Inspection on 07/12/05 for Budge Lane (21)

This inspection was carried out on 7th December 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Budge Lane (21) 19/07/07

Budge Lane (21) 05/01/07

Budge Lane (21) 07/07/05

Budge Lane (21) 26/11/04

Budge Lane (21) 05/07/04

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 Budge Lane (21) 21 Budge Lane Mitcham Surrey CR4 4AN Lead Inspector Ms Rin Saimbi Unannounced Inspection 7th December 2005 09:30 Budge Lane (21) DS0000007155.V270969.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 Budge Lane (21) DS0000007155.V270969.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. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Budge Lane (21) Address 21 Budge Lane Mitcham Surrey CR4 4AN 020 8640 5169 020 8640 5169 budgelane21@walsingham.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) Walsingham Mr Victor Stephen Green Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: 21 Budge Lane is a residential care home that was first registered in January 1997 to provide care for up to six adults with learning disabilities. The home specialises in providing a service to people who have a learning disability and who may also have a secondary physical disabilities. The overall support needs are medium to high. The accommodation compromises to six single bedrooms. There is a communal lounge towards the rear of the building overlooking the back garden, and a secondary lounge towards the front of the premises. Other facilities include a dining room, kitchen, laundry, garage, staff sleeping in room and staff office The home itself is located on a new estate, which has a mixture of housing association and private properties. The nearest shops are some 15 minutes walking distance away, it is not the most convenient place for some forms of public transport, however the home does have its own transport. The home is owned and run by Walsingham, which is a registered charity that has a Christian ethos. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/06. It was an unannounced inspection that started at 9.30 am. The inspection took approximately five hours. The inspection took the form of discussions with the majority of service users, four out of the six, with the manager, staff on duty and observations of staff interaction with service users. In addition, there was a tour of the building and looking through documentation, which related to service users and staff to make sure that they were relevant, accurate and up to date. The home needs to mindful of its category of registration and the age of its service users, so that it does not break any conditions of registration. What the service does well: The staff at the home and Walsingham consider the views of service users to be vital to the running of the home and the organisation. There are many examples of good practice, which can be highlighted as evidence of this. These range from day to day choices, such as what to wear and when to eat, through to one of the service users being on an interview panel for managers and senior staff within the organisation. The home should be commented for enabling service users to make as many decisions about their own lives as they are able, with support, information and guidance. The ethos within the home is that it is the ‘home of the service users’ and that staff are there to enable service users to live as independently as possible. With this aim in mind the building is specifically adapted so that service users can make their own drinks, meals, choose to spent time in their own bedrooms or to pursue their own leisure pursuits. One service user was asked ‘what they liked about the home’ they replied ‘everything’. Another was asked ‘do they look after you well’ they replied, ‘yes’. Waslingham are committed to ensuring that their workforce has a solid foundation during their induction period; and that staff then undertake regular training in order to improve their knowledge and skills. This was evident as Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 6 staff were all able to communicate effectively with service users even though they had very different communication patterns. What has improved since the last inspection? 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 Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Budge Lane (21) DS0000007155.V270969.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 Budge Lane (21) DS0000007155.V270969.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): 1,2 and 3 The home has gathered information from a variety of sources and then completed their own thorough assessment for all service users. For potential new service users this process would be completed in conjunction with the service users themselves and their family, friends and advocates. The aim would therefore be that service users would not just be fitted into a vacancy; but that the service users themselves would make an active choice about the accommodation that they wanted to live in. To aid in this process, a new service users guide has been written. EVIDENCE: The home has been open since 1997; all service users who arrived at that time came with an assessment. These were of variable quality. The home has subsequently devised a care assessment for each of its service users. This document contained general information, which was gathered from the original assessment plan, and from the homes own assessment process. Walsingham have their own ‘assessment of needs’ for all potential service users. This document was extensive and comprehensive with areas for likes, dislikes, significant friends and family, sexuality and level of disability. The home has recently developed a new service users guide, which comprises of photographs, drawings and some written text, which is in plain English. The Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 10 document is specific to the home in that it includes photographs of the local area, amenities and the home itself. It also includes a photograph and a brief pen picture of the service users that are currently living at 21, Budge Lane. A new contract has also been devised which focuses on the service users and what they can expect from the home, these new developments highlight the homes commitment to involving and informing service users at every level and should be commended. The home is able to meet the needs of the service users either by the skills and experience of the staff team, or by the use of outside professional agencies. A physiotherapist is currently involved with service users and visit on a regular basis; a psychologist and district nurse visit as and when is required. All service users within the home are able to communicate their needs either verbally or through gestures. The staff team all have the necessary skills and understanding of the varying forms of communication so that they can meet the needs of service users. From observations it was evident that this was the case. Budge Lane (21) DS0000007155.V270969.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 and 9 Service users are given opportunities to make choices regarding daily activities, what they eat and when, through to senior staff appointments and major life decisions for themselves. Service users are supported and given information when necessary, this ensures that they are able to achieve independent lifestyles and feel that they have control of their lives. EVIDENCE: All service users have completed a document entitled ‘my goals’. This is reviewed annually with service users and with appropriate family and friends. It is a clear document, which is written in plain English and is in pictorial format and is therefore accessible to the service users. The home does complete an internal review on an annual basis. However, the previous inspection identified that the formal reviews with Social Services were not being undertaken on a regular basis. In one example a service user had not had a review since 2000. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 12 There has been some improvement in this area in that a number of reviews have taken place and are now up to date. However, two of the service users have not had their reviews with Social Services for almost two years. The home needs to ensure that they can document that they have attempted to contact the placing authorities in order to arrange a review. This requirement is therefore deemed to have only been partially met. The home respects the service users right to make decisions in all aspects of their lives. As an example, two of the service users attend day centres, taking part in activities that they are particularly interested in. One of the service users volunteers at the local library once a week, a member of staff supports him in this. A joint conference was held earlier this year between Walsingham and Advocacy Partners entitled ‘Everyone’s Important’. As a follow on from this conference, two of the service users within the home attend monthly meetings, which are entitled ‘ Walsingham against Cotton Wool.’ One of the attendees said that they were currently trying to sort out which logo that they preferred for the group. One of the service users within the home had until very recently an involved independent advocate. The advocate’s family has now taken the role. The level of service user participation is commendable. The home does not hold residents meetings as the service users choose not to have them; Instead service users are encouraged to attend the staff meetings if they wish. Two of the homes service users have been on interview panels for staff for many years. They were given training in this area and undertook mock interviews. Subsequently, one of the service users has joined a regional interview panel which interviews managers and senior personal for posts. The questions asked were gathered from all the homes in the area. Risk assessments are in place for all service users, there are a range, which include general, environmental and those specific to the individual. From the documentation it was clear that these are seen as a working document and are updated on a regular basis. Service users are able to come and go as they wish, although this is something that they often do not do. One service user will take himself for a walk in the local area. There has only been one unexplained absence from the home since it opened, and on that occasion the service users was in the local pub; the home were notified quickly of this. Budge Lane (21) DS0000007155.V270969.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): 11,12,13,14,15,16 and 17 Service users within the home live ordinary and meaningful lives, and participate and contribute to the communities in which they live. Emphasis is put on service users making their own choices regarding interests and leisure activities so that they feel that they can live as independent a life as possible and that they can reach their full potential. EVIDENCE: Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 14 Service users are encouraged to be as independent as possible; they are supported to maintain friendships and family contact. Three of the service users do not have any family contact. The home is in the process of working with ‘Advocacy Partners’ to try and find independent people to work with these particular service users. Where there is contact with family, friends or advocates the home will try to maintain this. All the service users have a birthday party, if they chose; family are invited into the home at formal events such as Christmas and are welcome at other times; recently when a service user was in hospital, an elderly relative was provided with transport so that she could visit; a service user went to their advocates funeral. Three of the service users currently participate in spiritual activities and are encouraged to attend specific churches of their choice. Two of the service users choose to attend day centres. Staff know the daily routine and programme of each service user. There are a range of activities on offer, which is balanced between home and community. One particular service user is keen on jazz music. The home is able to access live jazz music in the community, which includes at pubs and music venues. The service user also attends a jazz holiday every year, most recently to Chichester. Service users are encouraged to participate in these activities by the provision of a house car. In addition all service users have their own bus pass. One service user has his own car, which is driven by staff; another service user has their own scooter. Service users are able to choose when they wish to have their meals and what they have. A meal was taken with service user although there were only two individuals around at the time. The meal was taken in a relaxed, unrushed way in the dining room. Service users were observed helping themselves to drinks, staff asked what they wanted to eat; service users were assisted in preparing their own meals if required. A previous requirement that service users must have their weight monitored on a regular basis has been removed as it is now being completed. Budge Lane (21) DS0000007155.V270969.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 and 20 In general the home is able to provide flexible and consistent support to service users and their changing needs. There is an awareness and understanding that service users have the right to expect the same healthcare as others in the community, although they may need to be supported in achieving this. EVIDENCE: Service users are supported to manage their own healthcare needs, some are able to take themselves to their own GP and have a private consultation, and others need support to do this. The home does maintain a record of all appointments that are kept. In general, there is also an overview of health appointments that are needed in the future, for example the annul health check; however, this was not in evident for all health appointments such as opticians and dentist. The previous inspection did identify this as an issue; the example given was of a service user who had not had an optician’s appointment since 2000; although this service user did not wear glasses she is an older person that would be reasonable to assume that she needed to be monitored. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 16 This requirement remains outstanding from the previous inspection, and must therefore be addressed for with. Service users within the home receive sensitive personal support, which maintains their privacy and dignity. Service users are able to choose their own clothes and toiletries; personal support in provided in private; discussions with staff, one of whom had just started two days previously showed that they were aware of the needs of the service users and the principals of providing personal care. Staff were observed at all times asking questions, giving options and being flexible in the care that they gave. No service users within the home are able to self-administered medication. The medication is stored in a locked metal cabinet, which is sited a locked cupboard. Medication arrives in the home in Dossette packs on a monthly basis. A previous requirement that only staff that have completed an accredited course regarding the administration of medication should administer, has been met, and therefore this requirement has been withdrawn. The Medication Administration Records (MAR) records were checked. There were found to be several omissions. A requirement has therefore been made in this regard. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 17 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 and 23 In general it appears that service users at the home feel listened to and confident that their views will be taken seriously. This acts as an added safeguard to ensure that service users safety is paramount and that they are protected as far as possible for risk as vulnerable adults. EVIDENCE: The home has a general complaints policy which was dated August 2004, it contains information about the process, how long it should take and what to do if you are not satisfied with the response. The home does have a complaints log although there has not been an entry since 2003. The home has robust polices and procedures in place to make sure that service users are kept safe. There is Walsingham’s own vulnerable adults policy and in addition they have a copy of Sutton’s own procedural guidelines. The home has a whistle blowing policy. Within the new service users guide developed by the home, there is a userfriendly format for making a complaint or a compliment; this format has been specifically developed for the service users who currently live within the home. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 The home is clean and comfortable, and provides service users with the specialist aids and adaptations required for daily living There is a respect for service users privacy, enabling them to come and go as they wish, to receive guests in private and to have a key to their own bedrooms. EVIDENCE: Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 19 The home’s accommodation is all on the ground floor and has been made wheelchair accessible by allowing sufficient width in all the doorways. The home is in keeping with its environment and is generally well decorated in an appropriate style and is reasonably well maintained. The furniture and fittings of the home are generally of good quality and domestic in style. All service users have their own bedrooms, which are personalised according to their interests and tastes. Service users have their own keys to their bedrooms which some of them use, and in addition a lockable space in their bedrooms. Four of the service users have recently been provided with new chest of drawers and wardrobes. A requirement was made at the last inspection for a replacement of the dining room table, which is not stable, this has not been actioned and is therefore still outstanding. The condition of the carpet needs to be reviewed throughout the building, in particular the lounge and bedrooms where it is stained. The home has sufficient outdoor space, including a grassed area and patio. These areas are accessible for wheelchair users. A previous requirement that the area around the manhole covers should be made safe has been completed and therefore this requirement has been withdrawn. The kitchen is domestic in style and has partly been adapted for wheelchair users, with lowered work surfaces. The kitchen is however in need of some refurbishment as some the kitchen doors are working themselves loose. A requirement was first made in regard to the kitchen in February 2004 and still remains outstanding. The Commission must be provided with an action plan of when this will be completed. A separate sleeping-in room is provided for staff, with some storage for personal belongings The home has some moving and handling equipment, this includes overheadtracking hoists observed in the bedrooms, and a shower trolley. There were adaptations in the bathrooms and toilets, which included grab rails. Electrical sockets and light switches were in accessible places for wheelchairs users and there was evidence of a call alarm system throughout the building. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33 and 36 The home and Walsingham try to ensure that the staff that they employ have the required qualities, training and support to undertake their roles effectively. There is an emphasis at the initial stages on an induction and that core skills are acquired so that service users feel that they are understood and listened to. EVIDENCE: All new staff at the home receives a six-week induction, followed by core skills training, which covers areas such as health and safety, food hygiene and manual handling. Discussions with a new member of staff confirmed the courses she had undertaken and that she was also undertaking her NVQ Level 3. The manager confirmed that all staff would be undertaking diversity training in January and also a two-day internal course on issues surrounding disability. With regard to the National Vocational Qualification Level 3, the home is on target to meet the revised deadline of 50 of care staff having completed the course by 2007. The current situation is that four members of staff have completed the course and two are in the process of completion. Budge Lane has a staffing establishment of eleven and a half. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 21 Currently within the home there are nine full time members of staff and a member of bank staff who is part time. The home is in the process of recruiting another full time and one part time member of staff. The only current vacancy is that of the deputy manager post which is being covered by someone ‘acting up’. Within the service users group there are four men and two women all of whom are white/European. Within the staff group there are six women and three men from a culturally diverse groups. Whilst acknowledging the male/female balance could be better, it is nonetheless positive that the home does at least have three male members of staff Staff records for supervision were viewed for two members of staff; notes were available for these meetings, which were signed by both parties. Discussions with members of staff confirmed the regularity of supervision as being approximately monthly. The staffing rota was checked for two weeks chosen at random, one in August and one in December. There appeared to be sufficient staff on duty at all times. It was noticeable that there was a marked difference in the use of agency staff over that period as staffing within the home improved. It is very positive to note that over the Christmas period there is only one shift, which will need to be covered by an agency member of staff. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 and 42 The manager of the home is competent and well qualified to do so; he has managed to create an atmosphere of openness where staff feel that their views are respected and listened to. This in turn affects the way in which service users feel about living at Budge Lane, they are happy and contented about living at the home, and feel that their views will be heard. EVIDENCE: The registered manager, Mr V. Green, has ten years experience in the field of learning disabilities; he has been a manager for six of those years. He is in the process of completing his NVQ Level 4. Mr Green was able to give examples of recent training he has undertaken which continually updates his knowledge and skills. There were discussions with two members of staff regarding the manager and their views of him; both were positive and stated that he was approachable and open in his work. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 23 Walsingham take seriously its responsibilities to ensure the safety and welfare of service users and staff. At the last inspection records were checked regarding fire checks and drills; gas and electric installations. It was noted however, at this inspection that the chemicals and other substances hazardous to health cupboard was not locked, and in addition there was a container of white spirits on the lounge floor. A requirement has therefore been made in this regard that chemicals and other substances hazardous to health must be locked away at all times. Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 4 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Budge Lane (21) Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 2 X DS0000007155.V270969.R01.S.doc Version 5.0 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2(b) Timescale for action The home must review the needs 07/05/06 of service users on a formal basis Partially met from previous inspection The home must ensure that service users have access to health facilities Outstanding requirement previous timescale 7/8/05 The home must ensure that the Medication Administration records are kept up to date a. The condition of the kitchen must be made good Outstanding requirement previous timescale 1/2/04 b. The dining room table must be replaced Outstanding requirement previous timescale 7/10/05 c. The condition of the carpet must be reviewed throughout Chemicals and other substances DS0000007155.V270969.R01.S.doc Requirement 2. YA19 12(1(a 13(1(b 07/02/06 3. 4 YA20 YA24 17(3)(a) 23(2) 07/12/05 07/04/06 5 YA42 12(1)(a) 07/12/05 Page 26 Budge Lane (21) Version 5.0 hazardous to health must be locked away 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 Budge Lane (21) DS0000007155.V270969.R01.S.doc Version 5.0 Page 27 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. 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