Inspection on 12/10/06 for Colham Road, 3

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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colham Road, 3 15/08/07

Colham Road, 3 06/04/06

Colham Road, 3 01/11/05

Colham Road, 3 16/05/05

Colham Road, 3 21/10/04

Colham Road, 3 10/06/04

Colham Road, 3 19/01/04

Colham Road, 3 10/12/02

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 Colham Road, 3 Hillingdon Middlesex UB8 3UR Lead Inspector Robert Bond Key Unannounced Inspection 12th October and 13th November 2006 10:00 Colham Road, 3 DS0000032552.V310937.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 Colham Road, 3 DS0000032552.V310937.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. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colham Road, 3 Address Hillingdon Middlesex UB8 3UR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 271 245 01895 236 588 London Borough of Hillingdon Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to care for no more than 13 adults with a learning disability. Of those 13 adults, no more than three may be accommodated on a respite basis. 6th April 2006 Date of last inspection Brief Description of the Service: 3 Colham Road is managed by the London Borough of Hillingdon and owned by the Health Authority. It provides residential care for ten permanent and three respite care service users. The service users have profound multiple learning, sensory and physical disabilities. All are non-verbal and two require PEG (pecutaneous endoscopic gastronomy) feeding. The home was purpose built in 1987 and is set on one floor, divided into four units: North, South, East and West Lodges. Each lodge is designed for three or four service users and leads out to an attractive central courtyard, laid out with paved sitting areas and fringed with shrubs and trees. Each lodge is self - contained with a lounge, kitchen/diner, bathroom with toilet facilities and single bedrooms for each service user. All the bedrooms are attractively decorated with individual colour schemes and furnishings. Seven of the bedrooms do not meet the National Minimum Standard of 12 square meters for service users needing to use a wheelchair within their bedroom. All service users attend day centres, for which The London Borough of Hillingdon provides a special minibus. Service users attend medical appointments and use the homes specially adapted transport for this. The home is set in its own large grounds near Hillingdon Hospital and is about three miles from central Uxbridge. The home has ample parking facilities and is easily accessed by public transport. The staff team consists of one Manager, four full-time team leaders (two of whom are seconded from Merriman’s whilst that home is refurbished), seventeen residential workers, five night workers, one domestic, one full time administrative officer and one part time handy person. The home is currently accepting additional respite care service users whilst the Merrimans home is being refurbished. 3 Colham Road is currently regularly using a large number of agency staff to support the permanent staff team. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection that looked only at the ‘key’ standards contained in the National Minimum Standards (NMS) for care homes for younger adults, published by the Department of Health. The Inspector assessed the homes performance against the expected outcomes for 23 NMS, and found that 17 were fully met, whereas 5 were only partly met, and 1 was not met. This led the Inspector to make 12 requirements and 1 recommendation. To undertake the inspection, the Inspector visited the home on two occasions as the Registered Manager was on leave on the first occasion. The Inspector toured the premises, interviewed the Registered Manager, met two service users, talked to staff members, examined a variety of records and ‘casetracked’ two care files. Seven of the bedrooms are under the minimum size permitted by the NMS. The London Borough of Hillingdon, who operate the home, are aware of this major shortcoming, and plans have been considered to refurbish the home to a modern standard. The other major shortcoming relates to the number of staff vacancies and the high use of agency employees. Of the 28 care posts at the home, 10 full time equivalent posts are vacant, and the holders of a further three posts are absent part of each week due to their secondment onto professional qualification training courses. These two major shortcomings reduce the overall CSCI assessment of the home, which would otherwise be higher. Both aspects are outside of the control of the Registered Manager who has succeeded in achieving 13 out of the 16 requirements made at the previous CSCI inspection, and has also met the four recommendations made at that time. What the service does well: What has improved since the last inspection? Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 6 Most of the placement agreements in use for service users resident in the care home have now been updated using an improved format. The system of risk assessments of service users has been improved. All the service users now attend day centres. Additional training has been organised on the Protection of Vulnerable Adults (Safeguarding Adults). Nursing equipment is no longer stored in a service user’s bedroom. Additional areas of the home have been redecorated. The care files and care plans for service users receiving respite care have been improved and brought into line with those used for long-term service users. All long-term service users have an allocated key worker. Long-term service users have their care plans reviewed internally at least every six months. All except two long-term service users have a person-centred plan in place. What they could do better: The client profile of each service user must contain a recent photograph of the service user. It is recommended that the care files for each service user are more clearly labelled to show which is the current file, and which is the original file. The records of food and drink consumed by service users receiving respite care must be improved in terms of detail and consistency. The home must be remodelled so that the bedrooms used for service users with physical disabilities are large enough to meet the NMS, and so that service users and staff are not potentially put at risk by having to live and work in cramped conditions. All bedrooms must contain wash-hand basins or have adjacent en-suite facilities. The home’s kitchenettes must be re-equipped to include dishwashers and/or double sinks. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 7 The home must be remodelled so that adequate storage space is created for portable electric hoists and other equipment that is used to assist service users’ mobility. The carpet in the lounge of one unit must be shampooed. Soiled and worn communal furniture must be replaced. Worn table-clothes must be replaced. All bathrooms and corridors must be adequately decorated. The home is operating with a 36 vacant rate, and with three permanent employees absent for part of each week whilst they undertake professional training. Vacant posts are covered by temporary agency staff, but a recruitment drive must be undertaken urgently to recruit to as many of the vacant posts as possible as the reliance on agency staff is too high. Hot water temperatures must be recorded, and if necessary adjusted, at least monthly. 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. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 8 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 Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. 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 the service. Prospective users’ individual aspirations and needs are assessed in a satisfactory manner. EVIDENCE: No new long-term service users have moved into the care home since before the last inspection. The Inspector case tracked the care records of two service users who have used the Colham Road respite service. Both care files contained appropriate and detailed need assessments. Colham Road, 3 DS0000032552.V310937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service user’s assessed and changing needs and personal goals are satisfactorily reflected in their care plans. Service users are satisfactorily encouraged to make decisions about their lives with assistance as needed. Service users are satisfactorily supported to take therapeutic risks and to be as independent as possible. EVIDENCE: The Inspector examined in detail the care plans for the two respite service users whose care files he case-tracked. One of the service users had transferred to adult service from children’s services. The original care plan and the transitional plan and transitional report were very good. Both service users had satisfactory Colham Road care plans. One service user had a personcentred plan in addition. Both files contained a ‘client profile’ document but the service user’s height and weight was missing from both profiles, and there was no photograph of the service user on the file. Requirement 1. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 11 The Inspector noted that each respite care service user had two care files, one being the current file and one being the original file. The Inspector found this confusing as the files were not clearly labelled. Recommendation 1. Service users and family are involved in drawing up the care plans, which are regularly reviewed. The key worker system is in place. The Inspector noted that risk assessments had been undertaken for the two service users whose care he case-tracked. Colham Road, 3 DS0000032552.V310937.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 at least once during a 12 month period. 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 the service. Service users are able to take part to a satisfactory extent in appropriate activities in the home, and in the community. Most service users maintain links with their family to a satisfactory extent and have personal relationships. Service users rights are recognised to a satisfactory extent. A satisfactorily healthy diet is provided but the records of food and drink consumed by individual service users are not sufficient. EVIDENCE: The Registered Manager reported that now every service user, long-term and respite, attends a day centre for part of the week. A variety of other community activities are available and the home has two mini-buses to take service users to outside events and appointments. The Registered Manager reported that one of the vehicles is soon to be replaced, and the home’s administrator is going to take the necessary test so that she may drive a bus. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 13 The Registered Manager reported that she is planning to restart Parent/Carer meetings. She added that service users are consulted so far as possible and relatives do often attend reviews. Two relatives have recently written letters of complaint to the home (see Concerns and Complaints Section). Relatives views are also sought by questionnaire periodically. The Inspector examined the home’s menu and found it to be satisfactory. The Inspector examined records of food and drink consumed by individual service users receiving respite care and found that the detail given was sometimes insufficient and not consistent. Requirement 10. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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 the service. Service users receive a good level of personal support in the way they prefer and require. Service users’ physical and emotional health needs are well met. Service users are well protected by the home’s policies and procedures for dealing with medication. EVIDENCE: The care plans that the Inspector case-tracked contained details about the appropriate provision of personal care, and details of medication prescribed. As the files case-tracked were for respite care users, there were no Health Action Plans, but the Registered Manager reported that these exist for long-term service users. The Inspector examined two weight charts and the PEG feeding records for two service users. The Registered Manager has devised a new form to be used when a service user attends a medical or paramedical appointment of any kind. The form is used to record what issues are to be raised by the member of staff escorting the service user, and what the subsequent outcomes are. The use of this form is commended. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 15 The Inspector examined the records of medication administration in three units of the home. No issues of concern were found. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Relatives who make complaints on behalf of service users can feel assured that their views are satisfactorily listened to and acted on. Service users are satisfactorily protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the four letters of complaint that the Registered Manager had received from relatives since the previous CSCI inspection. Two of the letters had also been copied to the Inspector. Two of the complaints were about the high level of temporary agency staff used in the care home, and the adverse effect that had on service users. One complaint was about the poor standard of some communal furniture in the home. One complaint concerned other aspects of inadequate service such as mislaid clothing. All the complaints had been appropriately investigated and acknowledged. The home has an improved system for reporting concerns and complaint issues to Head Office. There is also a new complaints poster displayed throughout the care home that gives the new CSCI contact details. The Registered Manager reported that all staff are to receive updated Protection of Vulnerable Adults training by March 2007. The Inspector confirmed this by examining the home’s training plan. Colham Road, 3 DS0000032552.V310937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home is not sufficiently homely and safe as the building is not appropriately designed. A few areas of the home are not sufficiently clean. EVIDENCE: The Inspector toured the whole home. As reported in previous CSCI inspections, seven bedrooms do not meet the NMS minimum size requirements for physically disabled service users. This has implications for the safety of service users and staff who live and work in bedrooms that are too small for equipment to be safely deployed within. Requirement 2. The kitchenettes also must be refurbished as they do not contain modern amenities. This is also a health and safety concern. Requirement 3. The Inspector noted that the batteries of electric hoists are recharged with the hoist stored temporarily in lounge areas. At other times unused hoists are stored in bathrooms as there is no dedicated storage space for them. The refurbishment plans must correct this omission. Requirement 4. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 18 The Inspector noted a soiled carpet in South Lodge that must be shampooed. Requirement 5. The Inspector noted worn and soiled communal furniture in several lounges. A relative had written to the Inspector concerning the same issue. The Registered Manager reported she had already requested permission to replace the furniture on a phased basis that could be afforded within the budgets at her disposal. Requirement 6. The Inspector noted that table-clothes in use were worn and must be replaced. Requirement 7. The Inspector noted that substantial redecoration of bedrooms and bathrooms had been undertaken by the home’s handyperson. However the corridor of West Lounge, and certain bathrooms remain to be done. Requirement 8. The Inspector noted that the bedrooms in West Lodge (respite care unit) do not contain wash-hand basins, nor do they have en-suite facilities. This omission must also be corrected as part of the refurbishment. Requirement 9. Other than the omissions identified above, the home was seen to be adequately clean and hygienic. Colham Road, 3 DS0000032552.V310937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported by permanent staff who are well qualified but also by temporary staff who are in general not sufficiently well qualified. Service users are supported by a staff team that has sufficient numbers in total, but not sufficient numbers of permanent staff members. Service users are well protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are well met by permanent staff members who are well trained, but less well by temporary agency staff members who do not have the same level of training. The proportion of the staff team who are not permanent members of staff is too high. EVIDENCE: The Registered Manager reported the following staffing level statistics. Three out of six Team Leader posts are vacant. One full time and two part time night residential worker posts out of five full time equivalent (FTE) posts are vacant. Four full time and two part time care worker posts out of seventeen full time equivalent posts are vacant. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 20 Hence in total, 10 FTE posts are vacant out of 28, which is a vacancy rate of 36 . This high rate is made worse by the fact that three permanent members of staff are undertaking professional training courses (social work degrees and occupational therapy qualification) and hence are away from the home on placement two or three days each week. Two relatives of service users have complained to the management of the service, and to the CSCI, about the high use of agency staff who in their opinion do not know how to meet their relative’s needs as well as permanent staff members do. On the credit side, the Registered Manager reports that five of the agency employees used are regular full time workers, and relationships with their provider, Hayes Staff, have improved along with induction and training of the temporary agency staff members. The Registered Manager also reports that the recruitment freeze that has meant new permanent members of staff could not be recruited for some months, is being lifted, and she has applied for permission to recruit to as many vacant posts as possible. See Requirement 11. On a positive note, The Registered Manager reports that 90 of the permanent staff are NVQ level 2 or 3 qualified. The Inspector examined a sample training needs analysis for a member of staff, and the training plan for the home as a whole. Recruitment records were not examined as no new permanent member of staff has been taken on since before the previous CSCI inspection. The Registered Manager however reported that Criminal Records Bureau and reference checks undertaken by the London Borough of Hillingdon’s Human Resources Department were being processed more quickly than before. Colham Road, 3 DS0000032552.V310937.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a home that is well managed. Relatives can be confident that their views are sufficiently taken into account when the operation of the home is being reviewed. The health, safety and welfare of service users and staff members are not sufficiently promoted and protected. EVIDENCE: Since the previous CSCI inspection, the manager of the home has been approved by the CSCI as the Registered Manager. She reports that she is undertaking the Registered Managers Award and hopes to complete it in January 2007. The Registered Manager has been successful in meeting most of the requirements set by the CSCI at the previous inspection. The Registered Manager reported that questionnaire surveys are sent to relatives on a regular basis, and are next due to be sent at the end of this year. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 22 The Inspector checked the following health and safety matters: Contents of first aid boxes; Fridge and freezer temperature records; Equipment maintenance records; Hot water temperature records. All were in order except the latter as these are done by an outside contractor who should undertake the checks monthly according to the Registered Manager but records in the care home indicated were being done as infrequently as every five months or so. See Requirement 12. As reported elsewhere in this report, operating the home with undersized bedrooms and with sub-standard kitchenettes has health and safety implications. Colham Road, 3 DS0000032552.V310937.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 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 24 yes 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. 1. 2. Standard YA6 YA24 Regulation Requirement Timescale for action 01/02/07 Sch1(2),17(1)(a) A photograph of each service user must be kept in the records. 01/12/07 12,13(4 As service users have 5)23(a,e,f) physical disabilities, the home will have to be registered for that category. In order to gain this registration, the registered person will have to consider how the home can be refurbished in order to increase the size of certain bedrooms. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT MADE THREE TIMES BEFORE. 13 (4) (a) 3. YA24 Kitchenettes must be 01/12/07 properly maintained and equipped in order to provide a safe service for service users. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT AS THE TIMESCALE SET HAS NOT BEEN MET. Adequate storage must be DS0000032552.V310937.R01.S.doc 4. YA24 23(2)(l) 01/12/07 Page 25 Colham Road, 3 Version 5.2 5. 6. 7. 8. 9. 10. 11. YA24 YA24 YA24 YA24 YA24 YA17 YA33 23(2)(d) 23(2)© 23(2)© 23(2)(d) 23(2)(a) 17(2)Sch4(13) 18)1)(a) 12. YA42 13 (4) provided for electric hoists and other equipment to assist mobility. The soiled carpet in South Lodge must be cleaned and kept clean Communal furniture that is not clean or in good condition must be replaced Worn table-clothes must be replaced. Redecoration of the home must continue. All bedrooms must have adequate facilities for service users to wash. Records of food and drink provided to service users must be in sufficient detail. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in sufficient numbers appropriate for the health and welfare of service users. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT THAT HAS BEEN MADE TWICE BEFORE AS SUFFICIENT PERMANENT STAFF MEMEBERS HAVE NOT BEEN RECRUITED WITHIN THE TIMESCALE SET. Hot water temperature must be recorded, and if necessary adjusted, at least monthly 01/12/06 01/05/07 01/02/07 01/05/07 01/12/07 01/12/06 01/03/07 01/01/07 Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations That current care files and original care files for service users are clearly labelled and kept in separate places. Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 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 Colham Road, 3 DS0000032552.V310937.R01.S.doc Version 5.2 Page 28 - 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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