Inspection on 04/07/06 for 54 Brookvale Road

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

54 Brookvale Road 31/08/07

54 Brookvale Road 22/11/05

54 Brookvale Road 15/06/05

54 Brookvale Road 24/11/04

54 Brookvale Road 16/07/04

54 Brookvale Road 20/02/04

54 Brookvale Road 13/12/02

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 54 Brookvale Road Olton Solihull West Midlands B92 7HZ Lead Inspector Joe O’Connor Unannounced Key Inspection 4th July 2006 11:15 54 Brookvale Road DS0000043666.V298228.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 54 Brookvale Road DS0000043666.V298228.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. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 54 Brookvale Road Address Olton Solihull West Midlands B92 7HZ 0121 708 1553 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) Robinia Care West Midlands Limited Ms Christine Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Should the standard of care within the home deteriorate due to the manager being responsible for two other homes, then an individual manager will be required. 22nd November 2005 Date of last inspection Brief Description of the Service: The service provided at Brookvale Road consists of a domestic three bedroomed house situated in a residential area of Olton in Solihull. The service is registered to provide accommodation and support three adults with learning disabilities. The current service users are three men. 54 Brookvale Road is in a road of similar properties and is within walking distance of local facilities. Solihull town centre is accessible by bus or train, as is Birmingham City Centre. Each service user has single bedroom accommodation. The rest of the house, consisting of a lounge, dining room, kitchen, bathroom, and shower room is shared on a communal basis. There is an office that is also used as a staff sleep in room. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a day. All the key standards were assessed. All the service users were present for part of the inspection. Only one was able to convey their views about life in the home while another declined to speak with the Inspector. Service users’ care records and risk assessments were examined, along with a number of health and safety records. Additional information was also examined in what is known as a pre-inspection questionnaire that is sent out to the home before the fieldwork visit and a history of the service that includes information about important events. The Inspector spoke to the Registered Manager. Observations of care practices were undertaken. The weekly fee for the service starts from around £1,173 What the service does well: Service users live in premises that are similar in appearance and structure to that of neighbouring properties and its purpose as a care home is not known. This provides them with a clean homely environment. The service users were observed to receive friendly support from staff and the atmosphere during this visit was relaxed. It was good to see the service users being encouraged to be independent and one was observed to be involved in preparing tea later that afternoon washing and chopping up vegetables. Another was supported to make himself hot drinks during the day. One of the service users has been receiving support from a specialist employment job service to help him find a job of his choice in the community. There is an open relaxed approach within the home and it is evident that if a service user has a grumble or a complaint the manager will take action in ensuring the views of the service users are listened to. One service had raised concerns about the delay in having additional lighting fitted in his bedroom but he has now had it installed and stated his satisfaction with how the manager dealt with his complaint. An examination of the health and safety records found the mains operated smoke detectors and emergency lighting were being tested regularly. There was also a recent fire drill and fire safety training. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 54 Brookvale Road DS0000043666.V298228.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 54 Brookvale Road DS0000043666.V298228.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): 3&5 Quality in this outcome is good. This judgement has been based on available evidence including a visit to the service. Service users needs are currently being met with friendly and positive being provided by staff. Service users have up to date information in their contracts about how much they have to pay towards their accommodation. Standard 2 was not assessed. EVIDENCE: The service has had no new admissions since the previous inspection. Two service users’ care records sampled found they had recently been re-assessed by social workers from Birmingham Social Care & Health. The service users were having their assessed direct support hours reviewed. There were copies of the assessments on the service users’ file along with an updated social work care plan that had very basic information as to what was required from the service. The manager stated that the outcome of two of the assessments identified the service users concerned remained within the “critical” criteria banding. The remaining service user assessment has identified that he wishes to live in more independent accommodation. Since the last inspection progress had been made in ensuring service users needs were being met with appropriate levels of staff on duty during the evening. The manager stated there was now provision within her staffing budget to recruit an additional member of staff so that all three service users have wider opportunities to go out in the evening. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 9 All three service users were out for most part of this inspection but comments received from one of the service users on his return was positive. The service user said he was happy with the support being provided and felt very settled. Another service user who has limited verbal communication used some signs to indicate that he wanted to have a new Argos catalogue. Observations made of staff interaction found these to be friendly and positive. There was a relaxed atmosphere during this visit. A requirement from the previous inspection for service users contracts to state the fees and any other charges to be paid had been addressed. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome is adequate. This judgment has been based on available evidence including a visit to the service. Service users needs and how these should be met are set out in care plans, which are available in an accessible person centred format. Service users risk assessments that inform staff how individual risks should be minimised in the home and in the community. Service users are encouraged to make decisions about their lives with some improvements needed in how any decisions are made and evaluated. EVIDENCE: Two service users care records were sampled. These have information including aims and objects. Progress in how they met the objectives is recorded by staff every month. However, one of the care plans seen last had a progress report written in April 2006. Since the last inspection each service user has had a person centred plan that combines the use of photographs and symbols. One service user stated he had been involved in the development and enjoyed being involved with the photographs. These referred to what was important to the service user and included their likes and dislikes. One stated that the service user liked collecting watches and that one of his favourite meals was fish and chips. Another referred to how proud the service user was 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 11 of his vast collection of Lego construction bricks. The person centred plans also referred to their daily routines and where they went for their healthcare appointments. Risk assessments were in place, which set out how service users should be supported in the home and in the community. One risk assessment seen referred to a service user requiring 1:1 support when going out to activities such as shopping. Another referred to the importance for one service user to carry his mobile phone out when he goes out so he can contact staff in an emergency. Service users are involved in meetings every Sunday where they can make decisions about the menu for the coming week and what activities they would like to do. There was some evidence to indicate that staff were using symbols and pictures to assist one of the service users with limited verbal communication to be involved in the meeting. However, the minutes for these meetings did not have enough evidence whether activities requested by service users were being followed up and evaluated by staff. One of the service users attends a monthly service user forum organised by Robinia where he has the opportunity to meet service users from other placements in the West Midlands area. The service user stated he continues to manage his own medication and written evidence was seen confirming that he was in agreement with staff to enable them to monitor his progress. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome is adequate. This judgement has been based on available evidence including a visit to the service. Service users have access to leisure activities in the community and are able to go on holiday as individuals and not as a group. Service users are encouraged to be independent with no unnecessary restrictions in place subject to individual risk assessments. Service users food records do not indicate service users are being encouraged to eat a healthy balanced diet. EVIDENCE: During this inspection one of the service users went out with a member of staff to the cinema to see Pirates of The Caribbean 2. While the service user was unable to comment verbally about the film the member of staff supporting him stated service user enjoyed the film. Another service user has recently registered with a specialist employment agency and spoke about a training course he attended to develop self confidence skills. The same service user had also recently his first ever football match to see Birmingham City and enjoyed it. The other service user who was present during this inspection goes horse riding once a week and attends Relaxaway, which is a centre that provides a multi sensory environment. He also goes to college once a week to participate in music and movement. The manager stated that the service user was 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 13 continuing to make good progress and did not have to be supported during the day by staff. She is working with the service user to increase his choice of activities at college next September. The service users are encouraged to choose their own holidays. The manager stated one will be going to Blackpool and chose this himself. Another will be going to Devon while the third service user will be going to Eire to visit his mother. An examination of the service users’ daily records indicated all three are involved in shopping for food and during this inspection one of them was observed to be preparing vegetables for tea later that evening. A member of staff was observed to encourage one of the service users to make himself a hot drink. An examination of the records for food eaten by the service users indicated that most of the meals eaten tended to be repetitive. For example there were three days during the week where service users were consuming chips for lunch, tea or dinner. The manager has developed the food menus in a photographic format. 54 Brookvale Road DS0000043666.V298228.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 Quality in this outcome is good. This judgement has been based on available evidence including a visit to the service. Service users receive support with their personal care and choose when they require assistance. Service users have access to community and specialist healthcare services with or without the need for staff support. Medication management is to an acceptable standard ensuring the promotion and maintenance of service users’ good health. EVIDENCE: The service currently accommodates three white males who are supported by an appropriate mix of staff to support their personal care needs. Three members of staff working in the home are male of whom two are of White UK while the third is from a Black African background. There is a policy and procedure on gender care. An examination of service users daily diaries referred to where service users were assisted or prompted to manage their personal care. Manual handling assessments were in place and these had been reviewed since the last inspection. Service users care records provided evidence to confirm they were accessing local healthcare services such as a GP, dentist, optician and chiropodist. The pre-inspection questionnaire stated two of the service users were able to attend healthcare appointments themselves. One service user stated he was 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 15 able to visit the GP himself and would sometimes ask staff to accompany him. It was good to see that two service users are able to self administer their own medication. There had been an improvement with the recording of individual weight, which was being carried out every month. There was written information confirming one service user was having support from a dietician to reduce his weight and encourage him to eat more healthily. Each service user has a health action plan which was a requirement from the previous inspection. The management of medication was to a good standard. An examination of the Medicines Administration Records found there were no gaps in recording and photocopies of prescriptions were attached to the MAR sheets. Since the last inspection each service user had their homely remedies protocols reviewed and signed by their GP. An examination of staff training records indicated they had received accredited medication training. Written protocols were in place for the use of PRN medication including paracetamol and diazepam. An examination of staff records indicated they were receiving accredited medication training. This was a requirement from the previous inspection. 54 Brookvale Road DS0000043666.V298228.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 is good. This judgement has been made based on available evidence including a visit to the service. Service users grumbles and complaints are listened to and by the manager. Service users’ interests are protected with information and training available to staff protecting vulnerable adults from abuse. EVIDENCE: The service has received two complaints since the last inspection. One was made by a service user who was unhappy in the delay with the installation another light fitting in his bedroom. The second was relating to concerns raised by the Local Authority’s Environmental Health Department regarding loud music being played from the premises. These had been documented on the complaints record and there was evidence confirming the manager had been addressing these concerns. The CSCI have not received any complaints. There is a complaints procedure of the organisation on display in the hallway along with a photograph of the Inspector. An examination of staff training records confirmed staff had received training in adult protection. There was a copy of the latest multi agency guidelines published by Birmingham Social Care & Health. The adult protection policy and procedure produced by Robinia had been amended to state that any concerns around suspected abuse to a service user should be notified to the CSCI verbally, although there is a procedure in place informing staff around the use of Regulation 37 notification that includes letting the CSCI know of any incidents of suspected abuse. 54 Brookvale Road DS0000043666.V298228.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 & 30 Quality in this outcome is adequate. This judgement has been based on available evidence including a visit to the service. Service users live in a clean, homely environment with some minor improvements needed. EVIDENCE: The building was generally clean and tidy at the time of inspection. Radiator covers had been fitted in the bathing areas since the last inspection. Improvements had been made to the back garden. One of the service users had additional lighting installed in his bedroom. It was noted a requirement for one of the service user’s wash hand basin to have its seal repaired had not been fully addressed. New coloured chopping boards were in place in the kitchen. There are policies and procedures in place for the control of infection. There are liquid soap and disposable towels in the toilet and bathroom. One of the service users was proud to show the work he had undertaken in refurbishing the back garden with the lawn edged neatly with new borders for the flowerbeds. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome is good. This judgement has been based on available evidence including a visit to the service. Staff recruitment records meet the requirements of the regulations protecting service users’ interests. The organisation offers and provides training to all staff enhancing their knowledge and skills to meet the needs of the service users. Staffing levels are being increased to meet the needs of the current group of service users. EVIDENCE: An examination of the pre-inspection questionnaire stated that out of five care staff 3 were qualified to NVQ Level 2 and above, which is just over 50 of the workforce. One member of staff had recently completed NVQ 3 while another was close to completing their Level 3. One new member of staff had been recruited since the previous inspection. An examination of their staff file found there was appropriate documentation in place including, job description, application form, a record of the interview, contract, CRB, two references, proof of identity and a record of induction. Each member of staff has a training file and there was evidence staff were receiving up to date training in mandatory training topics such as food hygiene, fire safety, and manual handling. The pre-inspection questionnaire stated staff had completed training in makaton and some had commenced training in physical intervention training with a new accredited training 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 19 provider called Team Teach. Future training being planned included adult protection, food hygiene and updated fire safety training. Observations at the time of inspection indicated the service users were comfortable in the presence of staff where there were positive interactions taking place. The manager stated that since the last inspection she was now in a position to provide additional staffing into the service. This will provide wider opportunities for service users to have more activities during the evening and at the weekend. The pre inspection questionnaire stated that during the previous eight weeks bank staff had covered a total of 175 shift hours. The staffing team has been stable since the last inspection with one promoted to Team Leader. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome is good. This judgement has been based on available evidence including a visit to the service. Service users benefit from a supportive manager who strives to improve practice. Service users are given the opportunity to comment on the service they receive through monthly visits from a representative of the organisation. Service users interests are maintained through appropriate maintenance and storage of records. Service users health and safety is appropriately managed that protects their interests. Key policy and policy and procedures have been updated informing staff about when the CSCI should be contacted. EVIDENCE: The Registered Manager was present during this inspection and demonstrated her commitment to making further improvements to the service. The service has recently been awarded most improved home in the West Midlands Region by the Robinia Group. The manager commented that this has made such a difference to the staff group within the service. She spoke positively about their commitment to working with the service users. There was evidence staff meetings were taking place every month. One of the service users’ commented 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 21 that he was pleased for the home and there had definitely been improvements in how it was being managed. He also had a copy of the previous inspection report on cassette format. Since the last inspection the manager has introduced satisfaction surveys to service users and relatives and these were available in a widget symbol/illustration format. A representative from the organisation was undertaking monthly visits to the service under Regulation 26 and the reports were available for inspection. The organisation has a regional and national quality assurance system where staff and other professionals also make comments about the management of the service. Amendments had been made to a number of policies and procedures, which included contact details for the local CSCI office. Overall the records maintained within the service were up to date and held securely and there was no evidence the service was breaching any confidentiality. Health and safety records were satisfactory. There was evidence confirming the mains operated smoke detectors and emergency lighting were being tested every week. A fire drill had occurred prior to this inspection and staff had completed training in fire safety. The risk assessment for the prevention of fire had been reviewed. The risk assessment for the premises included the front driveway and back garden which was a requirement from the previous inspection. Staff had received fire safety training since the last inspection. An examination of the accident book indicated eight had occurred since the last inspection and these had been notified to the CSCI via Regulation 37. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 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 Standard No Score 1 N/A 2 N/A 3 3 4 N/A 5 3 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 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 3 35 3 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 N/A LIFESTYLES Standard No Score 11 N/A 12 3 13 3 14 N/A 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 N/A 3 3 3 3 N/A 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. YA7 YA8 Standard Regulation 12(2)(3) 16(2)(m)(n) Requirement The Registered Person must ensure that service users meetings minutes include an action plan and to evidence they are involved in the running of the service. Timescale for action 04/09/06 2. YA17 12(1)(2) 3. YA24 23(2)(b) The Registered Person must 04/09/06 ensure service users are encouraged to eat a healthier balanced diet as part of maintaining their good health. The Registered Person must 04/09/06 ensure that the seal underneath the wash hand basin in the one of the service user’s bedroom is repaired without delay. 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 54 Brookvale Road DS0000043666.V298228.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 54 Brookvale Road DS0000043666.V298228.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!