Inspection on 02/06/05 for Alexandra Road Crisis Unit

This inspection was carried out on 2nd June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra Road Crisis Unit 24/03/09

Alexandra Road Crisis Unit 02/04/07

Alexandra Road Crisis Unit 18/08/06

Alexandra Road Crisis Unit 31/10/05

Alexandra Road Crisis Unit 03/02/05

Alexandra Road Crisis Unit 24/06/04

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

CARE HOME ADULTS 18-65 ALEXANDRA ROAD CRISIS UNIT 32 Alexandra Road Hornsey London N8 0PP Lead Inspector Peter Illes Announced 2 June 2005 @ 9:30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 3 SERVICE INFORMATION Name of service Alexandra Road Crisis Unit Address 32 Alexandra Road, Hornsey, London, N8 0PP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8365 7287 020 8888 9829 Mrs Karen Reilly of London Borough of Haringey Ms Jan Bryant LA Care Home 8 Category(ies) of MD registration, with number of places ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Younger Adults. Standards 24-30 - Environment or those equivalent Standard that may be published at the time, as required by Regulation 23 (1)(a); 23(2)(a-p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by April 1st 2005. 2. In order to promote health and safety needs of service users living in Alexandra Road Crisis Centre, the provider must ensure that the home complies with all requirements contained in relevant Health and Safety legislation on an ongoing basis and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Younger AdultsStandard 42 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by April 1st 2005. 3. The home may provide accommodation and personal care for up to 8 persons of either gender who are between the ages of 18-65 and who have Mental Health problems. Date of last inspection 3/2/05 Brief Description of the Service: The Alexandra Road Crisis Unit is owned and run by London Borough of Haringey. The unit is unique in the borough and is not a full time residential service. It provides short-term emergency and respite services for up to eight people with mental health problems. Stays are typically from three days up to two weeks and may be an alternative to hospital admission. The unit provided over two hundred and fifty short stays in the past twelve months. The unit is a three story converted and extended domestic premises situated in a quiet residential street between Wood Green and Turnpike Lane. There are eight single rooms, several bathrooms and shower rooms, a choice of two lounges, a staffed kitchen, a separate dining room with facilities to make drinks and snacks, an attractive conservatory that is used as an alternative place to relax and to do artwork and a private garden. The unit has several aims, the focus of which is to provide good quality individualised support that is strengths and needs led. To facilitate personal development, to assist service users in development of alternative crisis responses and to foster appropriate coping strategies in order to return to their appropriate environment. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took approximately eight hours with the registered manager being present or available throughout. There were seven service users accommodated at the home and two vacancies at the beginning of the inspection with one service user being discharged later during that day. The inspection included: independent discussion with four service users; independent discussion with three care staff and discussion with the local authority service manager that supervises the registered manager, who visited during the inspection. Further information was obtained from a tour of the premises, the pre-inspection questionnaire and a range of documentation kept at the home. What the service does well: What has improved since the last inspection? The home met three requirements made at the last inspection. These related to recording of complaints, replacing carpets and a maintenance issue in the laundry room. A fourth requirement regarding plans to refurbish some bath/ shower and toilets in the unit had a timescale beyond the date of this inspection and the timescale for this was further extended. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective service users can be confident that their needs will be fully assessed and agreed with them prior to admission to the unit. This is to ensure that they can be effectively addressed during their short stay. EVIDENCE: Three service user files were inspected and each contained detailed assessment information at the point of admission. Each file contained: a multidisciplinary pre-admission assessment including a detailed risk assessment coordinated by the referring agency; an in-house assessment of need, risk assessment and a risk management plan that had been signed by the service user at the point of admission. Three service users spoken to during the inspection confirmed that they had been fully involved and consulted throughout the above process. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users needs and aspirations are clearly set out in their care plans and these are very regularly reviewed with them to ensure that their changing needs continued to be met as their short stay progressed. Service users are supported to make as many decisions as possible for themselves to retain and maximise their independence. They are also supported to take responsible risks to assist keep them safe during their short stay at the unit. EVIDENCE: The three service user files inspected contained detailed care plans that included a range of relevant short term objectives for service users with clear guidance for staff on how to assist the service user achieve these. The plans were informed by a range of assessment material and included a separate risk management plan that had been based on both external and in-house risk assessments. As the service is short stay by nature the plans are reviewed on a daily basis if necessary, one service user’s plan inspected had been reviewed and modified on three occasions over four days to reflected that person’s changing needs. The plans seen had all been signed by the service users. The four service users spoken to stated that they were fully involved in the writing of their care plan, reviewing it and in changes where these had been made. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 10 The three service user files inspected all contained a signed copy of a client agreement form that specified what to expect from staff and what staff would expect from them. This contained some restrictions on service users while staying at the unit such as the prohibition of alcohol and illegal drugs. Other restrictions included where service users may meet with their visitors to the unit with a restriction on visitors using specified areas such as the main lounge so as not to disturb other service users. Service users were welcome to meet visitors in other parts of the unit including in their rooms. All service users make their own arrangements to manage their money while staying at the unit. As stated above, all service user files inspected contained a detailed risk management plan that had been agreed and signed by the individual service user. This was based on a range of detailed information primarily obtained from risk assessments undertaken by external health and/ or social care professionals and by an in-house risk assessment completed by staff at the point of admission. The plan showed identified potential risks and gave clear guidance to staff in assisting to minimise these. These plans were reviewed at the same intervals as the care plan. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users are supported to take part in a range of activities, including in the local community, where this is consistent with their agreed short-term goals. They are also supported not to take part in activities where this is in their best interests during their stay. Contact with friends and relatives is actively supported to the degree that the service user wishes. Service users are treated with respect and their rights and responsibilities are clearly stated with any limitations agreed with them. They also enjoy balanced and healthy meals that meet their needs and preferences although some further attention is needed regarding safe food storage. EVIDENCE: Service users are generally admitted to the unit for respite during a period of crisis to assist relieve some of the pressure they feel at that time. Where appropriate longer-term objectives such as to find appropriate employment or to continue their education and training can be included in their care plan where this is helpful to maintaining a service user’s mental health and stability in the longer term. ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 12 All admissions to the unit are for a short period and during a period of crisis with a main short-term aim often being to for the service user to rest and relax. One service user indicated that she was using her stay at the unit as a means of having some space for herself and that for that period she did not want to go out into the wider community. The inspector confirmed that service users are encouraged to continue to participate in the local community as they would normally do whilst at home if that assisted meet their needs at that time. Some service users were seen to enter and leave the house as they wished during the inspection. Service users are encouraged to maintain links with family and friends on terms that they can cope with. Where it is agreed with the service user the staff also support service users to maintain their privacy during their stay. There was evidence from talking to individual service users and from their files that contact with family and friends is actively supported where appropriate. One service user told the inspector of a recent meeting with relatives that the service user had considered very positive in the unit’s neutral environment and where she felt she had some control over the situation. Objectives in service users plans were clearly designed to assist them maximise their independence. Service users spoken to indicated that they also appreciated the ability of the unit to provide a safe short term period of respite and to receive support for when they returned to their daily lives. All service users spoken to confirmed that they had keys to their rooms and were treated with respect by staff. One service user who had used the service more than once, and who the inspector spoke to, wrote in their comment card “A rule of total respect prevails and every effort is made by frequent meetings with staff and through care plans for a return home and the outside world as stronger and more determined people”. The home has a weekly menu that is drawn up by the staff on the known needs of the service users who are likely to be in the unit on that week. The menu seen for the week of the inspection contained a range of balanced and healthy meals with a vegetarian option at each main meal where appropriate. The home has a full time weekday cook and a separate weekend cook that are responsible for the cooking of the main meals of the day. The weekday cook was knowledgeable and experienced and stated that the unit could cater for a range of special diets. These had recently included low cholesterol and low fat meals as well as meals to meet the differing cultural needs of service users. He also stated that the unit would prepare alternatives if needed for individual service users. The inspector saw a kitchen comments book for use by service users that was well used. Service users spoken to stated that they enjoyed the food at the unit, one service user told the inspector “ it sure beats takeaways”. The kitchen was well equipped and clean with sufficient quantities of food including fresh fruit that was generally stored satisfactorily and in date. The cook who came on duty during the inspection had been absent from the unit for a number of days and part of this was to attend food hygiene up date ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 13 training. It was noted that there was an item of food in the fridge that had been removed from its original packaging. This had been covered but not labelled with a use by date or the date it had been removed from its original packaging. A requirement is made regarding this. ALEXANDRA ROAD CRISIS UNIT Version 1.10 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 standard(s) 18, 19 & 20 Where service users need support with their personal care this is delivered in accordance with their needs and their individual preferences. They are also supported in meeting their physical and emotional health needs and to maintain as much control over this as possible for when they leave the unit. Service users are also encouraged to retain as much control over their medication as possible while they are at the unit, again to maximise their independence in this area when they leave. EVIDENCE: The nature of the service is such that service users are generally independent with regard to their personal care. Where any personal care needs are identified these are reflected in the individual’s care plan. No service users needed support with their personal care at this time. Records reflect that the staff support service users with any ongoing health care needs where they are identified in individual care plans. Professionals who are involved on a long-term basis would normally deal with such issues and service users are encouraged to maintain contact with such professionals while at the unit and when they leave. The registered manager stated that where service users access services such as community nurses in the community this same contact is promoted as much as possible while they are staying at the unit. Because of the short-term nature of stays, service users keep their own ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 15 GP’s. The inspector reviewed the records of accidents and incidents in the unit and they were satisfactory. Assessments and care plans seen clearly recorded where service users are able to retain and administer their prescribed medication and staff support service users retaining their own medication in the unit wherever possible. At the time of this inspection the unit was administering medication for two service users. The medication and medication administration records for these two service users were inspected and were satisfactory. Medication was stored appropriately including controlled medication being kept in a separate lockable metal medicine cupboard attached to the wall in the main office. ALEXANDRA ROAD CRISIS UNIT Version 1.10 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 standard(s) 22 & 23 Service users are able to express their views and concerns and have these appropriately dealt with by the unit. An identified addition is needed to the home’s information on how a complaint will be dealt with. Satisfactory policies and procedures, that staff were aware of, assist protect service users from abuse. EVIDENCE: The unit has a generally satisfactory stand-alone complaints procedure that is linked to the local authority’s procedure. The local authority procedure acts a second stage if the complainant is dissatisfied with the unit’s initial response. It is required that the unit makes clear in its own complaints procedure that complaints will be responded to within 28 days. There had been no complaints received at the home since the previous inspection. Service users spoken to were confident that any concerns that they raised with staff would be dealt with. The home had the local authority adult protection procedure that was seen along with satisfactory practical guidance for staff in the unit related to that policy and its practical implementation. Staff spoken to were clear about the action that they needed to take should an allegation or disclosure of abuse be made to them. The home also had a satisfactory whistle blowing policy that was seen. ALEXANDRA ROAD CRISIS UNIT Version 1.10 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 standard(s) 24, 27 & 30 Service users live in a home that is comfortable, well decorated and well maintained. Service users benefit from adequate numbers of toilets and bathrooms to meet their needs although planned improvements to these facilities have been identified. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home as well as for those that visit it. EVIDENCE: The unit is safe, comfortable, well decorated, well maintained and is fit for purpose as a short stay unit. The unit has a pleasant garden that is overlooked by decking attached to the main lounge. Service users enjoyed sitting out on this decking and the inspector spoke to a number of the users when they were relaxing there. These service users stated that they were surprised at how peaceful and quiet it was given that the unit is situated so close to the noise and bustle of Wood Green shopping centre. The unit’s bath/ shower and toilet facilities generally met the needs of the service users. These facilities were however described as “tired looking and institutional” at the last inspection. The previous inspector had been informed ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 18 at that time that the unit had successfully bid for money to refurbish these. As a result of this, a requirement was made at the previous inspection that an action plan for achieving this refurbishment was given to the Commission by 20th July 2005. Progress with this requirement was discussed with the registered manager and her service manager and it transpired that meeting this requirement was likely to be delayed. This was because the detailed planning work still needed to be completed by the local authority’s technical department that would be responsible for commissioning this work. It was agreed that timescale for this requirement would therefore be extended. The temperature of the water in the bathrooms was randomly tested and found to be satisfactory. A satisfactory record of the unit’s own regular monitoring of the water temperature in bath/ shower rooms was also seen. The home was clean, tidy and odour free during the inspection. The unit had satisfactory policies regarding continence promotion and infection control that were seen. ALEXANDRA ROAD CRISIS UNIT Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 The home has a well qualified staff team, in sufficient numbers, to support service users and to assist in meeting their assessed needs. Staff are offered a range of relevant training to further assist them in their own personal development and in meeting service users needs. EVIDENCE: The staff rota inspected showed a minimum of three staff members on duty for the majority of the day shift with two staff members on duty for the remainder. One waking and one sleeping in staff are on duty during the night. This level of staffing was satisfactory to meet the needs of service users accommodated at the time of the inspection. The staff on duty matched the record on the rota. No new members of staff had been recruited since the previous inspection. The unit had a satisfactory staff training plan that showed the current training needs of staff. The registered manager stated that she was in the process of arranging for these to be addressed. Three members of staff were spoken to independently and they stated that the unit provided a range of training to assist them meet service user’s needs. They variously reported that training they had undertaken in the past twelve months included: moving and ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 20 handling; first aid; dealing with alcohol; health and safety; data protection; infection control; fire prevention and adult protection. One member of staff spoken to confirmed that he was currently undertaking National Vocational Qualification (NVQ) level 3 in care. ALEXANDRA ROAD CRISIS UNIT Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Service users views are effectively sought to contribute to the overall development of the services provided by the unit. The unit takes health and safety seriously although further action is needed regarding identified potential hazards. EVIDENCE: The unit has developed satisfactory means of obtaining feedback from the short stay service users to contribute to the ongoing planned improvement for services offered by the unit. A major element of this is from service user evaluation forms that are filled in by service users as they complete their short stay. These were randomly sampled and were seen to be thorough and relevant. One service user spoken to, who had used the service previously, told the inspector that she had valued the opportunity to formally feedback to the unit her feelings about her previous stay that she had regarded as very positive. The other main method of obtaining feedback from service users is through the one to one contact with staff throughout their stay. The home has a business plan that links and contributes to the local authority’s overall ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 22 business plan and that was seen to have a range of practical objectives for the home. The registered manager stated that the service user evaluation forms were used as part of the process of setting these objectives. The service manager with overall responsibility for the unit visits regularly on an unannounced basis and submits copies of her findings to the Commission. A range of satisfactory health and safety documentation was seen including a gas safety certificate and testing of the water in the unit to minimise the risk of legionella. Satisfactory fire documentation including servicing of the fire alarm and fire extinguishers was seen and the record of the fire drills held. It was noted that the home’s own procedures stated that fire drills must be held every three months and the latest one to this inspection was over three months. A requirement is made regarding this. The registered manager stated that the electrical portable appliances had been tested recently but the home was still waiting for the certificate regarding this. At the time of the inspection the electrical installations in the home were being tested. A requirement is made that a copy of the certificates relating to the portable appliances and the electrical installation are sent to the Commission when they are received to evidence that these are both safe. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 23 CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 24 No 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 17 Regulation 16(2)(i) Requirement The registered persons must ensure that all food stored in the home is appropriately labelled and stored. The registered persons must ensure that the units complaints policy states that complaints will be responded to within twenty eight days. The registered persons must provide an action plan to the CSCI, which outlines the modification of the shower, toilet and bathroom facilities on the first floor. The action plan must include dates by which the work is to be undertaken and how disruption to service users is to be minimised. (The deadline for compliance with this requirement has been extended from 20/7/05.) The registered person must ensure that regular fire drills are undertaken and recorded at the home. The registered person must send evidence to the CSCI of a satisfactory electrical installation certificate and of satisfactory portable appliance testing. Version 1.10 Timescale for action 30/6/05 2. 22 22(4) 30/6/05 3. 27 23(2)(a) 31/10/05 4. 42 23(4), Sch.4(14) 13(4) 30/6/05 5. 42 30/6/05 ALEXANDRA ROAD CRISIS UNIT Page 25 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 none Good Practice Recommendations ALEXANDRA ROAD CRISIS UNIT Version 1.10 Page 26 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI ALEXANDRA ROAD CRISIS UNIT Version 1.10 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!