Inspection on 03/11/05 for Broomhill Lodge

This inspection was carried out on 3rd November 2005.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broomhill Lodge 20/12/06

Broomhill Lodge 23/02/06

Broomhill Lodge 10/03/05

Broomhill Lodge 27/01/05

Broomhill Lodge 04/02/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Broomhill Lodge 1 Broomhill Road Goodmayes Ilford Essex IG3 9SH Lead Inspector Stanley Phipps Unannounced Inspection 3rd November 2005 06:01 DS0000025889.V264151.R01.S.doc Version 5.0 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 DS0000025889.V264151.R01.S.doc Version 5.0 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. DS0000025889.V264151.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broomhill Lodge Address 1 Broomhill Road Goodmayes Ilford Essex IG3 9SH 0208 590 3427 0208 590 4308 Jon@roselock.com 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) Mrs Pamela Philp Mr. Alan Philp Mr John McGillick Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000025889.V264151.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Moderate to high level of disability. Date of last inspection 10th March 2005 Brief Description of the Service: Broomhill Lodge is a residential care home for eight younger adults, both male and female with a learning disability. The home is run by Alpam Homes, an organisation with a number of other similar schemes in which the service users may exhibit various forms of challenging behaviour. The building is situated in a residential street close to public transport and other local amenities. All bedrooms are single with all other facilities – shared. There is a large garden to the rear of the property and the premises are furnished in a way that values homely living. There are parking spaces to the front of the building as well parking on the street, which is not currently a controlled parking zone. The organisation also runs a day centre (Highview House) that is regularly attended by service users from the homes in the group. The home also offers assistance to service users to fully utilise other community facilities. DS0000025889.V264151.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place in approximately two hours. It was timed to coincide with the evening activities, meeting the service users and monitoring the progress of the service since the last inspection visit. The inspection found that the quality of the service continues to improve and despite the fact that there is room for further improvements – all service users spoken to were happy living at Broomhill Lodge. An assessment was made of a random sample of service user plans, the recruitment and training records held on staff, the staffing rota and the policies and procedures file. A detailed discussion was held with the registered manager and one service user as well as an informal discussion with the care staff on duty. A group discussion was also held with service users prior to their attendance to an evening club. A brief tour of the building was also undertaken and this included viewing the bedroom of one service user. At the time of compiling this report a business and financial plan was made available for inspection. This has been a requirement from previous inspections and the Commission was now able to fully assess the financial viability of the service. What the service does well: Broomhill Lodge provides a homely environment for its service users in which their independence, choice and interests are promoted to each of the individual’s maximum capacity. More importantly, the special needs of the group does not preclude them from living life to the full in that their spiritual, social, personal and healthcare needs are provided for safely in the community. Staff are committed and work close with individuals to enable them to maximise their individual potential. All service users live a structured life that is best suited to their individual needs. Despite this life in the home has become a little more flexible e.g. a service user could make a positive choice DS0000025889.V264151.R01.S.doc Version 5.0 Page 6 not to go to the evening club on a particular day, because he wishes to have an early night and this is respected. As part of enabling service users to maximise their independence and choice, staff work with the strengths of individuals and this creates a positive outcome for all service users individually and collectively. The service is also good at involving friends and families with service users and life in the home and this ensures that service users maintain a positive outlook on their life. Service users are also supported to show off their individual creations in the dining area of the home on a display cabinet and this enhances not only their pride but also their confidence and self esteem. In this respect it true to say that when you enter Broomhill Lodge there is a buzz of enthusiasm and liveliness. What has improved since the last inspection? In discussion with the registered manager it was determined that in relation to service user involvement and attendance to activities, that their wishes were respected. In speaking with service users on the day of the visit they confirmed that this was also the case. This therefore represents an improvement since the last visit. There were improvements to ensuring that recruitment details held on staff were in line with both Schedule 2 and 4 of the Care Homes Regulations 2001. This would go a long way in providing greater protection for service users. The registered persons had embarked upon a training and development plan for its staff and this was based on an individual training needs assessment. This ensures that staff are more equipped with greater knowledge and skills to competently carry out their duties in providing good quality care at Broomhill Lodge. There was evidence provided by the manager to confirm that staffing levels are reviewed in line with the needs of the service user group as a matter of course. More specifically additional staff is on duty now at that when the service users need them most e.g. prior to preparing them for attendance at the evening club. This practice is more beneficial to service users. Although there was an improvement in the frequency of formal supervision for the care staff, more needs to be done to ensure compliance with the national minimum standards for younger adults in this respect. This would be highlighted late in this report. DS0000025889.V264151.R01.S.doc Version 5.0 Page 7 At the time of the visit the manager was in the process of complying with the requirement of signing and dating all policies in operation at the home. In concluding there have been several improvements since the last visit, but more needs to be done to ensure fuller compliance with the national minimum standards for this service user group. 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. DS0000025889.V264151.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025889.V264151.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (2,3,4,5) A detailed assessment of service user needs is undertaken prior to admission. Individuals are also given the opportunity to visit the home to determine its suitability in meeting their needs. Acquiring more detailed medical histories on service users however, would enable the home to make a more informed judgement as to whether service users needs could be met at Broomhill. EVIDENCE: There was evidence that detailed assessments were undertaken by the home on all service users prior to them being admitted to Broomhill Lodge. It is on this basis that decisions are made about the suitability of the home in meeting their needs. Service users are also encouraged to visit the home prior to living at Broomhill and this is all a part of the admissions process. However there was the case in which the most recent service user arrived without his medical notes. This means that a full picture of the individual’s needs was unavailable and as such it would be risking the service user’s assurance that his needs could be met by the home. It was acknowledged that the registered manager was pursuing the matter, although the decision to admit had been taken. A detailed examination of the information obtained on the service user indicated that he had professional input from the psychologist, but the last report was well over one year old. It is also important that the home has access to recent and updated information on service users so that informed decisions about their suitability could be made. DS0000025889.V264151.R01.S.doc Version 5.0 Page 10 From assessing service users files it was not evident that amendments to the statement of terms and conditions of service users were made to include the facilities offered in each room and those elements of the care plan that are provided outside the home. A requirement was made at the last inspection regarding this issue and as such would be repeated in this report. As stated previously in this report a continued failure to meet requirements would adversely impact on the welfare of service users and the Commission would be minded to pursue enforcement action to achieve compliance. DS0000025889.V264151.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,9) The needs of service users are generally met at Broomhill Lodge and are reflected in their individual service user plans. They are appropriately reviewed to facilitate any changes and are linked to risk assessments, which are integral to how service users are supported in the home and wider community. Service users’ views are obtained and acted upon to help in shaping the service at Broomhill Lodge and they are supported to make decisions about life in the home. EVIDENCE: From a random sample of service user files there was evidence that individuals’ needs were recorded and a plan of action was in place for each person. The plan was user-friendly, reflected their personal goals and designed to promote the service user’s involvement as far as possible. They were also updated, including that of the most recent service user who had an initial six-weekly review, just prior to the inspection. There was an improvement noted in that service users indicated that they are able to make decisions about their life e.g. going to college or an evening club. It was the view of the staff at the last inspection that the routine of attending the day centre at a particular time infringed upon the service user’s choice for getting up. However it was clear that service users had signed up to attending DS0000025889.V264151.R01.S.doc Version 5.0 Page 12 the day centre as part of their commitment to engaging in structured daily activities. The registered manager confirmed that if and should service users choose not to attend, then this is explored, but ultimately the service users wishes would be granted. This was reassuring and would be greeted positively by all service users. On the evening of the visit one service user did not wish to attend the evening club and preferred to watch his live football on television. He also made a positive decision to continue attending a day centre run by Eastway Day Services, as opposed to the day centre run by the registered providers. Evidence taken from service users and minutes from their meetings confirmed that they are consulted on all aspects of life in the home. This gives them a sense of ownership and adds to their confidence levels, which were on display on the evening of the visit. Their contributions and involvement in life in the home and the community is enabled through a detailed risk assessment, which is aimed at minimising risk while promoting independence and choice. These assessments were updated and in place for all service users and is linked to their service user plans. A good example of this could be drawn from the fact that the most recent service user is enabled through the risk assessment process to independently make his way to his daily activities with the guidance and support of the management and staff at the home. DS0000025889.V264151.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (11,12,13,15) At Broomhill Lodge all service users are given great opportunities for personal development, pursuing their individual interests, participating in the local community and maintaining healthy social networks. This is a strong area of the home’s operations and is appreciated by the service users living there. Three of the four standards assessed exceeded the minimum requirements. EVIDENCE: All service users were involved in a range of activities that is aimed their personal and social development. They included attendance to: day centres, evening clubs and college. They were again quite keen to share what they did out in the community and at various points, gave insight into what they were doing. One service user informed that he had successfully completed key aspects of the courses he pursued at college and had moved on to yet another level. For others they talked about going to the disco where they met with their peers and generally had a good time. They also showed off pieces of their artwork from the day centre, which were on display in the dining area. On the day of the visit they were preparing to go to their evening club and were well presented and looking forward to it. It was clear that the service users at Broomhill enjoyed a pretty active lifestyle – one that they enjoy and are proud of and this is a positive reflection of the efforts of the staff and management of the home. DS0000025889.V264151.R01.S.doc Version 5.0 Page 14 The home is proactive in ensuring that family and other social networks are maintained in the interests of service users and though arrangements vary from service user to service user, they are each given the opportunity to engage with their networks. A good example of this was observed on the day of the visit during which the registered manager was making arrangements with the mother of the most recent service user for them to meet. This was treated with sensitivity, as contact had been a while. However the manager was able to make adequate and amicable arrangements in enabling the service user and his relative to meet. This is a strong area of the home’s operations. DS0000025889.V264151.R01.S.doc Version 5.0 Page 15 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) A sound system is in place for monitoring and maintaining the healthcare of service users at Broomhill Lodge and staff work closely and in a supportive manner to enable this. Staff also work flexibly whilst supporting service users to maintain their independence. EVIDENCE: From examining the healthcare records of service users, it was clear that staff worked closely with them to ensure, that their health needs are met. All medical appointments were duly recorded and all service users were registered with a GP. Arrangements were also in place for each service user to be seen by the opticians and/or the chiropodist when required. There were no instances of service users requiring hospitalisation since the last inspection and service users were generally is a good state of health. On the day of the visit staff worked with individuals in a sensitive manner in preparation for the evening club e.g. for those who were capable of independently preparing themselves, they were given gentle prompts to so do. For individuals requiring a bit more support, this was offered and carried out in a dignified manner. From observing the way in which staff carried out their duties, it was clear that they knew the strengths of each service user and worked positively in assisting them to meet their individual goals. The end result of this was that all service users looked in control and well presented. DS0000025889.V264151.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22) Service users and their relatives can be confident, that their concerns would be addressed in a satisfactory manner at Broomhill Lodge. This would provide a form of protection and promotion of their rights as individuals. However managing complaints could be enhanced further, by ensuring that updated information regarding the Commission is in the complaints procedure. EVIDENCE: From speaking with services users it was determined that, were they to become unhappy, then the management and staff would know about it. Service users could use several forums to do this i.e. with their key-worker, in service user meetings or with the manager. At the time of the visit there were no complaints recorded and this was taken from the time of the last visit. The complaints procedure was generally satisfactory and available to service users, staff and relatives. More importantly it was in a form that enabled the service user group to relate to it. However it needs reviewing to include the details of the Commission for Social Care Inspection. DS0000025889.V264151.R01.S.doc Version 5.0 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): (24,25,26,27,30) At Broomhill Lodge service users enjoy a clean, homely and safe place to live. They also benefit from having a spacious, well-maintained home and this includes toilets and bathrooms as well as the other communal areas of the home. EVIDENCE: All service users were happy with the layout and facilities offered at Broomhill Lodge. They take great pride in showing off their private spaces e.g. bedrooms, which are all individually personalised. They have the benefit of a large lounge that incorporates a television area as well as a snooker table, which is quite often used. Service users would often challenge you for a game following your arrival to the home and this is indicative of the confidence they exhibited when it comes to their home. A quick tour of the building indicated that sound systems were in place to maintain a high standard of hygiene in the home. Staff worked well with service users in making their contribution to this upkeep. There is also a cleaner and a handyman who has a positive impact on ensuring that the décor and presentation of the home remains at a high standard. DS0000025889.V264151.R01.S.doc Version 5.0 Page 18 There are adequate toilets and bathrooms in the home to promote the privacy and independence of the service user group and it was clear that the home remained fit for its purpose. The dining area is very attractively set out with tables and chairs that offer service users a choice. It is in this room that their artwork is laid out and it is a pretty impressive area of the home. It was unanimous that all service users were not only happy, but were satisfied with living at Broomhill Lodge. DS0000025889.V264151.R01.S.doc Version 5.0 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): (33,34,35,36) A dedicated staff team is in place at Broomhill Lodge. They are committed to enabling service users to attain their fullest potential. The staffing recruitment training and staffing arrangements at the home offers service users the assurance that their needs would be safely provided for. However this could be enhanced further by the provision of more regular, formal supervision for the care and support staff. EVIDENCE: The main core of the staff team is committed and motivated working with the service users at Broomhill Lodge. They pride themselves in achieving positive results under the direction of the registered manager. It was noted that staff are deployed strategically to ensure that the needs of service users are adequately met. One example of this is where additional support is provided from 5 p.m. to enable service users to have their supper and prepared to attend their evening engagements. On a daily basis designated staff take responsibilities for ensuring that the service is coordinated in the best interest of the service users. An improvement was noted in the area of recruitment records held on staff by the registered persons, as this was now in line with Schedule 2 of the Care Homes Regulations 2001. It means that service users now have better protection as a result of the documents held on file for al staff working in the home. DS0000025889.V264151.R01.S.doc Version 5.0 Page 20 From assessing the case files of service users and the training records of staff it was clear that staff are equipped with the knowledge and skills to provide a good standard of care to all service users, particularly in relation to their special needs (learning disability). Some of the training identified and provided included: Challenging Behaviour (De-escalation Tactics), Learning Disability Award Framework training, Health and Safety, Fire Awareness and Evacuation, Basic Food Hygiene and Nail Cutting. The training programme has been rolled out in a phased basis to ensure that consistency of the service is maintained. Although there was an improvement in the provision of formal supervision for staff, it did not go far enough in meeting the minimum requirements of the relevant standard (NMS 36). This was discussed with the registered manager and a repeated requirement made in this report to improve in this area. It was acknowledged that some formal supervision had been provided for staff and that there are other systems in place e.g. regular team meetings, daily informal contacts, to support staff. However given the demands of working with the service user group, staff and the service as a whole would benefit from regular supervision that is geared towards supporting all staff. The manager advised that staffing appraisals were planned for February 2006 and this is a positive pathway to improving and developing staff in providing a quality service. DS0000025889.V264151.R01.S.doc Version 5.0 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): (40,41,42,43) A sound framework of policies and procedures are in place and this is complimented by good record keeping at Broomhill Lodge. Adequate systems are also in place to promote the health and safety of service users and staff in the home. There is a clear and accountable management structure, which assures that the service is both stable and viable. EVIDENCE: Policies and procedures were in place and accessible to staff and service users if required. They were updated and the manager and in line with current legislation and national minimum standards. At the time of the visit the manager was in the process of signing them off as required by regulation. Staff were generally comfortable with the application of the key documents which are used as working tools. From assessing the records held by the home, it was found that they too were in line with regulation and an improvement was noted particular with regard to the information held on staff i.e. recruitment records. They included Criminal Records Bureau checks on staff, two references, copies of birth certificates/passports and medical declarations as an example. The records DS0000025889.V264151.R01.S.doc Version 5.0 Page 22 including that of service users were securely maintained in a locked facility in the staff office and preserved the confidentiality of the documents and the individuals related to it. From assessing records and walking around the building, including the rear garden, the environment was safely maintained. Fire records and records of fridge /freezer temperatures were adequately maintained. Fire safety signs were appropriately placed and the equipment used in the building was satisfactorily maintained, with records kept. Issues that would enhance the service users’ awareness of health and safety are raised at service user meetings and this is positive in the maintenance and promotion of health and safety in the home. There is a record and incidents/accidents in the home and they are generally kept to a minimum. There is a clear management structure at Broomhill Lodge and service users and staff showed an awareness of it. There is adequate insurance for the home that complies with the national minimum standards and there are clear arrangements in place for monitoring the service on a regular basis (monthlyRegulation 26 reports). The registered persons made available for inspection a business and financial plan and it was conclusive that the business is financially stable. There are satisfactory private arrangements in place for monitoring the financial aspects of the service. DS0000025889.V264151.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 2 3 2 Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 X 15 4 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score X X X 3 3 3 3 DS0000025889.V264151.R01.S.doc Version 5.0 Page 24 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 YA3 14(1)(b) Regulation Requirement The registered persons are required to ensure that all relevant medical and professional information is made available, prior to the admission of service users. The contract/statement of terms and conditions requires slight alteration to include the facilities offered in each room and those elements of the care plan that are outside the home. This is a repeated requirement that must be complied with without undue delay. The registered persons are required to review the complaints policy to include details of the Commission. The registered manager is required to ensure that all staff are given formal supervision in line with standard 36.4 of the National Minimum Standards for Younger Adults. This is repeated requirement that must be complied with, without undue delay. Timescale for action 28/02/06 2 YA5 12 28/02/06 3 YA22 22(7)(a) 28/02/06 4 YA36 18(2) 28/02/06 DS0000025889.V264151.R01.S.doc Version 5.0 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. Refer to Standard Good Practice Recommendations DS0000025889.V264151.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000025889.V264151.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!