Inspection on 11/01/06 for 17-19 Edgeware Road

This inspection was carried out on 11th January 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 but made no statutory requirements on the home.

Other inspections for this house

17-19 Edgeware Road 21/07/06

17-19 Edgeware Road 06/07/05

17-19 Edgeware Road 17/01/05

17-19 Edgeware Road 06/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 17-19 Edgeware Road Staple Hill South Glos BS16 4LZ Lead Inspector Grace Agu Unannounced Inspection 11th January 2006 09:30 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 17-19 Edgeware Road Address Staple Hill South Glos BS16 4LZ 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) 0117 957 0404 0117 9570404 Aspects and Milestones Trust Mr Alan Nuttall Care Home 17 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (17) of places 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 17 persons aged 19 years and over requiring personal care. May accommodate one named person with a Physical Disability (PD). Will revert back to LD when named person leaves. 7th July 2005 Date of last inspection Brief Description of the Service: The houses at 17-19 Edgware Road are properties run by Aspects & Milestones Trust, which is referred to in the report as The Trust. The houses at 17-19 Edgware Road were first registered as a nursing home for people with learning disabilities. However the registration changed in 1996 with the changing needs of service users to that of a Care Home. The houses are purpose built with off street parking. The Home is registered for seventeen people. The Edgware Road accommodation consists of seventeen single rooms split between the two houses. These are separately run. Each has it’s own staff group and is independent of the other with it’s own kitchen, dining /lounge and bathing facilities.There is a garden at the rear of the building that provides a small paved area for each house. Beyond this there is a larger, shared garden. The home is in a quiet cul-de-sac in a wellestablished residential area. The shopping area of Staple Hill is very close by with full public amenities. Staple Hill is on a main bus route to the city of Bristol. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over five and a half hours and was undertaken to review the care practice to ensure that it is in line with the legislation and that best practice is being followed at the Home. It was also undertaken to review the requirements made at the last inspection to ensure that they have been met. In addition to the above, the inspection was undertaken to review the care needs and recommendations for three residents with complex needs in relation to the Regulation 37 notification, which were sent to the Commission for Social Care Inspection. The inspections was an opportunity to followed up a proposal sent to the Commission in relation to alterations to be made in the facilities at the Home. The Home proposes to use one dis-used toilet on the ground floor for storage and that a training kitchen presently not being used, is utilised as an office space for residents’ records and work area for staff. The Commission for Social Care Inspection had approved this after discussion and re-assurance with the Manager. The Manager confirmed that the home had adequate numbers of toileting facilities to meet the needs of the residents. The areas to be used were seen and were noted to be satisfactory. As a part of this inspection one immediate requirement was made in relation to staff undertaking fire drills to ensure that all staff are familiar with actions to be taken to protect the residents in event of fire emergency. A tour of the building was undertaken and a number of records were viewed. Six residents and four staff members were spoken with during the inspection. What the service does well: Generally the Home was found to be clean, tidy, and warm with a good atmosphere. The residents looked well cared for and staff were noted respecting and acknowledging each resident’s individuality in different ways. During a discussion with the Deputy Manager, she stated and it was also evident that the Home provides person centred care planning for all the residents. Residents’ families, friends and visitors compliment on the atmosphere and homeliness Edgware Road offers for its residents. Residents are naturally included in conversations and everyday running of the home. The home empowers people to live fulfilling independent lives as much as 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 6 practically possible. During the inspection residents were noted being encouraged to perform simple tasks to include making a cup of tea. What has improved since the last inspection? What they could do better: At this inspection one Immediate Requirement was made. Review of staff records and fire log- book evidenced that staff have not attended fire drills. The home must ensure that staff attend regular fire drills to familiarise themselves with actions to be taken to protect residents in a real fire emergency. The home must ensure that the full details of the Commission for Social Care Inspection are included in the complaint procedure given to residents. In order to protect residents from harm cleaning liquids must not be left in the hallways unattended. Please contact the provider for advice of actions taken in response to this 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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): 2, 5. The Home ensures that prospective residents are adequately assessed before admission to the Home. EVIDENCE: Whilst the Home had no recent admissions, it was evident from the files reviewed that the Home’s process of admission is comprehensive. Residents are assessed before admission through the Social Services Care Management Team. The home ensures that a detailed individualised care plan is in place for all assessed needs. A copy of the Terms and Conditions of their stay were noted in the care files viewed. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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. Risk assessments are in place to enable residents to live independent lifestyles. Individualised care plans are provided to ensure that assessed needs are adequately met. EVIDENCE: Three care files were reviewed. Each care file had a person centred plan in relation to different aspects of their lives and more importantly their complex needs. One resident with complex problems had risk assessments in place and a care plan detailing how staff were to meet his/her needs. Evidence noted on the file showed that the resident was involved in formulating the ‘care plan’ and the reviews. The Deputy Manager during a discussion stated that the resident is much better and that the home is considering changing his/her day care provider to ensure adequate protection. Another resident with a deteriorating mobility problem, had a detailed care plan on how staff were to assist her/him and actions to be taken in the event of change in her needs. The Deputy Manager stated that the resident may need a nursing home placement in future and would ensure that the resident and a care manager are fully involved in the decisions making process. The 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 11 resident when spoken with stated that ‘the staff are looking after me, I am happy here’. Residents spoken with confirmed that staff encouraged and enabled them to make daily choices. Some of the statements made by residents include, “I make my bed”, “staff help me have a bath”, “I decide if I want to go out”, and “I go out with my key workers”. One staff member stated that one particular resident “wants to be included in the every day running of the Home”. We make sure that he/she is involved, “staff know him/her very well”. All the care files reviewed had risk assessments in place to include shopping, using the kitchen, laundry and going out with friends. Staff were noted interacting with residents in a sensitive and dignified manner and demonstrating understanding of the various needs of the residents. One staff member was noted handling difficult situation involving a resident in a professional and skilled manner. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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, 14, 15, 16, 17. Residents are supported to maintain contact with families, friends and community. Their individual rights are respected whilst providing healthy diets at chosen times. EVIDENCE: Evidence from discussions, reviews of the care files and the information seen in the visitors’ book in both houses confirmed that the home supports the residents to keep in touch with families, friends and representatives. One resident spoken with stated that ‘Mum and Dad’ visit on Fridays. She looks forward to seeing her parents. She would usually go to see them on planned weekends with the support of her key worker. The home enables and supports residents to participate in activities based on individual assessment and capabilities. Evidence from the activities programme noted at the home showed that one resident attends regular aromatherapy and attends College on Mondays, participates in games on Tuesdays and attends community group on Wednesdays. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 13 Another resident attends day centre at Almondsbury on Monday, Tuesday and Wednesday. One resident spoken with stated that he visits the pub on her own and staff support her to visit the Bank to withdraw money. Another resident stated that she attends Chipping Sodbury Day Centre for group work. “I work on Thursdays and get paid for it”. She recently visited Devon for a holiday with her key workers, “I also go out shopping”. The Deputy Manager during a discussion stated that one resident with complex behaviour had a special month of planned activity to support them due to their complex need in order to support them. The staff had a meeting in relation to this resident’s behaviour and it was decided that staff take him/her to different events to a major city once a month. The activities are put in a graph and posted on their wall. The aim of this is to enable the home and the resident to decide which activity works and is more appropriate. The residents’ menu was reviewed and was found to be satisfactory. Residents interviewed stated that they are supported to use the kitchen and participate in planning the menu. Some residents were noted making cups of tea in the kitchens with the support of staff members. Some of the comments made by residents include, “I help out with cooking”, “I help out with the washing up, I can make a cup of tea” and “I do my own laundry”. The kitchen was found clean and tidy. The stains noted under the kitchen sink at the last inspection had been fully removed however; it may need to be painted over to present a better kitchen décor. The laundry area was found to be clean and satisfactory. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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, 21. Residents receive preferred support as required, their emotional and physical health needs are met, also respect is given to their wishes in the event of death. Medication practices at the Home protect the residents from potential harm. EVIDENCE: The care files reviewed described detailed evidence of the level of support each individual receive at the Home in relation to their personal care. One resident spoken with stated, “Staff help me to have a bath”. Another resident stated that “I can wash and dress myself, I make my own bed, staff are kind to me, and they let me do things for myself”. One resident recently discharged from hospital with an increased need, had reviewed and updated care plans in place to ensure adequate support. The Deputy Manager stated that the resident may require nursing home placement in future, the home would ensure that the resident along with a care management assessment is involved in the decision making when the time comes. The resident was noted mobilising at the time of inspection and confirmed that they are happy at the home and well supported by staff to live as much an independent life as is practicably possible. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 15 There was evidence that residents have their General Practitioners (GPs) and are supported to access this service. On the day of inspection, one resident was noted asking a support worker to arrange a GP visit due to the chest infection. This was immediately arranged. It was also noted through the care files that residents have access to other health professionals to include chiropodist, dentist and opticians. There were regular medications reviews. Medication administration was reviewed and discrepancies noted were remedied before the end of the inspection. Systems were in place to support a resident to self-medicate at the home. The home had death and dying policy and details of resident’s choices and wishes in the event of their death were noted in the care files reviewed. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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. Complaints are investigated and action taken as necessary, however, the procedure fails to offer options for unsatisfactory complaint outcome. EVIDENCE: The Home had a complaint procedure displayed at the entrance of both houses. Each resident had a copy of the complaint procedure in their care files and are supported by their key-workers to complain. Whilst this procedure is written in a picture format suitable for the category of residents, however, it fails to provide information about the Commission for Social Care Inspection to enable the residents to complain if they were not satisfied with the organisations outcome of their complaint. The complaint book showed recorded complaints on 09/12/05. Information seen demonstrated that appropriate action was taken by the home to prevent further occurrence. The Commission received a Regulation 37; this was followed up at the inspection. The incident was discussed with the manager and the inspector is satisfied that appropriate action was taken to ensure the protection of the vulnerable adult. Staff have attended abuse training and are aware of their responsibilities in regard to bad practices. The home has policies and procedures in relation to protection of vulnerable adults. The Home’s recruitment procedure is satisfactory. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 17 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 18 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, 27 and 30. Residents are provided with a comfortable, clean and hygienic environment. There are adequate toilet and bathroom facilities to meet their needs. However, the home must ensure safe environment at all times. EVIDENCE: The Commission for Social Care Inspection received a proposal from the home in order to alter the use of the ground floor training kitchen for office use. This will enable the home to provide storage for residents’ files and staff work area. The home also proposed to alter the use of ground floor toilet for storage facilities for food and vegetables and also to house a freezer and large fridge that both houses can access. Following confirmation from the Manager that the above proposals will not affect the toilet and general facilities at the home the Commission for Social Care Inspection have approved these proposals. The home was found safe, tidy, clean and free from unpleasant odours. However, whilst touring the building, it was noted that cleaning liquids were noted unattended on the middle floor corridor. This is hazardous and poses potential risk to the residents. A requirement was made to ensure that this practice is not repeated. Residents were noted accessing different areas of the Home without restrictions. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 19 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 20 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, 34, 35, 36. The Home has skilled and competent staff that are well supervised to meet the needs of the residents. EVIDENCE: On the day of inspection, the home had adequate numbers of staff to meet the needs of residents at the Home. Staff on duty-demonstrated knowledge of the needs of the residents. One staff member spoken with stated that some residents have gone out to different day centres and day care services. Residents were noted interacting with staff informally. One resident met whilst touring the building stated that they are waiting to have a bath and staff supported to them when they asked for assistance. There was evidence of staff training, which included Person Centred Planning, Appointed Persons First Aid, Health and Safety, Fire Lectures, Abuse Training and Control of Substances Hazardous to Health Training. Training proposals for 2006 include approaches to Autistic People, Care of the Elderly training for the whole staff team at No 19, Person Centred Planning Methods and Essential Life Planning for the Home Manager, Deputy and Assistant Home Managers. There is evidence of staff supervision the records viewed; staff interviews and discussions with the Deputy Manager confirmed this was being undertaken. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 21 Appropriate and satisfactory procedures are in place for recruitment of new staff members. One staff member spoken with stated that they had been transferred from another Home owned by Aspects and Milestones and those they had been with the Organisation for many years. They had appropriate induction at Edgware Road to ensure they are familiar with the needs of the residents. There was evidence of good team building at the home. Staff were noted interacting with each other in a professional manner to ensure that residents receive appropriate care. The Deputy Manager stated that staff attend various staff meetings. Away days are organised to discuss different needs of the residents. At these meetings staff are encouraged and supported to familiarise themselves for meeting the complex needs of the residents including behaviours which challenges. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 22 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, 38, 39 and 42. The Home benefits from good leadership and management. The rights and interests for residents are well protected through health and safety practices. EVIDENCE: The Home Manager, Allan Nuttall is competent and well qualified. Evidence noted from staff interaction and team bonding on the day of inspection showed that the home is well run absence of the manager. Staff met on the day stated that the Manager was off duty, however, Allison Brice provided the Inspector with the records required. Allison showed a depth of knowledge of all the residents discussed and provided explicit information on complex needs of a resident. Another staff member was equally helpful in relation to medication administrations and ensured that appropriate actions were taken regarding identified issues. The Deputy Manager, Rachael Hicks, assisted with the process of the inspections on her arrival mid morning. Rachael quickly blended in with the whole team to ensure that the Home was run smoothly on the day. Residents 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 23 were noted interacting with Rachael informally and accessing the office when they wanted. The Deputy Manager stated that she is in the process of undertaking the Registered Manager’s Award and has applied for courses around management. The Deputy Manager is involved in the Vulnerable Adults Policies update with the Social Services. She stated that she supports the Home Manager in managerial and clerical duties and is very involved with staff development. All staff interviewed stated the Manager and Deputy are approachable and would listen to their concerns. The Deputy Manager stated that the home reviews its quality of service through Management Team meetings, meetings with support staff and general staff meetings. There is regular resident care reviews. Day care trial reports and day care reviews are regularly checked. The Home regularly interacts with residents formally and informally to inquire how they felt about the services. Families are contacted over the phone to check if they were satisfied with the services provided. The fire log -book was found to be satisfactory. However it was noted that staff had not attended regular fire drills to familiarise themselves with the procedures in actual fire emergency. An immediate requirement was for this and must be carried out and on regular basis. The Accident book showed that accidents were recorded and reviewed and Regulation 37 notification are sent to the Commission as appropriate. The Home has policies and procedures and are regularly reviewed in line with changes at the Home. 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17-19 Edgeware Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 2 X DS0000003375.V270203.R01.S.doc Version 5.0 Page 25 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 2 Standard 24 22 Regulation 13 22 Requirement Ensure that cleaning liquids are not left unattended. Include the name, address and telephone number of the Commission for Social Care Inspection in the Complaints procedure. Ensure that staff attend regular fire drills. Timescale for action 11/01/06 11/02/06 3 42 23 18/01/06 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 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 17-19 Edgeware Road DS0000003375.V270203.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!