Inspection on 17/08/05 for 20, Glamorgan Road

This inspection was carried out on 17th August 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

20, Glamorgan Road 08/08/06

20, Glamorgan Road 14/12/05

20, Glamorgan Road 03/02/05

20, Glamorgan Road 17/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Glamorgan Road, 20 20 Glamorgan Road Hampton Wick Middlesex KT1 4HP Lead Inspector Sandy Patrick Unannounced 17 August 2005 at 12:30 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 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 Stationary 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. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glamorgan Road, 20 Address 20 Glamorgan Road Hampton Wick Middlesex KT1 4HP 020 8296 8187 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap (Housing & Support Services) Mr Myles Stevens CRH 10 Category(ies) of Learning Disability (LD) 10 registration, with number of places Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd February 2005 Brief Description of the Service: 20 Glamorgan Road is a large house converted out of two buildings. The home is managed by Mencap and is registered for ten people with a learning disability. The building is owned by Richmond Churches Housing Trust. The home was set up to offer accommodation for service users leaving Normansfield Hospital, many of the original service users remain at the house. The philosophy of care is to offer ongoing support for service users to live within the local community and to develop and maintain skills of community living. The home is situated in a quiet residential street in Hampton Wick, and is close to local amenities. Staff support is offered twenty-four hours a day, and service users access a range of local services with support. Each service user is assigned a keyworker who provides individual support. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the Inspector found during the inspection. The inspection took place on the 17th August 2005, and was unannounced. The Inspector met with five service users, the Manager and other staff on duty. During the course of the inspection the staff team spent some time in a training session run by local health care professionals who work closely with the home. Staff reported that this session was useful and informative. Throughout the inspection service users were seen to pursue a variety of activities, both with staff and on their own. The atmosphere at the home was welcoming and relaxed and service users presented as comfortable and happy. Interactions between service users and staff were positive and indicated mutual trust and respect. What the service does well: What has improved since the last inspection? There has been significant developments for individual service users. Service users have pursued a wide range of activities of their choice and some service users have been on holiday. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 6 There has been an emphasis on producing person centred plans which allow service users to create their own plans of care using photographs, pictures, symbols and words of their choosing. Three new staff have been employed and two of these have completed their induction training. Staff on duty reported that they felt confident and happy in their roles and the Inspector noted that staff demonstrated a good knowledge of the needs of the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 & 5 Service users are given a range of information about the service and how their needs will be met whilst living at the home. There are appropriate procedures for assessment and admission of potential service users, including trial stays. Service users have received a copy of their terms and conditions of residency. EVIDENCE: The Registered Person has produced a comprehensive Statement of Purpose and Service User Guide for the home. These incorporate the Aims and Objectives of the service. Copies of the document have been issued to all service users. The home offers a service to people with a diverse range of needs. The ages of service users at the house range from people in their 40’s to people in their 80’s. Some service users have sensory impairment, some have mental health needs and some have high mobility needs. Staff are appropriately trained and able to meet these needs. The home works closely with the Community Team for Learning Disabilities and other health care professionals to ensure that needs are met. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 9 There is an appropriate procedure for assessment and admission. Assessments of need are made by placing authorities and additionally by the Manager. One service user moved to the home in the last year. Copies of assessment documentation were seen to be in place and were appropriately translated into plans of care. All other service users have had their needs reassessed over recent years. Service user plans are reviewed and reassessed at least annually. The procedure for admission allows for service users to stay at the home prior to moving. The most recently admitted service user visited the home on a number of occasions including over night stays prior to their admission. All service users are admitted on a trial stay and a review meeting involving the service user and their representatives is held after approximately six weeks for the service user to decide if they wish to stay and to decide if their needs can be met at the home. Evidence of review meetings was seen. Service users are issued with a copy of the terms and conditions of residency. Contracts with the pacing authorities are in place. Copies of the terms and conditions of residency were seen to be in place within the service user records examined. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9 & 10 Service users’ needs are represented within individual service user plans and person centred plans, which have been developed by the service user. Service users are able to make choices about their lives and the running of the home. Service users are supported to make informed choices and take risks where appropriate. EVIDENCE: Individual service user plans are in place for all service users. These give a comprehensive range of information on individual needs. There is evidence that plans are subject to regular review. Daily care notes are made and health and personal needs are monitored. Over the past year work has taken place to produce person centred plans designed to represent individual service users’ wishes and needs. One service user showed the Inspector their plan, which they had created with their keyworker. The plan included pictures and photographs and was written in Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 11 words and phrases chosen by the service user. Other plans were seen and these showed positive work by service users and staff. Each service user and their keyworker have made objectives around the things they want and wish to achieve. These were personalised and progress on achieving these was monitored. There was evidence in service user plans and other records that service users were appropriately consulted about the day to day running of the home and were able to make informed choices. Service users confirmed that they make choices about the activities that they participate in, the food they eat and how they live their lives. The Manager and staff have been working with other professionals to look at ways to support service users to make informed choices with regards to wishes identified at reviews. Staff are trained in various communication techniques. Information throughout the house is presented in pictorial form and with the use of photos. Staff meetings include training sessions in Makaton. Service users are supported to understand Makaton signs and symbols and staff work with service users to identify the signs and symbols that are meaningful to them. A comprehensive range of risk assessments are in place for all service users. These are subject to regular review. There are appropriate procedures in place covering confidentiality, data protection and access to records. Information is stored securely. Staff are issued with information regarding confidentiality as part of their induction. Staff at the home have consistently demonstrated a good understanding of confidentiality issues. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15,16 & 17 Service users are supported to develop and maintain skills. Service users are valued members of the local community and participate in a range of activities both inside and outside of the home. Service users are supported to participate in households tasks, menu planning, shopping and meal preparation. EVIDENCE: Service users are supported to develop emotional, social, communication and independent living skills. Service users are involved in household tasks, planning and preparation of meals and shopping. Service user plans include objectives. These are based on individual needs and how skills can be developed. On the day of the inspection service users were seen participating in preparing food, cleaning, money handling and shopping. Members of the house were very active throughout the inspection. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 13 Additional staffing is provided for named service users. This allows service users to be supported on an individual basis to meet a variety of needs. These include community based activities. Service user plans include information on supporting service users with self esteem, self awareness and assertiveness. Staff support service users to maintain contact with friends and families through emails, letter writing and using the telephone. Many of the service users regularly see their family and all have a network of friends in the local community. Service users access a range of day opportunities including local resource centres, colleges and employment. Information on these was held within service user plans. Day services reflect individual needs and wishes. A new initiative from the local day centre is for their staff to work alongside the staff from the residential homes to provide a greater range of activities. The success of this initiative is difficult to judge as the scheme had only recently commenced. Service users access a range of leisure activities based on individual needs. This was evidenced throughout the home in records and through photographs and conversations with staff and service users. Two service users told the Inspector that they were going on holiday the day after the inspection. They stated that they were looking forward to this and spoke about some of the activities they hoped to participate in when on holiday. There is an varied and balanced menu chosen by the service users on a weekly basis. Service users participate in the planning, preparation of and shopping for food. The kitchen at the home was well stocked with fresh food. Meal times are flexible and service users are able to choose where, what and when they eat. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 18, 19 & 20 Personal and health care needs are appropriately recorded and monitored. Medication is appropriately stored, administered and recorded with the exception of a small amount of excess medication. EVIDENCE: Personal and health care needs are recorded within service user plans. There is evidence that these are monitored by staff. Each service user plan contains a compatibility chart, which includes details on emotional needs, preferences for age and gender and cultural needs regarding personal care. The themes of upholding privacy, dignity and choice are present throughout all information. Information is subject to regular review. All service users are registered with local GPs. The Community Team for Learning Disabilities and other health care professionals offer support and training to staff and work directly with some of the service users. There is an appropriate procedure regarding medication. Medication was stored securely and records were accurate. All staff are trained in the administration of medication. The majority of medication was appropriately packaged and stored, however a small amount of medication was stored in small plastic bags within the medication cabinet and was not appropriately Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 15 labelled. This medication was in excess of the required amounts for the month. The medication must be returned to the pharmacist and this method of storing excess medication must cease. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 22 & 23 There are appropriate procedures in place regarding complaints, whistle blowing and protection of vulnerable adults. EVIDENCE: There is an appropriate complaints procedure, detailing timescales and information on contacting the Commission for Social Care Inspection. There is a record of informal concerns and complaints raised at the home. The Inspector examined this and saw that these had been responded to appropriately and that the complainant had been informed of any outcomes. The home has adopted the London Borough of Richmond protection of vulnerable adults procedure. Mencap have its own procedures on whistle blowing and abuse. All staff have received training in this area. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 The home is comfortable and suitable for its purpose. building are in need of refurbishment or redecoration. Some areas of the Service users have unrestricted access to communal areas and bedrooms have been personalised. The home was clean and well ventilated throughout. EVIDENCE: The home is situated in a quiet residential road in Hampton Wick. Accommodation is provided on three floors in a converted building. Areas of the building are starting to look worn. Redecoration and repair work has regularly been outstanding for long periods of time, some work only taking place after repeated requirements at inspection visits. The Manager reported that the outside of the building is due to be decorated and rotten window frames are being repaired. Other urgent work includes the redecoration and refurbishment of some of the interior. In Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 18 particular WCs, the kitchen and some other communal areas are in need of attention. The requirement made at the last inspection is restated. All rooms are for single occupancy and have been personalised by service users. There is a large amount of communal space including lounges on each floor (although some are not used) a large kitchen and separate dining room and a conservatory area. The home has a pleasant garden to the rear. Communal areas have also been personalised. There is evidence in service user plans of consultation with and assessment by Occupational Therapists and Physiotherapists about individual equipment and adaptation needs. The home was clean and well ventilated throughout. Service users participate in some cleaning and laundry tasks. A part time cleaner is employed and support staff undertake some of the cleaning duties. There are appropriate procedures regarding disposal of clinical waste, infection control and Control of Substances Hazardous to Health. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 Staff are employed in sufficient number and are aware of their roles and responsibilities. Staff undertake a range of training opportunities. There are appropriate recruitment and selection procedures which ensure a range of thorough checks. Staff are supported through team meetings and individual supervision. EVIDENCE: All staff are issued with job descriptions and contracts. Additional information on roles and responsibilities are available for staff. There are good systems of communication and care planning, including handovers of information and daily shift plans. Comprehensive information for temporary and new staff is in place. A new member of staff was working her first day at the home on the day of the inspection. She was working alongside permanent staff as part of her induction into the home. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 20 There are appropriate procedures for the recruitment and selection of staff including a panel interview chaired by the Manager. The Inspector examined two staff files and these included completed application forms, records of interview notes, copies of references and information on criminal record checks. There is a comprehensive training and induction programme for staff provided by Mencap. Induction and foundation training is externally verified and links directly into NVQs. Four members of staff were undertaking NVQs at the time of the inspection. Staff are able to participate in a range of training opportunities provided by Mencap and other agencies. Staff training records were examined and seen to include key training in food hygiene, first aid, fire safety and medication. The staff team participated in a training session at the home on the day of the inspection. Members of the Community Team for Learning Disabilities who work closely with the home were providing this training in physical interventions. Staff who spoke with the Inspector after the training reported that it had been useful and informative. The Deputy Manager left their post shortly before the inspection. The Manager reported that this post would not be recruited to and that managerial responsibilities would be shared with the staff team. The home supports service users with complex and varied needs, and has experienced a number of difficulties over the past year with changes in need. There must not be a reduction in staffing levels. The difficulties experienced recently have taken a great deal of management time and the decision not to recruit to the Deputy Manager’s post should be reconsidered. The staffing levels must be kept under regular review and the staffing structure must be designed to meet the needs of the service. Staff on duty reported that they felt supported and worked well as a team. Regular team meetings are held. Minutes of these were seen and indicated that staff were well informed and contributed to the running of the home. All staff receive regular supervision from they Manager. Signed records recording supervision were seen to be in place. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 & 42 The Manager is appropriately experienced and qualified. approach is open, positive and inclusive. The management There are appropriate procedures in place for quality monitoring. Suitable checks are made on health and safety to ensure that the environment and equipment used are safe. EVIDENCE: The Manager has been in post since 2002. He has the Registered Managers Award. He has a comprehensive insight into the needs of the service and has consistently demonstrated a commitment to meeting these needs. Staff on duty reported that they felt supported and that they were able to contribute their ideas and opinions to the running of the home. Staff who spoke with the Inspector were knowledgeable about the home. The Manager Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 22 reported that with changes to the management structure of the home he hopes that staff will be delegated greater responsibilities and have more involvement in the running of the home. Minutes of staff and service user meetings indicated that all parties had a forum to express their views. Mencap have an appropriate quality assurance procedure. The service has a full quality audit every three years. Unannounced health and safety inspections and financial audits are arranged periodically. The Area Manager visits the home to conduct unannounced quality inspections once a month. Reports of these visits are made and should be forwarded to the Commission for Social Care Inspection. These visits have taken place, but copies of the reports have not been sent to the CSCI since December 2004. The Registered Person must ensure that copies of these reports are sent to the CSCI. Records required by Regulation were seen to be in place and were appropriately organised, accurate and dated. Comprehensive checks are made on health and safety by staff at the home. Evidence of checks on general health and safety, first aid, the house vehicle, fire safety, water temperatures and food storage temperatures was seen. Regular fire drills are held and recorded. Individual assessments of risk are in place regarding fire safety. The record of checks on fire equipment suggested that there were problems with one or more fire doors and that this has been ongoing for several months. The Manager reported that repairs had been made to one fire door, however recent checks, including one made the week before the inspection, indicated that a different fire door was not closing properly and this poses a risk in event of a fire. Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glamorgan Road, 20 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 3 2 x G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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. YA9 13(2) The Registered Person must return the excess medication to the Pharmacist and must ensure that all medication is appropriately packaged. The Registered Person must ensure that: 1. The repair and decorative needs identified within the standard are addressed. 2. There is a regular programme of maintenance so that repair and decorative needs to not remain outstanding for unacceptable periods of time. Previous requirement 30/06/05 3. YA39 26(5)(a) The Registered Person must ensure that reports of monthly visits to the service by the line manager are forwarded to the CSCI The Registered Person must 30/09/05 30/09/05 Standard Regulation Requirement Timescale for action 2. YA24 23(2)(b) 31/12/05 4. YA42 Glamorgan Road, 20 23(4)(c) 30/09/05 Version 1.30 Page 25 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc (i) ensure that all fire resistent doors are effective. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. YA32 The Registered Person should keep staffing levels under regular review and the staffing structure must be designed to meet the needs of the service. Refer to Standard Good Practice Recommendations Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon SW19 3RG 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 Glamorgan Road, 20 G54-G04 S17365 Glamorgan Rd V235971 170805 Stage 4.doc Version 1.30 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!