Inspection on 20/09/06 for 44 Blyford Road

This inspection was carried out on 20th September 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

44 Blyford Road 10/09/07

44 Blyford Road 25/01/06

44 Blyford Road 24/08/05

44 Blyford Road 21/02/05

44 Blyford Road 04/08/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 44 Blyford Road 44 Blyford Road Lowestoft Suffolk NR32 4ST Lead Inspector John Goodship Key Unannounced Inspection 20th September 2006 10:00 44 Blyford Road DS0000024338.V312353.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 44 Blyford Road DS0000024338.V312353.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. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 44 Blyford Road Address 44 Blyford Road Lowestoft Suffolk NR32 4ST 01502 531007 F/P 01502 531007 h2031@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Karen Smith Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (2), Physical disability (2) of places 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: The bungalow is situated in north Lowestoft in a pleasant residential area. There are some shops close by. It was purpose built for 6 people with learning disabilities. The home was extended and refurbished in 2003 to offer more spacious accommodation for two individuals with physical disabilities, widening all the doors in the existing building, and lowering all light switches and plug sockets to wheelchair height. A third person with physical disabilities was admitted in March 2004. The building is owned by Orbit Housing Association. The service is provided by Mencap. The fees currently charged range from £541 to £1249 per annum. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was the first under the “Inspecting For Better Lives” policy of the Commission for Social Care Inspection. The aim was to cover all the key standards which are listed under each Outcome Group. The manager was present throughout the visit, with other staff. Residents came and went during the day according to their programmes. Survey forms had been sent out by the Commission to relatives, and to residents if they were able to complete them. Four relatives responded, and three resident forms were completed with the help of staff. The inspector toured the home, spoke to two support workers, and also to those residents who were able to communicate. One relative also phoned the home during the inspection and was happy to speak to the inspector. What the service does well: What has improved since the last inspection? 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 6 The staff supervision process is now fully underway. This provides opportunities for staff and managers to identify training needs and discuss care issues. The kitchen floor has been renewed for greater cleanliness and hygiene. 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. 44 Blyford Road DS0000024338.V312353.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 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that the home will assess their needs and the suitability of the home for them, and that they will have an introductory period to test that they will like living there. EVIDENCE: A new resident had been admitted to the home in March 2006. In their file was the pre-admission assessment, developed from a visit by the manager to their previous home, and also drawing on information from the Compass report from Social Care Services, a physiotherapy assessment and a visit to Blyford Road by the prospective resident. The individual placement contract for this resident was in their file. It had been signed in April 2006. Each resident also had a copy of the Mencap terms and conditions of residence. The trial period for the latest resident was now finished but as yet no date had been agreed with the funder for a review. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. 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. Residents can expect the home to be run according to their needs and wishes, with the development of independence through planned risk-taking as a primary goal. EVIDENCE: In addition to the home’s own care reviews, all residents had recently been reviewed by Social Care Services to assess whether each resident was correctly placed at Blyford Road, or if their needs could be met more appropriately in an alternative residential setting or in supported living accommodation. All the reviews were held with the resident apart from two who were judged as unable to understand the proceedings. Relatives were invited to the reviews. All the reviews commented that the home was very well managed, and that the paperwork required for the review was kept in good order. One resident had expressed a positive wish to live in a village nearby as they were familiar with it after living there earlier in their life. Until their recent heart attack, they were able to walk there, and often attended car boot sales in the village.The manager believed that the resident hoped they would be visited by local friends if they moved. However the review noted that this move 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 10 would necessitate providing the service user with a lot of support for many activities of daily living. This request for supported living was being considered by the local authority. The outcomes of the reviews were not known at the time of the inspection. Generic and individual risk assessments were held on file. They covered areas such as bathing and showering, transferring from wheelchair to armchair and to bed, travelling in the minibus, travelling on an aeroplane, using the kettle to make a hot drink, and risks associated with a resident who suffered from severe epilepsy, who needed staff to administer rectal diazepam on occasions. In all cases there was guidance for staff on supporting residents so that the risks were minimised without reducing the residents’ choice of activity. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given many opportunities to choose how to spend their time, as a group, and individually. Residents are encouraged to play an active part in the running of the home according to their wishes and abilities. They will be supported to maintain contact with their relatives as they wish. EVIDENCE: All residents had a planned programme of day care during the week, either at home or at an external day service. Four residents attended local authority centres, although there was some doubt about how long one resident, who was over sixty-five, would be allowed to continue. One resident attended a day service three days a week. On the other days and over the weekend, funded staffing levels allowed for two staff to be available to support them. The care plan for this resident noted that they prefer to spend time at their desk playing with their Lego. A sixth resident attended another local authority centre on five days although for one of those days they were taken to spend the day with their relative. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 12 The day before the inspection, some residents had been at home because of building work at their day centre, so the manager told the inspector that the residents had been to lunch at a nearby hotel. One resident was starting to exhibit behaviour which might be symptomatic of early onset dementia. An assessment had been booked with the Community team. The review commented that, following their move from another residential placement, this person had been successfully supported by the home’s staff to settle in the new environment with which they seemed happy. The care plan showed that instances of challenging behaviour had been reduced by staff following an agreed reaction process. Residents took part in a variety of leisure activities - inside the home, such as listening to their own tapes, watching television as a group or in their own room, helping with cooking and gardening; outside the home, such as swimming, going to shows, shopping and bowling. Some also participate in activities organised by SCOPE, Club 85 and the local Gateway Club. One resident was described as needing encouragement to go out, but then enjoyed doing so. It was noted in one review that a resident got on well with the other residents and the staff, and loved being in a group, choosing to spend time in the lounge with the other residents rather than in their bedroom. This resident told the inspector about their recent holiday to North Yorkshire on a coach trip with another resident. They said they enjoyed it but “it rained”. One resident was just leaving as the inspector arrived, to go and spend the day with a relative, which they did every week. A member of staff took them in the wheelchair-accessible minibus, together with another resident who wanted to go for the ride. The relative coincidentally phoned during the day and was happy to speak to the inspector. They said they were very satisfied with how their relative was cared for. “They always keep me informed.” One resident was taken regularly to see their sick relative. These visits were recorded in the daily records. These daily records contained full information for each resident on their activities, outings, health matters, and other aspects of each day. The resident who was in the home recovering from illness was asked what they would like for lunch. The support worker asked them if they wanted to make the sandwich themselves. In the end the resident got the bread out while the staff cut up the ingredients then both made the sandwich. There was a list in the kitchen giving staff information about the preferences of residents. Under each resident it listed requests in the first person such as: “Please don’t give me………” and “ I prefer breast meat to leg meat”. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 13 During the week residents took packed lunches to their day centres. The main meal was in the evening. Example menus included sausages, fresh vegetables with rice pudding, lasagne with chips and salad, liver and bacon, and a roast on Sunday. During the afternoon, a support worker was preparing the fresh lasagne for the evening meal. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect their needs to be identified, monitored and appropriate action taken. They are protected by the home’s training and administration policies for dealing with medicines. Their wishes around death will be respected. EVIDENCE: Each care plan contained an individual Support Plan written in the first person, to reflect the point of view of the resident. Examples were: “If I fall down and am unable to get up………”, “If I cut myself or hurt myself when I have a shower……….”, followed by clear instructions for support workers on how to support without reducing dignity or preventing independence. One resident had recently suffered a heart attack and spent four days in hospital. They were sent home early because the hospital believed they would be better off back at the home. They were temporarily unable to attend their normal day service until given permission by the doctor. However the medication from the hospital had had some side effects for which the GP was adjusting their medication. They also had an infected leg which was being treated, and also had an appointment at the hearing clinic later that week. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 15 They expressed their impatience at not being able to go “back to work”, as they described the day centre. The manager explained why that was. A knee brace and a stick had been provided but they refused to use either. The staff suggested things that the resident might like to do that day. They chose to watch a DVD, and then had lunch in the lounge before having a nap. The manager stated that an occupational therapy assessment had been requested for the latest resident, to identify how their bathing and showering needs could be met safely. Staff had noticed that one resident had a sore patch around the groin. There was a body map in the daily record with an instruction for staff to treat and monitor. The medication records were examined. It was good practice that there were medication profiles in the front of each MAR sheet giving explanatory information on each prescribed drug. Tablets were administered from blister packs which were stored by name and time of day. The rear of each sheet was used to record when medicines marked as PRN were administered and why. It was noted that bottles were not always dated when opened. A member of staff was observed administering medication to a resident at lunchtime. In fact the resident had asked the member of staff: “Is it time for my tablets?” The tablets were then handed to them and they were watched to check that they were taken. Staff who administer medication had been trained on the Mencap “Working safely with medicines” distance learning course. Evidence was seen in the training record. Staff had also been trained to administer rectal diazepam, although this was being superseded by an orally administered alternative. During the inspection, the manager received a phone call from one of the GPs changing a resident’s medication. They were asked by the manager to put the change in writing, and then the MAR sheet was altered with the date of the phone call. At the last inspection, the manager had described the effect of the death of a resident on the others and the links with that person’s family. The home had checked that it knew the wishes of residents and families on arrangements when the resident died. This information was recorded in their file. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are helped to understand how they are protected, and how to raise issues of concern. Full information cannot be provided until the details of the local CSCI office are available to residents and relatives. Residents cannot be assured that they are fully protected until staff training in adult protection can be evidenced. EVIDENCE: The home followed the Mencap Complaints policy and procedure which complied with the Standard except that it did not include the name and address of the local office of the Commission for Social Care Inspection. This has been made a Requirement. A poster was displayed in the kitchen explaining the policy to residents in cartoon format and clear lettering. There had been one complaint to the Commission in June 2006, from a relative concerned that they had not been informed of the holiday plans for a resident, and other matters around the holiday. The manager was asked to investigate and reply to the complainant. The home did not accept the complaint but did accept that there had been a lack of communication in this instance. Three of the four relatives who responded to the CSCI pre-inspection survey said that they were aware of the home’s complaints policy. Some staff had received recent training in adult protection as part of Skills for Care and NVQ training but there were no records that all staff had been trained. This has been made a Requirement. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents continue to live in a purpose-built home with the appropriate facilities and specialist equipment and furniture for their needs. The home is well maintained and hygienic. EVIDENCE: The home was upgraded two years ago to include facilities to met the needs of three residents with physical disabilities. The manager stated that no further residents with these disabilities could be accommodated without further alteration to the home. A tour of the building showed that there had been no change to the individual and communal facilities since the last inspection when all these standards were examined and were met. The kitchen floor had been replaced the week before the inspection. New kitchen units were planned but there was no date yet from the landlords, Orbit Housing Association, for them to be fitted. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 18 The kitchen was clean and tidy. Items in the fridge were covered and dated. Temperatures were recorded although there were some gaps over the previous week. The bathroom with the ceiling hoist was still awaiting refurbishment by the landlord. It was in a poor decorative condition and the fixtures were chipped. The manager would like to remove the ceiling hoist as it was not usable in the space available, remove the wall-mounted shower as it had never worked properly, and the possible installation of an adjustable height bath with hoist chair. The home already had a large assisted bathroom linking two bedrooms, which was usable by other residents. The bedroom of the newest resident had been personalised with their own photos, TV and video, Scalextric and drum kit. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment and training practices, which produce staff who are competent and in sufficient numbers to meet the needs of all residents. EVIDENCE: Staffing levels were determined by the daytime programmes of the residents. There were four staff programmed on each morning to cover getting up and having breakfast, and then three on in the afternoon and evening. A fourth member of staff was rostered on some days for certain activities. Additional hours had been funded for one resident to provide day care in the home on two days of the week. At weekends, the home was fully staffed all day. Staff training was organised through the provider’s training programme. Staff were up-to-date on the routine programmes such as moving and handling, fire procedures, food hygiene and medication. Not all staff had received recent training or updates in adult protection. The manager reported that Mencap was planning to introduce a distance learning pack on this topic. Staff were observed to interact well with the residents. They were able to communicate with them all. This was evident either by verbal responses or by non-verbal signs such as smiling and nodding. Staff were knowledgeable about the needs of residents and their likes and dislikes. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 20 The schedule for staff supervision sessions was displayed on the office wall. Records in the personal files showed that most were up-to-date. Some staff had received more than the minimum number recommended by the Standard. In addition all staff underwent an annual appraisal. This schedule too was displayed on the office wall. The file of a staff member was examined. It contained all the records, ID documents and safety checks required. 44 Blyford Road DS0000024338.V312353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42,43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that the home will be run in their best interests, and for their health and safety. EVIDENCE: The manager had read the documents about the Commission’s new policy on inspection, and had required the staff to sign that they had read the “Inspecting For Better Lives” document. Staff were able to summarise the content as far as it would affect the inspection visits to the home. The manager was registered with the Commission and was experienced in the care of this client group. She had completed her NVQ Level 4 and had got the Registered Manager Award. The home followed the comprehensive Mencap quality assurance system, samples of which showed the complimentary comments of residents, families and external professionals such as: “My relative is very well cared for and I have no worries at all about his happiness”. Monthly visit reports were up-to44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 22 date. Mencap was implementing a new internal monthly report called the monthly improvement and compliance report, which managers would complete for the area manager. The manager held staff meetings at six weekly intervals, and residents meetings when there was a topic to talk about. This was usually the Christmas arrangements, or decisions on where residents wanted to go on holiday. The fire log showed that there were regular maintenance checks on fire equipment. The fire alarm was tested weekly with a practice evacuation twice a year. There was also a fire risk assessment. Records were inspected of the weekly hot water temperature checks and the checks on the minibus. All were up-to-date and in order. Employers’ Liability and insurance certificates were up-to-date. The certificate of registration was up-to-date. It was however displayed in the office which was not “a conspicuous place” as required by the Care Standards Act 2000. The home abided by Mencap policies and procedures. Nationally Mencap had a process to involve users in the review and development of policies although none of the residents of Blyford Road were involved in this. 44 Blyford Road DS0000024338.V312353.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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 3 3 3 44 Blyford Road DS0000024338.V312353.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 Standard YA22 Regulation 22(7) Requirement The registered person must insert the name, address and telephone number of the Commission in the complaints policy. The registered person must ensure that all staff are trained and updated in the procedures for adult protection. The registered person must ensure that the certificate of registration is affixed in a conspicuous place. Timescale for action 31/10/06 2 YA23 18(c)(i) 31/12/06 3 *RQN Sec 28, Care Standards Act 2000 12/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA27 Good Practice Recommendations The registered person should ensure that all medicine bottles and medicinal creams are dated on the day of opening. The registered person should ensure that a definite date is given by the landlord for the changes to the bathroom. 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 44 Blyford Road DS0000024338.V312353.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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