Inspection on 19/07/07 for Church Avenue (12)

This inspection was carried out on 19th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Church Avenue (12) 26/07/06

Church Avenue (12) 08/02/06

Church Avenue (12) 28/11/05

Church Avenue (12) 07/02/05

Church Avenue (12) 07/10/04

Church Avenue (12) 02/03/04

Church Avenue (12) 14/10/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Church Avenue (12) 12 Church Avenue Harrogate North Yorkshire HG1 4HE Lead Inspector Mrs Irene Ward Key Unannounced Inspection 19th July 2007 09:30 Church Avenue (12) DS0000007886.V343651.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 Church Avenue (12) DS0000007886.V343651.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. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Avenue (12) Address 12 Church Avenue Harrogate North Yorkshire HG1 4HE 01423 531386 01423 541889 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) Henshaws Society for Blind People Mr Iain Houston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 6 residents with Learning Disabilities all of whom also have a Sensory Impairment Date of last inspection Brief Description of the Service: 12 Church Avenue is operated by Henshaws Society for Blind People and is registered to provide personal care for 6 younger adults aged 65 years and under who have learning disabilities with an additional visual impairment. The house is situated within walking distance of Harrogate town centre and there are local amenities close by in Bilton. It is a large three storey semi-detached house with a small garden to the front and rear paved area. All bedrooms are designed for single occupancy. The weekly fees on 19th July 2007 range from £625 to £750 and do not include costs for chiropody, toiletries and activities. People who use the service/relatives and other interested parties are able to have access to inspection reports by requesting them from the home. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • • • • A review of the information held on the homes file since its last inspection. Information submitted by the registered provider in the Annual Quality Assurance Assessment report. Surveys received from six people who use the service, two relatives and one care manager. An unannounced visit by one inspector to the home lasting three hours. This visit included a tour of the premises; examination of records, observation of care practices and talking to three people, care staff and management. A visit was carried out to the support services office to look at staff files. Looking at two people’s care files in detail. • • What the service does well: The staff at 12 Church Avenue continue to provide a clean, warm and comfortable home for people to live in. People at 12 Church Avenue have a sense of ownership about living there. The home is like a shared house rather than a registered care home and those living there are able to make decisions about themselves and the household with the support of staff and the manager. A relative’s written comments summed this up, “I have filled in the enclosed form with some reservations as I don’t think this form is appropriate to the type of community housing in which our (relative) lives”. “I should like to make it clear that I have the highest regard for Henshaws Society for the Blind, who run Church Avenue, and for the wonderful people who enable our (relative) and housemates to lead such independent and fulfilling lives”. Another relative said, “Fantastic care is given to our (relative) who is really happy there. Staff are fantastic, friendly, helpful and really encourage our (relative). The set up in the house and staff are excellent”. A care manager said, Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 6 “Provides a specialized service to people with visual impairment, which enables residents to live as independent life as possible. Overall the service provided has been excellent, the service user and family are extremely happy with the existing arrangements and have no complaints whatsoever.” The manager and staff are committed to providing care and support which helps each person to be as independent as they can, and some good examples of this were seen. Members of staff were observed to provide appropriate care when supporting people in maintaining their independence in daily tasks. People living at Church Avenue when spoke to said, “It is still brilliant living here at Church Avenue,” another said, “ I am really happy living here, staff are great”. 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. Church Avenue (12) DS0000007886.V343651.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 Church Avenue (12) DS0000007886.V343651.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. People who use the service experience excellent quality outcomes in this area. People’s needs are properly assessed prior to admission, this makes sure 12 Church Avenue is the right place for them to live. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service user guide. Both these documents are available on audiotape, Braille and large print. There have been no new admissions into the home for sometime. The manager confirmed if there was a vacancy people would be given the opportunity to visit the home and stay for a meal or overnight or a weekend, whatever they felt comfortable with. Two people’s files were looked at. Both files held initial assessments, care plans or (Individual Service plan) and risk assessments. Each person had an individual statement of terms and conditions or licence agreement, which had been agreed between the home and the person living at the home and was held on their individual file. A care needs assessment from local authorities was also in place where necessary. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 9 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. People who use the service experience excellent quality outcomes in this area. The care provided to people was good and encouraged them to make their own decisions about how they wanted to live their lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Whilst staff were supporting people during the morning it was clear they understood individuals needs. They supported people sensitively and encouraged them to make choices. Three people who were in at the time of the site visit were spoken to. People looked well cared for and made comments about the care they received. One person said, “It is still brilliant living here at Church Avenue” another said, “I am really happy living here, staff are great”. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 10 The care plans of two people who live at the home were looked at. These detailed how needs had been assessed and what actions were needed to meet these identified needs. Care plans also detailed people’s likes and dislikes, history and medical appointments, daily and weekly programmes and if people are able to spend time alone in the house. Individual risk assessments had been carried out to promote independence and safety. People’s care plans are written with them, reviewed regularly and audited monthly by the homes manager. The organisations scheme manager also audits them regularly. Through discussion with the manager and the contents of the care plans it was clear that people are able to make clear choices. People who use the service are continually consulted on a regular basis about how the home runs and have the opportunities to voice their views. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 11 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 who use the service experience excellent quality outcomes in this area. People who use this service are able to make choices about their lifestyle and are supported by staff to carry these out. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at the home have the opportunity to attend specialist day centres, college or work placements and have days at home to participate in personal shopping, laundry and household tasks. They have also opportunities to pursue other interests outside of the home. A number of them continue to enjoy visits to the local pubs, gym and other community facilities. Some like walking with the organisation Open Roads and also some people from the house are volunteers and do some clearance work, in making accessible routes for various disabled groups. All of the people living at Church Avenue also enjoy cycling. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 12 Four people from the house had recently completed a tandem marathon with the organisation (BOLD) Blind outdoor leisure development. People who live at the home had also had been away on holiday the previous week. All of them had been to Brittany for the week. Three of the people who were in at the time of the site visit were very enthusiastic about the holiday that they had just had, and said that they had thoroughly enjoyed every moment including the good weather that they had. It was clear on the day through the discussions with the manager and people who live at Church Avenue that they are given every opportunity in accessing community facilities. The manager said that people had become even more independent. The example given was that people from the home now go out shopping on their own via taxi or bus. The home liaises with customer services at the supermarket for them to provide assistance. This allows people from the home to be more independent without any assistance from staff. Observation of care practices in the home shows that people living at the home are able to make their own decisions, that they are able to choose their daily routines as they wish and made comments that they are encouraged to be independent. People who live at the home have been given opportunities in accessing both training and job opportunities. Examples of this were one-person works half a day in a local café, whilst another person works two days putting letters/ leaflets into envelopes. There was written information /weekly plans in people’s care plans / Individual Service Plan on how people spend their days. These arrangements are discussed with people who use the service and their representatives and staff. Details about family, friends and significant events are recorded in the plans. People who live at the home are able to plan their own menus, in advance and shopping was purchased on a weekly basis. They also cook their own meals. One person at the home enjoys baking and a staff member comes in twice weekly to assist them. Relatives commented positively via surveys sent to them and made comments such as; “Activities - varied activities, my (relative enjoys the gym, bike riding, going to the cinema, visiting the pub. Diet – encourages my (relative) to eat healthily and also assists my (relative) in learning new recipes”. Another relative said, “Small unit. Happy atmosphere. Excellent support staff”. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 13 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 who use the service experience good quality outcomes in this area. Service users’ personal and healthcare is provided appropriately and sensitively according to individual needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff aimed to promote the independence of people who use the service and to provide support in a sensitive manner. People’s preferences as to how they wished to be supported were recorded within individual care plans. Daily record entries reflected the care that was being provided. Each person living at the home had a GP and access to chiropody, dental and optical services. People living at the home attend Harrogate District Hospital for all A & E (Accident and Emergency) and for most out patient appointments. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 14 Three of the people living at Church Avenue require medication. All three people self-medicate. A dossett box system is in place. People are then given their dosssett box. Risk assessments have been completed and are regularly reviewed. People who take medication keep it in their own rooms and lockable facilities are provided. Although people who live at Church Avenue currently are able to self-medicate there is a policy in place for the storage and administration of medication. The Medication Administration Records were up to date and well maintained. All staff that administer medication have undertaken accredited training although currently the staff no longer administer any medication. The home does not hold any controlled drugs. One relative commented about personal health care needs regarding their relative, who lives at Church Avenue and said, “We are happy with the level of care and support our (relative) receives. However, as a result of the emphasis in independent living (which we fully support) it can happen that small, personal problems (e.g. toenails needing cutting) can be missed, if (like our relative) you are unwilling to ask for help”. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 15 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 who use the service experience excellent outcome in this area. People who use the service have access to an effective complaints procedure and are protected from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who use the service are provided with a complaints procedure, which is produced in different formats such as Braille, large print or audiotape. The complaints procedure is also summarised within the service user guide and people knew whom they needed to speak to if they had a complaint and felt confident that any concerns would be addressed properly. One person said, “If I had any concerns or a complaint I would go straight to the manager”. One complaint has been received by the Commission For Social Care Inspection, which had been investigated appropriately by the organisation. Following the discovery of some financial irregularities, that concerned people’s monies, which were commented on at the last inspection. The organisation instigated a full audit by an outside organisation into improving how people’s personal allowances are maintained. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 16 Recommendations were made about recording and were implemented making recording more clearer. There is a comprehensive policy and procedure with regard to adult protection and staff have a good awareness of this. All staff receives training in adult protection issues during induction and further training organised by the organisation. The recruitment procedure continues to be robust, and ensures that only suitable people are employed, which helps to safeguard people from abuse. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 17 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 who use the service experience good quality outcomes in this area. People live in a clean, comfortable and safe home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home provides spacious accommodation for people. This includes a lounge and a large kitchen/diner on the ground floor. The home is clean and comfortable. It is decorated and furnished to a good standard. The home has sufficient bathrooms and toilets that were clean and well maintained. People who use the service have single bedrooms. One bedroom on the ground floor has en-suite facilities. There is on site car parking to the rear of the property. However the carpet on the stairs was worn in several areas. This may have safety implications for the people living at the home and needs to be replaced. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 18 Three people showed the inspector their bedrooms, all rooms had been personalised with posters and their various possessions such as CD players, television and items they had collected and made. Rooms have been decorated and furnished appropriate for their age. One person’s bedroom carpet had recently been cleaned. However the carpet has become worn and needs to be replaced. Also the base of the bed had been damaged and repairs had been done, although these were not satisfactory and the base needs to be replaced with a new one. Another person had broken the base of their bed, and this was replaced with a new bed at the time of the site visit to the home. There were also discussions with the manager about people’s bedding. Such as pillows and duvets. The one’s seen on the day in some rooms were stained and needed to be washed or replaced. The manager said that they were hoping that next year the kitchen would be replaced, as it is outdated and improved by giving people who use the service even more space. A range of maintenance checks is completed on a regular basis to make sure that the house is safe and secure. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 19 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. People who use the service experience good quality outcomes in this area. Sufficient staffing levels, proper recruitment procedures and good staff training meant that people’s needs were met and their interests were safeguarded. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staffing levels were sufficient for meeting the needs of people who live at Church Avenue. Following a recommendation made at the last inspection where it was found the duty rota did not reflect accurately the number of staff working, the duty rota was checked. The rota seen was accurate as to who was on duty on the day of the site visit. The rota showed that there were two members of staff on duty both in a morning and evening when people are at home doing their living skills. This does not include the manager’s hours. In an afternoon through to the evening there are also two staff members on duty. This is increased at peak times such as evenings and weekends if people are going out, as staff rotas are based around what people living at the home are doing. This makes sure that people’s social activities are not compromised. At Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 20 night there is one member of staff on sleeping-in duties. The organisation operates an on-call service in case there is an emergency. The staff files of two members of the staff team were looked at. These showed that all the necessary pre-employment checks had been carried out prior to the new workers starting in post. All staff files are held centrally at the providers support services office, which is now based on the campus of Henshaws College. Staff training records examined showed a good training programme. Staff have undertaken training in health and safety, fire safety, moving and handling, first aid, food health and hygiene, protection of vulnerable adults and equality and diversity, (VIAT) visual impairment awareness training. Two staff have completed the (NVQ) National Vocational Qualification Level 2. Two staff are to commence NVQ Level 2 in September of this year. The registered manager has completed the National Vocational Qualification Level 4 Registered Managers Award. Staff receive regular supervision every 6-8 weeks and annual appraisals are carried out. Staff meetings are held regularly and minutes of meetings are recorded. Records of supervision were seen on both staff files. Surveys sent to relatives and care managers were positive and comments made were such as; “Fantastic care is given to our (relative) who is really happy there. Staff are fantastic, friendly, helpful and really encourage our (relative). The set up in the house and staff are excellent”. Another relative said, “Very professional, very caring staff”. A care manager said, “Provides a specialized service to people with visual impairment, which enables residents to live as independent life as possible. Overall the service provided has been excellent, the service user and family are extremely happy with the existing arrangements and have no complaints whatsoever.” Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 21 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. People who use the service experience excellent quality outcomes in this area. People benefit from a well managed home in which their needs and wishes are put first. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information provided from the (AQAA) Annual Quality Assurance Assessment and the examination of selected health and safety documents show that regular checks to electricity and gas and fire safety equipment are regularly undertaken. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 22 The home has a good and effective management team in place. The ethos of the home is open and positive. People who use the service and relatives all commented highly about the home. People who use the service are able to voice their views at regular house meetings. People’s finances were not checked at this site visit as a full audit had been completed by an outside organisation. An accident book is maintained in line with the requirements of Data Protection. Quality Assurance systems are in place. A manager’s monthly visit is carried out and a report is written. This is carried out by one of the managers from another of the community houses. A copy of the report is then sent to the Commission for Social Care Inspection. The schemes manager carries out regular three monthly visits to the home and reports are completed and a copy sent to the Commission. Record keeping is of a consistently high standard. One relative commented on how they felt the home could improve and said, “Small scale community housing of this kind with good staff is probably as good as it gets. One suggestion though – a monthly/quarterly/occasional round –robin newsletter/ e-mail from the house to parents/siblings/grandparents etc – to tell us about all the exciting goings on that our (relative) has neglected/forgotten to mention during phone calls”. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 23 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 X 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations The stairs carpet needs to be replaced to make sure that people living at the home and staff are not put at risk. The bedroom carpet in one room needs replacing as the carpet has become worn. Also the base of the bed in the same room needs replacing as it has been damaged and the repairs made are not to an acceptable standard. Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Church Avenue (12) DS0000007886.V343651.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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