Inspection on 04/09/06 for Beaufort House

This inspection was carried out on 4th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaufort House 07/11/05

Beaufort House 09/06/05

Beaufort House 14/10/04

Beaufort House 12/07/04

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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 Beaufort House Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD Lead Inspector Pauline Long Key Unannounced Inspection 4th September 2006 08:45 Beaufort House DS0000013563.V309776.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 Beaufort House DS0000013563.V309776.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. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort House Address 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) Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD 01483 475536 Whitmore Vale Housing Association Miss Heidi Michelle Beech Care Home 7 Category(ies) of Learning disability (7), Physical disability (2) registration, with number of places Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 18 - 65 YEARS. Two of the 7 persons accommodated may be within the category PD in addition to being within the category LD. Up to six named persons may be within the category LD(E). Date of last inspection 7th November 2005 Brief Description of the Service: Beaufort House is part of the Whitmore Vale Housing Association a charitable housing Society. It is situated in a residential area close to the centre of Knaphill Village on the outskirts of Woking. Beaufort House is registered to provide care and accommodation for 7 adults with complex daily needs and communication difficulties. The property has been converted from a private residence comprising seven bedrooms. One Bedroom has en-suit shower and toilet facilities. There is a kitchen, large through dinning/lounge room and a quiet/sensory room. Limited off street parking is available at the front of the property. The residents have access to a secure fenced garden. The fees at the home are £1225.54 per week. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. It commenced at 08.45, and ended at 14.45. Discussions were had with the residents, staff and a visitor to the home. Documents sampled, included service users files, care plans, staff records, policies, procedures and the preinspection questionnaire. Two comment cards were received at the CSCI office from relatives and are included in this report. A full tour of the home and garden took place. Verbal feedback from the resident’s at home on the day was limited, in view of the their communication difficulties. However observations of body language, facial expressions and sounds, evidenced a state of wellbeing. CSCI would like to thank the residents, manager and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? All of the requirements and the recommendations made at the previous inspection have been met. The quiet/sensory room has been redecorated providing a more pleasant environment for residents to spend time. The homes office has also been redecorated and refurbished with new shelving. Plans are being drawn up in respect of an extension to the home, in order to provide better facilities for those residents with mobility problems. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 6 What they could do better: The majority of the staff have undertaken training in safeguarding adults, however one member of staff who has been employed for some considerable time has yet to undertake this training, indicating that this staff member would not be aware of the policies and procedures in this respect. A requirement has been made that the staff member complete safeguarding adults training in order to protect the safety and welfare of residents. Beaufort House is an older property and therefore presents challenges for the providers in respect of the ongoing need for updating and refurbishment. The fabric and furnishings of the building were satisfactory, although it was noted that some of the carpets were soiled, particularly around the entrance hall, kitchen and dining room areas, which did not enhance the resident’s environment. The decoration in the communal areas will require updating in the near future, as the paintwork was chipped in several areas. Records indicated that the water temperatures in the kitchen and laundry rooms exceeded safe levels. Whilst it is noted that resident’s would not be left unsupervised in the kitchen, there is the potential risk of scalding. Other water temperatures were recorded as being low. Attention must be paid to all of the homes water taps to ensure that residents and staff are safe. Following the previous inspection the home was required to carry out risk assessments on all liquid soaps, which are regarded as potentiality hazardous to vulnerable residents. This requirement had been met. The risk assessments indicated that all of these liquid soaps presented a hazard to the residents, and should not be accessible to them. On the day of the site visit liquid soaps were found to be in some of the communal bathrooms and toilets. The laundry room door was not locked, a large box of washing powder was found to be stored next to the washing machine posing a hazard the residents as they have access to this room. The storage cupboard for hazardous substances was unlocked and also had the potential to pose a hazard to the residents. One of the garden paths was overgrown with ivy, causing a potential trip hazard to both residents and staff. Requirements have been made in respect of these areas. Please refer to page 24 of this report. Beaufort House DS0000013563.V309776.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. Beaufort House DS0000013563.V309776.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 Beaufort House DS0000013563.V309776.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure a full needs assessment takes place before any new admission, indicating that the home would be fully aware of a residents needs. Improvements have been made in respect of service users/ relatives agreeing with and signing the contracts drawn up by the home. EVIDENCE: Service users files evidenced that the home would seek a community care needs assessment from the local authority care management team prior to offering a care service. The homes own care needs assessments are comprehensive, to include all aspects of daily living giving the reader a good insight into a service users identified needs. Improvements have been made in respect of service users contracts, the majority of the contracts have been signed by a relative or representative. One had not been signed and the manager has documented evidence as to the reason why it has not been signed. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual care plan, where their assessed and changing needs and goals are reflected. Service users are encouraged and supported to make decisions about their own lives and to take responsible risks. EVIDENCE: Care plans were sampled, and were found to be good, with plans around all daily living activities. The care plans gave clear instructions and guidelines to the reader about a resident’s care needs and action plans as to how these needs could be met. Risk assessments were clearly documented and guidelines in place to minimise the risks. All of the documentation had been recently reviewed. The manager and staff were observed supporting the residents in respect of decision making and choices for example, choices for lunch and an outside activity. Service users were observed coming and going from the kitchen, care Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 11 staff observed from a distance, promoting service users independence but ensuing they were taking responsible risks. One relative commented, “the care staff work hard at maintaining the normality of every day life”. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff enable the service users to maintain fulfilling lifestyles in and outside the home, and promote contact with family, friends and the local community. The meals at the home are wholesome, nutritious and appealing. EVIDENCE: One of the residents at Beaufort House is in paid employment. Other resident’s go to various day services. This enables them to have a degree of independence, and the opportunity to meet with other day service users. The home is committed to ensuring that the service users maintain their relationships with their family and friends. Some of the service users receive regular visitors and keep contact by phone. A visitor to the home commented that the home and staff were very welcoming. A relative commented “that nothing was too much for the staff, and that they would always encourage families to come in to the home and spend time with their relative”, and I” Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 13 couldn’t ask for a more suitable home, I hope my relative will be able to spend many happy and healthy years in such a happy and friendly home”. The staff discussed various outings and a holiday planned for later in the year, for example trips to Longleat House and Centre Parcs. One service user discussed his love of animals and commented he was looking forward to the holiday. A lunch time activity was observed. Service users were encouraged and supported to get the dining table ready. All but one of the service users sat at the table. Care staff supported those service users who required help, this support was offered in a familiar yet respectful manner. The meal time was quite lively, with lots of laughing. All of the service users appeared to enjoy their lunch of fresh crusty bread, rolls and various cheeses. One service user commented that he enjoyed his lunch. The menus at the home provide a varied choice for the service users, staff commented that service users are involved in deciding the menus. Kitchen practices and procedures were sampled. The fridges, freezers and cupboards were well stocked with fresh, frozen food, fruit and vegetables. Food was stored according to food hygiene regulations with records kept. On the whole the records indicated that daily checks were carried out on fridge, freezer and food temperatures, though some gaps were noted in the recording. This was brought to the managers attention at the time. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff have a good understanding of the service users support needs, this was evident from the positive interactions and relationships observed. The health needs of the residents are well met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Care plans included clear guidelines on any support each service user required with personal and health care. Physical and emotional needs of the service users were also detailed in the care plans and daily records, which included visits to the doctor and hospital appointments. Care plans were regularly reviewed. Staff were observed supporting the service users with various aspects of personal care, this support was offered in a sensitive way The home has clear medication policies and procedures. None of the service users in the home administers their own medication. All of the care staff on duty were aware of the policies and procedures regarding medication. They described the training they received and commented that only those staff who has been assessed as competent were permitted to administer medication. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 15 Medication record sheets were checked, and were found to be properly completed, with no gaps in signatures noted. Since the last inspection two errors in medication administration have been notified to the CSCI. These errors were being dealt with according to the homes medication and disciplinary procedures. Medication storage was sampled and found to be good. The manager evidenced that she carries out and documents regular medication audits. There were documented protocols and guidelines in place for PRN (as required) medications. The protocols were signed by the manager and senior staff, but were not dated, this was discussed with the manager at the time. Medication administration was not observed on the day. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the service users. Improvements are required in respect of safeguarding adults training, to ensure all staff have an understanding of these procedures and that service users are protected from abuse. EVIDENCE: CSCI has received no complaints about this home since the last inspection. None have been received at the home. Discussions were had with the care staff around the homes complaints procedures, they demonstrated a good understanding. No safeguarding adult referrals have been made since the last inspection. Discussions were had with care staff in respect of the homes safeguarding adults procedures. Various scenarios were put to them in respect of abusive situations, it was positive to note that they had a good understanding of the safeguarding adults and whistle blowing procedures. Training records evidenced that safeguarding adults training is routinely undertaken at the home. One long standing member of staff had not undertaken this training, indicating that this member of staff would not have an understanding of the homes safeguarding adult procedures. A requirement has been made in respect of safeguarding adults training. Please refer to pages 26 and 27 of this report. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 17 Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is satisfactory and meets the needs of the service users. Improvements are required in the maintenance and cleaning, and attention must be paid to the decoration to ensure the service users benefit from a more pleasant environment. EVIDENCE: Beaufort House is an older property and therefore presents challenges for the providers in respect of the ongoing need for updating and refurbishment. The fabric of the building was satisfactory, although it was noted that some of the carpets were soiled, particularly around the entrance hall, kitchen and dining room areas, which did nothing to enhance the service users environment. The decoration in the communal areas will require updating in the near future, as the paintwork was chipped in several areas. The manager stated that attention would be paid to these areas whilst the service users were on their holiday in October. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 19 The service users bedrooms were clean bright and tidy and there was evidence of many personal items. Rooms contained many sensory pieces of equipment for example, lava lamps, mirror balls, water features which were good for those service users with communication difficulties. One bedroom had a sensory projector, however at the time of the visit it was out of order. The beds and mattresses were checked and found to be in satisfactory condition. The carpet in one of the bedrooms requires cleaning. The bathrooms although well adapted for service users needs were domestic in design and quite pleasant. It was noted that that the parker bath requires a new sealant. The manager evidenced that a work sheet had been submitted in this respect. A requirement was made at the previous inspection for all liquid soaps to be risk assessed. This requirement has been met, and the risk assessments identified that the service users should not have access to these. It was a concern therefore to note that these items remained in the communal areas. It should be noted that the manager removed these at the time of the visit when the inspector alerted her to this. The laundry room was unlocked and an open box of washing powder was accessible by anyone in the room. Discussions were had with the care staff in this respect in order to ascertain if the service users could get access to the room, they commented that the service users would normally bring their own laundry down, and they could not be confident that a service user would be supervised whilst in the room. This presents a potential safety hazard and did not promote the health and safety of the service users. It should also be noted that the box of washing powder was removed at the time and stored appropriately. The garden will also require attention in the near future. Some of the foliage around the perimeter is overgrown. The pathway from the building at the back of the house was overgrown with ivy, and presented a trip hazard. It should be noted, that the manager started to clear the pathway on the day. Requirements have been made in respect of these areas. Please refer to pages 26 and 27 of this report. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the recruitment practices at the home. The home employs an efficient, trained and well-supervised staff team in sufficient numbers, who provide a good quality of care to the service users. EVIDENCE: The home employs a diverse staff group. There were 4 care staff, and the manager on duty on the morning shift. The dependency levels of the residents on the day indicated that the present staffing ratio was adequate. One relative commented, “the staff to resident ratio enables staff to spend quality time with the residents”. The manager stated that recruitment was ongoing and whilst the home has to use agency staff, continuity is maintained by using the same staff, who, are familiar with the service users. Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Staff were observed going about their work in a confident and professional manner. One new member of staff has been employed at the home since the last inspection, and at the time of the site visit plans were in place for induction. This member of staffs recruitment file was sampled and evidenced good recruitment practice, with all of the appropriate documentation in place and checks carried out. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 21 Training in the home is given a high priority, care staff stated that they are offered many opportunities to attend statutory training and other training in line with current good practice, one was keen to discuss the equality and diversity training undertaken, however this could not be evidenced in the training records. Six members of the staff team have an NVQ (National Vocation Qualification) and a further three are undertaking one. Eleven of the staff team hold a First Aid certificate. A visitor to the home commented that the staff, were well trained, and that they were knowledgeable in respect of the service users needs. As discussed earlier in this report, improvements are required in respect of safeguarding adults training. There is a formal one to one staff supervision programme in the home. Records were sampled and evidenced that staff received regular formal one to one meetings with a manager. There was also evidence of a recent staff meeting on 19/06/06. Staff commented that they have regular team meetings with the manager and if needed meetings could be called at short notice, they also stated that the manager had a high profile in the home and was always there if support was required. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident that their views are listened to. Their rights and best interests are safeguarded by the homes record keeping policies and procedures. Improvements are required in some areas and practices to ensure the health, safety and welfare of service users is promoted and protected. EVIDENCE: The manager had an open and inclusive style of management. From observation of her interactions with the service users and the staff, it was clear that there was an atmosphere of openness and respect. The staff expressed confidence that they could take any issue to the manager and it would be dealt with in a timely manner. Observations evidenced competent and confident staff who appeared relaxed in her presence. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 23 Staff discussed the meetings held at the home where service users are supported and encouraged to air their views. The most recent one was held on the 17/08/06. Record keeping has a high priority at this home, through out the site visit, records were sampled and were found to be well documented and routinely completed. Health and safety checks are routinely carried out at the home and clear records kept. All equipment in use on the day of the site visit was properly maintained. The water temperatures in several rooms was sampled and were found to be satisfactory, however the records evidenced that there were considerable variations in temperatures. Water temperatures in excess of 58 degrees centigrade were recorded in the kitchen and laundry areas, some of the bedrooms/bathrooms were recorded as low as 35 degrees centigrade. As discussed earlier in this report there are concerns around the storage of hazardous substances and trip hazards in the garden. Requirements were made in respect of these areas. Please refer to pages 26 and 27 of this report. Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 X 30 2 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 3 X 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 2 X Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 25 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 YA35 YA23 Regulation 12(1)(a) 13(6) 12(1)(a) 13(4)(a(b(c Requirement The registered person(s) must ensure that all staff, including night staff undertake training in safeguarding adults. The registered person(s) must ensure that all hazardous substances are stored appropriately according to COSHH (Control of Substances Hazardous to Health) regulations. The storage cupboard must be kept locked at all times. The registered person(s) must ensure that the carpets in the hall, dining room and a resident’s bedroom are cleaned. The registered person(s) must ensure that all areas of the home are kept reasonably decorated. Attention must be paid to the paintwork. Timescale for action 04/10/06 2. YA42 04/09/06 3. YA24 23(2)(d) 04/11/06 4. YA24 23(2)(d) 04/02/07 Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 26 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 Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Beaufort House DS0000013563.V309776.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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