were knowledgeable about the procedures regarding raising concerns about abuse. Marriott Road 18 DS0000010529.V350945.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, 25, 26,28 & 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including visiting all areas of the home. The standard of décor and maintenance in the home is generally good and provides a safe and comfortable environment for residents and staff. The residents’ bedrooms are attractive and comfortable and reflect their individual interests and preferences. However, in one person’s bedroom, the standard of workmanship is poor and this must be addressed in the interests of the resident. The home is clean and tidy, and there are appropriate systems in place to minimise the risk of infection to residents and staff. EVIDENCE: An inspection of the premises was carried out, including all bedrooms. The exterior of the building was in good condition and the garden was well maintained. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 18 Since the last inspection, three bedrooms and the main lounge had been redecorated and a bathroom had been refurbished. The kitchen units and appliances were in good condition and the lounge and dining furniture was attractive and comfortable. The bedrooms had individual colour schemes and had personal items of furniture and equipment, for example; televisions, music systems and pictures and posters. I noted that there were two screw-nails protruding from the wall on the stairs. I am making a requirement that they be removed to prevent injury. I was concerned about the poor workmanship in one bedroom that had been recently decorated and also that payment for the work had been taken from the resident’s personal account. I wrote to the responsible person in the organisation, expressing my concern about this and received a reply that the money would be reimbursed to the resident and the work would be properly finished. Since the last inspection, an appropriate covering had been applied to a resident’s bedroom window to provide adequate screening that protects their privacy. I was informed that the cleaner had left and this post was being advertised. In the meantime, the care staff were doing the cleaning, and at the time of the inspection the home was generally very clean and tidy and smelled fresh. New pedal waste bins have been provided and disposable aprons and gloves are available to staff when supporting residents with their personal care. Marriott Road 18 DS0000010529.V350945.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): All these standards were assessed. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including interviewing staff and examining their records. The residents are involved in recruiting staff, which is excellent practice. The residents’ welfare is protected by appropriate screening of their carers and by staff having the skills to meet their needs and being regularly supervised in their practice. EVIDENCE: I spoke to three members of staff independently. They demonstrated a thorough knowledge of the residents and their needs, and described their roles and areas of responsibility for providing care and support. All the staff had a written induction when they started working at the home and they had undergone a training programme tailored to the needs of the residents. This includes mandatory health and safety subjects, autism, challenging behaviour and epilepsy. Four staff, (50 ) of the care staff, have attained National Vocational Qualification level 2. The rota accurately identified which staff were on duty during the inspection. The staff rota confirmed that there were sufficient numbers of staff available at all times to meet residents’ needs and staff said they were satisfied with the staffing levels. One resident has funding for one-to –one support. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 20 There was one vacancy that the manager told me has been filled, but he was waiting for references before the person could start. The home does not use agency staff, but bank staff who know the residents well, are employed to cover when necessary. The manager recruited a deputy in January, and he told me that a service user was involved in the recruitment process, which is excellent practice and highly commended. I examined the records of three new staff. Criminal Records Bureau checks had been made and references obtained before they started working at the home. The staff told me that they had regular supervision, which they said was valuable in providing an opportunity to explore and discuss work issues with their line managers. Marriott Road 18 DS0000010529.V350945.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, 38, 39, 40 & 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including discussion with the manager and staff, and looking at health and safety records. The manager is well qualified and experienced at running the home for the benefit of the residents. Staff are very motivated and caring, but they would benefit from having further team-building to improve their morale, which will have a beneficial effect for the residents. A resident’s financial interest was compromised, but this has subsequently been redressed satisfactorally. There are good monitoring systems in place for ensuring the health and safety of residents, staff and visitors to the home. EVIDENCE: Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 22 The manager has been in charge of the home for a number of years and has attained the Registered Manager’s Award and NVQ Level 4 qualification. He is registered by the Commission for Social Care Inspection. There was a relaxed atmosphere in the home and staff and residents were interacting with each other in a friendly manner. The staff who I interviewed, said that the manager was very competent and approachable and they thoroughly enjoyed working with this group of residents. I was aware of incidents that had occurred at the home last year, regarding poor practice. These matters had been investigated under adult protection procedures and were dealt with appropriately at the time. However, staff told me that these incidents had affected the morale of the team. The organisation had consequently organised some team-building sessions, using an outside facilitator, which had been successful. However, the staff told me that they feel they had not yet achieved closure and would welcome at least one more of these sessions to resolve some remaining issues. I discussed this with the manager and have recommended that the organisation seriously consider the staffs’ wishes. As commented under Standard 24 above, I was concerned to discover when I examined residents’ financial records, that money was taken from a resident’s account without permission to pay for their room to be redecorated. The manager said that there were no funds left in the budget for this work and he had been concerned about the poor décor in the resident’s bedroom. While I accept that the manager had acted in good faith, it is not acceptable for residents to fund what should be covered by the service fees. Following my representations to the responsible person in the organisation, I was informed that the resident was to be reimbursed. In the meantime, I am making a requirement to ensure this does not happen again. Reports of monthly inspections of the home by senior managers are sent to the Commission for Social Care Inspection. An audit of the service had been done last year that included the views of service users’ representatives. However, the manager was unsure whether one was carried out this year. A requirement is made for this to be done. It is not possible to hold meetings with the residents because of the nature of their disabilities. However, regular meetings are held with their relatives at which they are able to have an input into the running of the home. Minutes of these meetings were available for inspection. Staff meetings are held regularly to discuss the day-to-day operation of the home and discuss residents’ issues. There were records of health and safety audits and COSHH materials were stored securely. The fire logs showed that alarms are tested and drills are conducted regularly, and the temperatures of the fridge and freezer are recorded daily. Certificates of safety were seen for fire, gas, water and electrical installations and there was a current employers liability insurance certificate on display. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 23 Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 3 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 2 25 3 26 2 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 4 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000010529.V350945.R01.S.doc 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marriott Road 18 3 2 2 1 X 3 X Version 5.2 Page 25 Score 3 3 3 X 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. 2. 3. 4. Standard YA24 YA26 Regulation 23(2)(b) 23(2)(d) 24(2) 17(2) Sch 4.8 Requirement The protruding nails on the wall of the stairs must be removed to prevent injury. The poor standard of decoration in a specific resident’s bedroom must be addressed. A quality assurance survey of stakeholders’ views of the service must be carried out. The redecoration of bedrooms must not be funded through residents’ personal finances. Where this has occurred, the resident must be reimbursed. Timescale for action 30/12/07 30/12/07 31/01/08 30/11/07 YA39 YA40 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 YA38 Good Practice Recommendations A further team-building event should take place to improve the staffs’ morale. Marriott Road 18 DS0000010529.V350945.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Marriott Road 18 DS0000010529.V350945.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. 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