Inspection on 26/07/06 for Booth Road 82

This inspection was carried out on 26th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Booth Road 82 18/08/08

Booth Road 82 11/04/07

Booth Road 82 04/10/05

Booth Road 82 28/04/05

Booth Road 82 07/04/04

Similar services:

Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

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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 Booth Road 82 Colindale London NW9 5JY Lead Inspector Caroline Mitchell Key Unannounced Inspection 26th July 2006 10:50 Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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 Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Booth Road 82 Address Colindale London NW9 5JY 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) 020 8200 8504 020 8200 8504 PentaHact Care Home 8 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 4 adults who have a learning disability (LD) and who may also have physical disabilities (PD) and have associated nursing needs. Specific Service User One specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. 4th October 2005 Date of last inspection Brief Description of the Service: This home is owned and run by Adepta, previously known as PentaHact. It comprises two houses that are side by side and are adjoined by an open corridor. Numbers 82 and 84 Booth Road were previously registered as two homes. They have now been amalgamated and operate as one home, with a manager and two deputy managers. 82 Booth Road is no longer registered as a care home providing nursing care. On the ground floor of each house is a lounge, kitchen diner, toilet and laundry room. On the first floor, there are walk in showers, an assisted bath with a toilet and four bedrooms. On the second floor there is an office shared by both houses, a storage room and a meeting room. There is a small parking area at the front of the home and a garden at the back. The home is situated close to Colindale station on the Northern line, a short walk to Colindale hospital and approximately a mile away from Edgware Hospital. It is close to the shops, restaurants and public transport facilities that are located along the Edgware Road. The stated aim of the home is to provide twenty four hour care and support for people with profound learning disabilities to enable them to live as independently as possible within the community. Placements at the home costs around £1,336 for each person per week. Service users are expected to pay separately for some toiletries. Following “Inspecting for Better Lives” the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took around six hours to complete. It is a difficult to gain some of the service users’ opinions as they do not communicate in conventional ways. However, the inspector was able to meet an observe several service users during the course of the inspection and they appeared happy and relaxed in their home. The inspector was assisted by the manager Mrs Christine Balachandre during the inspection and also had the opportunity to meet several members of staff. The inspector looked at the care plans and risk assessments for three service users in some detail, and a number of the written records that are kept in the home including staff records, training records, team meeting minutes, supervision records, health and safety records, the record of complaints, and some policies and procedures. This service is judged as a good service as it has more strengths than areas for improvement and the key standards are generally met. There are some areas identified for improvement and the inspector is confident the provider will manage these issues effectively. What the service does well: What has improved since the last inspection? What they could do better: Some risk assessments need to be developed regarding particular healthy care issues, such as the use of metal bed rails, and the catheter care tasks currently undertaken by care staff. In terms of the environment, the kitchens need to be refurbished in both houses and the carpets need to be replaced in the corridors. In terms of the pre-employment checks undertaken regarding Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 6 the suitability of staff, CRB applications, which include POVA checks need to be submitted to the Criminal Records Bureau for all staff who commenced employment since July 2004. It is acknowledged that there is room for improvement in the area of written records, in that they need to be consistent in both houses. The inspector also recommends that staff receive a training update regarding infection control, and that the home continues to focus on increasing opportunities for service users to benefit from leisure and recreational activities in the local community. 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. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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 the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users have a needs assessment carried out before they are admitted to the home so that their needs and preferences are known to the home. EVIDENCE: The inspector looked at the written records of one service user, who had recently moved into the home, in respect of the assessment information that was available to the home prior to them deciding that this particular service user’s needs could be met and were compatible with the other people who were already living there. Some information had been made available about the service user, and the manager from Booth Road was able to visit and make her own assessment of the service user. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users changing needs are well documented. Any change is implemented and monitored. This results in service users being confident that their needs and wishes for independence are understood and staff act in the service users best interests. EVIDENCE: The quality of plans of care at Booth Road remains high. These plans are detailed and include methods of communication used by service users, all aspects of service users behaviour and how this is managed, service users activities timetable, relationship maps and other information relevant to building a holistic picture of service users. The plans seen are reviewed and amended regularly as needs change. As the service users and staff interacted with each other throughout the day, the inspector saw evidence that service users were encouraged to make decisions that are relevant to them. Encouraging people’s independence was also a feature of the service user plans and risk assessments that are in place for each person. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 10 The risk assessments that are in place are of a high standard and cover the majority of the known risks that are relevant to each service user’s life. The inspector has made requirements regarding risk assessments, which are needed in relation to service users’ specific healthcare issues, and this is included under standard 19 of this report. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users continue to exercise choice with regard to their personal, social and educational development. The home is working to improve the opportunities that service users have to participate in more age and culturally appropriate activities in the community. Service users are supported to maintain relationships with their families and are offered a healthy diet. EVIDENCE: On the day of the inspection one service user was attending the Jewish Day Centre, and another was attending a local day service in Flower Lane. The inspector met one service user, who was waiting for the transport to pick them up to go to the day service that they regularly attend. The inspector was told that another service user was attending a sing-a-long in Stanmore. The inspector noted that written records indicate that service users with limited communication are stimulated by one-to-one contact with staff, and engage in activities appropriate to their abilities and interests. They continue to participate in a variety of activities. These include attending college, Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 12 swimming and social clubs. Service users also have music therapy and aromatherapy sessions in the home. They attend a variety of daytime activities, which reflect their interests, and their cultural and religious backgrounds. In discussion with staff it became evident that they are aware that there is some room for improvement in terms of the opportunities that service users have to participate in activities in the community, and that this is on their agenda for improvement. A recommendation is made in respect of this. During the inspection the inspector gained the impression that the emphasis in the home is very much one of enabling service users to be as independent as possible, and to be involved in the decisions that are meaningful to them. Anecdotal evidence from staff, and records reflect that they are encouraged to be involved in the day-to-day running of their home, including the domestic side of things, such as doing their laundry and keeping their rooms clean, according to their interests and abilities. The manager explained that most service users have good levels of family involvement. The inspector was in the home while lunch was being served. The food looked and smelled appetising and was nicely presented. The staff member explained that as several service users were at home on that day, the main meal was being served at lunchtime and that people wanted to eat together in the garden. It was also noted that a detailed record is kept reflecting what service users actually eat, in order to monitor the quality of their diet overall. These records indicated that a varied and well-balanced diet is being provided. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 13 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 adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Booth Road staff work effectively with service users and other professionals so that service users continue to be provided with sensitive personal and health care support by staff. In order to safeguard both the service users and the staff there is a need to develop some risk assesments regarding service users’ health care needs. The arrangements regarding the storage and administration of medication are acceptable. EVIDENCE: There is very clear written guidance for staff regarding the way in which to work with each person, including helping them to be as independent as possible in their personal care. As previously stated, the standard of risk assesments that are in place for service users is generally very high. There were a number of risk assesments in place that relate to the specific health care needs of individuals, such as peg feeding, moving and handling and tissue viability. However, the inspector did note that the it is necessary for the home to put in place two risk assesments specifically related to three service users’ health care needs. One service user has a catheter in place, and MRSA has been diagnosed. The district nurses visit regularly and undertake the related nursing tasks, and care staff Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 14 undertake the day-to-day care. It is necessary to develop a risk assesments regarding the aspects of catheter care undertaken by care staff. The inspector noted that there are two service users for whom metal bed rails are being used to prevent them from falling from bed, without the risks having been properly assessed. A requirement is made in respect of this. As one of the service users has been diagnosed as having MRSA, it is recommended that staff be provided with refresher training regarding infection control. One service user has leg ulcers and is treated by the District Nurse, who visits on a weekly basis. A policy regarding tissue viability is in place, and staff have had training regarding pressure care at Edgware hospital. One service user has Insulin injections and the inspector was provided with evidence that staff are properly trained, and judged competent in the administration of Insulin, with the particular equipment that is in use. The inspector noted that, despite this having been a requirement in a previous inspection, in house 82, the record of medicines returned to the pharmacy did not include the name of the service user that they were originally prescribed for. However, this was addressed at the time of the inspection. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 15 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 from evidence gathered both during and before the visit to this service. Service users have access to information should they wish to make a complaint. The policies and procedures are robust and that staff are familiar with them. EVIDENCE: The inspector noted that there was evidence on staff files that they had undertaken training in the protection of vulnerable adult from abuse. Service users were unable to advise the inspector of their opinions in relation to the complaints process. However comment cards from relatives indicated that on the whole relatives and visitors were aware of the complaints procedure and how to use it. The record of complaints was seen on the day of the inspection by the inspector, and no complaints had been recorded since the previous inspection. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 16 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): 28 & 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Whilst the shared areas are homely and clean, there are some areas that require investment, such as the kitchen units and the carpets. EVIDENCE: During the tour of the tour of the two houses and the garden, the manager explained that the garden has been greatly improved as a staff member has been working with a particular service user, to make it more appropriate for the use of the service users. There is wheelchair access throughout the parts of the accommodation used by service users. Both houses looked and smelled reasonably clean. The manager explained that the staff help the service users to keep their home clean on a day to day basis, and a deep clean of the shared areas is undertaken once a month by a contactor, to maintain a good standard of hygiene in the communal areas of the home. The inspector did note however, that the carpets in the corridors are becoming quite worn looking, due to heavy use and frequent shampooing. A requirement is made in respect of replacing them. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 17 The home had sufficient toilets and bathrooms. They are adapted to provide access for wheelchair users. There was a total of two assisted communal bathrooms with toilets and two walk in showers with toilets. The inspector noted that the toilets in both houses had liquid soap and paper towels. The communal areas were well furnished. There are two lounges and two dining rooms on the ground floor. The kitchen/diners of both homes are accessible to service users. At the previous inspection the registered persons were required to ensure that the cooker hoods in both houses are kept clean and grease free. The inspector was able to confirm that this issue has been addressed and the cooker hoods were clean and grease free at the time of this inspection. The kitchen cupboards were clean, but they are getting quite worn and battered looking. A requirement was made at the previous inspection for the registered persons to ensure that the kitchen units in both houses are replaced. This had not been achieved within the given timescale and this requirement is reworded and restated as part of this report. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 18 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): 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient staff employed to meet the needs of the service users and they benefit from a good level of training and supervision. Generally, the preemployment checks for staff are in place. However, in order to properly protect the service users it is necessary to ensure that CRB checks are reviewed to ensure POVA checks have been undertaken for staff. EVIDENCE: An NVQ Assessor from a local college was visiting staff at the home at the time of the inspection, and the inspector had the opportunity to meet the Assessor in private. She said that she was made welcome in the home and that the home was on track with achieving an acceptable proportion of the care staff gaining NVQ qualifications. She added that the staff that she was working with had a good knowledge of their field. The inspector was able to meet and chat with a number of staff, as they were undertaking their duties, and the feedback from them about working in the home was positive, with one person saying that it is “like an ordinary home”. The inspector discussed the recent changes that have been introduced in respect of staffing at night and in respect of changing the registration of the home from nursing to personal care, with the manager. The manager was confident that the staffing levels are sufficient to ensure the safety and to meet Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 19 the needs of the service users at night. This was backed up by clear monitoring records of how service users are during the night. There is also clear guidance in place for staff, regarding their night duty responsibilities. The manager was confident that service users had not been disadvantaged through the change from nursing to care in the home. She told the inspector that the positive relationship that has been built with the other heath care professionals in the area, and the support that they provide to both individual service users and the team as a whole ensures that service users’ health care needs are properly met. She said that one of the areas that the home is concentrating on developing at the moment is expanding service users’ opportunities in the community, and that there is some flexibility with the way in which care hours can be used, to ensure service users’ needs can be met. The inspector was shown the planned rota and this indicated that there were staff in sufficient numbers for the running of the home. The inspector also saw the monitoring records kept of the shifts worked by staff and this showed that, despite there being three full time staff vacancies, that the use of agency workers is kept to a minimum. The manager explained that this is achieved by use of relief workers who are employed by familiar to the service users. The inspector reviewed the written records of several staff and found that they reflected that a good standard of recruitment. However, the inspector found that a number of staff, who had been recruited since July 2004, had CRB checks that did not include a POVA check. A requirement is made in respect of this. The written records for staff included evidence that they were receiving a good level of training and staff who spoke to the inspector were content with the training that was provided. There had been some difficulty regarding the NVQ training, but this is now resolved. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 20 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, 41 & 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A competent manager runs the home. Service users benefit from well planned support. Overall the service users and staff are protected by a proactive approach to health and safety in the home. However, very minor improvements are identified to improve in this area. Generally the record keeping in the home protects service uses’ best interests. However, improvements are identified to improve in this area. EVIDENCE: The manager, Mrs Christine Balachandre demonstrates competency in her management of the home. The manager ensures that all the homes policies and procedures are read and understood by staff. These are discussed in staff meetings. There is open communication between the staff and the manager, and staff are clear about the manager’s expectations in relation to the smooth running of the home. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 21 During the course of the inspection the inspector noted that there was a qualitative difference between the records kept in the two houses. Work needs to be prioritised to improve the records kept in number 82, to bring them of the standard of those kept at number 84. A requirement is made in respect of this. At the previous inspection the registered persons were required to ensure that a Legionella test is completed in both houses, and that the control of infection procedure was reviewed to ensure it remains relevant. The inspector has been provided with evidence that the Legionella test had been undertaken and was able to see the control of infection procedure, which had been reviewed as necessary. PAT (portable electrical appliance) testing was being undertaken at the time of the inspection. The inspector noted that, although there were plastic containers for storage of the breakfast cereal in the kitchen cupboards, they weren’t being used properly and there were several packets of cereal that were opened and partially used. The registered persons must ensure that opened dry food is properly stored in containers to prevent germs and maintain freshness. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 22 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X X X 2 2 X Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 YA19 Regulation 13(4) Requirement Timescale for action 30/09/06 2 YA19YA42 13(4) 3 YA28 16(2)(h) 23 (2)(c) The registered persons must ensure that a risk assessment is developed regarding the use of metal bed rails for each service user for whom it is relevant. The registered persons must 30/09/06 ensure that a risk assessments is developed regarding the catheter care tasks currently undertaken by care staff. The registered person must 01/10/06 ensure that the kitchens are refurbished in both houses. The previous timescale of 01/05/06 was not met. The registered person must ensure that the carpets are replaced in the corridors of both houses. The registered persons must ensure that CRB applications, which include POVA checks, are submitted to the Criminal Records Bureau, for all staff who commenced employment since July 2004. The registered person must ensure that opened dry food is properly stored in containers to DS0000010411.V291259.R01.S.doc 4 YA28 23 (2)(b) 01/10/06 5 YA34 19 & Schedule 2 30/09/06 6 YA42 16, (2) (g) 01/09/06 Booth Road 82 Version 5.1 Page 24 7 YA41 17 prevent germs and maintain freshness. The registered persons must review the standard of the written records that are kept and put in place systems to ensure that the standard of these records is consistent in both houses. 01/09/06 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 2 Refer to Standard YA35 YA13 It is recommended that the home continue to focus on increasing opportunities for service users to benefit from leisure and recreational activities in the local community. Good Practice Recommendations It is recommended that staff be provided with a training update regarding infection control. Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office 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 Booth Road 82 DS0000010411.V291259.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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