Inspection on 10/07/07 for Buxton Street (131-133)

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Buxton Street (131-133) 10/04/06

Buxton Street (131-133) 02/08/05

Buxton Street (131-133) 05/04/05

Buxton Street (131-133) 28/09/04

Buxton Street (131-133) 08/07/04

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 Buxton Street (131-133) 131-133 Buxton Street Whitechapel London E1 5AR Lead Inspector Anne Chamberlain Key Unannounced Inspection 10th July 2007 10:00 DS0000010293.V345394.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000010293.V345394.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000010293.V345394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Buxton Street (131-133) Address 131-133 Buxton Street Whitechapel London E1 5AR 020 7247 2004 020 7247 2004 rtapader@outward.org.uk 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) Outward Ruhul Amin Tapader Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000010293.V345394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No persons with wheelchair dependency Date of last inspection 10th April 2006 Brief Description of the Service: 131-133 Buxton Street is a 24 hour residential service for 5 people who have learning disabilities and complex needs. It is situated in Tower Hamlets in a central location close to public transport links and with local shops and a market. The home is located in a pair of terraced cottages which have been converted to provide two independent flats - 131 and 133. The flats have separate front doors but there is an intercommunicating door inside. The upper flat is occupied by three more independent service users. The lower flat is occupied by one service users who has rather higher needs. The homes share a small but pleasant and private garden. They are run separately from one office which is located on the ground floor in number 133. The staff team consists of a manager, and several care staff. The cost of a placement at the service is £1320.01 per week. DS0000010293.V345394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Annual Quality Assurance Assessment (AQAA) was received from this provider. It was well completed and gave much useful information. The inspector visited the service and spent a day and a half there. She talked to residents, the manager and staff, and inspected the premises including the garden. She case-tracked two residents viewing their files, the files of their carers, their finance arrangements and the arrangements for the administration of their medication. The inspector would like to take this opportunity to thank the residents, manager and staff at the home for their co-operation and support with the inspection. Inspection Report Summary The inspector was Anne Chamberlain and this is what she did when she was at the home DS0000010293.V345394.R01.S.doc Version 5.2 Page 6 What the service does well: The service has a competent manager and deputy in place. Some of the staff team have been at the service a considerable time and they offer consistency to the residents. Staff are calm and reassuring. Manager and staff are committed to continuous improvement and look for ways to encourage residents to develop themselves. The many activities residents undertake are well supported. The home has a friendly, welcoming atmosphere. What the home does well The people who live in the home are given good support to develop their social skills, and their skills around the house. DS0000010293.V345394.R01.S.doc Version 5.2 Page 7 The people in the home are supported to make their own decisions. What has improved since the last inspection? The management situation at the home was unstable for a long time and this is the first time that a manager and deputy have been in post at the same time. The documentation has improved and the systems in the home are clearer and more logical. Staff are adhering to them better and the quality of recording is improved. Staff have a better understanding of their role as keyworking and are taking more responsibility. The fabric of the home is greatly improved and the standard of décor is high almost all over now. The atmosphere at the home is relaxed and friendly. Decorating the house has made it better for the people who live there. DS0000010293.V345394.R01.S.doc Version 5.2 Page 8 What they could do better: The inspection resulted in six legal requirements and two good practice recommendations. The inspector acknowledges that significant improvements have been achieved in the service and she is pleased to state this. However the home has had a particular requirement restated for the third time. The first timescale being 1st July 2005. The requirement relates to staff training which is important for the welfare of residents and staff. A realistic timescale has been applied and the inspector trusts it will be met, to avoid an escalation of regulatory activity. Staff need to receive more training to keep them up to date. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000010293.V345394.R01.S.doc Version 5.2 Page 9 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 DS0000010293.V345394.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Pre-placement assessment is thorough and contracts are in place. EVIDENCE: The inspector viewed the service user guide. It lacks some specified items and needs to be expanded. The inspector explained to the manager what was missing and pointed it out to him in the National Minimum Standards (NMS). The manager agreed to revise the guide (see requirements). The manager is in the process of assessing a prospective service user for placement at the home. He explained to the inspector how the information as to the persons needs has been gathered and the professionals who have been involved. He also explained the opportunities the prospective resident has been given to help her decide if she wants to live at Buxton Street. The inspector felt that the assessment exercise has been comprehensive. In addition workers from Buxton Street will shadow work with the prospective resident at her present home to learn exactly how she likes her support to be provided. If the resident moves in, the inspector expects to see all the DS0000010293.V345394.R01.S.doc Version 5.2 Page 11 information gathered, recorded in a standardised assessment form on the residents file. The prospective resident has some needs which will require the home to make adaptations and these have been planned for. On inspecting residents files the inspector noted that one resident has no assessment information on her file, the section was empty. The manager said that this was because it has all been archived. The manager must arrange for the resident to have an up-to-date reassessment of need undertaken and placed on her file (see requirements). The inspector found that each resident now has an individual written contract on their file. DS0000010293.V345394.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. People experience good, quality service in this outcome area. This judgement has been made using available evidence including a visit to this service. Individual support plans are comprehensive. Residents are encouraged to take decisions and to participate in the running of the home. Risks are properly assessed. EVIDENCE: The inspector viewed the residents individual support plans which were comprehensive. Being on separate sheets they are easy to update and the manager said this would be done after reviews or any significant changes. The manager stated in the AQAA that one resident has developed a pictorial communication book to help with decisions. He said that residents are encouraged to make as many decisions as possible. They decide what they DS0000010293.V345394.R01.S.doc Version 5.2 Page 13 want to do and when, participating in day centres, clubs shopping etc. They have decided on their holiday arrangements. The inspector was pleased to hear that a qualified interpreter has been found for a resident who has English as her second language. The interpreter attends all medical appointments and the tenants meetings which are held twice a month. The inspector viewed the minutes of recent tenants meetings. The had good content and reflected well on the meetings. The AQAA states that a resident brought up having her room redecorated at a tenants meeting and this has been achieved. It also states that Outward, the providing organisation, retains a dedicated participation development officer. The manager said that one of the residents is now assisting with the safety checks in the house. The inspector viewed risk assessments on file. They have been brought up to date but there was no risk assessment for upcoming holidays. The manager said this is in hand. One residents risk assessments need to be reviewed about now and the manager stated that they have been done and are on the computer ready to print off. Risk assessments are based on positive interactions and the inspector was satisfied with them. DS0000010293.V345394.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents at the home take part in a wide variety of activities including day centres, clubs, sports centre, shopping etc. The inspector was able to confirm this by reading their log books. Two of the residents have good family contact and visit family homes. One resident has a very good friend who visits her every day. The AQAA states that one resident who was previously reluctant to engage in activities outside of the home has become much more outgoing. The manager mentioned this at the inspection and appeared delighted with this rewarding development. DS0000010293.V345394.R01.S.doc Version 5.2 Page 15 The AQAA gives many examples of respect for the rights and responsibilities of residents, also of how their cultural diversity is supported. One resident has a keyworker who shares his heritage and explores it with him. Another resident attends a Roman Catholic mass in her own language once a month and attends other community events specialist to her heritage. Residents have their own keys to the house and to their rooms, ensuring their privacy. Their mail is handed to them unopened and assistance with reading it is provided. The AQAA states and the manager confirmed that residents are involved in menu planning and are supported to shop for food and help with preparing it. Whilst the inspector was at the home a resident popped across to the corner shop to buy some snacks. DS0000010293.V345394.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Personal care is provided sensitively and physical and emotional needs of residents are met. Arrangements for the safe administration of medication are in place. EVIDENCE: The inspector felt that the support plans would form a good basis for personal support. The manager has stated in the AQAA that most of the staff have been working with the residents for some years. This is a great benefit in consistency. Residents have dedicated key workers and health action plans, which the inspector viewed in the residents files. The inspector understands from the AQAA that one resident is having input from a specialised autism support agency. The manager stated that the service has input from occupational DS0000010293.V345394.R01.S.doc Version 5.2 Page 17 therapy services and community nurse as well as general practitioners. The inspector is satisfied that the residents physical and emotional needs are met. The inspector viewed the arrangements for the administration of medication. The home uses the Boots bubble pack system. The resident who lives downstairs is supported to self administer medication which is kept in his room in a locked cabinet. Medications in the upstairs flat are kept in a locked cabinet. The inspector balanced medications for the two residents she was case-tracking checking the remaining stock against the Medications Administration (MAR) sheet. No discrepancies were found. There is a book for recording medicines received into the home and disposed of. The pharmacist signs this book for returned medication. The manager stated that everyone who administers medication has been trained to do so by Outward and a representative from Boots also came and talked them through the system. In addition they have a video. The inspector checked the training in the files of the two staff members she was case-tracking. They did not show that the two staff had had recent medication training. The inspector obtained from the organisation the staff training schedule for Buxton Street. One of the staff had had medication training in 1998 and 2003 and 2005. She is booked to have medication training again in September 2007. The second member of staff has not had medication training with the organisation as far as the inspector could tell. She may have had it previously but the inspector was shown no evidence of this. The manager must ensure that medication training can be evidenced for any member of staff who administers medication (see requirements). DS0000010293.V345394.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Residents views are heard and taken into account and residents are safeguarded by sound adult protection measures. EVIDENCE: The inspector viewed the complaints policy which was in a user friendly format. There was a complaints folder and the inspector felt that the complaints process was followed and was working. The home holds a listening book to record comments from residents. The inspector viewed the finance records for the two resident she case-tracked and counted the balance of their cash. There were no discrepancies. The inspector viewed the policies and procedures manual. There is an organisational procedure for adult protection. The inspector viewed the accident and incident records and they raised no concerns for her. DS0000010293.V345394.R01.S.doc Version 5.2 Page 19 DS0000010293.V345394.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic and very pleasantly decorated and furnished. Residents have been involved in choosing colours etc. and the home is very welcoming. EVIDENCE: The inspector toured the house including looking into the vacant bedroom and one other bedroom. A lot of refurbishment work has taken place since the last time the inspector was in the home and she noted a great overall improvement in the décor. The inspector remarked on the lively green colour in the kitchen and was told it was chosen by a resident. She also admired the colour in a residents bedroom and this was of course chosen by him. DS0000010293.V345394.R01.S.doc Version 5.2 Page 21 Some further changes are planned to a downstairs bathroom. A closemat toilet which is not needed is to be replaced to make a little extra space. The inspector noted that that bathroom needs some refurbishment as follows: Radiator rusty replalce or repaint Standing rail rusty replace or repaint Small hole in ceiling needs to be replastered Call alarm needs the cord replaced Any unused fixings to be removed Flooring emits an unpleasant odour - needs to be replaced A downstairs toilet needs a toilet roll holder. In the upstairs bathroom a tile is off and needs to be replaced. An upstairs toilet is in a poor state of decoration and must be redecorated. The inspector noted that a resident has dirty net curtains. The manager stated that they are often washed, so in that case they need to be replaced as they are too old to wash up clean (see requirements). The inspector suggests that the manager look at all the nets in the house and consider replacing them as they are small windows and the outlay would be minimal (see recommendations). The home is clean and hygienic. There were no unpleasant odours apart from in the the above mentioned downstairs bathroom. DS0000010293.V345394.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Residents experience adequate quality in this area. This judgement has been made using available evidence including a visit to this service. The staffing situation is generally good but staff training is not up to date. EVIDENCE: Staff have job descriptions and the AQAA states that some work has been done with staff to clarify for them the role and responsibilities of keyworkers. There are six full time staff including four permanent care staff, plus the manager. The manager has NVQ level 4 and MBA in management. The deputy manager has NVQ 4. All permanent staff have NVQ 3. The recruitment documentation is held at the human resources office but the staff files have a list of documents held. The inspector viewed two staff files and was able to confirm that the recruitment process is robust and safe. The manager said that he has been involved in short listing for new appointments at the home. He said that residents are involved in the recruitment process working as a second panel. DS0000010293.V345394.R01.S.doc Version 5.2 Page 23 The manager has created a training matrix so that he can see at a glance what the training needs of staff are. He agreed with the inspector that core training which should be renewed every year includes: Adult protection Fire Health and Safety, Moving and Handling The manager said that the Food Hygiene course staff undertake lasts three years. In addition to this staff might do one-off training courses. The inspector viewed the training records for the keyworkers of the two residents she was case-tracking. The first worker had done moving and handling in 2005, she had done medication in 2005 and 2006. She had done food hygiene in 2000 and adult protection in 2001. She had not done fire training. The manager stated that this staff member is booked on a food hygiene course. He agreed that her training is out of date and she needs to do several courses urgently. The second worker had done first aid in 2006, health at work in 2006, medication in 2006 and food hygiene in 2005, first aid in 2007 and adult protection in 2006. She had not done fire training. The manager agreed that this person also needed some updating of her training. A requirement has been made (see requirements). The inspector was surprised not to see evidence of medication training………. The inspector viewed the records of supervision in the files of staff. These evidenced that supervision is regular, and frequent enough. The manager stated that in addition monthly team meetings are held. DS0000010293.V345394.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run generally and the views of residents are fully considered. Log books could be used more productively and Control of Substances Hazardous to Health (COSHH) arrangements must be audited. EVIDENCE: The home is well run and the manager and staff are supporting the personal development of residents creatively. The manager is now registered with CSCI and the inspector had a sense that the whole service has been tightened up with systems being followed properly and recording much clearer and more logical. DS0000010293.V345394.R01.S.doc Version 5.2 Page 25 The views of service users are taken into account in a number of ways. As previously mentioned they are involved in the recruitment process. The AQAA states that Outward surveys its service users annually, and there are forum meetings every three months. The manager remarked that one resident understands a large part of the information which is produced from the forum because it is given in picture format. A quality manager is in post in the organisation. As previously mentioned the home holds regular tenants meetings. The inspector observed on the files of residents monthly progress reports. These evidenced regular sessions of positive keyworking. Staff members should try to get the reports prepared and into the files as quickly as possible after the meetings. When the inspector viewed log books she noticed that although many mundane activities had been recorded, the emotional wellbeing of the resident was not described. A resident happens to be going through a rather distressed phase at the moment, needing a great deal of reassurance which the inspector observed she is getting. However her log book said nothing of this. The inspector suggests that the manager undertake some work with the staff around the quality of recording in log books (see recommendations). The inspector viewed the health and safety folder. The electrical wiring was checked in 2006. Gas safety was checked in April 2007. There is a fire risk assessment which was reviewed in April 2007. The fire alarm is tested weekly. The outside contractor checked the fire protection arrangements in May 2007. The inspector noted that magnetic door closers are now in place. Coloured chopping boards are in evidence. The inspector viewed the arrangements for the management of COSHH. The substances are locked away in a cupboard. The cupboard also contained some substances which were used by the decorators. The manager agreed that he would give these back to the decorators next time they came or dispose of them. In the meantime they should be kept on a separate shelf and identified as not for home use. The cupboard also other some products which did not have data sheets. The COSHH safety had not been audited recently. The manager must undertake an audit of the COSHH arrangements and dispose of any products for which he does not have data sheets (see requirements). DS0000010293.V345394.R01.S.doc Version 5.2 Page 26 The inspector viewed the records of temperatures for the refrigerator and freezer, and water temperatures. She noted that the refrigerator is consistently 6 degrees Celcius. The manager adjusted the temperature setting. There would appear to be a training issue here if the staff member has been recording a temperature consistently without knowing it was too high. DS0000010293.V345394.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x DS0000010293.V345394.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation 5 Requirement The service user guide must be expanded to include all the necessary information to comply with the regulations (previous timescales of 1st September 2004 and 1st December 2004, 1st August 2005, 1st October 2005, 1st July 2006 not met). The resident who has no assessment information on her file must have an up-to-date reassessment of need undertaken and placed on her file. Evidence of training in medication must be available for any member of staff who administers medication. The following refurbishment issues must be addressed: Downstairs bathroom - radiator rusty - replace or repaint Standing rail rusty - replace or repaint Timescale for action 01/08/07 2. YA2 14 01/01/08 3. YA20 13 01/10/07 4. YA24 23 01/12/07 DS0000010293.V345394.R01.S.doc Version 5.2 Page 29 Small hole in ceiling needs to be replastered Call alarm needs the cord replaced Any unused fixings to be removed Flooring emits an unpleasant odour - needs to be replaced A downstairs toilet needs a toilet roll holder In the upstairs bathroom a tile is off and needs to be replaced. An upstairs toilet is in a poor state of decoration and must be redecorated. Net curtains which wont wash up clean to be replaced. 5. YA35 18 6. YA42 13 (6) The manager must ensure that 01/12/07 staff (including bank staff) receive adequate training (previous timescales of 01/07/05, 01/12/05 and 01/07/06 not met). The manager must undertake an 01/09/07 audit of the COSHH arrangements and dispose of any products for which he does not have data sheets. DS0000010293.V345394.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA24 Good Practice Recommendations The inspector suggests that the manager look at all the net curtains in the house and consider replacing them. The inspector suggests that the manager undertake some work with staff to improve the quality of recording in log books. YA41 DS0000010293.V345394.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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