Inspection on 17/10/07 for Chase (The)

This inspection was carried out on 17th October 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 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

Chase (The) 15/04/09

Chase (The) 01/07/08

Chase (The) 27/01/08

Chase (The) 25/05/06

Chase (The) 03/11/05

Chase (The) 10/06/05

Chase (The) 16/03/05

Chase (The) 30/11/04

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 Chase (The) 165 Capel Road Forest Gate London E7 0JT Lead Inspector Anne Chamberlain Unannounced Inspection 17th October 2007 10:00 Chase (The) DS0000041012.V353066.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 Chase (The) DS0000041012.V353066.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. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chase (The) Address 165 Capel Road Forest Gate London E7 0JT 0208 478 7702 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) Alpam Homes Thomas Francis Byrne Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 Brief Description of the Service: The Chase is a residential home, which is registered for up to eight service users, with a learning disability. The home is situated within a short walking distance of Manor Park over ground station, and some local shops and amenities. The home is comprised of an older end of terrace house with a new double story extension at the rear. The home is owned by Alpam Homes, a local provider of care services. Fees at the home range from £1,250 - £2,000. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager of the service, ahead of the site visit, provided an Annual Quality Assurance Assessment. This provided useful information. The site visit extended to the separate day centre, of which the inspector made a brief tour. The inspector spoke with service users, the manager and a manager of the day centre. She viewed the files of three service users and their medication arrangements. She also viewed the files of their keyworkers. The inspection was announced and took six and a half hours. The inspector would like to take this opportunity to thank the service users, staff and manager of the home and day centre for their assistance and cooperation with the inspection. The inspector came to see if people were being well cared for at the service. This is the report about what she found. What the service does well: This service has a compatible group of young, lively people. A varied programme of activities is provided for them. Some service users have behavioural issues and skilled care is provided to support these. The staff group is stable and experienced. The home environment is especially pleasant and the communal areas are roomy and comfortable. The location is open and very pleasant. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 6 People do lots of activities in the community and at their day centre they even put on shows. What has improved since the last inspection? The medication policy has been revised as requested at the previous inspection. The practice of dating opened food in the refrigerator has been followed. One service user has moved to a more appropriate placement and service users at the home now form a compatible group. They are making steady progress with the support of the manager and staff. The home continues to develop its community presence and to access a wide variety of events in the capital and locally. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 7 the home has changed the medication policy to make sure that people only take homely remedies and prescribed medications, which are O.K. together What they could do better: The inspection resulted in six legal requirements and two good practice recommendations. A requirement with regard to first aid training has been restated for the third time. A broader requirement with regard to basic training has also been made. Restated requirements have also been made regarding gas and electrical installation safety checks. The portable appliances have not been tested since 2005 and should be tested as soon as possible. The adult protection policy and procedure was not available in the home during the inspection. It needs to be available at all times so that staff are properly guided in their response to an allegation or suspicion of abuse. The home needs to have an adult protection policy and procedure available for staff all the time. So that they know exactly what to do if anyone says they have been abused. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 8 The inspector found that some staff needed to do more training. For example all staff should have up to date First Aid training. Also the home must make sure that all the safety checks are up to date, including for gas and electricity 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. Chase (The) DS0000041012.V353066.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 Chase (The) DS0000041012.V353066.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can have information about the home, and a thorough assessment is made of individuals before a placement is offered. EVIDENCE: The current residents of the home are all quite able young people who need support with their behaviour. The home currently has three vacant beds. The manager said that he is very careful about compatibility when assessing prospective residents. He is aware how important it is not to jeopardize the progress which has been made by the existing group. The manager stated that an assessment from the home would cover four different periods of the day and also look into what people do in the community. There would be much contact with the prospective resident with many opportunities for them to visit the home before a decision could be reached. The home would wish to see all professional reports and assessments available to further inform them. The home has produced a statement of purpose and a service user guide, both of which have been inspected previously and are unchanged. The documents are not available in user-friendly formats but a staff member has made an Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 11 audiotape recording of the service user guide. The inspector encouraged the manager to see if this can be used. The service user contracts which were on all three files inspected, were signed and dated, and are in a user-friendly format. Chase (The) DS0000041012.V353066.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 and 9. Quality in this outcome area is good. Service users have individual plans which are reviewed regularly. They are encouraged to take decisions for themselves and their activities are supported by risk assessment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have service user plans on their individual files. The inspector noted that these had been recently reviewed. The care plans were succinct, but were backed up by risk assessments and behavioural guidelines. The manager stated that he emphases the link between home and day care Service users are encouraged to transfer the skills acquired in either setting to the other. This is obviously a benefit of the close working relationship between the services and the crossover of staff which underpins a 24-hour package. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 13 Empowerment and independence are highly valued in the service. At monthly r meetings service users have opportunities, to take decisions over various issues. Meals, outings, activities and holidays are obvious examples. As previously mentioned individual risk assessments are in place on files. In addition there are general risk assessments. None of the service users have good road awareness and the home provides a safe environment with exits having keypads to unlock them. The manager stated that service users sometimes travel with staff on public transport and this is a good introduction to travel training. Chase (The) DS0000041012.V353066.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a wide range of educational and developmental opportunities, inside the home and in the community. Contact with families is supported and a healthy diet with variety and choice is offered in pleasant surroundings. EVIDENCE: Service users take part in a variety of leisure and recreational activities, inside the home, at the day centre, and in the community. The manager stated that the day centre offers a programme which is roughly 50 indoor activities and 50 community based. The inspector when she visited the centre noted some excellent art and craft opportunities. These are often linked to an upcoming celebration or event. The service users produce a show twice a year and there are lots of opportunities to work on scenery, props etc. A day centre manager said that when planning the programme the seasons of the year and special occasions are taken into account. The work is multi-cultural with events like Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 15 Italian day or German day. As well as art and craft the centre offers a sensory room and a beauty parlour, which the women really enjoy. The inspector had the impression that service users have a lot of fun at the centre. As mentioned there are also community activities with trips to local and not so local attractions. In the summer the service users go sailing on local Fairlop Waters every week. They also visit the sports centre, seaside etc. The day centre caters for service users for the four houses in the Alpam group, so service users have a wide network of possible friends. They meet socially at house parties and other outings. In addition to day centre activities residents attend Wednesday club, visit museums, theatres etc. Contact with family is encouraged and supported by the home. There is a fair amount of family involvement in the home. The inspector was pleased to hear that a parent had chosen the well-framed prints on the walls. Daily routines are build around the individuals with support available to get ready for the day, a buffet style breakfast and day centre on weekdays. Service users are encouraged to participate in the household chores. The inspector heard that one resident enjoys peeling and chopping vegetables and is very good at it. Service users come home for lunch from the day centre and return for the afternoon if they want to. On the afternoon of the inspection several service users elected to stay home for the afternoon for various reasons. The manager stated that a favoured activity is shopping, especially at the farm shop. Service users choose fresh vegetables for the home. Dinner is served at the table which is large enough for everyone to sit down together if they choose to. One service user often prefers to eat alone and this choice is respected. The inspector viewed the menu book which records what has been served each day. This evidenced a range of wholesome foods being served. The dining environment is very nice indeed. Chase (The) DS0000041012.V353066.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported sensitively and individually. Their emotional needs are considered. Administration of medication at the home is sound. EVIDENCE: The service users in the home have many skills of independence. Minimal assistance with personal care is needed. Support is available for any aspect of daily life including budgeting, shopping etc. The manager seemed aware of the emotional needs of service users. A member of staff was leaving the day after the inspection. The manager was concerned for a service user who is very attached to her. He felt the service user would miss her. He has a possible staff replacement lined up who gets on particularly well with the service user. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 17 The manager said that all the service users have good physical health. One service user has a diagnosis of epilepsy but this appears to be well controlled on minimal medication and no seizures have been observed. Nevertheless this service user always has a staff member close by when she is bathing. Another service user has some skin and allergy problems and he is supported with preparations for these. The inspector viewed the arrangements for the administration of medication. None of the service users are able to self-medicate at the moment. There are specimen signatures available for staff who administer medications and a photograph of the service user is attached to their individual medications. Medications are appropriately stored in a locked cabinet. There are no controlled drugs in use at the home. The home works with a local pharmacist and use a blister pack system. The inspector checked a number of medications balancing the remaining medications with the Medication Administration Record (MAR) sheets. One medication could not be properly balanced. There was a loose tablet and there appeared to be too many doses of evening medication remaining. The manager made enquiries and contacted the inspector the day after the inspection. He said that the service user had taken medication home but not used it. One tablet had been returned in an envelope. The manager stated that one of the workers is tasked with auditing the medications every week. The administration of medication in the home did appear sound but it must be possible to determine on any day and at any time exactly how much medication has been taken and remains. Loose tablets should be taped into the pack with a sticker explaining why they are there. Missed doses should be clearly marked on the MAR sheet. The inspector recommends that the manager and staff devise a system to ensure that any irregularities of medication are properly handed over on the MAR sheets with the information clear to anyone who is administering (see recommendations). Chase (The) DS0000041012.V353066.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector noted complaints information on the service users notice board. The manager has a format available for complaints but has not had any formal complaints to deal with. He did say that verbal comments are made sometimes but these are resolved straightaway. If a complaint were in any way serious or submitted in writing it would be dealt with in a formal way with actions and resolution recorded. The adult protection policy and procedure was not available in the home at the time of the inspection although the home did have a copy of the local authority policy. The manager faxed a copy of an adult protection flow chart to the inspector after the inspection. A procedural flow chart is helpful but does not replace a policy and procedure. The manager stated that he is an adult protection trainer and showed the inspector the manual he would use as a trainer. The inspector was happy that the manager would know what to do with an allegation or suspicion of abuse, but there needs to be a policy and procedure in the home for everyone to follow (see requirements). Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 19 Chase (The) DS0000041012.V353066.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home environment is modern, clean, comfortable and stylish. The design meets well the needs of the service users. EVIDENCE: The environment in the home is exceptionally good. The older part of the building has been re-plastered and the newer part is only a few years old. The floors are mainly non-carpeted with attractive tiles or floor covering material. The décor in the home is to a high standard and the furnishings are substantial and comfortable. The inspector viewed with permission the bedroom of one service user. It was light and airy with nice views over Wanstead flats. The bedroom had en suite facilities. The inspector was told that all the bedrooms do, although not all have showers. There are additional bathing and shower facilities. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 21 The inspector met one of the homes two handymen. They maintain the home to a good standard and do all sorts of jobs like clearing leaves from the garden and undertaking safety checks. Staff report, in a book, anything which needs fixing. The inspector mentioned a cracked windowpane to the manager. She trusts this will be replaced promptly. The home is clean and hygienic with no unpleasant odours. A cleaner is employed. The garden at the home is small but neat and pleasant and the home is located opposite the open spaces of Wanstead flats. Chase (The) DS0000041012.V353066.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff at the home are competent and experienced, but they must have the appropriate up to date training required to do their jobs. EVIDENCE: The staff at the home have generally been working there, or with the company for a number of years. The company runs a bank system where staff can apply to undertake shifts at other homes, so they broaden their skills and get to know other service users. The inspector viewed the personnel files of three staff members. They were untidy because the folders didnt hold the papers together properly, and the manager said they are going to be replaced soon. The inspector formed the view that recruitment procedure at the home is now sound, although it might have been less stringent years ago when some of the staff were recruited. The home now requires two professional references as well as the usual checks, Criminal Records Bureau Disclosure (CRB) etc. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 23 The manager said that NVQ 2 is now an application criterion. The inspector noted that the staff whose files she viewed have had a broad range of training. However the manager and inspector agreed that the following are basic training which must be renewed every year or when the certificates expire: Adult Protection First Aid Fire Health and Safety Food Hygiene Medication / or an annual competency assessment The three staff files inspected did not evidence the above training to be up to date. The manager must ensure that all staff working at the home receive the above training as specified, annually or when the last certificate expires. A previous restated requirement that staff possess a valid first aid certificate has not been met, one carer had First Aid training in 2006 and two in 2005 (see requirements). Chase (The) DS0000041012.V353066.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 adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run and measures are in place to assure quality. However there are a number of repeated requirements regarding safety. EVIDENCE: The manager is very experienced and the inspector believes based on this inspection that the home is generally well run. In his AQAA the manager stated that the home receives a monthly unannounced visit from an independent person as a form of quality control. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 25 The inspector viewed evidence of the annual quality assurance audit which is undertaken internally on the homes in the group. It is an independent audit undertaken by a manager from another home. The manager stated that the home is planning to run a quarterly relatives forum. This is a new initiative and the usefulness as a quality assurance tool cannot yet be estimated. The inspector applauds the above relatives forum initiative but recommends that the manager devise additional alternative ways to collect the views of service users and stakeholders for quality assurance purposes (see recommendations). The inspector viewed evidence of safety checks on, the radiators, water temperature and fridge and freezer temperatures. The fire protection systems are also checked. The emergency lighting, smoke alarms and glass covered alarm points are checked monthly, fire extinguishers annually. A fire drill is held every month and the evacuation time and any issues are noted. The first aid box is checked regularly and a visual check is made for trip hazards. Maintenance checks are made on the minibus. Records are kept of all these checks. The inspector asked the manager how the home manages the Control of Substances Hazardous to Health (COSHH). He stated that COSHH items are locked away in a shed in the garden and only small quantities are brought into the house for immediate use. The cleaner has a lockable cupboard for preparations she uses. However the home does not currently keep a data sheet for all products stored. The manager agreed to seek data sheets for all the products used (see requirements). The manager stated that he intends to teach himself how to test portable electrical appliances with the help of a DVD. The appliances were last tested on 10/02/05 and must be tested again as soon as possible (see requirements). The manager stated that an independent contractor tested the gas safety (i.e. the boiler) in May 2006, but there was no certificate available to evidence this. Also the safety test should be carried out every year. Similarly there was no certificate available to evidence that the hard wiring electrical installation has been recently tested. The manager stated that the hard wiring was tested in 2006 and lasts two years. Proof of this is needed (see requirements). Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 26 Chase (The) DS0000041012.V353066.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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 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 x 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 Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 YA23 Regulation 13(6) Requirement Timescale for action 01/12/07 2. YA35 A hard copy of the adult protection policy and procedure must be available in the home at all times. 18(1)(c)(i) Adult Protection First Aid Fire Health and Safety Food Hygiene Medication / or an annual competency assessment The manager must ensure that all staff working at the home receive the above training, annually or when the last certificate expires. The manager must ensure that all staff possess a valid first aid certificate (previous timescale of 31/08/06 and 15/01/07 not met) The manager must seek data sheets for all the COSHH products used in the home. The portable electrical appliances must be tested (previous timescale of 31/07/06 not met). The registered manager must ensure that the landlord’s gas DS0000041012.V353066.R01.S.doc 01/03/08 3. YA35 18 (1)(c) 01/12/07 4. 5. YA42 13(4) 13(4) 01/12/07 01/12/07 YA42 6. YA42 13(4) 01/12/07 Chase (The) Version 5.2 Page 29 safety test is renewed (previous timescales of 31/07/06 and 15/01/07 not met). The electrical installations certificate must have an accompanying letter from the engineer stating the valid period for the certificate (previous timescale of 31/07/06 and 15/01/07 have not been met) 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 YA20 YA39 Good Practice Recommendations The manager and staff must ensure that any irregularities in the administration of medication are clearly handed over on the MAR sheets. The manager should devise ways to collect the views of service users and stakeholders for quality assurance purposes. Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Chase (The) DS0000041012.V353066.R01.S.doc Version 5.2 Page 31 - 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. 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