Inspection on 27/07/07 for Angel Lodge

This inspection was carried out on 27th July 2007.

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

Angel Lodge 17/08/06

Angel Lodge 11/11/05

Angel Lodge 12/04/05

Angel Lodge 13/01/05

Angel Lodge 12/07/04

Angel Lodge 02/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Angel Lodge 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW Lead Inspector Ms Gwen Lording Unannounced Inspection 27th July 2007 09:30 X10015.doc Version 1.40 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 DS0000025883.V347873.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 Older People. 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. DS0000025883.V347873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Angel Lodge Address 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW 020 8597 4399 020 8597 4399 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) Chana Bros Limited Mr. Amrik Singh Chana, Mr. Bhupinder Singh Chana Pauline Ann Baker Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000025883.V347873.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2006 Brief Description of the Service: Angel Lodge is registered to provide personal care and accommodation for up to 20 service users over the age of 65 years who have related illnesses/ conditions. The home is owned and operated by a family business. The premises are situated in a residential area of Goodmayes, close to the busy Ilford High Road with access to shops and other community facilities. The home provides accommodation on two floors, which is mainly in single bedrooms with one double bedroom and there is a passenger lift. On the day of the inspection the fees for the home were £430.00 per week. A copy of the Statement of Purpose and Service User Guide to the home is made available to both the residents and the family. A copy of the most recent inspection report is available on request. DS0000025883.V347873.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 by the lead inspector, Gwen Lording and took place over one day. The registered manager was available throughout the visit to aid the inspection process. This was a key inspection in the inspection programme for 2007/ 2008. Discussion took place with the registered manager, members of care staff, the cook, domestic and laundry person. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector spoke to several residents and where possible residents were asked to give their views on the service and their experience of living in the home. A tour of the premises, including laundry and kitchen was undertaken. A sample of residents’ files were case tracked, together with the examination of other staff and home records. This included medication administration, staff training schedules, maintenance records, menus, complaints, fire safety and accident / incident records. Information was taken from an Annual Quality Assurance Assessment (AQAA), which was completed by the manager and responsible individual. This is a new self-assessment process, which all providers are required to complete once a year. Additional information relevant to this inspection was also obtained from monthly Regulation 26 monitoring reports and Regulation 37, notification of events. As part of the inspection the views of several community health and social care professionals who provide a service to the home were sought, and are commented on in this report. The inspector had a discussion with the manager and people living in the home about how they wished to be referred to during the inspection and in the report. They expressed a wish to be referred to as ‘resident’. This is reflected accordingly in the report. What the service does well: As part of the inspection, contact was made by phone with community health and social care professionals who visit the home, this included the District Nursing Service and placing authorities. They commented very positively on their involvement with the home and expressed no concerns about the care being provided; and that any advice given was well received and acted upon accordingly. DS0000025883.V347873.R01.S.doc Version 5.2 Page 6 There is a relaxed atmosphere throughout the home and residents appeared unhurried and are given sufficient time and support in their everyday lives. The residents are well groomed and staff were seen to be providing good personal care. 95 of care staff are qualified to National Vocational Qualification (NVQ) level 2 or above; and the domestic is also working towards a related NVQ. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025883.V347873.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025883.V347873.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 & 4 People using the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. A pre-admission assessment is undertaken for all prospective residents. Care plans are drawn up from the information in this assessment. However, the religion, ethnicity and social/ cultural needs of individual residents must be identified so that staff understand and are able to meet such needs. The home does not offer intermediate care. EVIDENCE: Individual records are kept for each resident and a number of files were examined, including the records for the most recently admitted resident. All files inspected have assessment information recorded and the information had been used to develop written care plans. The records showed that residents, DS0000025883.V347873.R01.S.doc Version 5.2 Page 9 where possible and their relatives are involved in the assessment process. Where appropriate, information provided by the placing authority was also included. All records examined had full assessment information recorded around the health and personal care needs of the residents. However, at the initial preadmission assessment the religion, ethnicity and social/ cultural needs are identified to a limited degree, and this area does need expanding so that staff understand and are able to meet such individual needs. The inspector was satisfied that the health and personal care needs of residents were being adequately met and understood. All residents receive a contract/ terms and conditions which sets out the fees. The manager was provided with a copy of the Commission’s Policy and Guidance on Provision of Fees Information by Care Homes’. This sets out what information care home providers need to include in the Service User Guide regarding fees and terms and conditions, and is in a format that is easy to understand. DS0000025883.V347873.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit this service. Residents’ health and personal care needs are set out in individual care plans The care plans are generally detailed but need to be more specific with regards to the recording of outcomes for residents around the cultural, religious and social care needs of the individual. There are clear medication policies and procedures to follow, so as to ensure that residents are safeguarded with regard to medication. EVIDENCE: Individual care plans were available for each resident and a total of four residents were case tracked and their care plans and related documentation inspected. The records for these residents were found to be generally detailed, but need to be more specific with regard to the recording of outcomes around the cultural, religious and social care needs of residents. For example residents DS0000025883.V347873.R01.S.doc Version 5.2 Page 11 religion is recorded but there was no evidence on the care plans as to the impact of a persons religion on the method and type of care provided. Staff need to have knowledge of what a person’s religion means in terms of care and activities. All residents have a specific ‘night’ care plan, which details individual’s routines and preferences. For example “Likes to lie in bed until around 10.30am, staff to assist when ready to get up”. The documentation/ health records relating to the management of diabetes; colostomy care and a resident admitted for a period of respite care were examined. These were found to be generally detailed and being adequately maintained. Where the District Nursing Service visits residents in the home, the notes are incorporated into the individual’s care plan. One resident currently on a trial placement in the home continues to administer her own insulin as she had prior to admission. The manager is concerned as the resident regularly declines to monitor her blood sugar levels and the District Nursing Service is not involved as the resident is able to self medicate. The manager has made contact with the Diabetic Nurse Specialist to advise staff regarding management of the current situation. Risk assessments are being routinely undertaken on admission for all residents, and were being regularly reviewed. Residents were being weighed on admission and then generally on a monthly basis with fluctuations in weight being monitored and action taken accordingly. Files evidenced involvement from the District Nursing Service; GP; optical, dental and chiropody services. There had been some progress since the last inspection on the development of care plans around ‘End of Life’ wishes and the importance of developing these further was discussed with the manager. All residents appeared clean, well groomed and dressed according to their individual preferences and spectacles and dentures were clean. Staff talked about and were observed to treat residents in a respectful and sensitive manner. They understood the need to promote dignity through practices such as the way they addressed residents and were observed knocking on bedroom, toilet and bathroom doors before entering. They were seen to be very gentle when undertaking moving and handling tasks and offered explanation and reassurance throughout the activity. An audit was undertaken for the handling and recording of medicines and a random sample of Medication Administration Record (MAR) charts were examined. There was an improvement noted since the last inspection. Monthly audits are undertaken by the pharmacy that provides a service to the home. DS0000025883.V347873.R01.S.doc Version 5.2 Page 12 The inspector spoke to a number of residents and asked about the care in the home. They all said that staff were kind and respectful, particularly when attending to personal care. Residents spoken to said: “All the girls are very good – nothings too much trouble” Another resident on a respite admission commented: “Staff are very nice, helpful people. The food is good and I have a nice room”. DS0000025883.V347873.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. There is a varied programme of activities available within the home, which suits individual needs, preferences and capacities. However, there is a very limited programme of activities outside the home and more consideration needs to be given to planning community activities, which are suitable to the needs and preferences of individual residents. This will ensure that all residents have a sufficiently stimulating and varied choice of activities available to them outside the home. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends. EVIDENCE: The home does not employ an activity co-ordinator. There is a general programme of activities available but this is not structured. Care staff are responsible for facilitating and arranging any activities. There are regular visits by professional entertainers, which are popular with most of the residents. During the visit staff were observed engaging with some residents, for example DS0000025883.V347873.R01.S.doc Version 5.2 Page 14 playing board games; one resident enjoys knitting; looking at the newspaper with another resident and discussing news articles. There is a very limited programme of activities outside the home and staff must endeavour to seek the views of residents around planning activities outside the home which take into account individual’s interests and capabilities prior to them moving into the care home. Some residents visit the local church and a priest visits the home to give Communion to three residents approximately once a month. One resident regularly goes out with her daughter and recently went home to celebrate her 80th birthday with her family and friends. Menus were inspected and found to be balanced and a choice is offered each day, including a vegetarian option. Drinks and snacks are available throughout the day and staff were seen to be offering drinks to residents during the visit. A visit was made to the kitchen and the inspector was able to discuss the storage and preparation of food with the cook in charge. She was aware of those residents requiring special diets, for example diabetic and vegetarian diets. Fresh fruit is provided each day and is also available on request. The inspector was able to observe the lunchtime meal being served. Meals are served in the dining room or lounges; or residents may choose to eat in their rooms. Staff were on hand to assist individuals when necessary and staff were observed to be offering assistance appropriately and residents were not being rushed. The manager stated that there are plans to refurbish the dining room with new curtains, a dresser and a new layout using smaller dining tables. This will provide residents with a more congenial setting in which to enjoy their meals. DS0000025883.V347873.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The manager and staff make every effort to sort out problems and concerns. However, all complaints made whether verbal or formal written must be recorded to ensure that any trends are identified and that residents and their relatives can be confident that their complaints are listened to and ill be acted upon. Staff working in the home have received training in safeguarding adults to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a written policy and procedure for dealing with complaints and the log inspected indicated that no complaints had been received since the last inspection. In discussion with the manager, and inspection of the complaint record maintained, it was evident that only formal written, or serious complaints were being logged. The inspector discussed with the manager as to what constituted a ‘complaint’ to be logged. This must include verbal complaints via telephone or face to face, and any expressions of concern or dissatisfaction with any element of the service. This will enable the manager to review the number and nature of complaints made and should be used as part of the home’s quality assurance procedures in order to improve the service. A written notice of how to complain and to whom is displayed in each bedroom. DS0000025883.V347873.R01.S.doc Version 5.2 Page 16 However, the information pertaining to the registered manager must be amended as it details the name of the previous and not the current registered manager. Those residents spoken to were aware of how to complain and to whom. One resident said: “I would speak to one of the carers, and they would get things sorted”. Another said: “I don’t have any complaints – but if I did I’d tell the manager”. All staff working in the home have received training in safeguarding adults and this is included in induction training for all new staff. This was evidenced on staff files and the training schedule. Those staff spoken to were conversant with the action to be taken if they had concerns about the safety and welfare of residents or if they witnessed any suspected abuse. DS0000025883.V347873.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The home provides a physical environment that is clean and very welcoming and improvements to the décor, some internal furnishings and refurbishment/ relocation of facilities has taken place since the last inspection. However, progress and plans to improve the environment have continued at a very slow pace. A commitment and investment to improve the premises is required by the registered providers in order to refurbish the home to an improved standard, which will be to the benefit of residents. EVIDENCE: The building was toured by the inspector, accompanied by the manager, at the start of the visit, and all areas were visited again later during the day. There were no offensive odours and all parts of the home were clean. All of the DS0000025883.V347873.R01.S.doc Version 5.2 Page 18 bedrooms seen were personalised and were reflective of the occupant’s interests. Whilst the home is clean, comfortable and very homely, the ongoing maintenance and refurbishment programme for the home appears to be reactive rather than proactive. It is acknowledged that the registered providers have made some significant improvements but progress to further improve the environment has continued at a very slow pace. Those bedrooms that have been re decorated are much improved with new bedroom furniture and bed linen. A number of issues highlighted at the last inspection have still not been actioned. For example replacement unit for the lounge and more suitable storage for crockery/ cutlery in the dining room. The manager stated that they have been successful in being awarded a government capital improvement grant through the London Borough of Redbridge. This will be used to make improvements to the garden, which includes a gazebo and water feature. This will greatly improve the garden area for the use and enjoyment of all residents and their families/ friends. The laundry was visited and clothing was being stored appropriately, pending washing. A new washing machine, separate dryer, iron and ironing board have been purchased. The machines were not operational at the time of the visit as they are waiting to be fitted by the manufacturers. The manager has received information and is fully aware of the recent legislation regarding smoking in care homes, which came into effect on the 1st July 2007. DS0000025883.V347873.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The home employs staff in sufficient numbers to meet the personal care needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Staff rotas were inspected and staffing levels were sufficient to meet the assessed care needs of residents. The home has a small but relatively stable staff team and only employs agency staff to cover any shortfalls such as annual leave and sickness. On the day of the inspection there was one agency member of staff on duty to escort a resident to a hospital appointment. There is consistency maintained in the number of agency staff provided to the home to ensure that such staff are kept to a minimum and are familiar with the residents and their care needs. The manager must ensure that the duty rota includes the full name of each member of staff i.e. first name and surname. A record is maintained of staff training and records showed that staff have undertaken training in essential areas such as fire safety, safeguarding adults, moving and handling and food hygiene. One of the senior carer’s has completed an accredited training course on ‘Training Skills in Dementia Care’. DS0000025883.V347873.R01.S.doc Version 5.2 Page 20 Plans for her to undertake a programme of training for all staff in dementia awareness has not yet commenced and should be included in the planned training programme for all staff in the home. A discussion took place with the manager around the recently introduced Mental Capacity Act 2005, and the impact it will have upon the delivery of care to vulnerable people. The manager has acquired a lot of information from the Department of Health around this legislation. It is essential that all staff working in the home receive adequate and appropriate training in this important area. The AQAA completed by the registered persons stated that 95 of care staff are qualified to National Vocational Qualification (NVQ) level 2 or above. The home’s domestic is also currently working towards a related NVQ. No staff have been recruited since the last inspection. A random sample of personnel files examined at the time of the last inspection evidenced that the home’s recruitment procedures were robust. DS0000025883.V347873.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The manager of the home is a qualified and experienced person and residents benefit as the home is run in their best interests. Monitoring visits are undertaken regularly by the responsible individual to monitor and report on the quality of the service being provided in the home. EVIDENCE: The registered manager is an experienced person, has completed the Registered Manager’s Award and is competent to run the home. She is very resident focused and works hard to improve the service with the support of the staff team. DS0000025883.V347873.R01.S.doc Version 5.2 Page 22 From viewing staff records and discussions with the manager and staff it was evident that formal supervision was not being undertaken nor were records of supervision being maintained. The manager and staff confirmed that there were opportunities for ‘ad hoc’ supervision and regular staff meetings but no formal system for staff to receive supervision on a regular basis. Regular supervision may include observational and peer supervision and it is important that such supervision is clearly recorded on staff files. The responsible individual undertakes Regulation 26 monitoring visits on a monthly basis to report on the quality of the service being provided in the home. This should include staff issues such as training and supervision. Currently the manger does not act as an appointed agent for any resident. Residents’ financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances of several residents. Secure facilities are provided for the safekeeping of money and valuables held on behalf of residents with written records being maintained. However, it is strongly recommended that there are two staff signatories on financial transactions made on residents behalf. This will provide safeguards for both residents’ and staff. A wide range of records were looked at including fire safety, emergency lighting, water temperature checks, portable appliance testing (PAT) and accident/ incident reports. These records were found to be detailed, accurate and up to date. More work needs to be done by the organisation to demonstrate that there will be progress and sustained improvements with regard to the environment. DS0000025883.V347873.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 DS0000025883.V347873.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 12 & 15 Requirement The registered providers must ensure that care plans are more specific with regard to the recording of religious, cultural and social care needs of residents and how these are to be met. The registered persons must provide a more varied programme of community activities, which are suitable to the needs of individual residents. This will ensure that all residents have a sufficiently stimulating and varied choice of activities. The registered persons must ensure that all complaints made whether verbal or formal written; or expressions of concern or dissatisfaction, are recorded in the complaints log. This will ensure that any trends are identified and residents and their relatives can be confident that their complaints are listened to and acted upon. The refurbishment programme for the home must be progressed so that all parts of DS0000025883.V347873.R01.S.doc Timescale for action 30/09/07 2. OP12 16(2)(n) 30/09/07 3. OP16 22 27/07/07 4. OP19 OP20 OP33 10(1) 23(2)(b) (d) 31/10/07 Version 5.2 Page 25 24 5. OP36 18(2)(a) the home are well maintained. This will ensure that the care home is always operated in the best interests of residents. The registered persons must ensure that there is a formal supervision system in place. This will ensure that all staff are appropriately supervised in all aspects of their care practice, and help to identify individuals development needs. 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000025883.V347873.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 DS0000025883.V347873.R01.S.doc Version 5.2 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. 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