Inspection on 09/09/05 for 246 Haymill Close

This inspection was carried out on 9th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

246 Haymill Close 23/10/06

246 Haymill Close 30/01/06

246 Haymill Close 24/02/05

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 18-65 246 Haymill Close Greenford Middlesex UB6 8EL Lead Inspector Sarah Middleton Unannounced 9 September 2005 9.55 AM 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. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 246 Haymill Close Address Greenford Middlesex UB6 8EL 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) 0208 810 6699 0208 810 8104 Ealing Consortium Limited CRH (Care Home) 7 7 Category(ies) of LD Learning Disability registration, with number of places 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24/2/05 Brief Description of the Service: 246 Haymill Close is a care home providing personal care and accommodation for seven adults learning/physical disability. The Registered Provider is Ealing Consortium. The home was purpose built in 1995 and is modern and spacious. The staff team comprises of a Registered Manager, seniors and support workers. All bedrooms are single, four are on the ground floor and three are on the first floor, for those service users who can use the stairs. There are sufficient bathrooms, with appropriate adaptations to meet the complex needs of the service users. There is a lounge and separate dining room and kitchen. There is a large garden to the rear and side of the home, which comprises of a patio area, lawn and shrubs. The home is on a residential housing estate, next door to the Ealing Consortiums activity resource centre. The home is linked, by a corridor, to another separately registered home. The home is close to the A40, which is a main road into London. In addition it is a short walk to a main road, where there is public transport to the local towns of Greenford and Ealing Broadway. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of almost three and half hours, 9.55am-3.20pm was spent on the inspection process. The Inspector carried out a tour of the home and inspected service user plans and maintenance records. Staff employment files were not inspected, as the Manager Designate was not available at this inspection. Three staff were spoken with as part of the inspection process. Currently the Manager is not registered and they are referred to in this report as the Manager Designate. It must be noted that it is sometimes difficult to ascertain the views of service users with a learning disability and communication needs. Several requirements were set following this inspection. What the service does well: What has improved since the last inspection? What they could do better: There were shortfalls identified in various areas inspected. The home must ensure that risk assessments are up to date or clearly reviewed regularly to ensure the safety of service users is protected. In addition daily records must offer details of the care provided and information relevant to the service user. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 6 Although there are some planned activities in place for service users, there are gaps throughout the day for some service users where there was no evidence that any activities relating to their leisure and social interests take place. Opportunities to engage in activities that offer stimulation and occupation must be encouraged by the home to ensure service users are provided with different experiences. Staff must receive training on the protection of vulnerable adults, (POVA), to ensure they have the skills and knowledge to respond appropriately in the event of a POVA incident. Meals must be recorded and menus must be completed to ensure the service users receive a balanced and healthy diet. Liquid medicines, creams and eye drops must have dates of opening written on them to ensure out of date stock is not used. Although it is acknowledged that some of the staff are enthusiastic and keen to work as part of a team, it is necessary for the whole staff team to work together and to take responsibility for ensuring service users receive a consistent, high standard of care. This includes the need for good effective communication between staff. Staffing numbers must also be reviewed to ensure there are sufficient numbers of staff working in the home on any shift. This would provide service users the personal care they require and also the opportunity to engage in daily activities. Finally fire practices must occur regularly for all members of staff to protect service users health and safety. Staff must receive additional training if they are unable to respond appropriately to fire drills. 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. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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) 2, 3 & 4 Service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training to meet service users specialist needs. Prospective service users and their representatives are encouraged to visit the home in order to consider if they are happy with the home and to make an informed choice. EVIDENCE: Pre-admission documentation was viewed on the new service user. The Manager Designate had completed a form that offered a picture of the service users needs. In addition it clearly outlined action that would need to be taken prior to the admission of this service user, to ensure the home could meet their needs. This included the need for health professionals to visit the home to assess the adaptations needed to meet the prospective service user’s needs. Staff receive training with regard to the specific health needs of service user’s. The home seeks to ensure the staff have the skills and knowledge to meet the varied needs of the service users. Staff confirmed that the new service user had made several visits to the home and stayed overnight prior to them moving in. It was recognised that the move could be stressful for the service user and so it was taken slowly and reviewed at every stage. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The health and personal care needs of service users had been identified and overall were being met. Where possible service users preferences and choices are recorded on their individual care plans to ensure staff are aware of the decisions service users, with assistance, have made. There were some risk assessments in place, however several were out of date. There were limited risk assessments in place with regard to the new service user. This must be completed and reviewed for all service users on a regular basis. These assessments can reduce risks identified to the service user. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users’ identified health, personal and social care needs would be met. There were guidelines for one service user as to how to support them at night and if they were upset. It is recorded on care plans where a service user and/or their family had requested gender specific care. Service user plans were up to date however only some care plans had been reviewed recently. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 10 Daily records were available and the sample viewed varied as to the content and information written on them. Several were sparse and did not offer any relevant information regarding the care or the mood of the service user was on that particular day. A requirement was made that daily records improve. Two of the care plans viewed had no photograph of the service users; a requirement was made that there must be a photograph of each individual. Assessments for moving and handling and eating and drinking were in place. Most of the service users are non-verbal and communicate through sounds and facial expressions. Staff spoken with described how service users inform them of their preferences. Staff could describe how individual service users show if they are happy/ unhappy with an activity or a suggestion. Likes/dislikes are recorded on service users care plans and updated following reviews. The senior was not aware if any of the service users had an advocate. There were no detailed risk assessments on the care plan for the service user who had just moved into the home. One other care plan viewed had a risk assessment that was three years old with no evidence to suggest it had been reviewed. A requirement was made for this area to be addressed. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 There are activities in place but there were gaps throughout service users days where there was no record of any planned activities. This must be addressed to ensure the home provides regular interaction, occupation and stimulation for the service users. Visiting is encouraged for service users to maintain contact with family and friends. Service users choices and rights are respected within the homes capabilities. Meal provision and mealtimes are well managed, however there must be a clear record of the food service users have eaten, recording any differences from the main planned menu. This is to ensure the health of service users is monitored and that there is a varied menu in place. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 12 EVIDENCE: Where interested, service users attend the local church. Service users access the local activity resource centre for sessions throughout the week. This might, for example, be for massage or dramatherapy. At other times staff offer one to one time with service users. Two service users require support, for different reasons, from two members of staff. One staff member felt there are not always enough staff members working in the home to take service users out and do activities with them, particularly where the home reduced staffing levels on the afternoon shift. This decrease has had an affect on how often service users go out into the community. Some service users were attending the activity resource centre or had briefly gone out with staff during the inspection, but many were in either their rooms or the lounge area. Service users activity plans outlined where set regular sessions took place, but many had gaps where no activities were noted or planned. Discussions took place with the senior, who was present during the inspection, that this area must be addressed and a requirement was made. The local community resources are accessed such as the pub, theatre and swimming pool. Where able, public transport is used for those service users who enjoy using this form of transport. Service users go on holiday each year. The numbers vary depending on if any service users have a positive relationship with another service user. Several service users have already been on holiday this year and these were successful. Where service user’s have family, the home encourages families and friends to visit regularly. In addition service user’s are supported by staff to visit their family, especially if they do not live nearby. It was clear, from the new service user’s care plan that their family are involved, as much as possible, with their lives. Staff were seen to interact with service user’s throughout the inspection. Some service user’s were in the lounge, whilst others remained in their bedrooms. One service user communicated to staff that they wanted to go out by going on the floor near to the front door. Staff were aware of this request and when it was possible staff did respond and take the service user out for a walk. The kitchen was clean and tidy. Four days a week there is a cook who prepares menus and meals. They had recorded fridge temperatures, but there were gaps both on menu charts and where staff complete what individual service users have eaten, a requirement was made that meals must be clearly recorded. One service user has a PEG fitted and staff are trained to use this. Two service users have pureed food. The menus reflected a well balanced diet to meet the health needs of the service users. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 13 There was food previously prepared by the cook, this had no date written on it to indicate when it had been prepared. This is a requirement. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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 Service users receive personal support which acknowledges their preferences and respects their privacy. Health needs are addressed and records are kept of any particular health needs that staff would need to be aware of to ensure they meet/support service users complex individual health needs. There were some shortfalls in the medication systems. Liquid medication and eye drops must have a date of opening on them to ensure out of date stock is returned to the Pharmacist. EVIDENCE: It is noted, as indicated earlier in this report, that service user’s can request gender specific care, and this is recorded on their care plans. One service user receives personal care from staff who are of the same gender and the home has altered rotas and waking night staff to accommodate for this preference. Personal care is provided in private and times for bathing, getting up/going to bed is flexible. There are aids and adaptations to assist staff in providing personal care safely and effectively. The health needs of service users are noted and addressed by staff. The service users are under various health professionals and escorted by staff to these appointments. The staff record when a service user has had an epileptic seizure. The form used offers details to staff regarding anything that had been occurring when the seizure took place. A Physiotherapist had recently assessed one service user and their report was present in the care plan. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 15 Samples of the medication administration records were viewed and these were correctly completed. The home has an up to date medication policy. There were several bottles of liquid medication and a box of eye drops with no date of opening on them. This was made a requirement. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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 The home has a complaints procedure but records of any recent complaints and action taken to respond to any complaints could not be viewed, as the Manager Designate was not present. These records must be available to the Inspector to ensure the home follows the procedure when responding to complaints. Staff were aware of what action to take to protect the service users living in the home. However there were shortfalls in staff receiving training on protecting vulnerable adults, POVA. This must be available for all staff to ensure they recognise and can act on a POVA concern/incident. EVIDENCE: The home has a complaints procedure in place. Complaints records were not freely available for inspection as the Manager Designate was not present during the inspection. A requirement was made that complaints records must be available for inspection. This is in order to inspect the number of complaints and any action taken by the Manager Designate. Systems were in place for the protection of vulnerable adults, (POVA). The senior was not aware of any POVA investigations currently taking place. Staff spoken with were aware of what to do if they had any POVA concerns. Staff spoken with stated they had not received training on POVA. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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, 26, 27, 29 & 30 The environmental standard of the home was high and offered a warm and pleasant home for service users. Large objects, such as a bed, must not be left in communal areas, as this could prove hazardous for service users. Service users bedrooms were personalised and offered the necessary equipment to assist staff to support service users appropriately. EVIDENCE: A tour of the home was carried out and samples of rooms were viewed. These were being satisfactorily maintained. There was a bed on the ground floor of the main hall; staff stated this would be removed. A requirement was made that this would be taken away as this could be a health and safety hazard. Some bedroom doors were open, but these were on self-closures that would respond in the event of a fire. The home was bright and well decorated at the time of the inspection. One service user agreed for the Inspector to view their bedroom. This was spacious and personalised, with photographs and personal items in their room. Ground floor bedrooms have doors leading out to the gardens. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 18 Where service users require adjustable beds or any other adaptation, such as a hoist or shower chair, then this is provided in the home. The assisted bathrooms and communal toilets viewed were satisfactory. The ground floor bedrooms have doors that lead onto bathrooms. All bedrooms have hand basins in them. There is a separate laundry and sluice room. Protective clothing is provided and was seen in one of the service user’s bedrooms. It was recommended that the policies and procedures for the control of infection to be visible in the laundry and sluice rooms. The home was clean, tidy and free from odour at the time of the inspection. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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) 32, 33, 35 & 36 The home must consider its staffing levels and review the numbers working to ensure they can appropriately meet the individual needs of the service users living in the home. Some staff need to consider working more effectively in the team in order to offer positive care for service users. Staff receive relevant training on areas that relate to the needs of the service users and are supervised on a regular basis. EVIDENCE: New members of staff receive an induction from the organisation and then proceed to study the Learning Disability Framework Award. Staff also study the NVQ courses. In addition staff have the opportunity to attend training on specialist areas that address the needs of the service users living in the home, such as how to support service users who have Epilepsy. The number of staff working on each shift had recently changed and this had caused staff to feel under pressure when working on the shift where there is now one less member of staff. Staff spoken with felt that staffing levels were not sufficient to offer personal care and to take service users out into the community as much as they might want to. Discussions took place with the seniors who stated that the decrease in staffing numbers was short term and that would be an increase in the near future. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 20 A requirement was made that staffing levels are reviewed and that the home can clearly evidence that the number of staff working on each shift is sufficient to meet the needs of the service users. The staff meet weekly, but often this is not the whole team. Some staff felt that these meetings were just to give information and not to openly discuss issues in the home. There were conflicting views from staff who were spoken with during the inspection. Some stated the management team is new and staff do not feel consulted on issues in the home. Whilst other staff members felt that some staff are reluctant to accept change. These issues within the staff team must be addressed by the Manager Designate to ensure any negative feelings do not have an impact on the service users. Staff were happy with the training offered by the organisation. A list of the training staff had attended was viewed. This included mandatory training and additional specialist courses. Staff stated they received regular one to one supervision by their line managers. Overall they felt it was useful to set goals and objectives with their supervisor. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 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) 42 Servicing records were up to date but there were shortfalls in regular fire practices/drills to ensure staff had the knowledge and skills to respond effectively in the event of a fire. This must be addressed to ensure staff can protect the health and safety of the service users living in the home. EVIDENCE: Servicing records were viewed at random. The testing for Legionella, Gas Safety Record and hoists had all been serviced and were up to date. There had been two fire drills carried out in 2005, however, the documents indicated that at the last fire drill in May there had been confusion and it was noted that there would need to be more regular drills to ensure all staff were aware of procedures. There was no evidence that this had been carried out and there were no other records regarding fire practices/drills available for inspection. Fire drills must be carried out at different times with different staff members to ensure all staff know what to do in the event of a fire. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 22 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 3 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 x 3 3 Standard No 11 12 13 14 15 16 17 3 2 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 2 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 246 Haymill Close Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 23 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 6 6 9 Regulation 17 (1) (a) Requirement Timescale for action 31/10/05 31/10/05 7/11/05 4. 12 5. 6. 17 17 7. 20 8. 22 9. 23 Daily records must be detailed and outline the care provided for service users on a daily basis. 17 (1) (a) There must be a photograph of each service user available in the home. 13 (4) Risk assessments must be detailed, relevant to the service user, up to date and reviewed regularly. 16 (m) & The home must, where possible, (n) consult with service users and provide leisure activities and promote their social interests. 13 (4) (c ) Food opened/prepared must have a date written on it. 16 A record must be kept of all food (2) (i) & eaten by service users. Menus 17 (2) must be completed to ensure service users are receiving a nutritious and well balanced diet. 13 (2) Liquid medication & eye drops must have a date of opening written on them to ensure out of date stock is not used. 17 (2) A record of complaints and the action taken by the Registered Person must be available for inspection. 13 (6) The Registered Person shall make arrangements, by training G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc 30/11/05 9/9/05 9/9/05 9/9/05 31/10/05 30/11/05 Page 24 246 Haymill Close Version 1.40 10. 11. 24 33 13 (4) (a) 12 12. 33 18 (1) (a) 13. 42 23 (4) (e) or by other measures, for staff to receive information on the protection of vulnerable adults. The bed located on the ground floor in the main communal hall must be removed. All staff must be able and willing to work as part of the staff team so as to provide a consistent high standard of care to service users. The Registered Person shall ensure that at all times there are sufficient numbers of staff working in the home to meet the health and welfare of service users. This must be reviewed on a regular basis. The Registered Person must ensure by means of fire practices/drills held at suitable intervals, that all staff are aware of the procedure to follow in the event of a fire. 19/9/05 31/10/05 30/11/05 31/10/05 14. 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. Refer to Standard 20 30 Good Practice Recommendations A list of staff trained to administer medication should be available, along with their signatures. The policy/procedure for the control of infection should be visible in the laundry/sluice rooms. 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 246 Haymill Close G61-G10 s58136 Una-246 Haymill Close v214401 090905 Stage 4.doc Version 1.40 Page 26 - 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. 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