Inspection on 20/04/07 for 20 Windlesham Road

This inspection was carried out on 20th April 2007.

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

Other inspections for this house

20 Windlesham Road 04/05/06

20 Windlesham Road 13/10/05

20 Windlesham Road 15/04/05

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

CARE HOME ADULTS 18-65 20 Windlesham Road Brighton East Sussex BN1 3AG Lead Inspector Merle Blakeley Unannounced Inspection 20th April 2007 10:00 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 20 Windlesham Road Address Brighton East Sussex BN1 3AG 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) 01273 735322 01273 778931 www.fosteringinbrightonandhove.org.uk Brighton & Hove City Council vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is four (4). Service users must have a Learning disability. Service users must be between eighteen (18) - sixty-five (65) on admission. 28th September 2006 Date of last inspection Brief Description of the Service: 20 Windlesham Road is a semi-detached property in a quiet, residential road in Brighton. It is possible to walk to the shops, and public transport systems are within close proximity. The service is for up to four adults with learning disabilities. At the present time there are four service users who are supported 24-hours a day. Single bedroom accommodation is provided on the ground and first floor. There is one bathroom upstairs and toilets are located on both floors of the home. Meals are prepared by the staff with the people being supported to participate in the preparation. The home is domestic in scale and consists of lounge, a kitchen with a dining area. A rear garden provides a safe area for the people to spend time in. More detailed information about the services provided at 20 Windlesham Road can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are kept in the homes office. Information received from the service on 28th March 2007 states that current contribution fees are from £61.70 to £98.60 per week. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of seven and a half hours on 20th April 2007. As well as this site visit information was also gained from a returned pre-inspection questionnaire, Regulation 26 Visit reports, three resident feedback surveys and informal talks with staff members and the manager. Positive feedback was received from two relatives. Document reading was also carried out and a health and safety check was conducted. The inspector was also able to spend time observing staff and residents throughout the day. What the service does well: What has improved since the last inspection? There have been a lot of improvements made since the last inspection in September 2006 and all the requirements that were made have been met. All four residents have now had assessments carried out by social workers. New person centred plans have been produced and new guidelines have been developed for personal restraint. All staff have received training in this new procedure, however the manager and staff still feel that this technique is too invasive and they are hoping to develop an alternative method that focuses on the individual needs of the resident involved. A requirement was made for all bedrooms doors to close correctly and this has been rectified. A fire risk assessment has now been carried out. The new manager has made some very positive changes within the home and staff stated that they felt the home was being managed in a much more proactive manner. The level of activities for residents has increased and they are all now spending much more time out of the home enjoying their own personal interests. The manager has also involved more professionals in the long-term care needs of residents and this in turn has enabled residents to communicate their needs more effectively. Residents also appear to be more involved in the day-to-day running of the home and they all appear to be 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 6 getting on reasonably well with each other. This has not always been the case and was a concern during a previous inspection. The adult protection alert that occurred as a result of conflicts between residents now appears to have been resolved as there have been no further incidences to date. The staffing situation also appears to have improved and the staff team are now more stable. Temporary staff are only being used on a very limited basis. Some improvements have been made to the general environment of the home. A new lounge suite has been purchased and bedroom doors have been repaired. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments been carried out on all the people living in the home. EVIDENCE: During the last inspection a requirement was made for the home to carry assessments on all four residents. All residents have had an assessment carried out by a qualified social worker in October 2006. There was a query regarding the compatibility of one resident as to whether she was suitably placed within the home. The assessment stated that the resident did have some additional needs but overall it was felt that this was a correct placement for her. Recently the staff team have carried out a lot of work with this person and the challenging behaviour towards other residents has dissipated to a certain degree once the resident is engaged in purposeful activities. The manager stated that overall relationships between the four residents had improved. The homes statement of purpose has been updated and the service users guide is being revamped and will be made available to people in a more userfriendly format. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred care plans have been produced for all residents. Residents are receiving support to assist them in decision-making. Risk assessments have been carried out. EVIDENCE: During the last inspection a requirement was made for the home to produce completed care plan documents. The manager is currently updating and reviewing all care plans and examples of completed care plans were viewed. The manager stated that all residents would have a person centred care plan, which will be informative and up to date. The care plan that was viewed did appear informative and clearly described the needs of this person and the action that was required to provide a safe, consistent and caring environment for his continued well being. The home is also trying to involve family members when these care plans are reviewed. As well as the care plans daily notes are maintained for each resident and this information is handed over to staff at each shift change. The home has a key working system, which provides 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 10 residents with a more consistent approach to their care. The manager also stated that they were intending to provide care and healthcare plans to people in different formats. One person would best suit having a video version, another a photo book and possibly a talking book for the other two people. There was evidence that residents were making decisions about certain aspects of their day-to-day lives. They are able to choose their meals, clothes and what they want to do during the day. As some of the residents are not able to verbalise a speech and language therapist has been asked to become involved and provide ways in which residents can communicate by identifying objects and pictures. These ‘points of reference’ have become quite successful for one of the residents, as he is now more able to clearly indicate his needs to staff. This method will also be introduced to another resident to see if it may help to increase his independence and communication skills. Risk assessments have been produced and cover all aspects of residents lives, such as being out of the home, travelling in a car, bath times, meal times etc. These assessments are being regularly reviewed. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are now able to participate in a wider range of activities. Residents are out and about in the community on most days and they maintain family links where possible. Residents are being encouraged to participate in the daily routines of the home. A well balanced diet is being offered. EVIDENCE: Since the last inspection it is evident that residents are being provided with greater opportunities to participate in fulfilling activities. The day before this visit to the service the inspector had arrived unannounced, however there was no one at home, as all the residents and staff were out on various outings and activities and they did not return home until later in the afternoon. The new activity schedule showed that they had been going out for day trips, lunches, shopping and train rides. The manager stated that they were keen to increase the level of activities for residents as this has proved to be very popular and they all enjoyed going out now. The increase in staffing levels has allowed 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 12 people to be able to go out on a much more frequent basis. This had not been happening before. As residents are now going out of the home more often they are becoming part of the local community, as they are visiting shops, restaurants and pubs and using public transport. The manager was asked as to whether any of the people had visitors or friends coming to see them. It was stated that one person has her brother come to see her fairly regularly and another has his sister coming to see him. The other two residents do not have any family contacts. There are no restrictions placed on visiting times, as people are free to come when they wish. People who live in the home are now being much more involved in the way the home is run. They are encouraged to participate in certain household chores such as helping to clean their rooms and assisting with meal preparations. Staff were seen to interact with residents in a calm and friendly manner. The manager said that she had reminded staff recently about the importance of knocking on peoples doors before entering their rooms to ensure their respect and privacy is retained. During the last two inspections there have been some concerns about how a person is restrained during a medical procedure. This was discussed with the manager who showed the inspector a plan of how restraint was to be carried out. This procedure had been agreed and authorised in September 2006 and had been formulated by a Strategies for Crisis Intervention & Prevention Trainer. All the staff had been trained in this particular procedure. It is still felt that this type of restraint is too invasive and there are records where the person clearly states that they do not like this procedure. It has been a difficult situation as the person does need this medical intervention to be carried out for her general health and well being, however she remains very adverse to having this medical procedure carried out. The manager has stated that she would like to try a less invasive method, which would involve staff being trained to carry out this particular medical role of dressing the person’s leg. This person has now built a good rapport with the staff and it is felt that she would feel more comfortable with just certain staff members being involved. The weekly menu was viewed and it appeared to be offering people a wellbalanced and nutritional diet. People are able to choose the foods they like. One person has recently had problems with swallowing food and the home involved healthcare professionals to ascertain what was the best type of diet for him. His meals will now be pureed and staff will receive information about how to cook and present this type of diet. During this visit the inspector visited the kitchen whilst lunch was being prepared. Staff reported that the oven was not working properly and it had taken almost two hours for the oven to reach the correct temperature. This means that staff have to commence 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 13 cooking much earlier then normal and meals are taking twice as long to cook; it is also possible that if the oven is not functioning properly that food could become undercooked/overcooked, which in turn may become a health and safety concern. It will be recommended that the home purchase a new cooker as soon as is practicable. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide personal care in a manner that residents prefer. The home has been proactive in regards to people’s healthcare needs. Medication is administered and stored correctly. EVIDENCE: All four people who live in this home require support with their personal care. Staff stated that personal care is given privately in bathrooms. The home has made a referral to an occupational therapist as two of the people are now experiencing mobility issues. Records show that people’s healthcare needs are being met by the home. People have access to a number of healthcare specialists who are assisting them in various aspects of their lives such as communication, mobility, doctor’s visits, district nurses, occupational therapist, behavioural support and physiotherapists. As mentioned previously staff are trying to be more proactive in providing a more positive experience for the person who needs to have her leg dressed weekly. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 15 Medication records were viewed and they were found to be in order. Medication information has recently been included into people’s files, so that staff are aware of how each type of medication works and what type of adverse effects could occur. The home is in the process of carrying out medication reviews for each resident and this will ensure that all people are still being prescribed the correct medicines. All staff are due to attend medication within the next six months. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in easy read format. The home has addressed an adult protection alert. EVIDENCE: Brighton & Hove Council has produced a complaints leaflet, which is in an easy read format. The home has not received any complaints. It was discussed with the manager that the use of advocates would be recommended. The manager said that she had looked into providing advocates for the residents but at the moment there was a very long waiting list. There has been an adult protection alert in this home involving two residents. One of the residents has had aggressive outbursts towards staff and another resident. The manager stated that these outbursts appeared to occur when there were not enough staff on duty and as a result the home is ensuring that additional staff are employed. The manager has requested a further 78 staff hours a week. Since the level of activities and staffing hours has improved there have been no further incidents to date. Two of the residents continue to need 1:1 support when they are present in the home and this has been clearly identified in their care plans. The adult protection investigation is now due to be finalised and closed. Resident’s finances are looked after by staff and these records were checked and found to be in order. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to the environment. EVIDENCE: A number of improvements have been carried out since the last inspection. A requirement was made for the home to ensure that three of the resident’s bedroom doors closed correctly. This has been carried out and a new lounge suite has been purchased for the communal area. A new sluice washing machine is on order. There is an area of peeling paint on the kitchen ceiling, which is close to the food preparation areas. This needs to be repaired as soon as possible as it could become a health and safety risk. The manager stated that this work is due to be completed soon along with the lounge, hallway and laundry also to be redecorated. Repairs also need to be carried out on the hole in the wall behind the hallway door on the first floor. The shared bathroom has peeling wallpaper and also need attention. The flooring in the kitchen and hallway is 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 18 non-slip and when it becomes wet it is quite slippery. Staff said that there had been three ‘near misses’ where people could have slipped over and hurt themselves and they were very concerned about this and would approach the council to see what could be done about it. On the first floor is a small room, which the home is hoping to make into a TV and sensory room for the residents. This would be an area where residents can come for some quiet time and relaxation. The inspector was able to view all four resident’s bedrooms and they appeared homely, clean and comfortable. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More staff need to obtain an NVQ qualification. Staff recruitment files did not contain all the required information. Staff are receiving adequate training opportunities. EVIDENCE: None of the current staff team holds an NVQ qualification, however one staff member has commenced this training and a further four staff are due to commence their NVQ training in July this year. Two staff members hold a psychology degree and another has a nursing qualification. The staff that were observed during the day working with residents appeared knowledgeable and caring. In the past a lot of temporary staff were being brought in to cover shifts, however the staffing team now appears much more stable. The rotas showed that temporary staff are seldom used now. The inspector was able to talk to a number of staff during the day and the feedback was that staff felt more settled in their jobs and they felt well supported by the new manager. The home currently has one full time staff vacancy. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 20 A number of staff recruitments files were viewed and not all of them contained the required information. Some only contained one reference instead of two, not all of them had copies of their CRB checks and several were missing photos. None of the staff had their application forms on file. These recruitment files have not been correctly maintained and this was discussed with the manager who stated that she was aware of this and it was another job that required attention. There is a current staffing issue, which in the long term may not be conducive in maintaining positive working relationships between staff. Half of the current staff team are employed by Southdown NHS Trust and the other half are employed by Brighton & Hove. There are significant differences in the pay and conditions of both these employers and this is a situation that will need to be addressed in the near future. Staff training records were viewed and it showed that staff have had access to a reasonable level of training. All staff have attended Adult Protection Training and Medication Training. Other staff have attended first aid, bereavement training, fire training, positive behaviour training and food hygiene. Other training courses booked for the future include Makaton and resuscitation training. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in a positive and proactive manner. There is a quality assurance system in place. Residents and staff are protected by the homes health & safety procedures. EVIDENCE: The new manager of 20 Windlesham Road was previously a manager at another Brighton & Hove care home for young adults with learning disabilities. Originally the manager was asked to come to this home on a 3-month temporary basis, however she has now become the permanent manager. She has fifteen years experience and she has obtained the NVQ Level 4 qualification plus the Registered Managers Award (RMA). Feedback from the staff regarding the way the home is managed was very positive. Staff feel the home is taking a more proactive and holistic approach in the way care is being 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 22 delivered to the residents. They also said that it has made them feel more positive and upbeat about their work. The manager stated that she appreciated that there was still a lot of work to do in the home, however from evidence gathered during this inspection it appears that a lot of good work has already been achieved. The home has a quality assurance programme in place. Annual questionnaire surveys are sent out to relatives and friends. Easy read service user surveys have also been designed by social workers. The feedback from two of the residents was carried out in October 2006. Regulation 26 visits are carried out monthly and currently these reports are being sent to the CSCI. There have been improvements to health and safety standards within the home. A Fire Risk Assessment has been produced and fire drills are being carried out on a regular basis, which involve the residents. This was a previous requirement from the last two inspections. Health and Safety checks are being carried out monthly. Fire alarms, emergency lighting and call points are also checked on a fortnightly basis. Door guards are to be installed on the kitchen door and hallway doors as these doors are always left open and this presents as a fire hazard. Once these guards are installed they will close automatically should a fire be detected. As mentioned previously in the environment section the kitchen ceiling needs redecoration as the paint is peeling off. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA42 YA42 YA34 Regulation 23(2)(b) 13(4)(c) Schedule 2 Requirement That the kitchen ceiling is repaired so as to prevent paint flaking off onto work surfaces. To ensure that non-slip surfaces are provided for all communal walkways. That all staff recruitment files contain the information as set out in Schedule 2 of the NMS. Timescale for action 11/06/07 11/06/07 11/06/07 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. 2. 3. Refer to Standard YA42 YA24 YA16 Good Practice Recommendations That the oven is either replaced or repaired to ensure that correct food cooking temperatures are maintained. To ensure that repairs are carried out to the hole in wall on first floor. That the manager continues to look into providing a less invasive method of restraint for the service user who requires weekly medical treatment. 20 Windlesham Road DS0000060477.V333185.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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