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

This inspection was carried out on 7th July 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 but made no statutory requirements on the home.

Other inspections for this house

Budge Lane (21) 19/07/07

Budge Lane (21) 05/01/07

Budge Lane (21) 07/12/05

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 Rin Saimbi Unannounced 7th July 2005 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 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 Stationary 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) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Budge Lane (21) Address 21 Budge Lane, Mitcham, Surrey, CR4 4AN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8640 5169 020 8640 5169 Walsingham Mr Victor Stephen Green Care Home 6 Category(ies) of Learning Disabilties (6) registration, with number of places Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th November 2004 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 dininig 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) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It was an unannounced inspection that started at 9.30 am. The inspection took approximately six hours and took the form of a tour of the building with a service user, opportunities to talk with four of the service users, and to observe contact between the service users and staff, interviews with staff and the manager and to check documentation to make sure that it was up to date, relevant and accurate. 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. Walsingham in conjunction with Advocacy Partners recently held a day’s conference entitled ‘Everybody’s Important’. In order to ensure that service users felt able to contribute, Advocacy Partners visited the home on a monthly basis prior to the conference in order to inform them about the event and hear their views. There has been a follow up from the conference in the form of service users group meeting on a regular basis. These meetings are supported by the home, and the service users from the home that attend receive minutes. 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. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 6 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 contacting your local CSCI office. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 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 standard(s) 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. 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. It has not been necessary to use this document as all the service users have lived at the home for some considerable time. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 9 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 and a district nurse are currently involved with service users and visit on a regular basis; a psychologist visits 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. This was observed, as one particular service user was persistent that he wanted a cup of tea made; another service user was able to communicate her disappointment to staff that tea dancing had been cancelled. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 10 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 standard(s) 6,7, and 8 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. In addition, the home is in the process of completing ‘Personal Centred Planning’ for all its service users. For this document to have any meaning it will take some considerable time to complete properly. It was positive to note that some work had already been undertaken and that staff were trying to make it relevant and appropriate to service users. It is hoped that this Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 11 document will be a ‘live’ document and therefore will be changed and reviewed on an ongoing basis. The formal reviews undertaken with Social Services were not being undertaken on a regular basis. One service user last had a review in 2000 and nothing since then; another service users had one review on 15.8.02 and the last one in 11.2.05. A requirement has therefore been made in this regard, that the home must ensure that regular reviews are undertaken, and that if this is not possible that the reasons why, are recorded. 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. Walsingham and Advocacy Partners held a joint conference in February entitled ‘Everybody’s Important’. The conference was for service users and staff. Advocates were coming into the home on a monthly basis, six months prior to the conference to ensure greater understanding and participation. A report was written after the conference and sub-group entitled ‘Our Voice’ continues to meet on a regular basis with others. Two of the service users from Budge Lane had recently been to Leicester as part of this sub-group. One of the service users within the home has very involved independent advocates. The home tries to ensure that they work with the advocates to best meet the needs of the individual service user. 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. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 12 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 standard(s) 11,12,13,15,16 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) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 13 Service users are encouraged to be as independent as possible; they are supported to maintain friendships and family contact, this is achieved by providing transport and the opportunity to see people in private if they so wish; service users are encouraged to participate in the activities of daily life these range from where to go on holiday and cleaning their own bedrooms. 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 service users spoke positively about his volunteering experience. Some staff training is open to service users to attend, for example all service users who attended the recent fire training were given a certificate of attendance. 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 two jazz holidays every year. 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 owns his own car, which is driven by staff; another service user has their own scooter. All service users registered to vote; however in the recent election no one chose to, despite an invitation and visit by the standing MP. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 14 The home has an open door policy, which allows for people to visit whenever they wish. There are occasions when family and friends are invited to the home, all service users have a birthday party at the home, and there is a summer barbeque and a Christmas party. A recent example of an open door policy was given when a service user was in hospital, and the home arranged to take a relative to visit as they would not be able to do so themselves. The inspector was able to view the ‘house menus’. The individual service users, to suit their own preferences, then adapt this general menu; a record is then kept of the actual meals taken. Three meals are offered on a daily basis, the evening meal is a cooked meal. There were snacks and drinks available to service users whenever they wished and service users were observed to be helping themselves. There has been an ongoing issue regarding one particular service users who is reluctant to eat; previously the home has involved a dietician. It is of concern therefore that this particular service user has recently been in hospital and has not had her weight monitored. A requirement has therefore been made in this regard, that is to say that all service users must have their weight monitored on a regular basis, and significant fluctuations must be acted upon. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 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 standard(s) 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. The home could improve their procedures and protocols to ensure that all service users were receiving the highest standard of healthcare, and that there needs were regularly monitored. 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. As previously mentioned, one service user has recently been in hospital for some considerable time; a member of staff from the home supported her for twelve hours a day. Medical appointments are recorded for all service users. However, there was no overview of the ongoing check ups that service users may require with the dentist or optician for example. One service user had not had an opticians Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 16 appointment since 2000, although this individual did not wear glasses, she was an older person and therefore needed to be monitored closely. A requirement has therefore been made that the overall health needs of service users must monitored and acted upon accordingly. 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; Records were checked regarding the administration of medication, which was found to be up-to-date and accurate. The home has regular pharmacy inspections from Boots the Chemist, the last of which was on 28.2.05. A previous requirement that medication must be stored at the appropriate temperature is now withdrawn as the home has purchased a refrigerator for the purpose. However, a requirement remains that only staff that have completed an accredited course regarding the administration of medication, must to do. This requirement must be acted on henceforth. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 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 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. In addition, the home has its own complaints policy, which is written in a format that its service users would understand. Two of the service users were able to say what they would do if they had a problem about the home, one said that they would talk to the manager, the other to a member of staff. 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. The manager of the home has recently attended a refresher course regarding vulnerable adults. The current deputy is in acting up role, and has not attended a recent refresher. However, staff within the home seem to have an awareness of the issues. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 18 Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 19 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 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) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 20 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. A previous requirement that the home must review the condition of the carpet has been withdrawn, as a replacement carpet has been fitted. A requirement has been made and that is the replacement of the dining room table, which is not stable. The home has sufficient outdoor space, including a grassed area and patio. These areas are accessible for wheelchair users. The manhole covers in the garden could cause a tripping hazard; therefore a requirement is made in this regard. There is ample communal space within the home, a lounge at the rear of the building, also a lounge to the front of the building, and a large dining area. 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 has been made therefore that the kitchen is revamped to an appropriate standard. 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 used, and in addition a lockable space in their bedrooms. Service users brought in their own entertainment into the home, for example one service users had a range of music. 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) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35 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: Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 22 The inspector was able to observe the interaction of staff with service users; there was an understanding of the individual service users, their needs, preferences and speech patterns. Staff were observed to be acting within their roles and responsibilities, and during interviews with the inspector they were able to confirm this. There was an awareness of the various policies and procedures within the home, and there was evidence that staff had also signed and dated them as evidence that they had been read and understood. There is a registered manager in post at the home; however, he is currently only part-time at the home as he is also covering another home. This is not an ideal situation, but it is hoped that it will be only a short-term temporary measure. All new staff at the home receive a six-week induction, followed by core skills training, which covers areas such as health and safety, food hygiene and manual handling. Discussions with staff and checking records regarding training undertaken confirmed that this was the case. 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 one member of staff has completed the course and four are in the process of completion. Budge Lane has a staffing establishment for eleven. The previous acting manager of the home was not completing supervision at the required level. Since the registered manager has been in post, supervision of staff is taking place, and is being recorded. This situation will be monitored closely by the Commission to ensure that supervision is conducted on a regular basis. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40 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. The home has a number of quality assurance programmes in place to monitor the level of service provided. This includes monthly monitoring visits completed by a senior manager, a copy of which is sent to the Commission; finances are also regularly audited internally. In addition, Walsingham Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 24 undertake an annual survey of its service users. This takes the form of a questionnaire, which is in an appropriate format for service users. The home has policies and procedures in place, which are written centrally. These documents were revised in August 2004 in order to meet the requirements set out in the National Minimum Standards. Staff within the home are then required to read these policies, which they then sign and date as confirmation that they have read and understood them. Waslingham takes seriously its responsibility to ensure the safety and welfare of the service users and the staff that it employs. Documentation was checked which related to these matters and all was found to be in order. Fire testes and drills were completed regularly; gas installation was checked in July 2005; Electrics were checked on 14.9.04 and Employers Liability Insurance was up to date Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 25 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 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 4 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 2 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score 3 x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Budge Lane (21) Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 x 3 x G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 26 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. 2. 3. 4. Standard 6 17 19 20 Regulation 15(2)(b) 12(1)(a) 12(1)(a) 13(1)(b) 13(4)c Timescale for action The home must review the needs 7.10.05 of service users on a formal basis The home must ensure that 7.7.05 service users weight is Immediate monitored on a regular basis The home must ensure that 7.8.05 service users have access to health facilites The home must ensure that only 7.7.05 staff who have completed an Immediate accredited course, administer medication a. The condition of the kitchen 7.10.05 must be made good b. The dining room table must be replaced The manhole covers in the garden must be made safe Requirement 5. 24 23(2) 6. 28 13(4) 7.10.05 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. Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 27 Refer to Standard Good Practice Recommendations Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 28 Commission for Social Care Inspection CSCI 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 Budge Lane (21) G53-G53 S7155 Budgelane V236569 070705 stage 0.doc Version 1.40 Page 29 - 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!