Inspection on 12/06/06 for 61 Somerset Road

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 5 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 27/02/06

61 Somerset Road 11/07/05

61 Somerset Road 28/02/05

61 Somerset Road 22/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 61 Somerset Road Barnet Hertfordshire EN5 1RF Lead Inspector Anthony Lewis Key Unannounced Inspection 12th June 2006 10:50 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 61 Somerset Road Address Barnet Hertfordshire EN5 1RF 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) 020 8364 8222 020 8364 8222 www.pentahact.org.uk PentaHact Ms Rachel Gabriella Parker Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Specific Service Users 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. 27th February 2006 Date of last inspection 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 PentaHact provides the care, 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 off street parking to the front 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 sleep-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. Two managers, Ms Rachel Gabriella Parker and Ms Cheryl Adele Kearns, on a job-sharing basis, manage the home. The range of fees for people living in the home is £62.35 to £94.45 depending on the level of their disability. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 12th June 2006 at 10.50am and was completed at 5.10pm. One of the two registered managers who job shares, was available throughout the inspection process and was very helpful and accommodating. The operations manager was also available near the end of the inspection. Evidence was gathered for this inspection from the pre-inspection questionnaire prior to the inspection and talking to two support workers individually and in private. None of the resident were spoken to at length due to their communication difficulties. However, throughout the inspection, residents were indirectly observed and brief questions were asked. One resident was able to respond using either monosyllabic communication or body language, which indicated that he was able to understand some of the questions asked. Evidence was gathered by viewing all of the residents’ and five staff files along with various safety certificates and other documents. An internal and external tour of the home was conducted with the registered manager. What the service does well: What has improved since the last inspection? The staff team have ensured that six of the ten requirements made at the previous inspection have been met. The staff have also ensured that the two administrative recommendations made at the previous inspection were incorporated. This has improved the quality of care to residents and information is more readily available and up to date. The staff have ensured that the knobs on the hob have been changed. The ground floor shower room has been repaired, eliminating the offensive odour and some of the water retention. All areas of the home are kept clean and free of any offensive odours. Staff are receiving adequate training and a review of staffing levels has been conducted. The four contraventions identified by the London Fire and Emergency Planning Authority (LFEPA), have all been rectified. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 6 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. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The home has an effective and robust assessment process to ensure staff can meet the needs of potential residents to the home. EVIDENCE: The registered manager said that she carries out assessments of potential residents to the home. The registered manager went on to say that she carried out the assessment of the most recent resident who moved into the home just over two years ago and that the resident was able to visit the home with her social worker to ensure that the home could meet the persons needs. When the resident’s assessment information was viewed, it contained relevant information about the persons previous history, health and medication, dietary needs, communication abilities and staffing requirements. The home also has the organisation’s “criteria for the selection of service users,” which is used when assessing potential residents to the home. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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, 8 and 9. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Comprehensive recording of information ensures that residents’ needs are being met and that they will be supported in decision-making and to take informed risks. EVIDENCE: The care plans for all of the residents were viewed. They all contained comprehensive and up to date information on the individual resident’s present and changing needs such as their routines and rituals; for instance, one resident enjoys having a bath and splashing about in it. Another resident gets up at about the same time every morning and according to the registered manager and the resident’s care plan, seeks out a member of staff for support. Other information in care plans detail how some residents wish to be supported by staff when eating. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 10 Due to communication difficulties and the level of their learning disabilities, residents are restricted in making decisions for themselves. This was discussed at length with the registered manager who said that staff are able to understand some of the residents choices through their physical gestures and limited verbal communication. Recorded in residents’ care plans was information on their comprehension abilities and how staff will support them to make decisions. The registered manager said that at one time there use to be regular residents’ meetings to discuss issues in the home and to enable residents to participate in life in the home but that they were unsuccessful due to some residents either not wishing to attend or not participating when at the meetings. On the day of the inspection, one resident went out shopping with a member of staff. When they returned another resident was observed helping the staff with the shopping. In addition, the registered manager said that residents help in some of the chores in the home, such as cleaning, doing the laundry and clearing the table after meals. The staff have ensured that various everyday risks to residents have been recorded in the resident’s file. The risk assessments include the risk to the resident, others and the organisation. There was also a section regarding the benefits to the resident, others and the organisation. The recording of risks was discussed with the registered manager who will be reviewing and updating them shortly. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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): 12, 13, 15, 16 and 17. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered prior to and during the visit to this service. Through understanding of individual resident’s needs, staff are ensuring that residents engage in appropriate social activities within their local community, although they have limited personal relationships. Staff are not ensuring that the residents receive a varied diet based on their likes and dislikes. This practice does not ensure that residents’ choices are taken into account. EVIDENCE: All of the residents have lived in the home for many years. In this time, staff have recognised their interests and abilities and have produced a “structured week” chart for each resident. The chart details the individual resident’s daily activities within and outside the home such as: attending collage, reflexology for residents with physical disabilities and day centre attendance. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 12 The pre-inspection questionnaire includes activities such as bowling and trips to a café. Care plans viewed included information on community activities that residents are involved in such as going swimming, trips to the pub, and trips out for walks and to restaurants. According to the registered manager, one resident regularly attends church. Evidence of the resident’s wish to attend church was seen in their care plan. The registered manager stated that none of the residents have personal relationships, although one resident occasionally meets with an acquaintance from another home. The registered manger also said that visits from family and friends is sporadic but that the staff keep the relatives and other stakeholders informed of the resident’s progress. The registered manager went on to say that she is in the process of finding advocates for the residents. Throughout the inspection process, staff were observed interacting with the residents in a courteous and supportive manner at all times and calling them by their first name. A member of staff was observed taking advantage of the warm weather by walking and talking with a resident in the garden. Another resident was observed spending periods sitting in the garden relaxing, seemingly in contemplation. Residents seemed relaxed and comfortable in the company of each other and the staff team. At times some residents sat out in the garden on their own and others were observed moving about the home without restrictions. Although there has been some improvements in variety when planning the menu, staff are not taking all of the residents’ likes and dislikes into account. The care plans of each resident was viewed and although one resident does not like certain foods, these foods were seen to be on the menu yet there was no evidence as to whether the resident was receiving these foods or not. A review has not taken place to ensure that the menu planning correlates with residents’ likes and dislike as stated in their carer plans, this was a requirement at the previous inspection. The registered manager said that she will be carrying out a review of the menu with staff. This requirement is restated. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and 20. Qualities in these outcome areas are good. This judgement has been made from evidence gathered prior to and during the visit to this service. The staff team are ensuring that residents’ preferences, physical and emotional needs are being respected and that robust medication policies and procedures are being practiced to ensure residents’ safety. EVIDENCE: Residents’ personal support was discussed in detail with the registered manager and later with one member of staff. The registered manager stated that although the residents are able to support themselves to a certain extent, such as putting on some items of clothing, washing and sorting their clothes, staff support them in all areas of their personal care. The care plans of all of the residents contained information on their personal care needs. There was information on whether the resident prefers to have a bath, shower or wash and how the staff will support them. The care plans also contained information on oral and nail hygiene and support with dressing. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 14 All residents are being supported by the staff team in areas of their health care needs. This was evident when the health care sections of their care plans were viewed. Staff are ensuring that residents have regular check ups with their GP, dentist, psychiatrist, hospital out patient and optician appointments. The residents’ care plans also contained information on all health care appointments, any advice and treatment arising from the appointment and any follow-up arrangements. According to information in the pre-inspection questionnaire, some health care professionals will contact each resident by post for their next appointment. The registered manager stated that no resident administers their own medication and that all medication is administered by trained staff. When looked at, the residents’ Medication Administration Record (MAR) sheets were completed correctly and staff files seen contained their medication training certificate. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 15 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 and 23. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. The staff team are ensuring that complaints are being taken seriously and that residents are protected from abuse by trained staff who have a good understanding of protection of vulnerable adults. This has also ensured that residents and other stakeholders may feel confident that concerns will be acted upon. EVIDENCE: At the previous inspection, a recommendation was made that a review of the recording of complaints is conducted. When spoken to, the registered manager said that a review had taken place and that staff are more aware of the recording of complaints. Since the previous inspection, two complaints have been made. The staff have ensured that these complaints have been recorded correctly in the complaints book and that they have been reported to the relevant agencies and appropriately investigated. A member of staff was spoken to about protection of the residents in the home from abuse. The staff member had a good understanding of the protection of vulnerable adults and said that she has completed the protection of vulnerable adults (POVA) training, her certificate was seen in her file. The member of staff also explained some past issues that had occurred in the home and how the registered managers dealt them with effectively. She was also able to explain the “whistle blowing” procedure and an example of occasion when she may need to use it. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 16 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, 27 and 30. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although some maintenance issues are being taken seriously, the staff are not ensuring that all maintenance issues that will improve the appearance of the home are robustly rectified. EVIDENCE: The home is an old Victorian building that has been in constant use for many years. This has resulted in parts of the home looking rather dated and worn. A number of cracks have appeared in various places in the home, some of which appear to be hairline cracks and others a little larger. In light of this requirements have been made at previous inspections that the cracks are repaired. This has still not occurred. The registered manager stated that the cracks have been looked at by a builder who stated that they do not pose a health and safety risk and that a request has been made for the work to be carried out to repair the cracks and that she will chase up the request. This requirement is restated. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 17 A requirement made at the previous two inspections that the downstairs shower room/toilet is upgraded to an acceptable standard has been met. On the tour of the home, the shower/toilet was seen to be repaired and to an acceptable standard. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 and 36. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Robust recruitment procedures are ensuring that residents living in the home are being supported by a competent, effective and adequately trained staff team. However, the staff’s personal development is not being supported sufficiently. EVIDENCE: Talking to two members of staff and the registered manager gave a good indication of their qualities, skills and knowledge. They all demonstrated a good understanding of the needs of people with learning and physical disabilities and have a good understanding of the needs of individual residents living in the home. One member of staff said that she has completed the National Vocational Qualification (NVQ) level 2 and the other member of staff said that she was undertaking the (NVQ) level 2. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 19 Throughout the inspection process, some residents seemed to be happy being in their own company when they wished and with staff at other times. With regards to staff, although there were only two on shift, they were observed interacting with and supporting residents at intervals whilst still carrying out other duties. Because there is usually only two staff per shift, a requirement was made at the previous inspection that a review of the staffing levels is carried out. This was discussed with the registered manager and the operations manager who said that a review had taken place on 6th March 2006 and that the staffing was sufficient to meet the needs of all of the residents. This requirement has therefore been met. The personal files of four staff were viewed to ensure that recruitment policies and procedures are being followed. The files contained all of the required information for each member of staff such as: a correctly completed application form, two references, a recent photograph, birth certificate details and a Criminal Records Bureau (CRB) check. At the previous inspection, it was recommended that all staff files are sorted into a logical and consistent sequence, this has been done and the files are now tidy and information is more readily accessible. Also contained in staff files was a variety of training certificates such as health & safety, protection of vulnerable adults, food hygiene and moving and handling. Staff spoken to discussed further training that they have received specific to the residents in the home to enable them to meet the needs of the residents. While looking through staff files, their supervision records were viewed and although most staff are receiving regular supervision, there was no evidence to show that two members of staff have received more than one supervision this year. At the previous inspection it was a requirement that all staff must receive regular supervision at least six times a year. The registered manager stated that staff supervision will be discussed with her colleague and that all staff will in future receive regular recorded supervision. This requirement is restated. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Residents are being supported and staff are being managed by a competent and qualified registered manager. However, residents views regarding the quality of service is not being taken seriously and residents, staff and visitors to the home are being put at risk due to health and safety issues not being appropriately monitored. EVIDENCE: Throughout the inspection process, the registered manager displayed a good knowledge and understanding of the residents needs. She also demonstrated her leadership qualities with the staff team in the way she communicated with them. When asked about qualifications, the registered manager stated that she has a City & Guilds in Advance Care Management (325/3) and a Registered Management Award (RMA). She went on to say that she is, at present, undertaking her (NVQ) level 4 and has been in management since 1995. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 21 PentaHact has a quality assurance manager, whose role is to co-ordinate reviews of the quality of service provided, through sending out questionnaires to residents, staff and other stakeholders. The results of the questionnaires are forwarded to operations managers and registered managers who will structure their development plan according to the views and comments from the questionnaires. At the previous inspection, a requirement was made that an anonymous system is developed where staff do not fill in the questionnaires on behalf of the residents. This was discussed at length with the registered manager and operations manager who said that no system has yet been devised but that they will review it together and ensure that a method is devised. This requirement is restated. A variety of safety certificates and various other documents and files were viewed and most were up to date and in order. Fire tests and drills are carried out regularly and recorded. The gas certificate was up to date and in order and the London Fire and Emergency Planning Authority (LFEPA) contraventions identified at the previous inspection have been met. However, there has not been a Portable Appliances Test (PAT) since 29th November 2004. The registered manager stated that she will contact the appropriate agency to carry out a (PAT) as soon as possible. A requirement is made that the registered persons must ensure that a (PAT) is carried out and a copy of the certificate is forwarded to the Commission. 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 x 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 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 Timescale for action 14/07/06 2. YA24 3. YA36 4. YA39 The registered persons must ensure that a review of the menu takes place and that there is comprehensive information in residents’ care plans regarding the foods that they like and dislike. (Timescale of 31/03/06 not met). This requirement is restated. 23 (2) (b) The registered persons must 03/11/06 ensure that the cracks in the walls are repaired. (Timescale of 05/05/06 not met). This requirement is restated. 18 (2) The registered persons must 03/11/06 ensure that all staff receive recorded supervision at least six times a year. (Timescale of 31/03/06 not met). This requirement is restated. 24(1),(b(2) The registered persons must 03/11/06 (3) ensure that they find a way of conducting an anonymous quality assurance monitoring 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 23/09/05 not met). This DS0000010530.V292054.R01.S.doc Version 5.1 61 Somerset Road Page 24 requirement is restated. 5. YA42 23 (4) (a) The registered persons must ensure that a (PAT) test is carried out and a copy forwarded to the Commission. 03/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 61 Somerset Road DS0000010530.V292054.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office 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 DS0000010530.V292054.R01.S.doc Version 5.1 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. 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