Inspection on 13/08/08 for Shirland Road, 93-95

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

Other inspections for this house

Shirland Road, 93-95 23/06/06

Shirland Road, 93-95 24/06/05

Shirland Road, 93-95 19/01/05

Shirland Road, 93-95 02/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Shirland Road, 93-95 93/95 Shirland Road London W9 2EL Lead Inspector Wynne Price-Rees Unannounced Inspection 13th August 2008 10:15 Shirland Road, 93-95 DS0000010874.V364009.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 Shirland Road, 93-95 DS0000010874.V364009.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. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirland Road, 93-95 Address 93/95 Shirland Road London W9 2EL 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 7266 0161 020 7289 3050 Rachely@MUNGOS.ORG St Mungo Association Ms Rachel Elizabeth Yates Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Shirland Road, 93-95 DS0000010874.V364009.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. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 18 10th October 2007 Date of last inspection Brief Description of the Service: 93 - 95 Shirland Road is a residential care home providing accommodation for eighteen homeless men and women with mental health support needs. There is a current occupancy of fifteen. The property is owned by Paddington Churches Housing Association and the care is provided by St Mungo’s, a voluntary organisation. It is located in a residential area of Maida Vale, close to shops and transport links and is accessible to people in wheelchairs. The home works closely with the Joint Homelessness Teams (JHT) in Westminster and Kensington and Chelsea and all referrals come from these teams. It provides medium term placements, usually for up to 18 months, preparing people to move on to more independent accommodation. Shirland Road, 93-95 DS0000010874.V364009.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 stars. This means the people who use this service experience good quality outcomes. The inspection was unannounced and took four and three quarter hours to complete over one day. During the course of the inspection we spoke with five people who use the service to get their views of the service they receive. We also spoke with some staff and care practices were observed, records and procedures checked and a premises tour undertaken. The Care Manager was present during the inspection. We inspected all key standards and the information seen was triangulated with that gathered since the previous key inspection including Regulation 37 notifications forwarded. Regulation 37 notifications inform us of any accidents or incidents that affect people who use the service. This was compared with the AQAA information returned to us by the home before the inspection. An AQAA is an annual quality assurance self-assessment carried out by the home. The files of three people who use the service were case tracked. What the service does well: What has improved since the last inspection? Fridge and freezer temperatures were not being checked and recorded on a regular basis. They are now being checked and recorded twice daily. A new user-friendlier interview template has been introduced; that focuses on rehabilitation needs, what people can expect from the service and their expected behaviour. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 6 The outside of the building is being redecorated. 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. Shirland Road, 93-95 DS0000010874.V364009.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 Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs of people who use the service are fully assessed prior to moving in and they choose if they want to move in. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented on the assessment procedure and opportunity to visit the service before deciding if they wished to move in. These comments are included in the evidence text. The home has a thorough written assessment procedure that the files of three people who use the service, that were case tracked, revealed is followed. The only change to the procedure from the last inspection is that a new interview template has been added; for the first visit by a person who uses the service. This focuses on rehabilitation needs, what people can expect from the service and their expected behaviour in a more user-friendly way. “What we can expect and what is expected of us was made very clear”. Commented a resident. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 9 There is also a handbook for people who use the service that contains comprehensive information about living at the home, the services provided and local amenities. Westminster City Council and Westminster Primary Care Trust make all referrals through the Joint Homelessness Team and there is a block contract with the home. Case tracking showed there is good quality information forwarded to the home including the most up to date available care plan, adult mental health assessment and risk assessments. The staff team discuss this information and make comments on the referral sheets that feed into the home’s own assessment before deciding if needs could be met and a placement would be appropriate. If the outcome is positive the prospective client is invited for a short visit and then a three-day stay to determine if they want to move in and further identify if their needs can be met. One person said, “I visited before I came in”. Shirland Road, 93-95 DS0000010874.V364009.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 and 9. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are comprehensive care plans with information that shows how staff support people to develop their independent living needs. People who use the service are encouraged to make decisions for themselves in a risk-assessed environment. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented about their involvement in the planning of the care and support they receive. They also commented on their opportunities to make their own decisions in a supportive environment. These comments are included in the evidence text. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 11 The files of the three people who use the service that were case tracked showed they each have a comprehensive care plan in place. The care plans are generated from the original assessment that identifies needs, wishes and how to meet them from which goals are established. These are gradually developed as the person who uses the service settles in. They identify separate goals and action plans for people who use the service and staff that work in tandem with them. The plans are underpinned by regularly reviewing risk assessments that enable goals to be achieved. The first risk assessment takes place during the first visit to the home. Although the goals are individual, they all work towards the common aim of eventually enabling people who use the service to live independently. The speed with which this happens depends on the individual and level of life skills they have achieved. The level of care planning involvement is a matter of personal choice with some people who use the service being more involved than others. Residents commented “I am involved in my care plan as it is helping me develop the skills I need”. “I am doing a business course and am being helped with my English and maths”. Monthly care plan reviews take place that feed statutory six monthly reviews with the placing authority. “I choose what I want to do,” said a resident. People who use the service are encouraged and supported to make their own decisions on a daily basis to progress towards independent living within a risk-assessed environment. “I’m going to the Terrace Centre,” said another person in relation to their chosen activities. They decide what activities they wish to participate in with one person attending a photography group. He also contributes photographs of other people who use the service to the weekly printed newsletter. This incorporates everything discussed during house meetings. Topics in the last newsletter included maintenance, equal opportunities, activities, complaints, holidays and hellos and goodbyes. A house meeting was planned for that evening. Most people who use the service are responsible for handling their own financial affairs with support although the local authority is appointee for some. There is a suggestions notice board in the dining area so that people, who would prefer not to put forward their views in public, can have their say anonymously. The organization also distributes annual feedback questionnaires to people who use the service. Monthly Regulation 26 provider visits also take place and a person who uses the service said they sometimes talk to them to get their views. Regulation 26 visits are monthly quality assurance visits carried out by representatives of the provider. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 12 Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 16 and 17. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have their preferences observed and their social, cultural, religious and recreational needs and interests met, meaning they have fulfilling lifestyles. They also receive a variety of meals geared to their individual tastes. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented about their opportunities for personal development, involvement in the local community, daily lives, meals, family contact and activities available to them. These comments are included in the evidence text. People who use the service are encouraged and supported to develop a range of life-skills partly through the activities they undertake. Whilst encouragement and support is given it is still up to the individual to decide what they want to do, when and how often. The activities vary depending on the individual with one person who uses the service working as a volunteer in a Salvation Army Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 14 homeless centre whilst also finishing their 4th novel. “I am involved in my care planning and it has helped me find a course that will enable me to do the kind of work I have chosen”. Another person has just completed initial interviews and tests before starting a college building course. “I feel very well supported”. One person is a Muslim and visits the mosque daily as well a local Lebanese restaurant. This is his cultural and ethnic background. They also have a male Arabic speaking flexi carer who visits daily to assist with any required personal care. “We use the shops and do the weekly food shopping”. Good use is made of local facilities such as day centres, parks, cafes and local shops. There have also been a number of visits to places such as boat trips at Little Venice, local library, Hyde Park and the Gym. A group trip to Brighton is planned for Friday. These activities are co-ordinated by a life-skills worker who visits every other week. They also provide support in developing literacy and IT skills and run a book club. One to one sessions are also available particularly for people who don’t engage easily with others. Daily house routines are fitted around the needs of the individual rather than the other way around. People who use the service are responsible for looking after their own rooms as part of life skill development. They decide if they would prefer to eat as a group or individually with menus reviewed during house meetings. One person who uses the service requires Halal meat as part of their religious beliefs and a vote was taken to see if everyone was happy to have Halal meat, as it would be easier in food preparation. Everyone voted for the Halal option. People who use the service also decided they would prefer a longer breakfast time and this has been introduced. They also said “We go out for meals”. The house rules are based on health, safety and respect for other people and their property. They are contained in the guide for people who use the service. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have their physical and emotional health needs met. The medication administration records contained some gaps without explanation. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented about the emotional and health needs support they receive. These comments are included in the evidence text. Personal care is provided if required although this generally takes the shape of prompting people to attend to their own personal hygiene. All people who use the service are registered with GPs. They are also offered annual check ups and a “Well being” clinic run by CPNs (Community Psychiatric Nurses.) They also visit every other week. People who use the service have full access to community based health services and are supported to access them, by staff, as required. The individual’s health care needs are identified and addressed as part of the care planning system. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 16 There is a written policy and procedure regarding medication administration and only those qualified to do so administer. There are some people who use the service that are self-medicating with differing levels of support. One person said, “My meds are under control”. No controlled drugs are kept on the premises. The MAR (Medication Administration Record) sheets were checked for all residents and three gaps were found with no written explanation. This was addressed at the staff meeting that afternoon. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can feel confident that they are listened to and their complaints and concerns investigated with outcomes. They are safe and well protected by the home’s adult protection procedures. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented on how they feel about the way the home deals with their concerns, complaints and if they feel safe living there. The comments are included in the evidence text. “I have been informed of the complaints procedure and would complain to the manager or staff”. There is a written complaints policy and procedure that people who use the service confirmed they are aware of and access if required. Generally any complaints or concerns between people who use the service are resolved individually or during the house meetings. “My only complaint is that I can’t stay here longer”. The complaints records showed they are investigated and outcomes recorded. “I have been told of the outcomes of any complaint I have made”. “We discuss any problems as a group or individually depending on what they are”. The home does not tolerate abuse, bullying or intimidation of any kind and people who use the service are frequently reminded of this. An accident and incident book is also kept. “We know the house rules are for our benefit”. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 18 Currently there are no complaints or POVA issues. There was one last month that was investigated and no evidence found to support the allegation. POVA is the protection of vulnerable adults. There is an adult protection procedure that staff are familiar with and know how to initiate. Adult protection training is included in induction and refresher training and staff. This also covers abuse identification and what to do if encountered. The phone number of the Westminster City Council Safeguarding Team was clearly displayed on the manager’s office notice board. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 19 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 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. A safe, homely and comfortable environment is provided for people who use the service to live in. Everyone has their own bedroom and there are suitable shared areas that can accommodate everyone comfortably. EVIDENCE: Whilst meeting with people who use the service during the inspection, they commented about where they live and if they felt safe, comfortable and happy there. These comments are included in the evidence text. A tour of the premises showed the home is suitable for its stated purpose. It is comfortable, homely and safe. “I like living here it meets my needs,” said one person. Everyone has his or her own bedroom. “You can bring in stuff to make you feel more at home”. There are adequate communal areas that people can use comfortably including a back garden with sitting areas. “I make good use of the garden”. New carpets are in the communal areas and seven bedrooms Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 20 have been re-carpeted when people have moved out. Legionella was detected and treated during an annual test and the water pipes are flushed weekly as part of the treatment. The home was clean and hygienic. The outside of the building is being re-decorated. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 21 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 and 35. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are suitably trained, competent and diverse staff employed to meet the needs and wishes of people who use the service that have been properly vetted. People can be confident they are protected by the home’s robust recruitment policies and procedures. EVIDENCE: Whilst meeting with people who use the service and staff during the inspection, they commented about the staff and staffing at the home. These comments are included in the evidence text. Currently there is one person on maternity leave who is a fulltime project worker. A contracted agency worker is covering this post and the agency confirmed to the manager that they have been fully vetted. Use of a long-term agency worker provides familiarity and continuity of care for people who use the service. “Staff are well-trained, nice and supportive”. The organisation provides a thorough induction training and access to a rolling training programme to meet needs identified within monthly supervision and annual appraisal. Training courses include adult protection, boundaries, equality and diversity, health and Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 22 safety, IT and managing violence and aggression. Staff also have access to training provided by Westminster City Council. Over 90 of staff have achieved NVQ level 2 or above. Supervision takes place 10 times per year and a standing agenda item is individual training and development plan. Training needs are also identified during annual appraisals. One staff member is doing a City and Guilds award in community mental health. Staff meetings are weekly and one took place during the inspection. The staff rota demonstrated that staff ratios are adequate to meet the needs of people who use the service at all times. “Staff are there when I need them,” said a resident. There is a comprehensive recruitment procedure that protects people who use the service and meets all the criteria required by the standard. This includes CRB checks, taking up references and health checks. CRB is the Criminal Records Bureau. People who use the service are involved in staff recruitment at the interview stage and a training session took place on Monday to give them some practice by interviewing staff already in post. “I did the panel and interviewed one of the staff”. Care practice observed including when staff were unaware we were present and conversations with people who use the service indicated the staff team are competent, efficient and also friendly. “The staff are excellent particularly the life-skills worker” said a resident. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 23 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 and 42. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed in the interests of those who use the service and the quality assurance system is effective. Health and safety is well managed meaning that people who use the service live in a safe environment. EVIDENCE: Whilst meeting with people who use the service and staff during the inspection, they commented about the home’s management. These comments are included in the evidence text. The Care manager has extensive experience in the care field, focused on mental health and holds an NVQ 4 diploma in management of care studies. People who use the service that we spoke with said the manager was very Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 24 approachable. “I feel comfortable talking to the manager and staff if I have a problem”. They also feel the home is well run with their interests at heart. There is an identified health and safety officer and up to date health and safety risk assessments in place. Weekly fire alarm, call points and emergency lighting checks take place and the contractor visits 6 monthly. There are regular recorded fire drills and the fire fighting equipment had an annual check in June 2008. PAT tests on electrical equipment also take place annually and the last one was in April 2008. The accident book recorded one had taken place this month. Fridge and freezer temperatures are checked and recorded twice daily and hot water once per week. The building risk assessment is updated annually. The quality assurance system operated within the home, and by the organisation picks up shortfalls in the standards. It contains measurable performance indicators that are regularly reviewed. Part of the system is for homes to audit each other and staff carries this out with specific training for the task. Monthly provider monitoring visits also take place in conjunction with the Westminster Supporting People Team. Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 25 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 3 25 X 26 X 27 X 28 X 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 3 X 3 X 3 X X 3 X Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 (2) Requirement To protect residents from harm any gaps in recording of medication administered must have a written explanation. Timescale for action 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 27 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 Shirland Road, 93-95 DS0000010874.V364009.R01.S.doc Version 5.2 Page 28 - 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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