Inspection on 01/07/08 for 94 Tennyson Road

This inspection was carried out on 1st July 2008.

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

The inspector found 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Tennyson Road 12/05/09

94 Tennyson Road 15/01/08

94 Tennyson Road 28/08/07

94 Tennyson Road 13/10/06

94 Tennyson Road 03/02/06

94 Tennyson Road 19/10/05

94 Tennyson Road 11/03/05

94 Tennyson Road 22/12/04

94 Tennyson Road 29/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 94 Tennyson Road Luton LU1 3RR Lead Inspector Andrea James Unannounced Inspection 1 of July 2008 09:00 st 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 94 Tennyson Road Address Luton LU1 3RR 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) 01582 725735 ann.dalton@advanceuk.org Advance Support Ltd Ms Ann Dalton Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2008 Brief Description of the Service: 94 Tennyson Road is a semi- detached house situated in a quiet residential road in south Luton. The home is owned by Advance Housing and Support Limited and provides accommodation for four service people with mental health needs. The home has four single bedrooms and a bathroom and toilet on the first floor. The ground floor contains a lounge, dining room, toilet laundry room and a kitchen. The people use the garden at the rear of the house in the summer months. There is a parking area at the front of the house. The home is within walking distance of the town centre and two local parks and the bus stop. Mrs. Ann Dalton is the current registered manager. The fee ranged from £580.17£600.00 per week. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a 1star. This means the people using the service experience adequate quality outcomes. This was an unannounced carried out on the 1st of July 2008. The registered manager was not present but the team leader assisted in the inspection process. The inspection process lasted for 5 hours. The purpose of this inspection was to check compliance of requirements made in the last inspection in January 2008 and to undertake a full key inspection. The inspection process followed a case tracking methodology where a sample of people using the service was case tracked. Their files and documentation were inspected and they were also spoken to. The inspection report also consists of information received from the team leader; people using the service who were not case tracked, care staff, surveys received and the AQAA (Annual Quality Assurance Assessment). What the service does well: The service provides a good standard of care to people by having effective and skilled staff that deliver good standards of care. The aim of the home was evident in that people were encouraged to maximise their potential and become more independent in developing living skills. People spoken to were able to say what they did on a weekly basis. One person was seen accessing the community independently at the start of the inspection. One person said “I like living here because staff look after me and I have friends”. Another person when asked what he liked about the home said “Its always warm and there is always food in the fridge”. The home allows several social work students to undertake their placements and one spoken to said she enjoyed her placement. She described the home as “it has a very relaxed atmosphere and all people feel able to approach any member of staff”. She summarised the home, as “it’s a happy house”. Care staff spoken to said the service offers good standards of training, are effective in their communication skills and offered the best to people using the service in regards to meeting their needs. The staff team also receive support and supervision. The Statement of purpose showed that a survey was undertaken this year and 92 of people using the service stated that they liked the meals, 95 liked their rooms and 98 were happy with the home. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure that further outstanding requirements are met in order to meet the National Minimum Standards. These shortfalls include the recording of clear and measurable care interventions for all people using the service, ensuring all aspects of decoration identified from the previous report are met and the quality assurance systems are in place to monitor the views of people using the service on a regular basis. The home should also ensure that satisfactory care interventions are in place for people whose illness may be deteriorating. Staff and others spoken to said the people using the service would benefit from having more group activities. The home should also ensure that all doors are able to shut on their rebates and ensure immediate interventions are put in place for people whose mental health appears to be deteriorating particularly in relation to ensuring healthy diets and proper medical help is sought. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 8 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 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory systems were in place to ensure people using the home received enough information and are assessed. In order that they know about the home and that their needs will be met. EVIDENCE: The home had a Statement of Purpose and a Service User Guide that was updated and reviewed in February 2008 and reflected the aims and objectives of people using the service. The document provided enough information for potential users and their relatives to be able to make informed choices. This document also had recent surveys undertaken to seek the views of people using the service. The files inspected showed that a comprehensive assessment of need was undertaken with the consultation of the person and reflected their current needs. There was also evidence to suggest all except one person has received a review of their care needs since the beginning of the year. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Systems were in place to ensure some people’s needs were accurately reflected and that they were able to make decisions, take risks and participate in all aspects of life, but further development was needed to ensure all needs are identified and are met. EVIDENCE: Two of the four people’s files were inspected. For both people appropriate documentation was seen on file to suggest the care staff had worked hard in ensuring the files were updated and reviewed. The files consisted of a photo of the person, personal information, needs assessments, risk assessments, reviews, contracts, history of the user, daily notes, monthly reports, health and safety reviews and a planned activity programme. There were also some systems in place to monitor and record when people failed to comply with their care plan and records seen suggested 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 11 relapse indicators were also recorded. One file had a positive risk assessment in dealing with medication. The care planning documentation however needed further development because although the needs of the people were identified in the care plans the care interventions of what the staff should do or how to do it was not recorded. This was concerning as one of the person being case tracked had regressed in his mental health. It was reported that this person had refused to take his medication and it was stopped by the consultant, furthermore that the person was spending a lot of time in his room, refusing to eat and consuming large amounts of alcohol. There was no evidence of how the home was managing this person except that a review was booked for the week following the inspection. Staff spoken to explained that they tried to encourage shopping and other forms of stimulation but the care plan does not have a consistent approach to meeting this person’s needs. This person was spoken to and when asked what he did during the week said “I go out 2 or 3 times per week but prefer to lie in bed”. It was evident that this person did not comply with the activity programme in his file. Other people spoken who were not case tracked said they enjoyed the fulfilled lifestyle they were encouraged to live by the staff team, one said “I go to MIND 3 days per week and I enjoy it there”. We observed one person telling the staff that some food provisions had run out and they needed to go shopping. Another person was also observed preparing a meal. Risk assessments were implemented for people to ensure they were able to embark on activities of their choice. These included risks on self medication, managing their own money and accessing the community. These assessments had incorporated interventions in the event that the risk was high or medium. One person commented that he had friends that he visited and was encouraged to make friends. The telephone rang several times during the inspection where friends were asking people who live at the home to go out. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13,14,15,16 &17. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Opportunities were presented to ensure some people using the service were able to have personal, cultural and social development and were offered a healthy diet; but for one person the outcome was not so good and their needs were not met. EVIDENCE: The care staff and people using the service spoke positively of the various activities undertaken both in house and in the wider community. The procedures in place for these activities were satisfactory for some people but some, because of their mental state were not stimulated and the experience for them in regards to personal development was poor. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 13 One person case tracked was not developed personally and had regressed to doing very little during the day. The home did not encourage group activities and some staff members spoken to felt this could benefit the home. The team leader said a group meal was prepared for the people by the staff team but not all people participated in this activity. There was evidence that the majority of people were able to take part in age appropriate activities access, the community and engage in activities. One person was actively involved in various associations such as MIND and ACE enterprise. All people spoken to had regular contact with their families. One person was out for the day with his parents on the day of the visit and other people spoken to said he visited his parents on a weekly basis. There was evidence that relatives were kept informed of changes to the people using the service. The home implemented systems to ensure people were able to take part in house chores. One person cleaned his bedroom and did his laundry on the day as a part of his weekly programme. People were responsible for their own diet but staff spoken to said they try to encourage healthy eating but not all people were willing to eat healthily. One person’s main diet consisted of take away meals. Staff found it difficult to stimulate this user to cook or do food shopping. Care staff also said that the person did not want to eat most of the time because he was watching his weight. Records suggested other people enjoyed a healthy diet. The staff also prepared meals for all people once per week and at other times people are encouraged to prepare their own meals with the support of the staff team in an attempt to promote independent living skills. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory systems were in place to suggest most people’s health care needs were being met and they received support in the way they required but this was not so for all people, as a result one person’s health care needs was compromised. EVIDENCE: The records inspected suggested people using the service received personal support to carry out tasks to include menu planning, food shopping and maintaining family contact. Two people who use the service were also encouraged to self medicate and manage their own finances. The medication policies and procedures were satisfactory and the records inspected showed that people were safeguarded. The home maintained safe systems for homely remedies, although these were used very occasionally. The outreach nurses also provided medication to the home. The medications provided from them were hand written and it is recommended that wherever possible there is typed recording of the prescribers instructions. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 15 One person’s emotional health needs were not being met and they were showing signs of regression. The person commented that he asked the consultant to stop his medication and this was done. The team leader said the home was not formerly informed of this decision and to date the home have not had this decision in writing to say why the medication had stopped. The home was advised to ask for this information in writing. The wishes of people in the event of their death was recorded and kept on file for most people using the service. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory procedures were in place to ensure people using the service are listened to and safeguarded against abuse. EVIDENCE: We found that the home had made improvements to the complaints procedures and people spoken to said they had no complaints and would know how to complain and who to complain to should they have a problem. The home had on display the complaints procedures and a copy was seen in individual people’s files. The complaints records showed that no complaints have been made since the last inspection. Staff spoken to explained the processes to follow in the event of a complaint. One person said, “I have all the numbers in my room and I know I can always call you”, referring to the commission. The home had satisfactory safeguarding procedures in place and training records seen suggested all care staff received safeguarding training. The home had recorded all incidents to include those made by the people using the service. The nature of these incidents was in the form of peoples’ belongings going missing. One report explained that a person reported his gold ring missing and the staff asked permission to search his room, where the ring was found. Another person complained that several of his games had also gone missing and staff carried out a search of his belongings and found all but one 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 17 game. The missing game was then reported under the Safeguarding procedures in the event it could have been stolen. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27,28 &30. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home appeared to be comfortable and promoted independence that suited people’s lifestyles and independence but further development was needed to ensure all areas of the home are satisfactorily decorated and homely. EVIDENCE: Since the last inspection several aspects of the environment have been improved. The home had new carpets in the lounge. Some people using the service received new furnishings to include beds and wardrobes and a new flat screen television was provided in the communal area. The staff team said new cooker and washing machine was purchased and new kitchen tops were also installed. We were presented with a letter written on the 18th of June 2008 asking all the people who use the service to choose the colour scheme they would like for 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 19 their individual bedrooms and communal areas. This letter stated work to redecorate the home was due to commence in the near future. The staff team said all the people who use the service had already chosen the colours to their bedrooms. The people’s bedrooms inspected showed that they were encouraged to have personal belongings and were encouraged to keep their rooms tidy. This was to enable people to maximise their independence. One person spoken to said he was assisted to clean his room on the day of the inspection. The rooms’ appeared tidy and all areas of the home were free from offensive odours. All people who use the service had keys to their bedrooms and to the main door. The bathroom and shower facilities were satisfactory to meet the needs of people who use the service. However, in one bathroom there was no shower curtains as a result when the shower was used the bathroom floor had a puddle of water which could then become a trip hazard. The hygiene standards of the home were good and no offensive odours were identified throughout the home. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 &36. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People who use this service were protected by the safe recruitment, training and supervision of the staff team. EVIDENCE: The staffing levels at the home is a ratio of 1 to 4, twelve hours per day, the home does not provide night staff. The Statement of Purpose and Service User Guide stated this was not a 24 hour care provider. The people spoken to said they were happy with the staffing levels and felt that their needs were met. They said they also had the extra security that in the event of an emergency staff from next door could be contacted. The home had an on-call system in operation. The staff team was complemented by trainee social workers who worked closely with the people who use the service to achieve good pieces of work in areas of personal development. One student spoken to said, “it’s an extremely relaxed atmosphere, people are able to approach any member of staff”. Staff said “it’s a happy home”. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 21 Records seen suggested satisfactory recruitment and training was undertaken for all care staff and monthly supervisions were undertaken. The home had recruited two new employees since the last inspection and records showed that satisfactory references and Criminal Record Bureau checks were carried out prior to staff commencing employment. The home also ensured all new staff had a basic induction process. One staff member had achieved her NVQ level 3 qualification and another had embarked on her NVQ level 2. The training records seen suggested care staff had completed training in fire safety, epilepsy, anger management, handling medication, self harm, challenging behaviour and supervision. Staff spoken to said they received regular staff meetings. Records were seen to suggest this occurred on average of every 6 weeks. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 &43. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The management of the home was satisfactory in ensuring positive outcomes for people who use the service but the homes ability to maintain all aspects of health and safety needed further implementation, as a result people’s needs could be compromised. EVIDENCE: The manager had worked hard along with the staff team to promote the standards of the home and to safeguard the people using the service. The manager said she worked 17.5 hours per week at the home to ensure effective management structures are in place. The home had a new team leader who assisted in the inspection process. 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 23 All staff and people spoken to said the manager was approachable and effective in her management style. The home had made some improvement in their quality assurance monitoring procedures to show that people’s views were sought. The Statement of Purpose showed that some analysis of the views was undertaken, the document showed that 92 liked the meals, 95 liked their rooms, 99 felt listened to and 98 were happy with the service. This procedure still needs further development in order to meet the requirements of the National Minimum standard. The home had satisfactory health and safety policies but improvements are needed on some procedures. For example the hot water temperature records detailed that the temperatures for all hot water taps were tested on a weekly basis. Records dated back to May 2008 all stated that some taps exceeded 57degrees but on testing the taps all except one was 43 degrees which is satisfactory for safe usage. This suggested people were not testing just recording what previous care staff had written. The temperature recorder seen in the home was satisfactory. Since the last inspection temperature control valves have been fitted on all persons sink units and communal bathroom and toilet water systems. The home also failed to ensure communal doors shut on their rebate; this could become a hazard in the event of a fire. The fire logs checked were satisfactorily maintained but the home failed to have a fire risk assessment, this was identified in the previous inspection report. Records seen suggested the fire authorities have not visited the home in four years. (Since August 2004). 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 24 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 3 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 2 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 3 3 2 2 X X 1 3 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 (2) (c) Requirement Each person must have a current support plan that clearly identifies the care intervention required for staff to undertake. Previous timescale : 30/03/08 Timescale for action 30/08/08 2 YA19 12 (2) 3 YA24 4 YA27 5 YA39 6 YA42 Care interventions must be implemented to ensure the health and emotional well being of all people should their mental health deteriorate. 23 (2) (b) All areas of the home must be (d) decorated and furnished to create a homely environment for people living at the home. Previous timescale 30/04/08: Partially met. 23 (2) ( Shower curtains must be C) provided to avoid water spilling on the floor and prevent unnecessary slips and trips. 24(1) (a) A clear quality assurance system (b) must be in place that monitors and seeks the views of the users in order to meet the aims and objectives of the service. Previous timescale 30/11/07 and 30/03/08. Partially met 13 (4) ( c) Fire risk assessments must be up DS0000014976.V367901.R01.S.doc 30/07/08 30/08/08 30/08/08 30/08/08 30/09/08 Page 26 94 Tennyson Road Version 5.2 7 YA42 to date to ensure avoidable risks are identified. 13 (4) (c). Doors that do not currently shut on their rebate must be made safe in order to protect people in the event of a fire. 30/08/08 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 YA14 Good Practice Recommendations You should ensure interventions are implemented to ensure all people who use the service receive sufficient stimulation to undertake activities, to avoid relapse of mental health. You should ensure where possible that medication received in the home follows safe medication policies and procedures for example ensuring that the prescribers’ instructions are not handwritten. You should ensure that the dietary needs of all people using the service reflects healthy eating. 2 YA20 3 YA17 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 94 Tennyson Road DS0000014976.V367901.R01.S.doc Version 5.2 Page 28 - 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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