Inspection on 20/04/06 for 10 - 11 Rowan Close

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 - 11 Rowan Close 25/07/07

10 - 11 Rowan Close 18/10/05

10 - 11 Rowan Close 14/12/04

10 - 11 Rowan Close 28/06/04

10 - 11 Rowan Close 01/03/04

10 - 11 Rowan Close 28/04/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 10 - 11 Rowan Close Pilands Wood Bursledon Southampton Hampshire SO31 8LF Lead Inspector Debbie Oliver Unannounced Inspection 20th April 2006 10:30 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 - 11 Rowan Close Address Pilands Wood Bursledon Southampton Hampshire SO31 8LF 023 8040 7870 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) www.macintyrecharity.org MacIntyre Care Mr Matthew Reeves-Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: 10-11 Rowan Close is managed by Macintyre Care, and is registered to provide residential accommodation for six service users with learning disabilities. Comprising of two adjoining bungalows that mirror each other in size and layout, the home is accessible to wheelchair users and has been adapted to provide low kitchen surfaces, lowered light switches, specialist baths, moving and handling equipment and wide doorways. A sensory and herb garden is being established to one side of the property, with a patio and lawned area on the other. The home is located in a residential cul-de-sac, and is within 100 metres of local shops, a community centre and a church. The service also provides an unmarked minibus to provide transport for service users. Although requested from the manager on two separate occasions the home’s fees have not been given to the Commission. Information about the service provided at the home is made available to potential service users by providing a copy of the home’s service users guide, statement of purpose and the home’s brochure. A copy of the last inspection report is available in the office. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced beginning at 10.30 and finishing at 17.50. During the visit, records and documents were examined, an opportunity was taken to tour the premises and staff working practice were observed. Four staff and the manager were spoken to. Due to the nature of the service users’ disabilities it was quite difficult to talk to them but observation enabled the inspector to gain a better understanding of how the needs of service users were being met. On the day of the visit all six service users were at home. At the time of the visit there were no vacancies with six service users being accommodated, three were female and three were male. There were no service users from ethnic minority groups. No comment cards or pre-inspection questionnaire were received prior to the visit. What the service does well: What has improved since the last inspection? What they could do better: Each service user must have information in their plans describing how they show they are in pain and may need pain relief medication. This will ensure 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 6 service users are not left in unnecessary pain or given pain relief when there is another reason for their distress. Much work is still needed within the home such as the replacement of the kitchen, the replacement of the carpets, the replacement of the broken divan bed and repairing two broken fire doors. However it was confirmed by the home manager that in relation to the kitchen and the carpets there is a plan for these to be replaced. This work completed will ensure the service users continue to live in a safe and comfortable home. Generic and individual risk assessments must also be undertaken for any area of risk to service users or staff, and prompt action must be taken to ensure a safe working practice. 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. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s systems and procedures for identifying the needs of existing service users are satisfactory. EVIDENCE: No new service users have been admitted to the home. Three service users were case tracked and they had assessments of their individual needs and aspirations. This process is being developed further with assessments being undertaken by the Speech and Language therapist and communication passports are being devised so staff are fully aware what service users are trying to communicate. There was additional information such as assessment of physical needs in one plan and this showed the need for various equipment and these have been accessed. One service user also had information in their plan relating to visits made to the home prior to moving in. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 9 On observation throughout the day it was evident staff can meet service users’ needs. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a clear and consistent care planning system in place that adequately provides staff with the information they need to satisfactorily meet service user’s needs and this shows service users being able to make decisions about their lives. Risk assessments are in place and ensure service users are able to take risks as part of an independent lifestyle. EVIDENCE: Three service users were case tracked and the information available is person centred, including hopes and dreams, what is important to the service user and likes and dislikes. They also showed they were being reviewed on a regular basis, however there was no evidence to show service users are involved in these reviews. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 11 The information is detailed about each individual including communication needs and this showed that one service user enjoyed spending time with people. It was discussed with the manager that evidence should be available to indicate how the plans are working for people such as how hopes and dreams are being attained. The manager stated they were in the process of discussing this with staff at the next team meeting. One staff member spoken to said they are involved in the care plans and use them to assist service users and to refer back to as needed. The manager stated it has been difficult to put the care plans onto DVD format as it would be hard to review them and there is an extensive amount of information to put onto a DVD. However some service users have information on DVD’s relating to their likes. An advocate has started visiting the house and is getting to know the service users. She is currently visiting twice a month and accompanying service users on trips out. In discussion with staff, decision-making happens using photographs, Makaton and knowing service users’ non-verbal communication. Recently one service user chose the colour of her bedroom and took great delight in showing the inspector. Some service users are supported to make decisions with the help of their families and this was detailed in the plans. Evidence was seen within the files to support that risk assessments are available and that service users are supported to take risks including having a bath and eating. The manager is currently doing all the risk assessment but one of the senior staff members is booked on to the training and will assist once they have completed the training. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities to engage in suitable activities and are part of the local community, so promoting independence and choice. However record keeping must be available to evidence this. Contact with families is well supported, and nutritional needs of service users are well managed. EVIDENCE: The home has introduced an individual daily diary where staff are encouraged to record all areas of a persons’ day. On sampling three there was limited information concerning what activities have been undertaken. This was discussed with the manager who said this is on the agenda at the next team meeting. It was also discussed that personal information such as toileting habits should not be recorded in the daily diary for everyone to see and should be recorded in a more private place to protect the dignity and privacy of an individual. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 13 On discussion with staff they confirmed service users have been supported to go out for meals, to the circus and to shows. During the visit one service user showed the inspector their fancy dress outfit for a party that is being held to celebrate three service users’ birthdays. Another service user attends the local church on a weekly basis, with staff support. Contact with families is very positive. In one service users’ file it says regular contact with their family is very important and there was evidence to show this happens every three weeks. Additionally the home has purchased a speakerphone so they are able to hear their family when they ring the house. In an earlier inspection report it was identified that written consent must be obtained for the use of bedrails. There was a letter in the three files sampled to show the families consent and this is detailed in the relevant risk assessments. A four-week rotational menu was seen and offered a varied and nutritious diet and staff confirmed this was based on the likes and dislikes of service users. Staff also confirmed that alternatives are available if needed. Service users were observed having lunch and drinks and this was a calm and relaxed atmosphere. Staff were seen giving eye contact when assisting service users with their meals and told them what they were eating. Another service user was being supported to eat more independently and were having the food put onto a spoon and then picking up the spoon themselves without support. It is also detailed in the plans how individuals are supported with their meals. The food that was available for tea had been pureed individually for service users who needed this. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The personal, physical and health care needs of service users are well met but written evidence should be available to support this. There are good systems in place that ensures the medication needs of service users are also met. EVIDENCE: Care plans show how service users like to be supported in regard to their personal care, including their choice of staff gender. It is indicated this will be supported whenever possible but sometimes this may not be an option but states what happens in these circumstances. The manager advised that all service users have positive input from opticians, general practitioners, dentist and chiropodists but there was limited documentation to evidence this happens. The manager said this information is to be detailed in the daily diaries and will be discussed at the next team meeting. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 15 One service user was wearing glasses and they were clean and well looked after. The staff on duty confirmed their family support them to attend the opticians. The home has a policy on medication but needs to obtain a copy of The Royal Pharmaceutical Society Guidelines. All the relevant documentation is in place relating to receiving, administering and disposal of medication and the inspector viewed this. There was a discussion with the manager that a running total of ‘as required’ medication should be kept so as to see how much an individual is taking during a 28 day period. It was also discussed that as the service users living in the home have limited verbal communication it needs to be detailed in their plans how they show they are in pain as there was no information available on how staff know service users are in pain and as a consequence when they would administer pain relief. This could mean a service user would not receive pain relief when they required it. The manager agreed to include this. All staff receive training through Lloyds pharmacy and the administration of medication is also assessed within the home. The inspector saw samples of certificates. None of the service users in the home self-administer. Since the last inspection all staff have received training in administering rectal diazepam and suppositories and the records for this was seen. Additionally each service user who has epilepsy has a risk assessment in place showing what support is needed in the event of having a seizure. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for protecting service users and responding to concerns are generally satisfactory. EVIDENCE: The manager confirmed there have been no recent complaints or allegations of abuse. All staff have received training on adult protection and the staff spoken to were clear on the procedure to follow in the event of suspected abuse. One staff member spoken to said ‘The training was very useful’. The home had the relevant procedures and policies and the manager demonstrated their knowledge and understanding of the policy. However the manager agreed to obtain the updated adult protection policy published in October 2005. The complaints procedure is available, in a pictorial format for service users. All staff spoken to were clear on what to do if they received a complaint or had a complaint themselves. The complaints log was also seen and showed clearly the details of old complaints and the action taken but it was discussed with the manager who took the complaint should also be included to assist with auditing if needed. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a clean, hygienic home that generally meets their needs, however the identified deficiencies could compromise the safety and comfort of the service users. EVIDENCE: A tour of the premises showed that since the last inspection there has been improvements within the home. This includes: The two electric raiser beds have been repaired All the bedroom furniture that was in a bad state of repair has been replaced or repaired. A new fridge and freezer has been purchased. The WC with the leak has been repaired. The sensory room has been decorated and was being used on the day of the visit. The laundry room floor has been repaired and the laundry room was clean and tidy. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 18 Additionally the colours have been chosen by the service users for the carpets that need replacing and the home is now waiting on a date for them to be replaced. It was discussed with the manager this will remain a requirement until this has been completed. Staff are working with service users to see who wants easy chairs and they will then be purchased. One staff member is in the process of planning a sensory garden. They have already purchased many items and showed the inspector the plans. This will be of benefit to service users as some have sight difficulties and the garden will be adapted to suit individual service users with strong smells and plants that can be touched. The manager is currently organising time for the staff member to be off shift and spend time working specifically in the garden. The main kitchen is still out of action but the manager confirmed a new kitchen has been chosen and they are waiting for a date for this to be fitted. This will remain a requirement. Additionally a new table has been ordered with the kitchen. The other kitchen is satisfactory and is being used for all the service users at the current time. It was also noted that the divan bed for one service user had not been replaced and this was ripped at the sides with all the springs showing. Also there was an ill-fitting mattress on the bed. It was made clear to the manager this is not acceptable as it was likely to be very uncomfortable for the service user and must be replaced. On speaking with staff they felt there had been many improvements but more was needed such as a new kitchen. Some also felt the ‘walkie talkies’ being used, as a means to call staff were not appropriate as it was hard to hear people and there was interference. They felt the original call system was a more appropriate system. It was agreed with the manager an evaluation should be undertaken to determine the best system to summon help in the case of an emergency, especially when there are only two staff members on duty and at night. The home has an infection control procedure and protective clothing was readily available and staff were observed using it appropriately. The premises were clean and free from offensive smells at the time of the visit. A cleaning rota has been devised and is being adhered to. The inspector saw the rota. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has procedures and systems in place that ensure staff are properly recruited and that there is always enough staff on duty. Staff training is appropriate which, ensures staff have the necessary skills and knowledge to meet the complex needs of service users accommodated in the home. EVIDENCE: From observation and discussion with staff members, they have built good relationships with service users and have a good understanding of their behaviours. Since the last inspection all staff have now received training in administering rectal diazepam and general epilepsy training. The inspector saw some certificates. Two staff were spoken to and confirmed they have received mandatory training including food hygiene, first aid, health and safety and manual handling and the records reflected this. There is now clear documentation to show who has received training and who is soon due an update. Staff have 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 20 also received training specific to the needs of the service users including communication and challenging behaviour. Eight staff have also completed, have started or are about to start either a National Vocational Qualification (NVQ) or The Learning Disability Awards Framework (LDAF). Staff members spoken with said they are regularly supervised and felt supported by the management. There was adequate staff on duty at the time of the visit and staff spoken to confirmed this. The inspector sampled three staff files and they contained all the necessary information relating to recruitment with the exception of one. The manager stated this is kept in head office and whilst this is acceptable there needs to be confirmation in the home the relevant checks have been undertaken. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The management of the home is more organised and efficient, although additional work on risk assessments is required to fully promote the health and safety of service users and staff. The new quality assurance system will ensure that the views of service users and that of their families are acted upon. EVIDENCE: The registered manager has been in post since May 2004 and is currently undertaking NVQ level 4 and the registered managers award. Discussion with the manager evidenced a number of training courses he has attended to update and expand his knowledge. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 22 Maintenance issues are now recorded in a file clearly indicating the jobs that need to be done or those that have been completed. The policies seen are in place and up to date and staff access them as needed. There was an issue with a service users’ bedroom door not shutting properly and this is a fire door. It was made clear this must be fixed and in the mean time the manager agreed to put up a notice reminding staff to check the door is closed, especially at night. All staff have been trained in fire safety. Other records of fire checks identified everything to be satisfactory. All mandatory training has also been completed. It was discussed with the manager that general health and safety risk assessments such as driving the house minibus and night time security must be put in place to further protect staff and service users. Records indicated that systems and equipment in the home are tested and serviced including, portable electrical appliances, boilers and central heating and electrical wiring. Systems are in place to review and monitor the service including monthly visits from the service manager, a copy of these are sent to the Commission. Staff meetings are held on a regular basis and show where action has been taken. The manager confirmed comment cards were sent to families two weeks ago and are currently waiting for a response. He stated any actions resulting from these comment cards would be addressed on an individual basis via letter. There are also comment cards for service users and it was agreed that in time the advocate would be able to assist with this process. The service plan was also seen showing actions throughout the year such as training and recruitment. A staff member said a suggestion box would be useful for anyone connected to the home to put forward ideas and this was passed to the manager. The accident book was not viewed on this occasion but there have been no recent regulation 37 notifications that have given cause for concern. 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 2 X 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23(2)(c) Requirement The registered manager must ensure the broken divan and mattress for one service user is replaced. The main kitchen area must be refurbished. Previous timescales of 30/09/05 and 01/02/06 not met. 3 YA24 23(2)(d) Badly stained carpeting in communal areas and bedrooms must be replaced. Previous timescale of 31/12/05 not met. The registered person must ensure the fire doors that do not shut properly are repaired promptly. The registered manager must undertake generic and individual risk assessments for any area of risk to service users or staff, and must take prompt action to ensure safe working practice. 20/07/06 Timescale for action 20/06/06 2 YA24 23(2)(b) 20/10/06 4 YA42 23(2)(b) 20/05/06 7 YA42 13(4)(C) 20/07/06 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 25 Previous timescale of 30/11/05 not met. 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 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 10 - 11 Rowan Close DS0000012378.V289272.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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