Inspection on 01/08/06 for Brighton Road (851)

This inspection was carried out on 1st August 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

Brighton Road (851) 19/06/08

Brighton Road (851) 07/01/08

Brighton Road (851) 12/07/05

Brighton Road (851) 07/12/04

Brighton Road (851) 20/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Brighton Road (851) 851 Brighton Road Purley Surrey CR8 2BL Lead Inspector Michael Williams Key Unannounced Inspection 1st August 2006 11:15a Brighton Road (851) DS0000028529.V303480.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 Brighton Road (851) DS0000028529.V303480.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. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brighton Road (851) Address 851 Brighton Road Purley Surrey CR8 2BL 020 8763 0062 NONE 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) Ms Alice Manteaw-Dankyi Iris Naa A Asiedu-Addo Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: 851 Brighton Road is registered with the Commission for Social Care Inspection [CSCI] as a care home for adults 18 to 65 years of age. The registration category is for up to 8 people with past or present mental health problems. The home is situated on the Brighton Road (Purley) and is therefore on bus routes and within walking distance of shops and other local community resources. The premises comprise six single and one double bedroom. The home has a lounge, dining room and several conservatories plus the usual facilities comprising kitchen, laundry, toilets, bathroom and a small office. There is off-street parking to the front of the home and a small, landscaped garden to the rear. Fees are from £450 to £850 per week with any additional charges by negotiation with the purchasing agency. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was conducted in the afternoon of 1st August 2006 and this report is based upon information provided during that visit and other information held by the Commission including the results of any questionnaires returned from interested parties. Several residents were at home and assisted in the inspection and the manager was on site to provide up to date information about the service. No new staff have been employed since the previous inspection in 2005 but a new service user has joined the home and commended the staff and manager for their support and for the comfortable setting of the home itself. What the service does well: What has improved since the last inspection? What they could do better: There were omissions in the recording of medication; fire doors (that is, bedroom doors) were being wedged open; the record of money held for residents needs improvement to make it auditable and finally, the complaint leaflet has yet to be included in each resident’s ‘welcome pack’. Several suggestions are made including the inclusion in care plans of any Mental Health Act provisions that apply and to support residents in getting an advocate if appropriate. An up to date guide to the Mental Health Act is also needed. Minor damage to décor, furniture and fittings was noted and needs attention. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 6 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. Brighton Road (851) DS0000028529.V303480.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 Brighton Road (851) DS0000028529.V303480.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 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 using available evidence including a visit to this service. Assessments are in place for each service user and form the basis of the initial care plan and risk assessments. So this ensures the care needs, including mental health care needs, of service users is made clear from the outset and that those service know their needs have been identified and will be met. EVIDENCE: Each service has a case file, samples of which were examined during the inspection. The service users confirmed that they have contributed to the compilation of these documents and usually sign their care plans. In previous inspections the home’s manager was not clear about the legal status of some service – particularly when they had been subject to the provisions of the Mental Health Act. The staff have since had mental health law training and are much clearer about these technical issues. This is especially important because it does affect the decision to admit and will certainly inform the staff as the services rights and any restrictions that may apply at the time of admission. Areas of strength include the clearer way in which a resident’s legal status was checked and re-checked before admission went ahead and the involvement of residents in the pre-admission process; and as there are no matters requiring improvement this section, about choice of home, is assessed as good. Brighton Road (851) DS0000028529.V303480.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users confirmed that they do know their needs and personal goals are set out in individual plans and are reviewed periodically. During the process of assessment and review, and in the drawing up of care plans, service users are involved in making decisions about their own lives and lifestyle. Responsible risk taking is an integral part of the care and care planning in this home. So this enables service users to develop independence and confidence. EVIDENCE: Several service users and one visiting friend were interviewed during this visit and relatives have been involved in previous inspections; they confirm that they are involved in the assessment and subsequent reviews of care planning and by way of example one service user was to be included in a care review the day after the inspection. Risk taking was discussed in some detail with service users and their representatives. It may be concluded that the home strives to achieve a sensible balance – encouraging some service users to increase their scope of activities and risk taking whilst supporting others to moderate activities that are inappropriate and pose unacceptable risks to their Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 10 own well being or other people’s. Whilst checking a sample of care plans it was noted that in one instance Mental Health Act restrictions apply to a resident and these details were not included in the care plan making it difficult to identify what exactly the conditions of residence were, any timescale that apply and any contingency plans needed. The details of the supervising psychiatrist (the ‘RMO’) and rest of the mental health team details were available but a requirement is made to include the conditions of residence in the care plan so they are clear to all staff. The resident herself was already quite clear about these matters and will be able to help compile this additional care plan. A recommendation is made to support service users in attaining an independent advocate if they so wish. Areas of strength are the full involvement of service users in the care planning and review processes. This means service users are therefore involved in making decisions about their lives and aspirations. Matters suggested for improvement are firstly, the need to include Mental Health Act restrictions in care plans and secondly, make arrangements for service users to gain access to advocacy in they wish. So this section, about individual needs and choices, is assessed as good. Brighton Road (851) DS0000028529.V303480.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress continues to be made in enabling service users so they can take part in appropriate activities, educational, therapeutic and social and in doing so are making increasing use of community resources. Staff support and encourage service users to have appropriate relationships. Staff were clear about their duty to respect the rights of service users and so assist them in taking responsibility where that is appropriate for their personal development. EVIDENCE: On the day of inspection most service were out and about for at least part of the day and returned to the home to share the day’s events with the inspector. Activities include college courses, day centre attendance, care reviews, shopping, visiting family and friends and social activities such as swimming and keep fit classes. Activities such voluntary shop-work testify to the service users participation and contribution to the local community. In view of the enduring mental health issues of service users in this home relationships tend to be confined to the Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 12 long-standing ones; that is, enduring friendships rather than new ones. In discussion with staff it appears that the ability to meet people and form new relationships is something staff help service users to work towards. The rights of service users appears to be respected; for example each service user has a right to privacy, to make choices and meet whomsoever they wish – baring any restrictions applied in the best interests of the service user. During this site visit the inspector observed how in practice the balance between maintaining social relationships and protecting service users was put into action. With the support of staff a resident was maintaining contact with an old and close friend who himself was supported in doing maintaining this social link. Residents are supported in cultural, gender and religious matters when they express a wish to do so; thus one resident attends a group provided for people from minority ethnic groups and another women-only group. In respect of the rights of service users, a recommendation is made under the previous section to involve advocates in supporting service users where this is needed and possible. Meals are wholesome and plentiful and the residents themselves are fully involved in the preparation of meals. Areas of strength are the social and educational work done in the home and as no matters requiring improvement were identified this section, about lifestyle, is assessed as good. Brighton Road (851) DS0000028529.V303480.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 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 using available evidence including a visit to this service. Support is provided in a manner that suites the service users so their various needs are being met. Staff usually store and administer medication but can assist service users to be more independent when appropriate so as to increase their person skills in this area. EVIDENCE: Service users in this care home are quite articulate and therefore able to discuss how they prefer support to be provided; some prefer a lot of support throughout the day others prefer more time alone or with friend and need less support hour by hour. The home is able to facilitate this variety of choices. In respect of equality and diversity issues, all residents in this eight-bedded home are female and this is reflected in the staff team. Whilst the residents are predominantly White/English the staff team is predominantly AfroCaribbean reflecting the proprietor’s background rather than residents’. In respect of personal and health care the progress and stability of service users indicates the home is managing service users’ social and mental health needs and aspirations very effectively and is commended for doing. In respect of medicines and their safe handling one area of serious concern was identified – the administration charts referred to as ‘MAR sheets’ were not Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 14 in all cases competed for 31st July and none for the morning of 1st August because the old July MAR sheets had not been replaced and, in the absence of the manager, staff - who have had training in the safe administration of medicines - did not use their initiative to make any form of written record of medicines they are said to have administered to residents after 30th July. Other aspect of medication were acceptable including storage, stock records, review of medicines and so forth. Areas of strength are the support provided by staff and the progress residents are making whilst a matter requiring urgent improvement is the need to ensure staff follow correct procedures when administering medication and use their initiative if problems such as lack of record sheets arise in future and as this was a critical area of omission that could affect the wellbeing of residents this section, about personal and health care, is assessed as only adequate on this occasion. Brighton Road (851) DS0000028529.V303480.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 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 a clear and simple procedure for dealing with complaints so service users’ are confident their concerns will be dealt with promptly and effectively but not all service have copy of the procedures as required. To ensure vulnerable service users are safeguarded from abuse the home has written policies and procedures about the protection of service users and their property; this includes procedures for passing on concerns to the relevant authorities including the local authority care management team and the Commission. EVIDENCE: Both elements of this section were subject to requirements in 2005. The complete absence of complaints in the complaint record book suggested that the home, the manager and proprietor need to make much clearer their willingness to listen to and act upon matters that concern service users or their representatives. The record of complaints remains empty and no new complaints have been recorded for several years. However the home has taken up the suggestion of comments and concerns book which is now readily accessible to all residents and their visitors in the lounge. It is also noted that staff hold resident meetings from time to time, and of course staff meet with residents regularly both informally throughout the day and more formally for individual support sessions. This contact enables residents to make known their concerns without using the formalised compliant procedures. Nevertheless they must be given a written copy of the procedures as required by regulation and the manager is planning to do so by including it in a ‘welcome pack’. The Commission will continue to monitor the complaints Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 16 procedures to ensure the home is demonstrating in a tangible way that it will listen to service users’ views without reprisal or recrimination. At the time of the previous inspection in July 2005 a new temporary manager was in charge and she was not familiar with the local procedures for referring allegations of abuse to the relevant authority under the Vulnerable Adults Procedures. The current registered manager is familiar with these procedures and has confirmed her understanding that these procedures must be referred to, and followed, if allegations of abuse in any form arise. No such allegations arose during the course of this inspection. Areas of strength are the positive way in which residents are supported to make known their concerns and the procedures that are in place to safeguard residents from abuse; whilst a matter still requiring improvement is for each resident to have a written copy of the complaint procedures. Despite this shortcoming this section, about complaints and protection, remains assessed as good. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained and comfortable environment. This care home is an adapted family home and therefore very homely. It is well maintained. It was clean and tidy on the day of inspection but on a very hot day some areas such as the conservatories can be a little too hot. So service users are assured they will live in a safe and comfortable setting. EVIDENCE: Communal areas are pleasantly decorated and individual rooms are spacious and comfortably furnished. No bedrooms (except the one in the annexe) have ensuite facilities but each bedroom has a wash hand basin and each has a range of suitable bedroom furniture and fittings. Some areas of damage were noted such as broken furniture in a bedroom; broken metal strip in doorway to dining area; broken units in the kitchen (the fridge and a cabinet); and lack of paper or linen hand-towels in both ground floor toilets. The Commission is confident these are matters that will be addressed by the manager or owner without further prompting but a requirement is made to deal with them. Staff should be reminded to take some initiative and report matters needing Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 18 attention and then follow up by making sure such items are fixed without undue delay. The garden is very attractive and makes a pleasant location for service users to relax and meet visitors. As usual, the care staff were busy cleaning the house while the inspector was present and so the home was clean and tidy and free of unpleasant odour. However the lack of suitable hand-washing facilities in the ground floor toilet is a lapse in hygiene standards particularly as the toilet near the kitchen will be used by staff and residents preparing food. A requirement is made to address this point. Areas of strength are the very comfortable surroundings in which residents live and the good standards of hygiene maintained in the home; whilst matters requiring improvement are need to ensure hand-washing facilities are available in all toilets at all times and also the need to repair or replace broken equipment. This section, about the environment, is assessed as good. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. The required procedures are now in place to ensure recruitment of staff protects service users. The home has a staff induction, training, support and supervision regime in place so service users can be assured that staff are competent in their jobs. The recruitment, training and support of staff will ensure service users are ‘safe in their hands’. EVIDENCE: Recruitment practices were found to be not safe when the home was inspected in 2005 in so far as two staff were being employed and neither the person in charge nor the proprietor could confirm that all necessary checks have been completed prior to their appointment. The precipitate employment of staff before checks are completed compromised the safety and well being of service users but this matter has now been addressed and the manager confirmed that all staff have had the required police checks and a sample of staff records were checked to confirm this important point. As identified in 2005, the staff team is a well established and loyal team of carers; they do reflect the gender of the resident group, that is, all resident are female and so are the staff but the staff team does not reflect the racial and cultural mix of residents. As noted in the summary of this report the staff team reflects the background of the Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 20 Africo/Caribbean proprietor not the predominantly White/English resident group. Areas of strength are improved staff recruitment practices and the support and supervision provided for staff and as no matters requiring improvement arise this section, about staffing, is assessed as good. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 39 41 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well run home whose proprietor has many years experience managing such homes. There is little doubt that the home’s aims and objectives benefit the service users in all aspects of the service, the environment, catering staffing and so forth. The safety and well being of services is not best protected if safe recruitment practices and procedures are not followed methodically and precisely in all cases (standard 34). The home was safe and without hazard with the exception of the kitchen (fire) door that was wedged open. EVIDENCE: A series of inspection in which the home has achieved good standards confirms this to be a well run home; administration and record keeping has improved considerably in recent years and it is a clean, safe and generally hazard free environment. Requirements were made about recruitment including the appointment of suitably qualified, experienced and competent manager and Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 22 this is now completed. Whilst the magnetic door holder on the kitchen door, which was faulty, has been fixed other doors need these devices if residents wish to prop their bedroom doors open; the requirement is that all fire doors must be kept shut and not wedged open unless with magnetic device that will respond to the fire warning system. Damage to the fabric of the building must be dealt with such as the carpet strip in a doorway, which could be a trip hazard and bedroom furniture and, as a matter of health and safety, all toilets must have suitable hand-washing facilities including hand-drying towels. A sample of records were checked including the visitors’ book; food records; residents files; staff files; complaints; accidents; fire records and so forth, all were found in good order. The medication records was deficient and this was addressed in an earlier section. Areas of strength are the generally good management of the home and matters requiring improvement are medication records and the potential fire safety hazards as well as the maintenance matters but as the Commission is confident these matters will be addressed in full without further prompt this section, the conduct and management of the home, is assessed as good. Brighton Road (851) DS0000028529.V303480.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 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X 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 3 X 3 X 3 2 X Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2)(b) Requirement Timescale for action 30/09/06 2 YA20 3 YA22 4 YA30 5 YA42 Care Plans: the care plans must include any provisions under the Mental Health Act 1983 that apply to a service user including any restrictions. 13(2) Medicines: the home must record the administration of all medication issued by staff to service users. 22(5) Complaints: The registered person shall supply each service user with written copy of the complaints procedures. 16(2(j) Hygiene: the registered person must ensure that there are suitable hand-washing facilities in toilets including towels. 23(4)(c)(i) Fire safety: The registered person must ensure that fires can be contained by ensuring that all fire doors, including bedroom doors are shut unless held open by a magnetic door holder that responds to the fire warning system. 30/09/06 30/09/06 30/09/06 30/09/06 Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations Advocacy: it is recommended that the home advise service users about local advocacy including legal advocates. Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Brighton Road (851) DS0000028529.V303480.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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