Inspection on 11/07/05 for 61 Somerset Road

This inspection was carried out on 11th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

61 Somerset Road 08/04/08

61 Somerset Road 25/06/07

61 Somerset Road 12/06/06

61 Somerset Road 27/02/06

61 Somerset Road 28/02/05

61 Somerset Road 22/09/04

Similar services:

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Edenvale

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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 61 SOMERSET ROAD Barnet Hertfordshire EN5 1RF Lead Inspector Anthony Lewis Announced 11 July 2005 at 09.00am th 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. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 61 Somerset Road Address 61 Somerset Road, Barnet, Hertfordshire EN5 1RF 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) 020 8364 8222 020 8364 8222 Cedric Frederick of PentaHact Rachel Parker & Cheryl Kearns PC Care Home only 5 Category(ies) of LD Learning Disability registration, with number of places 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two specific service users who are currently resident in the home and are over 65 years of age can reside in this home. This condition will need to be reviewed when one such service user vacates the home. Date of last inspection 28 February 2005 Brief Description of the Service: 61 Somerset Road is a care home for five adults who have a learning disability. The home was opened in February 1991. The building is owned and maintained by Sanctuary Housing and the care is provided by Pentahact , a Barnet based organisation, which manages several projects specialising in the provision of care for people who have special needs. The home is a detached two-storey building in a quiet residential area with shops and amenities close by. There is a gradient driveway leading up to the front door, and an area for parking to the front and side of the building. There is a large attractive garden at the rear of the premises. One bedroom is located on the ground floor, with the remaining bedrooms upstairs. There is no lift available, so the home is not suitable for people who have problems with mobility.There is a shower and toilet on the ground floor and two bathrooms and toilet facilities on the first floor. On the second floor there are two bedrooms, a bathroom/toilet and a slep-in room for staff. There is a kitchen-diner, a large lounge and an activities’ room, a laundry room and an office located on the ground floor. The home is managed by two managers, Ms Rachel Gabriella Parker and Ms Cheryl Adele Kearns, on a jobsharing basis. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place on Monday 11th July 2005 at 9am and was completed at 5pm. One of the two registered managers who job shares, was available throughout the inspection and was very helpful and accommodating. In order to collate the evidence for this inspection, two support workers were spoken to individually and in private. None of the resident were spoken to formally due to their communication difficulties. However, throughout the inspection, residents were informally asked various questions and some were able to respond using either monosyllabic communication or body language or through staff support in relating what they thought the residents meant. Information was also extracted from the pre-inspection questionnaire, four service users comment cards and one relatives/visitors comment card. A tour of the home was conducted, which included the front and back gardens. What the service does well: What has improved since the last inspection? What they could do better: There needs to be more variety of meals included on the menu so that the menu does not become predictable or too repetitive and so that residents can sample a variety of foods and for staff to build a large portfolio of residents’ likes and dislikes. This was a requirement at the previous inspection. In order to ensure that all complaints are being taken seriously and that all complaints are dealt with in accordance with the complaints procedure, there needs to be a review of the home’s complaint reporting and recording procedures. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 6 In order to bring the house up to a satisfactory condition, the cracks in walls identified in this report must be repaired. To ensure that residents live in a homely and comfortable environment, all areas must be decorated to an acceptable standard. To ensure that all meals are cooked appropriately, the cooker must be repaired or replaced. Parts of the home are in need of repair to ensure that the home remains homely and adequately decorated. To ensure this the carpets and walls in the activities room need to be replaced and redecorated respectively. This was a requirement at the previous inspection. To ensure that all staff are aware of their roles and responsibilities, all staff must have a copy of their job description in their file. To ensure residents are protected and that the home is following the recruitment procedures correctly, all staff must have two appropriate references. In order to ensure that staff are being fully supported and that their personal development is monitored, staff must receive regular supervision, which is recorded in their file. In order to ensure that residents are receiving appropriate care and all of their needs are being met, there needs to be a more robust way of carrying out a quality assurance and quality monitoring system other than staff filling in questionnaires on behalf of the residents. To ensure the safety of resident’s, staff’s and visitors to the home, a copy of the Portable Appliances Test certificate and the Water/Legionella test certificate must be forwarded to the Commission. 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. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5. Prospective residents to the home and other interested parties are provided with clear information in order to make an informed choice whether to move into the home and if the home will be able to meet their individual needs. EVIDENCE: The home has a satisfactory statement of purpose and service user guide, which contains relevant information regarding the aims and objectives of the home. Four residents’ files were viewed, each contained a copy of their placement agreement, which included conditions of occupancy, the care that the home will provide, the rights and responsibilities of all parties involved and the fees charged. The registered managers ensures that the placement agreement is updated regularly. All were updated in May 2005. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 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, 8, 9 and 10. Residents are confident that staff will support them to live as independently as possible and will respect any choices that they may make and support them to take reasonable risks. EVIDENCE: The care plans of four residents were viewed and were found to contain comprehensive information relating to the individual resident. Information contained in the care plan included; details regarding challenging behaviour and triggers that may cause such behaviour, medical and mobility information and all dietary needs. All care plans were signed and contained the dates of when they were last reviewed. All were reviewed in May 2005. Recorded in residents care plans was information on decision making and choice and how residents communicate to others and how staff will support the residents with their choices. All residents have difficulty with their communication. Records show that there was some input from the speech therapist in 2002. All resident’s files contain information of one to one meetings between the resident and their individual 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 10 key-worker. Service user comment cards indicate that all of the residents enjoy living in the home. The home has a risk assessment file, which contains information on all identified risks to residents and the action taken to minimise or eliminate the risk. All risk assessments were seen to be reviewed on a regular basis. The home has procedures on confidentiality, which contain information on the limitations of confidential information and when to disclose confidential information. There is also a procedure on residents seeing their files, which is based on an open access policy and with staff support where required. All confidential information regarding residents is kept in a lockable cupboard in the office. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 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 and 17. Residents are confident that their lifestyle is being enhanced and that staff are ensuring that they have the opportunity to increase their social, domestic and personal development, with staff support when necessary. EVIDENCE: Resident’s personal development is maintained by staff ensuring that residents are included in all aspects of the running of the home. The registered manager stated that residents go shopping daily with staff. With regards to domestic chores, the registered manager and a support worker stated that staff will support residents to clean their bedroom and the kitchen. There is also information contained in one residents file stating that staff will support with religious beliefs and escort the resident to church. None of the residents are employed at the moment although two residents are at college doing every day living skills such as cookery, art, music and music & movement. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 12 The registered manager said that residents have integrated into their local community and are known by their local community due to the fact that residents are continually out and about and. Staff ensure that residents are supported to use local facilities such as the park, cafe, shops, church and pub. Service user comment cards indicate that the home provides suitable activities. Resident files contained a variety of leisure activities that residents regularly participate in such as pubs, walks and drives. The home has an activities room, which also doubles as a lounge. Art work was seen along with paints, paper, paintings and other items for residents who wish to engage in art work. According to the registered manager, all but one of the residents parents are deceased, which limits family links. The one resident whose mother is still alive does not have regular contact with her daughter. Other residents have minimal contact with distant relatives. Friendships are, at present, limited to other residents in the home. The registered manager stated that residents have unlimited access to all areas within the home except other residents bedrooms, without permission. When asked about how residents express some of their choices, especially with regards to meals, the registered manager stated that at breakfast for instance, residents are shown certain foods such as a packet of cereal and other items and the resident will point, indicating their choice. Service user comment cards indicated that the residents like the food. At the previous inspection, a requirement was made that meals be more varied. The menu was viewed for the past few weeks and although it showed that residents are receiving nutritious meals, the variety is limited. Most weeks there was spaghetti Bolognese and shepherds pie on the list and it looked as though staff had been copying in meals from one week to another. A requirement is made that the registered persons ensure that a variety of meals are included on the menu and that the menu does not become predictable or repetitive. This requirement is restated and revised. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 13 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) 19, 20 and 21. Residents are confident that their health care needs are being met by a competent staff team and that the staff will support them in all areas of their health and with their wishes. EVIDENCE: There was evidence on three resident’s files that staff are ensuring that residents receive regular professional health care checks. There was recorded information regarding each time a resident visited a health care professional and the outcome of that visit. The accident file was viewed and all accidents were recorded correctly. The last recorded accident occurred on 27th June 2005. No resident administers their own medication due to the nature of their learning difficulty. The Medication Administration Record (MAR) was viewed and staff have been administering residents medication correctly and filling in the MAR sheet appropriately. Training records show that all staff have received training in administering medication. On viewing all of the residents files, their “wishes for funeral arrangement” in the event of them dying had been filled in by their next of kin, dated and signed. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 14 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 and 23 Residents are confident that they will be protected form any from of abuse and that any issues that may arise will be listened to and taken seriously by a competent staff team. EVIDENCE: The home has a complaints procedure file, which includes information on how to make a complaint. There is also information for residents on making a complaint in the service user guide. However, although the home has a complaints book, the last recorded complaint was made on 23rd April 2001. The reasons and possibilities for so few complaints were discussed with the registered manger. A recommendation is made that the registered persons ensure that there is a review of the complaints procedure and ensure that all complaints are reported and recorded in the complaints file. The staff training files showed evidence that all staff has received training in, abuse of vulnerable adults between 16th June 2003 and 24th June 2005. Two staff were spoken to regarding protection of vulnerable adults and both had a good understanding of the issues involved. Both were also aware of who to make a complaint to if needed. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 15 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, 27, 28, 29 and 30. The registered persons are not ensuring that residents live in a homely and reasonably decorated environment due to the neglect of some areas and the lack of maintenance work being taken seriously and acted upon when notified. EVIDENCE: The external condition of the home is in a reasonable state. The home has a well kept rear garden. The interior of the home is in need of repairs. There are cracks to the walls in a number of areas, such as the activities/lounge room, the front lounge and to the front entrance hall. A requirement is made that the registered providers ensure that the cracks identified in this report are repaired. In the kitchen, the cooker was viewed inside and out and found to be generally in poor condition. The inside door glass had fallen off and their was burn marks above the door where heat had been escaping. The cooker also looked shabby and worn. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 16 An immediate requirement is made that the registered persons must ensure that the cooker is repaired or replaced. A requirement at the previous inspection that the ground floor shower/toilet is upgraded has not been met. The registered manager stated that she is still waiting for the work to be carried out. This requirement is restated. A requirement at the previous inspection that the carpets and walls in the activities room be replaced and redecorated respectively has not been met. This requirement is restated. All areas of the home has been made accessible to residents with mobility difficulties. There is a long hand rail leading up from the driveway entrance to the front door of the home. There is a raised toilet seat in one of the toilets and hand rails in all bathrooms and toilets. On a tour of the building, all areas were found to be clean and free from any offensive odours. There is a laundry room separate from other rooms and away from the kitchen, which houses a washing machine, which has a sluice programme. The home also has a policy in place regarding the control of infections, with information on the basic principles of infection control with regards to hand washing, spillages and the wearing of protective clothing. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34 and 36. The registered providers are not ensuring that staff receive sufficient support and that documents required for the protection of residents are up to date and sufficient. EVIDENCE: Two support workers were spoken to, individually and in private. Both had a good understanding of their roles and responsibilities and the care required for the residents. However, while looking through five staff files, it was noticed that three of them did not have a copy of their job description. A requirement is made that the registered persons ensure that all staff have a copy of their job description in their file. The home has a statutory training record, which shows that all staff working in the home have received the required statutory training. It also contains information on training renewal dates. Five staff files were viewed; all had satisfactory Criminal Records Bureau (CRB) checks. Four of the five staff files viewed, contained two appropriate references. However, one member of staff, who has worked in the home for a number of years, although having two references, one was from the employment services stating that the person in question was receiving job 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 18 seekers allowance. It was agreed with the registered manager that this was not a sufficient reference and that a further reference would have to be obtained. A requirement is made that the registered persons ensure that the member of staff in question, receives a further reference. On looking through staff supervision notes, it was noticed that some staff had not received supervision for some months. For instance, one member of staff had not received supervision since 10th February 2005. A requirement is made that all staff receives supervision at least six times a year and that a record is kept of the minutes of the supervision. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41, and 42. Residents are not confident that their views will be used in developing the service. However, residents’ wellbeing is safeguarded by the homes safety checks. EVIDENCE: The home has two managers who job share. According to information obtained from the questionnaire, one registered manager works twenty-two hours per week and the other works fourteen hours per week. One has achieved her Registered Managers Award (RMA), a City & Guilds in advanced management and has been a care manager for the past six years. The other registered manager also has achieved her RMA and has been a registered manager for two years. The registered manager stated that both managers would be commencing their National Vocational Qualification NVQ 4 this year. Although the home has a service user feedback answer form, with questions regarding service users’ opinions of the home and the care that they receive, it is not in accordance with the requirement from the previous inspection where 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 20 the registered person were required to find a way to conduct an anonymous quality assurance system in order to enhance the reliability of the findings, other than staff filling in the forms for the residents. This requirement has not been met. This requirement is restated. Confidential information such as resident and staff files were seen to be kept in a lockable cupboard in the office. All resident and staff files were up to date and generally in good order. All other records and files were kept in the office and were in good order and used appropriately. A number of the homes certificates were viewed as follows to ensure that they were up to date. * * Gas safety record last checked on 10th August 2004. Portable Appliances Test (PAT) 29th November 2004. Although the certificate was not available, there was evidence from the visitors book that the test took place on that date. Water/Legionella test carried out on 14th October 2004. Again the certificate was not available, there was evidence from the visitors book that the test took place on that date. Employer’s liability insurance expires on 31st March 2006. Electrical wiring was checked on 16th October 2001. The next due date was written in as October 2006. The home has a fire procedure file, detailing the homes evacuation procedures and what to do in the event of the fire alarm sounding. * * * * Fire equipment was tested in June 2005. The fire alarm is tested weekly from a different call point each time and recorded. The last such test was conducted on 7th July 2005. The fire panel was tested on 11th April 2005. The home conducts planned and unplanned fire drills regularly. The last planned drill was on 31st March 2005 and the last unplanned drill was on 16th June 2005. There was also an evening fire drill at 8.45pm on 27th November 2005. * * * 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 21 * The London Fire Emergency Planning Authority (LFEPA) visited the home on 25th May 1999. They stated on their form that they would be next inspecting the home again on 13th July 2005. A requirement is made that the registered persons ensure that a copy of the Portable Appliances Test certificate and the Water/Legionella test certificate is forwarded to the Commission. 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 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 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x 1 1 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 2 3 x 2 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 61 SOMERSET ROAD Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 3 3 x G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 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. Standard YA17 Regulation 16 (2) (i) Requirement The registered persons must ensure that a variety of meals are included on the menu and that the menu does not become predictable or too repetitive. (Timescale of 21/03/05 not met). The registered persons must ensure that the cracks in the walls identified in this report are repaired. An immediate requirement is made that the registered persons ensure that the cooker is repaired or replaced. The registered persons must ensure that the ground floor shower/toilet is upgraded to an acceptable level. (Timescale of 21/04/05 not met). The registered persons must ensure that the carpets and walls in the activities room are replaced and repaired respectively. (Timescale of 21/04/05 not met). The registered persons must enure that all staff have a copy of their job description in their file. The registered persons must Timescale for action 19/08/05 2. YA24 23 (2) (b) 23/09/05 3. YA24 16 (2) (h) 15/07/05 4. YA27 23 (2) (a) (b), (d) 23/09/05 5. YA28 23 (2) (d) 23/09/05 6. YA31 Schedule 4, 6 (e) Schedule 19/08/05 7. YA34 12/08/05 Page 24 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 2 8. YA36 18 (2) 9. YA39 24 (1), (b), (2) and (3) 10. YA42 12 (1) (a). 23 (1) (a), (c). 22 (1) 11. YA22 ensure that the member of staff identified in this report receives a further reference. The registered persons must ensure that all staff receive supervision at least six times a year and is recorded. The registered persons must ensure that they find a way of conducting an anonymous quality assurance system in order to enhance the reliability of the findings. A summary of the findings must be produced and an action plan developed. (Timescale of 31/05/05 not met). The registered persons must ensure that a copy of the Portable Appliances Test certificate and the Water/Legionella test certificate is forwarded to the Commission. The registered persons must ensure that there is a review of the reporting and recording of complaints. 23/09/05 23/09/05 23/09/05 23/09/05 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. Refer to Standard Good Practice Recommendations 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 61 SOMERSET ROAD G59 S10530 Somerset Road V230870 11.07.05 Stage 4.doc Version 1.30 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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