Inspection on 12/10/06 for Closereach

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Closereach 26/01/06

Closereach 02/09/05

Closereach 27/10/04

Closereach 26/05/04

Closereach 08/10/03

Similar services:

Clouds House

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

CARE HOME ADULTS 18-65 Closereach Longcause Plympton St Maurice Plymouth Devon PL7 1JB Lead Inspector Megan Walker Unannounced Inspection 12th October 2006 10:00 Closereach DS0000003532.V308203.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 Closereach DS0000003532.V308203.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. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Closereach Address Longcause Plympton St Maurice Plymouth Devon PL7 1JB 01752 348348 01752 347555 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) Broadreach House Services Vacancy Care Home 17 Category(ies) of Past or present alcohol dependence (17), Past or registration, with number present drug dependence (17) of places Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Male only Age 18yrs Date of last inspection 26th January 2006 Brief Description of the Service: Closereach is one of three residential centres owned by Broadreach House Services. The company is a registered charity, overseen by a board of trustees, and provides a range of services in Plymouth for the treatment of alcohol and drug dependence. Closereach is registered for continued treatment (post first stage detoxification) for drug and alcohol dependence for up to seventeen males over 18 years of age and up to of 65 years of age. It is a short stay centre, usually between three to six months. The house is situated in Plympton St Maurice and is arranged over three floors. The ground floor consists of offices, laundry, dining room, kitchen and two lounge areas that are also used for group meetings. The first floor has residents’ accommodation and shower and toilet facilities. The top floor has an office and an area that can be used as a meeting room. The home has a manager, a team of counsellors to run the programmes of care designed for the residents, and other support staff to ensure the home runs effectively on a day-to-day basis. Closereach is not registered to provide nursing care. The current fee at Closereach is £473.00 per week. This information was provided by the Manager in the Pre-Inspection Questionnaire received by the Commission in October 2006. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit of this inspection took place on 12th October 2006 over a period of about eight hours. It included a tour of the premises, observation of staff and residents in the home, talking to residents and to staff, case-tracking residents, inspection of care plans, staff files, medication, and other records and documentation. The Manager was present at the time of this fieldwork inspection visit, and part of the time was spent talking with him about the dayto-day routines as well as the management of the home. In addition other information used to inform this inspection: • The Pre-inspection Questionnaire completed by the Manager. • Of thirty-one Comments’ Cards sent out the Commission received back one from a Health and Social Care Professional in Contact with the Home, one from a Care Manager/Treatment programme Officer, one from a General Practitioner, and two Care Workers Surveys. • Also taken into account were the previous two inspection reports and all other information relating to Closereach received by the Commission since the last inspection. Four “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The interior of the building is in need of a face-lift. The general environment was shabby and did not encourage respect to clean and look after it. For example, carpets had holes or were frayed causing potential trip hazards, furniture needed replacing, the toilets and shower room were institutional in style, all the showers had black mould building up around the bases, a urinal and the washing machine were leaking, doors did not have suitable fire safety door closures, and chairs were stacked and stored in a corridor and one of the lounges. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 6 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. Closereach DS0000003532.V308203.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 Closereach DS0000003532.V308203.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): 1, 2, 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about the home. EVIDENCE: Each resident had a thorough assessment of need before being accepted at Closereach. Prospective residents were able to have an overnight stay if this was practical and feasible as well an informal visit. At the time of this inspection the process of assessment was under review and it was expected that it would be centralised at Broadreach House for all four Broadreach House Services’ centres, including Action For Change and the Quay Project. This new system could include assessment by telephone as well as consultation with the care manager and a meeting (if possible) with the prospective resident. The manager was hopeful that a centralised system with two assessors could potentially generate more information to inform the treatment programme. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 9 Each care file inspected had a contract with terms and conditions of the treatment programme. New residents were given clear information about the purpose, duration and requirements of the programme, including any restrictions of liberty, and circumstances/behaviour that would result in a resident being asked to leave the treatment programme. Closereach DS0000003532.V308203.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, 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are involved in their individual plan of care and are supported and encouraged throughout the treatment programme. EVIDENCE: Residents were enthusiastic about their treatment programmes at Closereach. Three independently acknowledged that they had “learnt a lot”; “it was a good experience”; “learning to break old habits” and make changes that would improve daily living such as getting on with tasks rather than putting them off until they became overwhelming. Residents were supported and encouraged to manage their own daily routines and personal decision-making within the restrictions of the treatment programme. Care plans inspected were thorough in identifying individual needs and how these could be met. Each resident was also involved in the review of his individual care plan on a regular basis. The care plans also Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 11 included medium to long-term goals so each resident was working ultimately towards his discharge plan. Those residents spoken to identified clearly their wishes for the future after they left Closereach. Closereach DS0000003532.V308203.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, 15, 16, 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents have a variety of opportunities for personal development as well as leisure activities as part of the treatment programme and on which they can build after they leave Closereach. EVIDENCE: On the day of this fieldwork visit there was a lively atmosphere in the house in anticipation of a football match between residents and staff versus a local community based team. There were several comments from residents about how unfit they felt and light-hearted bemoaning about weight gains “because the food is excellent”. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 13 The manager explained that on admission a lot of residents are malnourished with poor appetites, fragile skin tissue, and generally deficient healthcare. They are therefore offered a well-balanced diet with a choice of meals and special diets are catered for. The menus are changed every four weeks and also to accommodate any new residents. The cook confirmed that she setting up the kitchen using the guidance of the “Safer Food, Better Business” in conjunction with meetings at the home with the Environmental Health Officer (E.H.O.). The cook also explained how each resident had in-house training in Basic Food Hygiene following a recommendation by the E.H.O. because residents assist with meal preparation, particularly at weekends, as part of their treatment programme. In light of this the cook also pointed out that it was recognised that catering equipment was unsuitable so domestic size and style items such as a food mixer, had been purchased. Each resident was given a certificate on completion of the in-house training course and these were seen as part of this visit. To ensure that residents could fully participate in community support groups such as “Alcoholics Anonymous” and “Narcotics Anonymous”, each resident was provided with a bus pass to travel within the boundaries of Plymouth. Restrictions on going out alone or accompanied were decided as part of the individual’s care plan, as were relevant activities such as access to the local College of Further Education and involvement in voluntary work placements. The contracts issued when a resident entered the home clearly stated the restrictions that would apply during the programme. Most of the residents shared rooms. They did not have keys to their rooms (agreed as part of the treatment programme), however they could personalise them to suit their preferences. One resident, for example, showed the inspector a picture he was intending to hang over his bed. A list of household tasks was displayed on the notice board and after lunch this was the subject of frivolous squabbling between residents and who was better at which chore! These tasks were again part of the treatment programme and residents were informed at the start of their treatment programme that they would be expected to be part of the rota. One resident in spite of disliking washing up said that having to do household tasks was helping him learn how to look after himself and would benefit him when he left Closereach. Staff comments both verbally and written indicated that levels of cleanliness were very much dependent on whose turn it was to clean although everyone was encouraged to keep the house clean and tidy. Occasionally residents are required to open their post in front of a staff member; the reasons for this were set out in the Service Users Guide. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 14 Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a supportive and reliable staff team will ensure that their personal, physical and emotional health care needs are met. EVIDENCE: At the time of this fieldwork inspection visit all the residents were independent with their personal care. As part of the treatment programme each resident attended group sessions as well as individual counselling sessions. They all kept a daily diary that was seen by the manager and could be used in individual counselling sessions. Residents were encouraged to participate in group sessions and one of the counsellors explained that generally others in the group would object if they felt someone was not contributing. This might be taken up in an individual counselling session to explore why an individual was withdrawing rather than contributing to group sessions. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 16 Care plans inspected showed long-term aims as well as immediate issues. Generally after care was part of the assessment process so residents started their treatment programme with an outcome in mind. Residents spoken to talked about their aspirations for after the treatment programme and how as part of their individual programmes they were working towards, for example, supported living and attending “Action For Change” at Ocean Quay (a day centre providing ongoing support for people post treatment programme). A member of staff commented positively that the pace at Closereach enabled both staff and residents to take a relatively long term approach in dealing with issues, and that this was important given that referrals came from a variety of backgrounds (e.g. prison discharges, community social workers, probation officers and Broadreach House -Stage One in treatment and recovery of substance dependence). The Comments Card received by the Commission from a local General Practitioner (GP) confirmed that in the GP’s opinion the staff at Closereach demonstrated a clear understanding of the care needs of the residents, and in response to the question “ Are you satisfied with the overall care provided to the residents within the home?” the GP confirmed “Yes” and “Excellent”. A Comments Card received from a Social Worker stated that they had received good feedback from two clients placed at Closereach, and an overall comment about visits to Closereach was “ I have been impressed with the service provided”. Medication was seen stored in a locked, fixed cupboard. Residents are responsible for taking their own medication. It is given out on a daily basis except at weekends when two days doses are given. The resident signs to confirm receipt of the daily medication and the member of staff on duty at the time also signs to confirm that the medication was given to individual. The amounts of prescribed medication are maintained at a low level and are monitored regularly. At the time of this fieldwork visit all the staff were undertaking a medication management course. Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents feel that they are listened to and that they are protected from abuse, neglect and self-harm. EVIDENCE: Residents were able to express their views in both group sessions and in one to one sessions with a counsellor. They could also speak to the manager if they had particular issues. The manager explained that other residents and/or staff sometimes might challenge views of another resident because those opinions may be inappropriate and could be reflecting other issues that the person was dealing with at that point in time in their treatment programme. Since the last inspection a former resident had died because he had taken a drug dose the same as that when he was “using”. A staff member said that all the residents were warned about the possible consequences, potentially death, if taking alcohol and/or drugs again after a period of detoxification and sobriety. Closereach DS0000003532.V308203.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, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The environment at Closereach is shabby and does not promote respect and a willingness to care for it. EVIDENCE: A tour of the premises found it generally to be tired and shabby. The building has high windows and ceilings that could be striking and attractive however were daunting and added to the institutional feel of the building because it was painted in dark colours with little additional homely features such as pictures on walls, plants and other soft furnishings. Although it was relatively clean and tidy, it needed redecoration and refurbishment throughout. All the carpets needed replacing or removing as they were worn and in some places had holes, or were frayed or split causing potential trip hazards. In discussion with different staff members they suggested that wooden floors Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 19 would be more practical to maintain and keep clean, although it could increase the noise levels within the building. The armchairs were well used and worn-out from daily use for both relaxation periods as well as group sessions. There seemed to be limited places for storage so hardback chairs were seen stored precariously stacked in one of the lounges, and also on the first floor landing between two fire doors. It was unclear from a conversation with the manager and staff about these chairs if they were actually necessary or regularly used. The showers had an institutional style and did not promote privacy and dignity for residents. The sealant around the showers needed to be renewed and there were areas of black mould around shower bases. There was no bath to offer residents a choice of bath or shower. The toilets were more akin to a public toilet with urinals and individual toilet cabins. The flooring in the toilets was wet from a leak as was the laundry floor because the washing machine was leaking. A resident confirmed that the washing machine had recently been repaired however the repair hadn’t lasted very long. Both the washing machines and tumble driers were domestic in size. Both the toilets and the laundry room required new floor covering. Residents’ bedrooms reflected individual personalities and to some extent were personalised although this was limited due to treatment programmes being short term and most residents share bedrooms. Doors did not have fire safety closures and evidence of door wedges being used was seen during this visit. The meeting room/library on the top floor was cluttered with a number of full black bin bags and did not seem to be a room in regular use other than for storage. Closereach DS0000003532.V308203.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): 32, 34, 35,36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are cared for by qualified and motivated staff that are well supported and supervised. EVIDENCE: At the time of this fieldwork visit six people were employed to work at Closereach and other staff from within the Broadreach House Services supported them. Additionally there was a third year university Psychology student on treatment programme at Closereach for a year. Staff records inspected and the Pre-Inspection Questionnaire showed that all the staff were appropriately qualified for their jobs. Additionally since the last inspection staff had attended an Intermediate Course in Food Hygiene, and ongoing was an ASET course on Health and Safety in the Workplace. The manager and two counsellors all of whom had responsibility for medication were continuing with a Certificate in the Managing and Safe Handling of Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 21 Medicines. Staff additionally had training in First Aid and Fire Safety Awareness. Inspection of staff files also found that all necessary recruitment checks had been done. Staff had contracts with job descriptions and terms and conditions of employment. One staff member had transferred from another Broadreach House Services centre and the manager was made aware at the time of this inspection fieldwork visit that the contract needed to be updated to reflect the change of place of work. The staff confirmed that they had regular staff meetings, and they received regular formal supervision. They said could also seek “adhoc” advice from the manager when required. The manager during a separate conversation about supervision was encouraged to routinely keep records for the formal sessions with all staff, and if appropriate the “adhoc” discussions too. He explained that the Chief Executive was approachable and supported him in his position as manager although he didn’t have regular formal supervision. As part of this conversation the manager was also encouraged to seek an alternative working practice such as working at home one day a week to ensure that he maintained a work-lifestyle balance. The manager and the two counsellors operate an “on-call” system that covers evenings, overnight and weekends. The residents had an “Out of Hours” contact telephone number that would put them through to the Duty Person. The manager was confident that this system worked as residents knew that it would be one of the three “treatment” staff who would respond. Closereach DS0000003532.V308203.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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents benefit from the ethos, leadership and management of the home because it is transparent and promotes their health, safety and welfare. EVIDENCE: The Manager is popular and approachable. This was shown in conversations with staff and residents, and observation during the inspection fieldwork visit. He is appropriately qualified, competent and experienced for his role as a counsellor and as the manager of the home. The home is run in an open and transparent way with responsibilities delegated appropriately amongst staff. Residents were aware of boundaries and restrictions imposed upon them, and Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 23 had these explained to them both at the beginning of their treatment programme as well when required during the treatment programme. In some cases it was recognised by the manager and staff that circumstances of an individual being referred to Closereach could cloud his opinion of the treatment programme. For example, someone on a Drug Rehabilitation Order with a longstanding history of substance misuse and associated criminality might perceive the manager and staff as “authority” so compliance with the restrictions of the programme possibly would be limited. All the staff as well as the manager however kept a consistent approach to all residents in encouraging them in their recovery. The manager stated that it was important that residents understood that it was their own optimism and will for the treatment programme to work that made it work, and that Closereach was an aid in their recovery. The Chief Executive visits Closereach on a monthly basis specifically to spend time with residents, collectively and individually, seeking their views and opinions about the home. The Commission receives “Regulation 26” reports (i.e. visits by Registered Provider) from these visits. Referrals to Closereach come from all over England. A wide network of social workers and probation officers as well as other referring authorities therefore use Closereach as part of the plan of care to meet assessed needs of their clients. This network forms part of the quality monitoring of the service as it also acts as a national grapevine promoting good practice or occasionally raising concerns about possible poor practice. Such incidents were clarified and resolved because Broadreach House Services is an approachable organisation that communicates its responsibilities to achieve its aims and objectives in the treatment of people who are dependent on alcohol and/or drugs. An independent research project was starting at the time of this fieldwork inspection visit. A third year student of Psychology was looking at reasons why some residents did very well when they left Closereach, and why others did not succeed and returned to “using” again. This research work was expected to be over a period of a year and the results would be used to inform the practice of the service. Closereach DS0000003532.V308203.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 4 2 4 3 X 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 4 4 X X 4 X Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard YA24 Good Practice Recommendations The premises should be refurbished and redecorated throughout with good quality furnishings, fittings, adaptations and equipment that promote a style and ambience reflecting the home’s purpose. The leaking urinal and washing machine should be repaired or replaced to prevent accidents caused by slipping on wet floors. Residents’ toilets and bathrooms should provide sufficient personal privacy and meet their individual needs. The Registered Provider should consider the installation of at least one bath to provide residents with a choice for washing. The sealant around the showers should be renewed and the black mould cleaned to prevent risk of cross-infection. 2. 3. 4. 5. YA24 YA27 YA27 YA30 Closereach DS0000003532.V308203.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Closereach DS0000003532.V308203.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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