Inspection on 27/04/06 for 63a Victoria Avenue

This inspection was carried out on 27th April 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63a Victoria Avenue 17/08/07

63a Victoria Avenue 13/10/05

63a Victoria Avenue 21/04/05

63a Victoria Avenue 16/11/04

63a Victoria Avenue 19/04/04

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 Victoria Avenue (63a) 63a Victoria Avenue Wallington Surrey SM6 7JP Lead Inspector Deborah Yapicioz Key Unannounced Inspection 27th April 2006 09:10 Victoria Avenue (63a) DS0000007210.V287804.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 Victoria Avenue (63a) DS0000007210.V287804.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. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria Avenue (63a) Address 63a Victoria Avenue Wallington Surrey SM6 7JP 020 8669 4559 020 8669 4559 manager.victoriaavenue@careuk.com 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) Care Solutions Limited Ms Karen Campbell Care Home 7 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 7 people with learning disabilities and physical disabilities. 13th October 2005 Date of last inspection Brief Description of the Service: 63a Victoria Avenue is owned managed and staffed by Care U.K. The home is registered to provide residential care for up to seven adults with learning and physical disabilities. At the moment there are six service users at the home with one vacancy. The current service users have complex needs. The premises are a modern purpose built two-storey house set back in a quite residential road in Wallington. The home was built approx four years ago. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The home is in the process of changing one of the rooms on the first floor to a sensory room. The home is homely, bright and clean. The furniture is domestic, flame retardant, and of good quality. The home has a lift and is fully accessible to the service users. The home has parking to the front and a pleasant garden at the rear of the home which the service users spend time in during the summer months. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2006/2007 and was an unannounced visit, which took place on the morning of 27h April 2006. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. The service users at the home have limited communication skills, which restricted the way that service users could be involved in the inspection process, the staff team have built up a good relationship with the residents and use that knowledge to advocate on their behalf. Other methods of inspection included a tour of the premises, observation of contact between staff and service users and a meeting with the home manager. Records examined included service user plans, care manager assessments, risk assessments, medication records, complaints, staffing records, health and safety and fire records. The inspector would like to thank the service users, the staff team and Ms Enever for their help in facilitating the inspection. What the service does well: What has improved since the last inspection? The original group of service users to the home were admitted on a block contract, which was a common practise at the time. The service users at Victoria Ave have now all got a copy of their individual contracts, which specify the rooms to be occupied; fees charged, what they cover, and the cost of extras not covered by the basis cost of the placement. Copies of the service users contracts were seen on their files. For the last two years the home has been considering turning an unused bathroom upstairs in to a sensory room. This is now in the final planning stages and the home manager informed the inspector that she has agreed the funding and is in the process of furnishing the room with the appropriate sensory equipment. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 6 The home manager has recently attended the Person Centred Planning for facilitator course run by the London Borough of Sutton and will be cascading the information down to the staff team as well as arranging training for them. Care U.K. has recently reviewed their policies and produced a new policy file, which is specifically for homes providing care and accommodation for people with Learning disabilities. 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. Victoria Avenue (63a) DS0000007210.V287804.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 Victoria Avenue (63a) DS0000007210.V287804.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): 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An up to date service users guide and statement of purpose is not generally available, although the home manager is in the process of compiling a more up to date document. Each of the service users is now issued with an individual contract setting out the terms and conditions of the placement, which safeguards the interests of both parties EVIDENCE: Victoria Ave currently has five service users living at the home with two vacancies. The home has a service users guide and statement of purpose in place. The service users guide is in a widget format. There has been a change in the management structure at Victoria Ave since the last inspection. The new manager is in the process of updating the information on the service users guide and statement of purpose to reflect the current management and staffing arrangements at the home. The home manager stated that the updated information should be available at the next inspection. The home has a referral process for new service users, which includes having a full assessment of service users needs in place to ensure that the service users needs can be met by the home. All service users files looked at had a care manager’s referral on file as well as supporting information from other healthcare professionals and the homes own assessment records. No new referrals have been received since the last inspection. The home manager confirmed that cultural and religious issues were discussed at the time of referral to the home and ways of meeting these needs would be included in the Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 9 service users care plans. The home manager would also discuss cultural and religious issues with family members. The service users at Victoria Ave have now all got a copy of their individual contracts, which specify the rooms to be occupied; fees charged, what they cover, and the cost of extras not covered by the basis cost of the placement. Copies of the service users contracts were seen on their files. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 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 area is good. This judgement has been made using available evidence including a visit to this service. The service users have comprehensive individual care plans with good information on their needs and personal goals. Individual care plans are regularly updated to reflect current needs. EVIDENCE: The home is in the process of introducing Person Centred Plans to the assessment process used by the home. The home manager informed the inspector that she had recently attended the Person Centred Planning for facilitator course run by the London Borough of Sutton and will be cascading the information down to the staff team as well as arranging training for them. The care plans will then be updated to incorporate the principles of Person Centred Planning. Main reviews occur every year. Care plans are internally reviewed every six months and updated by key workers regularly using monthly reports, which form a useful tool in monitoring changing needs, and ensuring goal/targets can be met. The home manager completes a regular check of the service users files to ensure they are kept up to date. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 11 The service users at the home have limited communication skills and the home manager stated that the staff team have built up a good relationship with the residents and use that knowledge to advocate on their behalf. The organisation has recently introduced service users meetings for the group of homes in the local area. A meeting was due to take place later on the day of the inspection. The manager explained that the meeting is also a social occasion with service users going to a fire station, having a meal out as well as the consultation element of the session. Service users choose the venue for the meetings. The staff members spoken to during the inspection felt that the service users seemed to enjoy the meetings. The home operates a risk management strategy. Service users at the home have individual risk assessments depending on their needs and goals. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 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 area is adequate. This judgement has been made using available evidence including a visit to this service. The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. The daily routines and house rules promote residents’ rights and encourage independence. The home has an open visitors policy to ensure friendships and family links are maintained. EVIDENCE: It was noted at the two previous inspections that the vehicle used by the home was not appropriate for the service users and this was having a negative impact on the activities accessed. The home manager has discussed this with the area management team and the home is currently leasing a more appropriate vehicle from a local disabled transport provider and is in the process of purchasing a suitable vehicle for the home. One of the service users who is able to use public transport also has a disability travel pass. It has been one of the homes aims over the past year to increase the range of activities accessed by the service users. This has resulted in the service users having a varied programme of social activities. The activities have been organised by the staff team to reflect service users individual interests and a Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 13 record of the sessions undertaken by the service users was seen on their files. The activities include accessing Orchard Hill College and the Cheam Centre. The service users also go on a variety of social outings to pubs, restaurants and outings including the theatre and the London Eye. The service users also have in house activities including “Us in a bus” and aromatherapy sessions. For the last two years the home has been considering turning an unused bathroom upstairs in to a sensory room. This is now in the final planning stages and the home manager informed the inspector that she agreed the funding and is in the process of furnishing the room with the appropriate sensory equipment. The staff members spoken to during the inspection feel that this will be a useful addition to the home which service users will get a lot of enjoyment and stimulation from. The home arranges for the service users to attend local churches. This is noted on the service users care plans. The home is currently in the process of arranging the service users holidays. The home manager explained that the service users are planed taking into account the service users individual interests and needs. Possible venues include Centre Park’s and Butlins. At the last inspection it was recommended that for the minority of service users who would not be comfortable being away from the home one night, the service users should have at least five individual days out to places that are of interest to them. The staff team are in the process of planning the days out and this will be monitored at the next inspection. Menus at the home are based on the service users likes and dislikes. Any health needs would be taken into consideration when planning meals. The home has a nutrition policy and the menus appeared varied. Each of the service users has a programme for feeding, which was compiled by the Community Team for People with Learning Disability. The manager explained that any ethnic options are included in the menu choices. Many of the service users have lost touch with their families. For those service users who are still in contact with family members, the home encourages families to visit and is invited to attend social events and reviews. One of the service users also has an advocate. The home has built good links with other homes in the area and the service users are invited to social events at other homes and vice versa. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 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 area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical and emotional health needs are detailed in personal plans to offer consist care in this area. Medication records at the home are not filled in correctly which could potentially place service users at risk. EVIDENCE: The service users all need assistance with their personal care and at meal times. The service users have all had manual handling assessments and risk assessments. There are hoists, overhead tracking, specialist baths and handrails in place to assist with manual handling. The staff team at Victoria Avenue have all had instructions on manual handling, which forms part of the induction and is, followed up by mandatory training. The level of support a service user needs would be detailed at review meetings and their preferred routines are set out in their individual Plans. Personal care is provided in private, and timings of this are flexible. The home provides consistency and continuity through designated key workers Healthcare needs were recorded in the service users’ files. Several of the service users are wheelchair users, and Water low assessments have been completed and placed on the service users file. The staff team at the home Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 15 monitor the health of each of the service users and would ensure they receive any treatment needed. Service users are registered with a local General Practitioner. The service users are able to access community health facilities such as opticians, chiropodist and district nurses as required. The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. On the day of the inspection the medication records were incomplete. This will be monitored at the next inspection. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a complaints procedure, which is included in the statement of purpose. The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The homes complaint record was examined during the inspection, this confirmed that there had been no complaints since the last inspection. Incident and accident records are also in place The home has a copy of the local authority Adult Protection Policy on site. The home records confirmed that the majority of staff have done adult protection training with the remaining two staff due to attend the training early next month. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: 63a Victoria Avenue is a modern two-storey house set back in a quite residential road in Wallington. It is situated between Carshalton and Wallington town centres and is also close to local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The service users artwork is on display throughout the communal areas of the house. The home was “purpose built” for service users with a physical as well as a learning disability and is accessible for wheelchair users. The home has a lift and overhead tracking systems as well as a hoist. It has been opened for approx six years. There is a pleasant garden at the rear of the home which the service users spend time in during the summer months. Each of the service users in the home has a single room. All of the rooms have been personalised and decorated to reflect their individual taste. Bedrooms viewed provided sufficient and suitable furniture. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 18 All areas of the premises viewed were clean and free from offensive odours. There are appropriate laundry facilities. Systems are in place for controlling the spread of infection. This includes staff training in this area. The home has a lift and is accessible for wheelchair users. The home also has The home has two assisted baths, one on each floor. The home has thermostatic valves fitted to each of the baths to avoid any scalding accidents. The temperature of the water is taken and recorded on a chart. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home, although staff supervisions and staff meetings have not been taking place as regularly as necessary. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users EVIDENCE: There are four staff members on duty during the day plus the manager. There are two waking staff members at night. Staff records looked at during the inspection confirmed that Criminal Records Checks are completed before a new member of staff can begin work in the home. Care UK Trust offers a wide range of training opportunities to staff at all levels within the home. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The staff on duty at the time of the inspection confirmed that they had completed an induction. The staff team at the home are encouraged to complete National Vocational Qualifications at all levels. Training records are held on staff files. The staff job descriptions held on staff files were comprehensive in their content and linked to achieving service users goals, as set out in their individual care plans. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 20 Due to a change in management at the home, some of the staff supervisions have not taken place as often as they should. This was discussed with the home manager who is aware of the issue. The atmosphere in the home is friendly. The staff members spoken to felt they worked well as a team and would have no difficulties approaching the manager and senior members of the staff tram if they needed to. The home has had some staff meetings, although they have not been held as often as they should. The staff team were observed to treat service users with dignity and respect during the inspection. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management style appears to be transparent with clear lines of accountability, however the home manager must register with the Commission for Social Care Inspection. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. EVIDENCE: Victoria Ave has had a new manager since the last inspection. Mrs Carol Enever is now managing the home and must register with the Commission for Social Care Inspection. Although Ms Enever is new to Victoria Ave she has managed another care UK home in the area and is therefore familiar with the companies working practises. Care U.K. has recently reviewed their policies and produced a new policy file, which is specifically for homes providing care and accommodation for people with Learning disabilities. The home has self-monitoring systems in place such as a Quality Assurance audit carried out by “Care U.K.”, which takes place every year along with regular “follow up” visits. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 22 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. All staff attends mandatory health and safety training including moving and handling and adult protection. The home has a health and safety policy in place. Environmental risk assessments are in place. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen. Health and safety law posters issued by the health and safety executive were on display. A representative of the registered provider visits the home regularly and copies of the visit report are sent to the Commission for Social Care Inspection Corydon office. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 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 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 X 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 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4. -(1)(c) Requirement The home manager must update the information in the statement of purpose and service users to reflect the current arrangements at the home. The registered person must ensure all staff working at the home have regular supervision sessions and an annual appraisal The home manager must ensure all medication records are correctly filled in at all times The home manager must apply for registration by the Commission for Social Care Inspection, The home manager must ensure that monthly staff meetings take place. Timescale for action 28/08/06 2. YA36 18(2) 28/08/06 3 YA20 17 (1)(a) Sch 3 3. (I) 8. -(1)(a) 27/04/06 4 YA37 28/08/06 5 YA31 12. - (5) (a)(b) 28/08/06 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 Good Practice Recommendations DS0000007210.V287804.R01.S.doc Version 5.1 Page 25 Victoria Avenue (63a) 1. Standard YA14 The home manger must ensure that all service users have an annual holiday. For those service users who do not go away on an annual holiday then at least five days out to places that are of particular interest to them should be planned. A record of the activities should be kept on their file. Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Victoria Avenue (63a) DS0000007210.V287804.R01.S.doc Version 5.1 Page 27 - 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!