Inspection on 06/02/06 for 137b Tentelow Lane

This inspection was carried out on 6th February 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

137b Tentelow Lane 26/07/07

137b Tentelow Lane 05/02/07

137b Tentelow Lane 19/05/05

137b Tentelow Lane 28/01/05

137b Tentelow Lane 27/05/04

137b Tentelow Lane 03/02/04

137b Tentelow Lane 10/09/03

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 08/07/2008.

CARE HOME ADULTS 18-65 137b Tentelow Lane Norwood Green Southall Middlesex UB2 4LW Lead Inspector Sarah Middleton Unannounced Inspection 6th February 2006 10:25 137b Tentelow Lane DS0000027764.V278366.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 137b Tentelow Lane DS0000027764.V278366.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. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 137b Tentelow Lane Address Norwood Green Southall Middlesex UB2 4LW 0208 893 6635 0208 893 6635 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mr Charles NII Ashong Mettle Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: 137b Tentelow Lane is a home for four male service users with learning disabilities. The owner and provider is Milbury Care Services. The home is a four bedroomed, semi-detached house, located on a busy road between Southall and Hounslow. There are local shops nearby and Southall, Ealing and Hounslow shopping centres can be accessed by car. There is a house car for both 137b and the adjoining care home, (137a). There are no bus or rail routes close by. The adjoining house is for four female service users. There is a joint staff team for 137a and 137b Tentelow Lane. 137b has four single bedrooms. One is on the ground floor and has its own shower. There is a shared toilet nearby. One first floor bedroom is en-suite, with its own bath. The two further bedrooms on the first floor share a bathroom and toilet. The lounge, dining room, kitchen and laundry room are located on the ground floor. The office is on the first floor. There is a rear garden, which is mostly lawn with a patio area. There are parking spaces for both homes to the front of the house. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of almost four hours, 10.25am-2.05pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service users plans, staff files and maintenance records. Two members of staff were spoken with as part of the inspection process. The majority of service users were out of the home during the inspection. The Inspector briefly saw three service users. There were no visitors present at the time of the inspection. It must be noted that it is sometimes difficult to ascertain the views of service users who have various learning and communication disabilities. The Registered Manager was not present during the inspection. The Deputy Manager assisted the Inspector with the inspection process. There were no service user vacancies and at approximately one staff vacancy. These vacant staff hours are covered by the permanent members of staff or the regular relief staff who are familiar with the service users. This report should be read in conjunction with the previous inspection report dated 19th May 2005. Key and additional standards were inspected at both the previous and this inspection. Both of the previous requirements had been met and nine new requirements were made following this inspection. What the service does well: The service offers an active social life for service users and provides opportunities and experiences for service users on a daily basis. The home has sufficient numbers of staff to offer many service users one to one support and time throughout the week. Service users are encouraged to make decisions and choices in their lives and staff work together in the interests of meeting service users requests and preferences. Overall the home offers a warm and welcoming home for service users, some of whom have lived there for many years. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home has begun the process of developing essential lifestyle plans, that are more person centred, alongside more traditional care plans. However the care plans viewed did not give a full picture of individual service users needs. These must be detailed in order to inform staff on how they need to encourage and support service users appropriately. Risk assessments must be completed on any potential risk or hazard identified by members of staff. It had been noted on several fire drills/practices that one service user, who has a hearing impairment, did not respond effectively to the fire alarm being set off. This must then be followed up by highlighting the risks in a care plan and risk assessment, as staff are then always reminded and aware of the potential hazards in a service users life. Meals had been recorded, including when service users had eaten an alternative meal, however staff had not recorded when service users had eaten a meal out in the community. This must be documented in order to show service users diet and to ensure they are eating healthily on a regular basis. Health needs had not been clearly identified on care plans viewed. Health needs, such as maintaining oral hygiene, must be documented to ensure staff are aware of any problems or issues in meeting particular health needs. The home has a duty of care to ensure they meet or aim to meet any identified need. If there are any issues in meeting individual health needs, this must be evidenced on the care plan, with appropriate risk assessment also completed. The flooring in both first floor bathrooms needs replacing. In one bathroom the flooring was lifting and in the other it looked old and was not fitted correctly. Furthermore the dining room carpet had a small hole in it that was clearly visible. These shortfalls must be addressed as they can affect the presentation of the home and do not look inviting for the service user or visitor. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 7 The Registered Person must ensure there are staff photographs on staff employment files. Finally servicing records must be up to date, such as the testing for Legionella and Portable Appliance testing in order to safeguard service users and visitors. 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. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 8 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 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 9 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): 3&4 The home has a suitable mix of staff who have various experiences and skills in order to meet the needs of the service users. Prospective service users are encouraged to visit the home in order to make an informed choice. EVIDENCE: The majority of the service users living in the home have resided there for several years. Staff have the necessary skills, experience and qualifications to meet the needs of the current service users. Some staff were seen to speak in another language than English to a service user. The Inspector was informed that for this particular service user, they understood and often responded to staff than if they were spoken to in English. Staff receive training on specialist subjects, such as Autism, in order to meet the needs of the service users. The Deputy Manager confirmed that where possible, service users, their relatives and any representatives are encouraged to visit the home and have over night stays prior to moving into the home. The Deputy Manager stated that the last service user admitted into the home had visited the home several times and had met with the other service users and members of staff. 137b Tentelow Lane DS0000027764.V278366.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 & 9 Some of the health and personal care needs of service users had been identified and were being met. However care plans did not completely provide a detailed enough picture of service users needs. These must be comprehensive and relevant in order for staff to know how to support and care for the service users. Where possible, service users are encouraged to make decisions about their every day lives so that they benefit from making choices and they can feel empowered. Overall risk assessments were in place and identified how to minimise potential hazards in a service users life. However the home must ensure they have identified all risks that are individual to a service user, as there was a shortfall in evidencing how staff can support and inform one of the service users more effectively when the fire alarm has been set off. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 11 EVIDENCE: Individual service user plans were available and samples were viewed. These contained an essential lifestyle plan, which documents service users preferences, routines and things that are important to them. In addition care plans were also completed regarding the service users needs and where possible service users or relatives are involved in devising or reviewing care plans. Those care plans viewed did not sufficiently evidence a full picture of an individual’s needs and how these needs would be met. This shortfall was discussed with the Deputy Manager and a requirement was made for the home to address care plans. Reviews had taken place and service users and family members were invited to attend and contribute to these reviews. In addition, service users met with their keyworker every few months to look at the care plan and identify any concerns or interests the service user might have. Daily records were viewed and overall these were detailed offering relevant information to staff members regarding the service users mood and any activities they had taken part in. The home has introduced a meeting between one service user who is able to verbally communicate thoughts and ideas to Management. The aim of this meeting is for this service user to attempt to represent the views of all the service users living in the home. This has only just been introduced and is too early to say if it will prove successful. Staff aim to promote service users to make decisions and give them every opportunity to make choices about their daily lives. Staff spoken with could describe how service users let staff know if they are happy with options put to them and when they do not want something that is offered to them. Staff are confident they understand what service users communicate to them, as they look for body language and gestures, if the service user cannot verbally communicate to them. Where they are not so sure, they will offer suggestions to the service user with the aim to identify exactly what they want. Risk assessments were in place and overall covered a range of potential hazards in a service users life. These had been reviewed and altered where necessary. The Inspector had noted that one service user, who has a hearing impairment, had difficulty in knowing how to respond in the event of a fire drill or real fire. They have a light in their bedroom, that will flash when the fire alarm is being set off, however they do not leave the home as other service user do. This is a requirement as the problem had not been highlighted on a risk assessment, this must be completed and also noted on their care plan. 137b Tentelow Lane DS0000027764.V278366.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, 14, 15 & 17 Social activities are in place and offer service users variation, stimulation and occupation throughout the day. Often service users receive one to one time with a member of staff and so have the encouragement and attention they often need to engage in an activity. Appropriate leisure options are provided by the home and service users have the chance to have holidays and day trips away from the home and their usual routine. Visiting is encouraged for service users to maintain contact with family and friends. Meal provision is varied and offers service users the opportunity to choose the meals they want to eat. Staff must record meals eaten in the community to ensure service users are eating a well-balanced and nutritious diet. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 13 EVIDENCE: The home offers service users a full and varied activity programme. The service users are not able to seek employment. Several service users attend day centres or local colleges. Often during the week service users have one to one with a member of staff, who might take them out to do personal shopping or for a long walk. Where possible, service users are also encouraged to assist with cleaning their room and doing their personal laundry. Staff are aware of the activities service users enjoy taking part in and incorporate these into the week. Each day is planned by Management to ensure all members of staff know what each service user is doing for the day and who is to support the service user for each activity. Local leisure facilities are accessed, such as the pub, bowling or swimming. Service users all have holidays with the support of staff and occasional day trips are planned throughout the year. Service users who have relatives are supported to see them either in the service users home or at the relative’s home. Visiting times are flexible for visitors. The kitchen was viewed during the inspection and was clean and tidy. Fridge/freezer temperatures had been taken daily and were within an appropriate range. Fresh produce was seen and is used in meals. Service users each have a day where they can choose what the main meal will be for the day. The lunch was sampled by the Inspector and was tasty and nutritious. Halal food is purchased for one service user. It was noted that on some occasions where service users have eaten an alternative meal it is recorded. However when service users go out in the community for a meal staff have not been recording what the service user ate. This must be documented and is a requirement. 137b Tentelow Lane DS0000027764.V278366.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 & 20 Service users receive personal support in a respectful and private way. Overall service users health needs are being met, however there must be clear evidence through documenting on a care plan and, where appropriate, a risk assessment, the service users individual health needs and how these needs are to be met. Medication systems in place are robust and aim to safeguard service users health and safety. EVIDENCE: Service users routines are noted and staff are aware of the support service users need regarding ensuring their personal care needs are met. Personal support is provided in private and times for getting up and going to bed are flexible. Staff working in the home are a mix of gender, age and ethnic background. Male members of staff mainly work in the home, as all of the four service users are men. The Deputy Manager stated the Registered Manager is hoping to employ in the future more male members of staff. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 15 Most service users health needs are being met through various health care professionals being accessed on a regular basis, such as GP’s, Chiropodists and Psychologists. However some health needs, such as maintaining oral hygiene, had not been noted on care plans and this shortfall must be addressed and is a requirement. Samples of the medication administration records were tracked. The records viewed had been correctly completed. Service users are not able to self medicate. The home did not have any service users on controlled drugs at the time of the inspection. All medications were appropriately and securely stored. Staff receive training on administering medication and a new member of staff spoken with confirmed they had not received training yet and so did not administer medication to service users. 137b Tentelow Lane DS0000027764.V278366.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 & 23 The home has a clear complaints procedure and for at least one service user they would be able to make a complaint. It is difficult to assess how the other service users would be able to let staff know if they were unhappy about something. Systems were in place for the protection of vulnerable adults. Robust procedures are in place to safeguard service users finances. EVIDENCE: The home has a detailed complaints procedure that is freely available. There have been no complaints recorded. One service user could raise concerns and complaints to members of staff, however, it is not clear if or how the other three service users would be able to make a complaint due to their communication needs. The home has not had any protection of vulnerable adults, (POVA) investigations. Staff had received training on POVA and were aware of how to respond in the event of a POVA situation and would report any concerns to Management. Two service users finances were counted and were correct at the time of the inspection. 137b Tentelow Lane DS0000027764.V278366.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, 26 & 30 The service users live in a home that is comfortable and safe. However the flooring in both of the first floor bathrooms needs replacing and the dining room carpet must be made good or replaced, in order to offer a hygienic and presentable home for service users and visitors. Service users bedrooms are spacious and personal to the service users individual preferences. Overall the home was clean and well maintained by the staff team, which aims to offer a pleasant environment for service users to live in. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. In one of the service users en-suite bathrooms the flooring was lifting off and was in need of replacing. Additionally the main bathroom flooring had been poorly fitted and also would need replacing. A requirement was made regarding these two rooms. Overall the home was bright and tidy at the time of the inspection. The lounge had suitable furnishings and lead onto the garden. The dining room carpet had a small hole as you entered the room and would need replacing or made good, this is a requirement. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 18 The home is near to amenities and local transport and offers service users the opportunity to go for long walks and to use public transport. Samples of service users bedrooms were viewed and had been personalised with service users personal possessions. These bedrooms were single and offered service users the opportunity to have a private space to relax in. The home was clean at the time of the inspection and staff maintain the cleanliness of the home. Laundry facilities are located in a separate room and staff support service users with washing their laundry. Hygiene is promoted through the use of paper towels in the toilets to dry hands and hand soap being available. 137b Tentelow Lane DS0000027764.V278366.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): 32, 33, 34, 35 & 36 Service users are supported by competent staff who are encouraged to study NVQ courses. The staff team is stable and works well together for the benefit of the service users. Overall the recruitment procedures are robust and protect service users. However there must be a photograph of each member of staff employed to work in the home. Training is offered on a variety of subjects in order for staff to meet the needs of the service users. Service users benefit from staff who are supported on a regular basis and receive one to one time to discuss any issues and/or to reflect on their practice. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 20 EVIDENCE: The staff team comprises of staff who have various knowledge and experience, with some having worked in the home for several years. Staff observed were able to communicate effectively with the service users and those spoken with were enthusiastic and committed to work in the interests of the service users. The home recognises the cultural and religious needs of some of the service users and seek to meet their particular needs and beliefs. The home has several members of staff who have either obtained an NVQ or are in the process of completing this course. Staff spoken with felt there were sufficient numbers of staff working in the home at any one time. Often there is an additional floating member of staff to assist with activities. One member of staff spoken with had recently joined the team stated they had been supported by the staff team throughout their induction. Staff said the team work well together and communicate successfully. Permanent members of staff or regular relief workers cover staff vacant hours in order to provide a consistent approach. The home has ceased to use agency members of staff a long time ago. Regular staff meetings are held for staff to meet and discuss any issues or to look at ways to work and support the service users. The staff employment files viewed contained details of the applicants completed application forms, Criminal Record Bureau checks, medical declaration and references. The files viewed did not contain a recent photograph of the members of staff, this is a requirement. Training programmes were viewed and demonstrated that the staff team attend mandatory courses, such as health and safety and first aid. Other specialist courses are available for staff for example on mental health and autism. In addition the Registered Manager also runs workshops for all members of staff on various topics such as report writing. A workbook used to induct a new member of staff was seen. This covers different subjects that are relevant for staff to be familiar with. The Managers then check the new staff member has worked through these sections and signs the workbook. This process enables Management to know exactly what the new member of staff has been informed of and areas that might still need attention in the future. Staff spoken with stated they received regular one to one supervision from their line manager and that this was supportive and useful for their professional development and to seek advice and guidance. 137b Tentelow Lane DS0000027764.V278366.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): 38 & 42 Service users benefit from the open and flexible approach of the Registered Manager, who supports both staff and service users on a daily basis. The shortfalls in the servicing records could pose a risk to service users, staff and visitors. These must all be up to date and available for inspection. EVIDENCE: The Registered Manager was not present during the inspection, however staff spoken with commented on how he is approachable and supportive to the staff team. There is a clear sense of leadership and he maintains a visible presence in the home. Servicing records were viewed at random. Water temperatures had been taken on a weekly basis and were within an appropriate range. Fire drills had been carried out on a regular basis and with different members of staff. 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 22 Please note the earlier comment and requirement regarding ensuring all service users know how to respond in the event of a fire and risk assessments, where necessary must be completed, on service users who fail to recognise the fire procedure. The Gas Safety record was up to date but the testing for Legionella and Portable Appliance testing was out of date, requirements were made regarding these shortfalls. 137b Tentelow Lane DS0000027764.V278366.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 x 3 3 4 3 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 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 4 13 x 14 4 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x x 3 x x x 2 x 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Timescale for action 30/03/06 2. YA9 3. YA17 4. YA19 5. 6. 7. 8. 9. YA24 YA24 YA34 YA42 YA42 Care plans must detail how the service user’s identified needs in respect of their health and welfare are to be met. 13(4)(c ) Risk assessments must be completed on all potential hazards in a service user’s life, e.g responding to the fire alarm. Schedule 4 There must be a record of food eaten by service users, to include when they eat out with staff in the community. 12(1)(b) Service users individual health &15 needs and how these are to be met must be clearly evidenced in care plans. 23(2)(b)(d) The flooring for both bathrooms on the first floor must be replaced. 23(2)(b)(d) The dining room carpet must be made good or replaced. Schedule 2 There must be a photograph of each member of staff on their employment files. 13((4)(a) The testing for Legionella must be up to date and available for inspection. 13(4)(a) The testing of Portable Appliances must be up to date and available for inspection. DS0000027764.V278366.R01.S.doc 28/02/06 07/02/06 30/03/06 31/05/06 31/05/06 28/02/06 30/03/06 30/03/06 137b Tentelow Lane Version 5.1 Page 25 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 137b Tentelow Lane DS0000027764.V278366.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 137b Tentelow Lane DS0000027764.V278366.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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