Inspection on 27/05/08 for Brackenbury Road, 37

This inspection was carried out on 27th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brackenbury Road, 37 23/02/09

Brackenbury Road, 37 20/08/07

Brackenbury Road, 37 29/11/05

Brackenbury Road, 37 11/07/05

Brackenbury Road, 37 18/01/05

Brackenbury Road, 37 19/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Brackenbury Road, 37 Brackenbury Road 37 Brackenbury Road Hammersmith London W6 0BG Lead Inspector Sheila Lycholit Key Unannounced Inspection 27th May 2008 10:10 Brackenbury Road, 37 DS0000019145.V364359.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 Brackenbury Road, 37 DS0000019145.V364359.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. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brackenbury Road, 37 Address Brackenbury Road 37 Brackenbury Road Hammersmith London W6 0BG 020 8563 2125 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) info@yarrowhousing.org.uk Yarrow Housing Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thee registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 20th August 2007 and 10th March 2008 Date of last inspection Brief Description of the Service: 37 Brackenbury Road is a registered care home providing accommodation, support and care for five men and women with a learning disability. At the time of this inspection there were four women and one man living in the home. Notting Hill Housing Trust owns the property and the care is provided by Yarrow Housing, a not-for-profit organisation. The home is well located, close to facilities in the local community and the shops and transport links of Shepherds Bush and Hammersmith. The home provides accommodation over three floors and is not accessible to people with mobility difficulties. Each person living in the home has a good sized single room with wash hand basin. Shared facilities include a bathroom, separate shower room, lavatories, sitting room, kitchen/dining room and garden. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The unannounced visit took place from 10.10am until 2.20pm on Tuesday 27th May 2008. There was one permanent member of staff on duty who was introducing a new bank worker to the home. Another bank worker, who had worked at Brackenbury Road on previous occasions, was also on duty. The Inspector spoke with the Manager, who was not on duty that day, later in the week to clarify a number of issues. The Manager also provided additional information by email. Two staff completed feedback questionnaires. Four of the residents were at home at the beginning of the visit, watching TV. One person has just left to attend activities at The Gate nearby. Three of the residents had completed questionnaires, with staff support, all of which were positive about life at the home. The Inspector looked around the building, with two residents showing her their rooms. What the service does well: What has improved since the last inspection? Since returning to the house in March after a fire in November 2007 led to its temporary closure, staff have taken steps to create a more attractive and homelike environment. Storage of files in the office has been improved. Residents’ meetings take place regularly and the notes in an accessible format are displayed on the notice board. The complaints procedure has been discussed at a residents’ meeting and individually and is also displayed. Several in-house training sessions have been arranged for staff to ensure that practice is up to date, including training in medication, safeguarding adults and food safety. A supervision schedule has been arranged for the year, with staff normally receiving supervision monthly. COSSH assessments are available for all products used. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 6 The Manager and staff have worked hard to settle residents back into the house, after a period of supporting them in different settings and have minimised the distress and disruption experienced. 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. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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 Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well produced information is available about the service, in an accessible format. EVIDENCE: Yarrow Housing produces information for its residents, which is of a high standard and is in accessible formats. Two residents’ files were looked at. Both contained an up to date copy of the service user’s guide and a revised contract. No new residents have been admitted to the service since the last inspection, or for a number of years. A sound admission procedure is available, which includes an assessment by the service in addition to a needs assessment by the multi professional team. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff make good use of multi media to involve residents in the development of their PCPs. Regular meetings have been re-introduced and other steps taken to increase residents’ participation in the home. EVIDENCE: Two residents’ individual files were looked. One was in good order, with well written support guidelines, a copy of the resident’s PCP in an accessible format and a recent review. No review since March 2007 was available on the other resident’s file, though the Manager confirmed later that a care plan review had taken place in February this year. The Manager explained that the resident was actively involved in the presentation of his PCP, including the production of a DVD and that this had delayed the date for his PCP meeting this year. The absence of the key worker, who had been on sick leave for 4 weeks, may have contributed to this resident’s file not being up to date. Staff must ensure that the care plan or PCP is reviewed at least every six months. Monthly summaries Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 10 seen on file were not up to date but some gaps are explained by the disruption caused by the fire in November 2007, with residents located in different settings. It is recommended that monthly summaries refer to action agreed at PCP, review meetings and in health action plans to ensure that support to residents is focussed. Staff support residents, who vary considerably in their level of independence, to make decisions about their day to day lives. Increasingly, multi media has been used to enhance communication and to determine people’s views and wishes. Some restrictions are placed on residents in line with risk assessments, for example the external doors are kept locked and the kitchen is also locked when staff are not present following earlier incidents. The taps in one resident’s bedroom have been tied together to prevent her opening them, after she blocked the sink and flooded the floor. No records were available to show that this problem had been discussed with her Care Manager or other colleagues in the multi professional team to find a solution. Nor was the incident included in her otherwise comprehensive risk assessment. Since the last inspection, residents’ meetings have been rescheduled to a weekday to allow those people who regularly stay with families at weekends to attend. Notes of meetings are produced in an accessible format. Menus are agreed at these meetings. Two of the residents’ are more independent and are able to make some journeys on their own, for example one person attends the nearby Gate Day Service and Yarrow’s central office unescorted following travel training. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are well supported to take part in a range of social and leisure activities. EVIDENCE: 37 Brackenbury Road has a day services officer, who takes the lead in developing day activities. A weekly schedule is displayed on the notice board. Two residents attend local day services, including Yarrow’s own service at The Gate and good use is made of local leisure and community facilities. Staff support residents on individual and group holidays, including trips abroad. Photos from holidays and days out are displayed in the house. Good relationships have been established with families, which was reflected in two residents going back to their families while the house was being repaired and redecorated between November 2007 and March 2008. Families are invited to review meetings and to other events at the house. Residents’ cultural and ethnic needs are identified and supported, for example through church attendance and visits to restaurants and cultural events. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 12 The dining area has been refurbished following the kitchen fire and with the new dining table and chairs, provides a very pleasant setting. Attention is paid to healthy eating, as the weight of a number of residents is of concern. Notes of a recent staff meeting showed that staff had again been reminded, as at the previous inspection, to make healthy choices when shopping with residents for the house. Records show that residents’ weight is recorded and advice sought regarding diet when needed. Fresh fruit and vegetables are regularly included in the menu. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Support guidelines are good, reflecting the team’s understanding of how people wish to be supported. Health care plans in an accessible format have been developed. Steps have been taken to improve the administration of medication, though errors remain. EVIDENCE: Support guidelines were seen on the two individual files looked at. Very well written information was available for one resident, showing that her key worker has a detailed understanding of how she likes to be supported with personal care. The support guidelines for the other resident seen were less detailed, though he requires little support. A health action plan has been developed by Yarrow House, which is in an accessible format. One plan seen was fully completed, while the other required further work. Generally staff ensure that residents’ health care needs are identified and referrals made to health care colleagues. Records show a recent appointment with a consultant was not kept. Staff explained that the Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 14 appointment letter had been filed in error with no note made in the diary. The record of health care visits shows that a new appointment was made. Steps have been taken to improve the administration of medication, with staff attending an in-house session run by Boots earlier this month. Recent MAR sheets were seen, which included a gap for the previous evening and a gap in the sheet signed by the person witnessing the giving of medication. The file of one resident notes that he is self-medicating, though staff confirmed that this is not the case. Arrangements for his medication when he is away at weekends need to put in place, to prevent any errors. It may be helpful to seek the advice of the Pharmacist, as the member of staff on duty when he returned had difficulty in reconciling the number of tablets returned. Medication is stored in a locked cupboard in the office. As this room does become very warm at times, a thermometer should be available to check that the temperature does not go above 25C. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. A clear and accessible complaints procedure is available. An up to date safeguarding adults policy and procedure is available. EVIDENCE: The complaints procedure is available in an accessible format and is displayed on the notice board in the kitchen. Notes of key working sessions show that the procedure has been discussed individually with residents. No complaints have been received since the last inspection. Staff awareness of safeguarding procedures has been raised by recent training for the staff team. No safeguarding referrals have been made since the last inspection. CSCI were notified of possible concerns regarding a resident’s finances, which the Manager confirms have been resolved. The notes of the meeting held with the Care Manager about the matter were not yet available. A note was seen on the resident’s finance folder but this was not signed or dated. Staff must ensure that action taken is fully recorded. (See standard 41). Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The house is looking bright, homelike and comfortable since it reopened in March 2008. Staff have worked hard to provide a more attractive environment. EVIDENCE: The house, which is in a good location, close to local services, is indistinguishable from others in the road. Considerable re-decoration has taken place and carpets and floor coverings have been replaced or refitted. An attractive modern kitchen has been installed and residents and staff now have the use of a dishwasher. Some new furniture has been purchased and steps have been taken to improve the appearance of communal areas with pictures, photos and other accessories. Two residents showed the Inspector their rooms, which have been personalised to reflect their interests. Bedrooms vary in size but all have sufficient furniture, equipment and storage space. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 17 The building provides a choice of communal areas, with a large kitchen/dining room and an adjacent sitting room. There are sufficient bathrooms and lavatories throughout the house. The back garden is well kept and a large table and chairs have been provided for meals outdoors. The building was clean and tidy at this unannounced visit. Some essential repairs are still taking a considerable time to be resolved (see standard 42). Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have access to a comprehensive training programme and receive good support from the Acting Manager. Staff vacancies and long-term acting arrangements need to be resolved to ensure a stable and consistent staff team. EVIDENCE: At the time of the inspection the staff team was operating with a number of staff absences. There were two vacant posts, one member of staff was on maternity leave and one had been off sick for 4 weeks. Acting arrangements are in place for the Manager’s and Deputy Manager’s posts (see standard 37). Vacancies have been covered by staff from Yarrow’s bank and by a small number of agency staff. Rotas indicate that sufficient staff are on duty but notes of staff meetings comment on problems with the availability of bank and agency staff. Staff are recruited by Yarrow Housing’s HR team, who undertake all recruitment checks. Staff files are kept at Yarrow’s head office and were not checked at this inspection. Staff files have been in good order when seen at previous Yarrow Housing inspections. A number of Yarrow Housing tenants, Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 19 including one person from 37 Brackenbury Road, have received training in selection interviewing and take part in staff recruitment. Yarrow Housing provides a training programme for staff including induction and NVQs. One support worker has achieved NVQ3 and two staff have started the award. One staff member has started NVQ2. The remaining member of the support staff is undertaking a Diploma in Social Work course. A range of training has been provided for staff this year including medication, food safety and safeguarding adults. In discussion and in their feedback staff confirm that they receive good support from the Acting Manager, through supervision, staff meetings and day to day. Notes of staff meetings are available and a supervision schedule for 2008 seen on the notice board indicates that supervision is now taking place regularly. Supervision records were not checked at this inspection. Information in the office shows that Yarrow Housing are currently using an external organisation to consult with staff regarding a range of issues, including diversity. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42, and 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Yarrow Housing has established a range of initiatives to encourage participation by its tenants in the development of the organisation. A permanent senior staff team must be established at the service. Some aspects of health and safety need further attention. EVIDENCE: Interim management arrangements have been in place at the service since the Manager left to manage another project in September 2007. The Deputy Manager has been acting up, with a support worker, who has just resigned, filling her post. The Acting Manager has completed NVQ4 and is awaiting confirmation of the award. She has provided leadership to the team during an unsettled period while the house was temporarily closed. The Acting Manager is applying for registration. Permanent senior staff need to be appointed and Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 21 recruitment made to remaining staff vacancies to reduce the use of bank and agency staff and to provide a stable staff team. Yarrow Housing have developed a range of systems to involve tenants in the development of the service including regular ‘Have your say’ meetings, participation on the Yarrow board and annual quality assurance surveys. Information about meetings and developments is produced in accessible formats. Although improvements in record keeping have been made, a regular file audit would ensure that residents’ files are up to date and include care plans, monthly summaries and other documents. The amount of detail provided in residents’ logs has increased since the last inspection visit in March this year. Ways of involving residents in completing their logs should be considered and other information, for example the activities timetable and staff rota, made available in an accessible format. A range of steps are taken to promote the health and safety of residents and staff, though some issues need further attention, including essential repairs being undertaken more promptly. Training records show that staff receive training in health and safety, including refresher training. Fire drills and checks of the alarm take place regularly. Records show that the emergency lighting was not connected when the home reopened in March and took several weeks to be repaired. A recent visit by the Food Safety Officer resulted in a ‘good’ rating. The use of a temperature probe was recommended, which has been purchased and is in use. Staff have been booked on Food Safety training later in the summer. The temperatures of the fridge and freezer are taken daily. The fridge was clean and tidy, with the opening date of packets and jars noted. The freezer contained packets of frozen food left opened, including 2 bags of peas, oven chips and two Tesco Value sausages in an opened wrapper. Staff must ensure frozen food is properly stored. Accidents and incidents are carefully recorded. A resident’s risk assessment has been updated following an incident where she recently choked on some dry food. Hot water temperatures are regularly checked. These records show that the hot water at some outlets is quite tepid. The member of staff on duty said that there is a problem with one of the boilers and residents’ baths and showers have to be spaced out to ensure the water is hot enough. The Manager confirmed that plans to provide an additional or larger boiler are in hand. One resident pointed out that the radiator in his bedroom is not working. This was noted in the monthly building check. He was using a fan heater on top of a chest of drawers. The member of staff on duty said that she would check that it was being used in a safe position. Steps to control the risk of Legionella need to be in place. Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 22 No record of the provider’s monthly visits for April or May 2008 were on file, though at the inspection in March 2008 regular visits were taking place, with reports available. Brackenbury Road, 37 DS0000019145.V364359.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 x 3 x 2 2 3 Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA7 Regulation 15 13 Requirement Care plan’s/PCPs should be reviewed at least every 6 months. Restrictions should only be applied to a resident’s use of facilities, after discussion with the Care Manager, family or advocate and following a risk assessment. Staff must sign for medication straight after giving it to a resident. A thermometer should be purchased for the medicine cupboard. A clear procedure should be in place for residents who take medication home with them or to other settings. Recruitment to vacant posts needs to take place to ensure a stable staff team. A permanent Manager must be appointed to the service. Residents’ files must be kept in good order, with all required information available. Ways of involving residents’ in their recording should be developed. A Regular audits would ensure that files are up to date. Further attention needs to be DS0000019145.V364359.R01.S.doc Timescale for action 30/06/08 30/06/08 3 YA20 13 30/06/08 4 5 6 YA33 YA37 YA41 18 8 17 31/07/08 31/07/08 30/06/08 7 YA42 13 30/06/08 Page 25 Brackenbury Road, 37 Version 5.2 paid to the following health and safety issues. Chemical products such as dishwasher tablets must be kept locked away. Essential repairs must be undertaken promptly to prevent accidents and incidents. Steps to control the risk of Legionella must be in place. 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 3 Refer to Standard YA6 YA42 Good Practice Recommendations It is recommended that monthly summaries refer to progress made regarding action and goals agreed in the resident’s care plan, PCP and health action plan. Staff should be reminded to re-seal opened packets of frozen food and to freeze any fresh food in a sealed, dated bag. Staff should ensure that fan heaters issued to residents are placed in a safe position. YA42 Brackenbury Road, 37 DS0000019145.V364359.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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