Inspection on 06/06/07 for Chapel Lane, 74

This inspection was carried out on 6th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chapel Lane, 74 21/02/06

Chapel Lane, 74 03/11/05

Chapel Lane, 74 05/11/04

Chapel Lane, 74 08/04/04

Chapel Lane, 74 23/10/03

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 Chapel Lane, 74 Hillingdon Middlesex UB8 3DS Lead Inspector Ms Pauline Griffin Key Unannounced Inspection 6th June 2007 12:00 Chapel Lane, 74 DS0000032581.V339736.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 Chapel Lane, 74 DS0000032581.V339736.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. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel Lane, 74 Address Hillingdon Middlesex UB8 3DS 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) 01895 446958 01895 440826 mhowell@hillingdon.gov.uk London Borough of Hillingdon Mrs Margaret Anne Howell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21st February 2006 Brief Description of the Service: The home provides a service for six people with learning disabilities. The property is owned by Shepherds Bush Housing Association and the care is supplied by London Borough of Hillingdon. The house is a large detached family residence, which has been extended. The house is situated in a quiet residential avenue in Hillingdon that is within easy reach of public transport links to central Uxbridge and other shopping centres in the area. There are a few local shops within walking distance. All of the six bedrooms are single occupancy and have wash hand basins. There is no lift in the home. The ground floor accommodation comprises two bedrooms and all the shared communal facilities. There is a very large lounge with dining area and access to the garden via French doors. The garden is wheelchair accessible and there is a wheelchair accessible shower/toilet on the ground floor as well as a large domestic kitchen, laundry and office. The first floor has four bedrooms, a shower/bathroom and a toilet. The stairs are fitted with support rails. The home is accessed at the front by ramp and new ramps now give wheelchair access to the rear garden. The home has a minibus used for outings with residents contributing to the cost. The home continues to give care to three men and three women. All the residents make varying financial contributions to their upkeep, which ranges from £168 to £357 per month. The Registered Manager is supported by three Care Staff and are currently 56 permanent hours short per week. These hours are made up by an employment agency. Plans are now in place to recruit one full time and one part time permanent staff for these hours. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a five hour period. A senior careworker and a shift leader assisted with the inspection in the absence of the Registered Manager who was on leave. One resident and two members of staff were interviewed. Two resident’s files were examined together with records, staff rostas, menus, minutes and training records. The inspection included a tour of the home and the evening meal being served. Staff were observed interacting well with the residents throughout the course of the inspection. The home continues to have one staff member on sleep-in duty each night and this was a subject of discussion between the Registered Manager and the Inspector following the inspection. A recommendation will be made in the body of the report for the Registered Manager to explore measures to back up lone staff on duty overnight. The Registered Manager has confirmed that the vacant permanent staff hours are in the process of being filled and this should reduce the reliance on agency staff in the future. Two residents were in the home when the inspection commenced and one sat with the Inspector and provided opinions and comments concerning her lifestyle and choices. The remaining four residents arrived from their respective day centres during the latter part of the inspection and were observed being served their evening meal. Questionnaires were returned to the CSCI by each of the six residents. It was apparent that these had been completed with assistance from staff. Four questionnaires were returned to the CSCI by members of the families of the residents and each one praised the staff highly for the excellent care they provided. The home was observed to be clean and hygienic throughout and in good decorative order. What the service does well: The service provides residents with good quality personal care from a team of experienced staff who are familiar with their needs and wishes. Each of the three permanent members of staff are nominated as the key worker for two of the residents and are responsible for their overall health and welfare. The atmosphere in the home is relaxed and homely. Records were well maintained and up to date. Medication is well managed. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 6 All three members of the permanent staff team have achieved a NVQ level 3 in care. 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. The summary of this inspection report can be made available in other formats on request. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate its ability to meet the residents’ needs. Residents have a contract and terms and conditions on their individual files. EVIDENCE: Care needs assessments are produced for each of the residents and are updated at regular intervals. Two of the residents’ files were examined and found to be up to date and comprehensive. Individual requirements were included in the care plans and these were person centred and showed evidence of input from the individuals themselves. Health care needs were well documented and included the aging process, medical appointments, dietary needs and weight charts. The six residents have all lived in the home for more than five years and there have been no new admissions to the home. Each of the residents have a member of staff who acts as their key worker. The Registered Manager said that the home is also proposing to purchase a camera to generate Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 9 photographic symbols and these can be used when residents are making choices of things like food items for the weekly menu. Each of the four questionnaires returned to the CSCI by members of the residents’ families, spoke highly of the staff team and their commitment to providing a high quality care service. Training records showed that staff receive specialist training courses and the permanent staff team have all achieved an NVQ qualification in care. Residents have a contract and terms and conditions in their individual files. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of the residents were fully detailed in their care plans and provided evidence that they had contributed to the formulation of them. EVIDENCE: Two of the residents’ files were examined and these detailed the assessed needs with regard to their personal, social and healthcare and how these would be met. The plans included evidence that both the resident and their representative had been involved in the formulation of them. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 11 None of the residents are able to manage their own finances and all receive support. Staff accompany them to the bank to withdraw their money and to produce cheques to pay for their rent and for personal spending. Staff encourage the residents to make choices regarding the things they purchase like clothes, makeup or what hairstyle they want. One resident’s cash box and cash records were checked and the amount tallied exactly with what had been recorded. During the course of the inspection, it was noted that the staff were encouraging the residents to participate in carrying out small tasks around the home like sweeping the patio and setting the table for the evening meal. Minutes of the meetings held for the residents and staff were examined and it was noted that there was an agenda book to record topics for discussion. Meetings are held at regular intervals and the minutes showed that the residents contribute to the proceedings. Risk assessments are carried out for all activities concerning the residents. The home assesses risks to ensure that the residents are supported to live an independent lifestyle and to make choices within an assessed framework. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a lifestyle and a variety of activities that they enjoy EVIDENCE: Each of the six residents attend a day centre on four days a week. They take a packed lunch to the centre and have their main meal of the day in the home in the early evening. None of the residents are in paid employment. The range of activities the residents participate in include the attendance at a variety of social clubs, Sunday club, shopping, cinema, take away meals, cinema, restaurants and pubs. One of the residents told the Inspector that she had enjoyed a trip to a large car boot sale on the previous Sunday. The home has a minibus for staff to take the residents out on excursions but staff said that they rarely had time to go very far a field. Staff said that their Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 13 shifts were too short to take the residents out for longer shopping trips or full days out. One resident said that her favourite activity was to go shopping and she would like to do this more often. Each of the residents have a lock on their bedroom door but only one of the residents chooses to hold his own key. Staff were observed to interact with the residents in a respectful but relaxed manner and staff addressed residents by their chosen name. Staff were also observed to be encouraging the residents to contribute to the daily routine of the home by helping in the garden, kitchen and cleaning their bedroom with them. Residents were observed being served with their evening meal of chicken kiev or vegetarian sausages with tinned spaghetti or vegetables. There was a bowl of fresh fruits on the dining room table and staff said the residents could choose a dessert of yoghurt and fruit. Staff said that biscuits and ice cream are kept if residents want them but the majority of the residents have high cholesterol or need their weight monitored. The Registered Manager said that the residents have chosen to have a dessert with their Sunday meal and to have yoghurt and fruit on the six remaining days. The Registered Manager said that the residents have also been asked if they would like a cooked breakfast occasionally but preferred to choose from a selection of cereals. Minutes of the residents’ meeting confirmed that choice of food had been discussed in the past. However, more evidence should be available to show that the residents were provided with a full selection of foods they can choose from in accordance with their individual preferences and dietary needs. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 14 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): 18,19,20 & 21. Quality in this outcome area is good. Residents receive personal care support in a sensitive manner that takes into account their needs and wishes. Medication and health related tasks are well managed by the staff in a way that safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The six residents require low levels of assistance with their personal care. Choice is offered as to the gender of the person who provides their care and each resident has a designated key worker from the permanent staff team. Two residents’ files were examined and records of regular health checks with their general practitioners and other appointments with specialist services Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 15 accessed through the Primary Health Care Services or the CTPLD (Central Team for People with Learning Disabilities) with the Local Authority. The home operates a system of health action planning to monitor the health care needs of the residents and to which they contribute where possible. The home uses the administration of medication policy and guidance produced by the Local Authority who provide training for the staff at regular intervals. Most of the resident’s medication is prepared in the Boots Monitored Dosage System. Medication is stored in a secure cabinet in a satisfactory manner. Medication administration records were examined and were well maintained. The home’s policy states that it does not offer places to people over the age of 65 years and there needs to be clarification as to the arrangements for residents who reach this age. Files examined showed that the residents have been assisted to complete a statement entitled ‘When I Die’. This covers a range of questions to establish Their wishes in relation to death, dying, treatments, wills and religious observances. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home facilitates the residents to feel that their views are heard and acted upon. Residents are protected by the home’s policies that ensure their safety and wellbeing are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints received in the home and there was, therefore, no records to examine. There is a special complaints leaflet designed for the residents in a simple pictorial form and this is on clear display in the entrance hall of the home. Each of the residents have a one-to-one meeting with a member of staff or an advocate and these meetings are used to obtain their views. The monthly residents meetings are also used to obtain the views of the residents and the meetings where topics are discussed and recorded. All staff have attended a training course concerning the protection of vulnerable adults provided by the Local Authority. The home plans to ensure that the Local Authority’s Dignity Challenge Policy and guidance is in place in the home to heighten awareness of what is acceptable and unacceptable behaviour through the residents meetings. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 17 One of the resident’s money float and records was chosen at random and the float tallied exactly with the written record. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 & 30. Quality in this outcome area is good. The premises are clean and well maintained throughout and provides a suitable environment to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made as part of the inspection and the property was clean and well maintained throughout. The kitchen units and upstairs bathroom were observed to be worn looking. The upstairs toilet was out of commission Staff said that these issues were part of the home’s renewal programme with the Shepherds Bushing Housing Association who own the property. The Registered Manager aims to improve communication with the Shepherds Bush Housing Association to ensure that more regular house maintenance programme meetings take place. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 19 The resident’s bedrooms were well furnished and personalised and the communal areas of the home were well equipped and homely. The garden is pleasant, well maintained and easily accessible through French doors from the lounge. The home has three toilets, two showers and one assisted bath across the two floors. The toilets and bathrooms have locks but most of the residents need some form of assistance when using them. The upstairs separate toilet in the home is out of commission at present and this means that the four residents on the first floor have to use the toilet in the communal bathroom. This makes routine morning bathroom use very difficult when all the residents are trying to prepare for their day centre. The two of residents who have bedrooms on the ground floor use wheelchairs and walking aids. The bathroom on the ground floor is adapted for people with disabilities and all the ground floor accommodation is accessible for people who use wheelchairs. The stairs and landings in the home are fitted with handrails. One of the residents on the ground floor has an alarm to enable her to call the sleep-in Care Worker during the night if necessary. There is a cyclical cleaning programme in place and the cleaning programme is displayed on the laundry room wall. Infection control guidance is posted in the kitchen and laundry and the home is free from mal odours. Hand washing facilities are available throughout the home. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 & 36. Quality in this outcome area is good. The residents benefit from a committed team of staff who work together to provide an effective care service and have the combined skills to ensure the assessed needs of the residents are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to have one staff member on sleep in duty at night. The Registered Manager said that she would investigate formal back up measures to support the situation if there were to be an emergency. The permanent staffing levels have been supplemented with agency staff and the service is currently running with a 33 vacancy that includes staff on long term sick leave and training. Recruitment of one full time and one part time member of permanent staff is now taking place. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 21 Staff recruitment will be conducted according the policies and procedures of the Local Authority. These policies and procedures operate to ensure that vulnerable people are protected and in accordance with equal opportunities. Each of the permanent staff team has accomplished an NVQ at levels 3 and 4. The Local Authority provides training for staff at regular intervals in subjects like moving and handling, food hygiene, fire, infection control, first aid, POVA, complaints equalities and Data Protection. All staff receive regular one to one supervision and the appointments are incorporated in the staff rota. Staff files were not available for examination but staff said that they received supervision with the Registered Manager and annual performance and development meetings. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 & 43. Quality in this outcome area is excellent. Residents benefit from a safe environment where their rights and views are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is suitably trained and competent to manage the home. The Registered Manager has an Advanced GNVQ in Health and Social Care, NVQ levels 3 & 4, Registered Manager Award and has attended other training and management courses to ensure she has the skills to lead and develop the staff team. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 23 The home is well managed and the ethos is positive and inclusive. The atmosphere and the general care of the residents is very good. The quality monitoring system developed by the Registered Manager includes questionnaires for the residents and their representatives, regular residents meetings, one to one meetings and Regulation 26 (quality spot inspections carried out by senior staff from the Local Authority). The Registered Manager wishes to further develop areas where the residents can be facilitated to make choices without the need for the staff to help by prompting them. The Registered Manager wishes to purchase a digital camera and to take photographs of the things the residents might be offered as choices that they can readily recognise. Questionnaires were returned to the CSCI by each of the six residents. It was apparent that they had been completed on behalf of the residents with assistance from staff. Four questionnaires were returned to the CSCI by members of the families of the residents and each one praised the staff highly for the excellent care they provided. Recording keeping in the home is satisfactory. The accident record book, complaints log and training records were all in order. Fire drills and alarm testing showed that these were carried out at regular intervals. The Fire Brigade visited the home in April 2006, the alarms were checked by an accredited company on 05/06/07. The Health and Safety Officer for the Local Authority has visited the home recently to ensure that risk assessments have been completed to cover the activities of the home. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 3 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 3 25 X 26 X 27 2 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 4 3 X X 3 3 Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA27 Regulation 23(2)(j) Requirement The toilet on the first floor must be repaired. Timescale for action 01/08/07 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. 3. 4. Refer to Standard YA14 YA17 YA21 YA33 Good Practice Recommendations Evidence that residents have chosen from a selection of activities that appeal to them (either as a group or individually) should be provided. Evidence that residents have chosen from a selection of foods that appeal to them (within their dietary needs) should be provided. The home has a policy that people over 65 years of age cannot remain there. This should be included in the Service User Guide and any exclusions detailed. Back up measures to support lone care workers on sleep over duty at night should be put in place. Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Chapel Lane, 74 DS0000032581.V339736.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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