Inspection on 15/01/08 for 94 Tennyson Road

This inspection was carried out on 15th January 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 13 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 01/07/08

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 08/07/2008.

CARE HOME ADULTS 18-65 94 Tennyson Road Luton LU1 3RR Lead Inspector Andrea James Unannounced Inspection 15th January 2008 10:00 94 Tennyson Road DS0000014976.V358060.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.V358060.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.V358060.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.V358060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th August 2007 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 users 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 service users use a 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.V358060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 15th of January and lasted for 6 hours. The inspection was undertaken by Andrea James, the lead inspector for the service. The manager Ann Dalton was present for some of the inspection process. The inspection process followed a case tracking methodology where 50 of the people using the service were chosen. Where possible these users were spoken to and their files and documentation inspected. The care staff and external professionals also contributed to the inspection process. The inspection report also consists of information received from relatives of the people using the service who were interviewed by telephone. The inspector would like to thank the manager, care staff, relatives and users of the service for their contribution to the inspection process. What the service does well: The service offers people with mental health the opportunity to be reintegrated back into the community by developing their daily living skills and learning to manage their behaviours responsibly. The service only provides care for four people in an environment where users can feel comfortable and work at their own pace in maximising their full potential. Two users spoken to explained that they were able to access community resources, form relationships and visit family and friends on a regular basis. One user said, “this home is good, its quite laid back”. Relatives spoken to said they felt that the people living at the home were “well looked after” and they had no complaints. One relative commented that the care staff were welcoming and friendly and they knew that their son had found the right place. The home also ensured that the staff team were qualified and trained in meeting the changing needs of people who use the service. There was evidence to suggest at least 90 of the staff team had obtained their NVQ level 2 or above in care qualification. Staff also commented that they received regular training. The staff team also received supervision and support in the way they preferred. 94 Tennyson Road DS0000014976.V358060.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: 1. Homely remedies used for people in the home are not pooled but all users have individual medication for use. 2. All users of the service have a current and up to date assessment of need and a care plan that reflects their needs. 3. People are safeguarded against theft. 4. The communal areas of the home and some users bedrooms are decorated to reflect a warm and welcoming environment with modern entertainment. 5. All areas of the home are safe for use to include the water temperatures dispensed throughout the home. 6. Repairs are made to users bedroom fixture and fittings. 7. Window restrictors are fitted to users windows above ground level. 8. Clear and accountable management of the home is in place on a daily basis. 9. Effective quality assurance procedures are implemented that reflects users views being monitored. 94 Tennyson Road DS0000014976.V358060.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.V358060.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.V358060.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): 1,2,3,4 &5. 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. Some systems were in place that ensured potential users were issued with sufficient information, but further development was needed to ensure Service User Guides were up to date and needs assessments reflected the needs of all the people using the service, as a result some users needs were not met. EVIDENCE: The home had a Statement of Purpose and a Service User Guide but these were dated 2005 and did not reflect the current practices of the home. A new user was admitted to the home since the last inspection and there was evidence to suggest that he received a full comprehensive needs assessment that accurately reflected his needs. The home had also implemented in house assessments for this person. There was however a need to ensure these new and improved documentation was implemented for all the people using the service as the other user’s file inspected showed that there was no needs assessments available. There was evidence that the new person to the service who said he had only been in the service for two month had an opportunity to visit the home and have tea stays and over night stays before he moved in. His relatives spoken to also said this person was offered a smooth transition to the home. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 10 All users had a signed and dated contractual agreement and tenancy agreement of file. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 11 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. Some systems were in place that ensured users needs were reflected and they were able to make decisions, take risks and participate in all aspects of life but the outcome was not positive for all users, as a result some users needs were not satisfactorily met. EVIDENCE: We case tracked two people that used the service and for person A his files had had a new service user content sheet, current photo, passport, initial needs assessment, a comprehensive needs assessment that covered various health care issues to include mental health issues, brief history of the person, risk assessments that included relapse indicators and risk control measures, planned activity programme, a support plan detailing what care intervention was required by the staff team and a challenging behaviour programme. These documents showed that the person was consulted and there was a date for review and implementation. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 12 There was also a complaints procedure, which had pictures for clearer understanding and completed information detailing the requests users wanted upon their death. The user and care staff spoken to confirmed the recorded evidence seen, for example the user was able to say what he did as an activity and this was evidenced through observation and in daily records. However person B’s file was not as detailed and up to date. The documentation seen showed that there was no needs assessment on file and the support plan was dated December 2006. This was so for all the risk assessments and guidelines. The manager said they had undertaken a review for person B but could not evidence where the support plan and other documentations were. There was no evidence that a review was undertaken and the current plan as stated before was outdated. It was therefore difficult to know how the user’s needs were being met. We were also concerned that risk assessments identified one of his relapse indicators as staying in bed all day and the user informed us that he stayed in his bed until 8pm the day before. Daily records did not suggest staff reported this to the consultant as stated in his care plan. This person was spoken to and he confirmed that he enjoyed living at the home and was able to undertake his activities. He commented that he went food shopping, had access to community resources, was able to form relationships and would like to attend Further Education College in the future. It was clear that both persons case tracked were able to make decisions about their daily lives. One user who was not case tracked also said he was able to make decisions about his daily life, he commented what he was planning to have for his meal that evening and that he had plans to go to the shop later that afternoon. All users spoken to confirmed that they were able to make decisions about their daily lives and contributed to residents meetings and menu planning. The home also ensured that users were able to take risks in order to develop and maximise their independence. One user said he was able to attend the gym when he wanted and visit his friends. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 13 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. People who use the 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. Systems were in place that ensured users were given opportunities to maximise their lifestyles in regards to leisure activities and forming relationships, as a result users were able to develop. EVIDENCE: The care staff and people using the service spoke of the various activities both in house and within the wider community that the users undertake on a daily and weekly basis. One user said he lived at the home for 7 years and was able to attend MIND 3 days per week, others said they went to ACE enterprise attended the gym, art projects and visited friends. This was recorded in some of the activities on file but not all. We observed some users undertaking inhouse chores to include hoovering, cleaning bedrooms and preparing meals. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 14 People who use the service were also encouraged to maintain personal hygiene and healthy living skills. It was noted however that some users lacked motivation and as a result care staff had to support users in achieving their goals. Various risk assessments were undertaken to ensure users safety while undertaking tasks. Daily records seen suggested some activities were not carried out, care staff said sometimes users just does not want to do anything. People who use the service were able to participate in age appropriate activities and form relationships. All the users spoken to said they were able to visit their family members on a regular basis and relatives spoken to said they attended the home weekly. One user said he had a girlfriend who regularly visited the home. Users said they were not allowed to have overnight guests but said they understood this. The home implemented systems to ensure users understood their responsibilities both in house and the wider community. One user said he had to clean his bedroom and Hoover the lounge, this was to encourage motivation and develop personal skills. We were informed that one user had developed in such a way that he was now ready to move on and purchase his own property. This was a great step and it was being worked at systematically with the guidance of the manager and other professional bodies. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 15 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 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 users were protected from medication errors and recorded evidence was seen to suggest users received personal support in the way they preferred, however further development was needed to ensure the procedures for storing and administering homely remedies are reviewed, as a result users safety could be compromised. EVIDENCE: The records we inspected suggested the people using the service received personal support to carry out tasks, this was evident in users ability to undertake menu planning, food shopping, attending community facilities and maintaining relationships with family and friends. Records seen suggested users were enabled to attend various health practitioners to review their health care needs on a regular basis and nurse and other professionals including socials workers visited the home to administer controlled drugs and injections under the mental health act. The home had reviewed and updated the medication policies and procedures to ensure safety for the people using the service. We were informed that the 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 16 pharmacist and district nurses had audited the medication procedures and ensured that all medications administered were satisfactory in regards to receipt, recording and administration. There was however further development needed to ensure homely remedies were not pooled. We inspected the medication stocks and found that several boxes of Paracetamols, cough syrups and flu type medications were stored and given to any one of the users. These were not prescribed medication and could be open to ambiguity and errors in administration and stock control. The home ensured that users wishes in the event of their death was recorded and consultation was given through signatures from the users and relatives. These were kept on the users personal files. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 17 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 the service experience a poor quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Procedures were in place for dealing with compliments and complaints but further development was needed to ensure all users receive a response to any concerns or complaints and all care staff have an understanding of the safeguarding procedures, as a result some users needs were neglected. EVIDENCE: The manager said they have received no complaints since the last inspection and had worked hard in ensuring the people who use the service knew how to complain should they wish to. Two of the users spoken to said they did not know how to complain but would speak to staff if they had a problem. One user said he complained about repairs to his room but received no response and don’t know how long it would take to repair the maintenance issue. This same user complained on three occasional that he felt he was a victim of theft as on three separate occasions money went missing from his room. He also stated this was because his lock on his bedroom door was broken. We found evidence of this in the daily notes but nothing had been done to investigate the theft and he was not reimbursed for the missing money. We were shown evidence to suggest care staff made efforts to get the lock repaired but was told it was very expensive and needed a special lock. Since the site visit we received a regulation 37 to say the lock had been fixed and procedures were in place to reimburse the user for the money he claimed to have been stolen. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 18 We were concerned that such an incident was not reported under Safeguarding procedures until we brought it to the attention of the manager on the day of the inspection. The training records seen suggested several staff received Safeguarding training but they seemed oblivious as to when to report incidents to protect users welfare. This was also noted in the last inspection when a user no longer at the home physically and verbally abused one of the other users, and no referrals were made to protect the victim. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 19 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’s premises were suitable for its stated purpose in regards to accessibility, hygiene and comfort but further development was needed to ensure all areas of the home reflects the homeliness created in other areas, as a result the present condition could detract from the homeliness required by the users of the service. EVIDENCE: The home was welcoming but basic in nature. The communal areas had suitable seating arrangements and in general the home was clean and free from offensive odours. On having a tour of the environment it was evidently that further development could be made to make it homely. The carpets in the lounge was discoloured in several areas and detracted from the comfort created in the dining room and other areas of the home. Several wardrobe doors were also broken away from their hinges in users bedrooms. Relatives spoken to said they felt the carers created a welcoming environment but also 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 20 commented that the home was in need of modernising, one example given was that the television was very old and only supplied limited channels for entertainment. The cooker and kitchen facilities were also old and in need of modernising. The bathrooms and toilet facilities were sufficient to meet the needs of the people using the service but again these could be improved through refurbishment and modernising to reflect warmth and comfort. The users bedrooms appeared satisfactory in meeting their needs and users spoken to said they were happy with their bedrooms but again these were in need of decorating one user’s bedroom appeared brown in colour, this could be a result of continuous cigarette smoking but the ceiling and paint work appeared dirty. The hygiene standards of the home were of a high standard. Users were seen hoovering and cleaning. Care staff said they would also clean when the users left the home to ensure high standards of hygiene were maintained. They also assisted users to clean their rooms on a regular basis. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 21 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 the service experience a good quality outcome in this area. We have made this judgement using arrange of evidence to include a visit tot the service. The people using the service were safeguarded by the training, recruitment and supervision of the staff team; as a result users needs were not compromised. EVIDENCE: The staffing levels of the home had not been increased since the last inspection but the manager said one staff during the hours of 8:30 am to 9pm was sufficient, as the people using the service were not challenging and that level of support was satisfactory. The home has no night staff but users were told that they could contact staff members across the road at the neighbouring home in an emergency. The current staffing levels stood at 6 care staff across both homes. The manager said the deputy manager was due to leave on the week of the inspection and two staff were due to take maternity leave. The manager had made contingency plans using relief staff and was due to start recruiting for the deputy manager’s post. Staff spoken to spoke positively about the service and were knowledgeable about the needs of people using he service. That said they received training 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 22 and all said they had received their NVQ level 2 in care qualification. The home had a training programme that identified the training needs of all the care staff for the present and the future. Two staff files inspected showed that satisfactory recruitment procedures were in place to include Satisfactory Criminal Record Bureau checks, references and application forms. Staff spoken to said they received regular supervision this was triangulated by the manager and recorded evidence. Staff also commented that they received support and attended regular staff meetings. All staff meeting records except for the month of December were seen. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 23 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. People who use the service experience a poor 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 outcome were obtained for people using the service but further development was needed to ensure the homes ability to seek the views of people using and maintain their safety are met, as a result users views could go unheard and their safety compromised. EVIDENCE: The manager has been in post for several years and had almost completed her Registered Managers Award qualification. She was based mainly in the neighbouring home across the road but was confident that the home could be managed effectively as she also visited the home on a weekly basis. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 24 We were informed that the deputy manager for the service was due to leave and as a result the manager was due to start recruitment procedures. Staff spoken to said they felt able to speak to the manager at any time. The people using the service were also observed to speak to the manager in a friendly manner. Relatives spoken to said they never met the manager as she was not at the home when they visited. The manager spoke positively about the service, which showed her knowledge of the people’s needs and plans she had to improve outcomes for them. The home still needed to improve their quality assurance procedures in ensuring the views of the people are heard and evaluated to reflect positively for them. There was evidence that residents meeting were undertaken but the results of these were not used to affect the quality assurance system. The home had a health and safety policy and procedures were in place for checking various safety procedures. We found evidence to show that regular fire tests, and evacuations were undertaken on a regular basis and that users were made aware of the procedures but it was concerning that several hot water taps within the home both in users bedrooms and communal bathrooms dispensed water hot enough to cause a bad scald or burn to someone’s hand or body. The home also failed to produce a fire risk assessment. While touring the home it was also noted that some users bedroom windows failed to have window restrictors, this was concerning because of the people who use the service whose mental state may deteriorate at any time. One user was also a heavy drinker and could fall out the window when intoxicated. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 25 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 2 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 2 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 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 3 1 X X 1 x 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14 (1) (a) Requirement Arrangements must be made to ensure all users have in place a comprehensive assessment of need. Previous timescale 30/09/07. Arrangements must be made to ensure all users of the service have a current support plan that clearly identifies the care intervention required for staff to undertake. People using the service must have up to date risk assessments that ensures they are enabled to take assessed risks in promoting independent living skills. Satisfactory medication policies and procedures for storage and administration of homely remedies must be implemented in order to safe guard users. Effective complaints procedures must be implemented to ensure users concerns are recorded and dealt with in line with the homes complaints policy. Previous timescale DS0000014976.V358060.R01.S.doc Timescale for action 30/03/08 2 YA6 15 (2) (c) 30/03/08 3 YA9 13 (4) (b) 30/03/08 4 YA20 13 (2) 28/02/08 5 YA22 13 (6) 28/02/08 94 Tennyson Road Version 5.2 Page 27 30/10/07. 6 YA23 12 (1) Arrangements must be made to ensure people using the service are safeguarded from financial abuse. Arrangements must be made to ensure care staff are competent in identifying and reporting any aspect of life that may affect the wellbeing of users under the Safeguarding procedures. Previous timescale 30/10/07 Arrangements must be made to ensure all areas of the home is decorated and furnished to create a homely environment for people using the service. Arrangements must be made to replace or repair broken furniture in the users bedrooms in order to create comfort for people using the service. Clear and accountable management structures must be in place to ensure consistency in the home. Previous timescale 30/10/07 A clear quality assurance system 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 Arrangements must be made to ensure the water temperatures dispensed from the taps in the bedrooms and communal bathrooms are safe for use by people using the service. Arrangements must be made to ensure window restrictors are fitted to users bedroom windows that are above ground level. 28/02/08 7 YA23 18 (1) (a) 28/02/08 8 YA24 23 (2) (b) (d) 30/04/08 9 YA25 23 (2) 30/03/08 10 YA37 10 (1) 30/03/08 11 YA39 24 (1) (a) (b) 30/03/08 12 YA42 13 (4) (a) (c) 28/02/08 13 YA42 13 (4) (a) 28/02/08 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 28 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 YA28 Good Practice Recommendations Arrangements should be made to ensure new entertainment is provided in the home in the form of an up to date television set. 94 Tennyson Road DS0000014976.V358060.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Inspection 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.V358060.R01.S.doc Version 5.2 Page 30 - 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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