Inspection on 15/08/07 for Colham Road, 3

This inspection was carried out on 15th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colham Road, 3 12/10/06

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 15 August and 14 September 2007 10:00 th th Colham Road, 3 DS0000032552.V335936.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.V335936.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.V335936.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 Jan Bell Major Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Colham Road, 3 DS0000032552.V335936.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. 12th October 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. However work is about to commence to bring the three respite care rooms up to the required standard. 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, seventeen care workers, five night workers, one domestic, one full time administrative officer and one part time handy person. 3 Colham Road is currently regularly using a large number of agency staff to support the permanent staff team, but this is about to change as new staff have been recruited and are undergoing recruitment checks at present. Colham Road, 3 DS0000032552.V335936.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 home’s performance against the expected outcomes for 23 NMS, and found that 3 were exceeded, 15 were fully met, and 5 were only partly met. This led the Inspector to make 8 requirements, 4 of which are restated from the previous inspection as the timescales set have not been achieved. The previous CSCI inspection made 12 requirements. In advance of the inspection, the Registered Manager completed and returned a pre-inspection questionnaire. A total of 10 relatives of service users also completed and returned questionnaire surveys to the inspector. Selected quotations from these replies are contained within this report. Some relatives express concern about the lack of transport on some occasions and the lack of activities at weekends. In general however the feedback is positive and is summed up by the relative who said, “Everyone at Colham has always gone out of their way to make sure everything is alright.” To undertake the inspection, the Inspector visited the home on two occasions as the Registered Manager was undertaking interviews for new staff on the first occasion. The Inspector toured the premises, met two service users, talked to staff members, interviewed the Registered Manager, examined a variety of records and ‘case-tracked’ two care files. At the time of second inspection visit, the home had two permanent resident vacancies. Occupancy of the respite care beds was said to be about 80 . Pending new staff being cleared to start work and further staff recruitment planned, the home has the following vacant staff posts covered by temporary staff: 2 Team Leaders, 4 Care Workers, and 1 Night Care Worker post held open for a redeployment. Work on improving the facilities in the respite wing of the home, and work to refurbish all the kitchenettes is expected to start shortly, but remain outstanding requirements at the time this inspection report has been written. What the service does well: Good quality assessments are undertaken before prospective residents are accepted to move into the care home. High levels of needs amongst the residents are met by high levels of skilled care provision. All the residents have multiple and complex care needs. Three places at the home are used for respite care that is often provided on a rotating basis. All residents attend day Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 6 centres. The permanent staff team are very well trained, and dedicated. There is a good team spirit. The Registered Manager has made great strides in improving the home’s performance against the NMS. Records and files are maintained to a high standard. Person-centred plans are being introduced. Risk assessments have been improved and use photographs to aid staff. The Friends of Colham Road raise money for the home. The home is well decorated and well furnished and well equipped. What has improved since the last inspection? What they could do better: The system for recording the weight of residents must be reviewed to avoid any confusion over dates. Kitchenettes must be properly maintained and equipped in order to provide a safe service for residents. Adequate storage must be provided for electric hoists and other equipment to assist mobility. All bedrooms must have adequate facilities for residents to wash. The management must recruit more permanent staff members in order to reduce the dependency on temporary agency employees. Regulation 26 reports must be provided to the CSCI on a monthly basis. Cleaning materials that come under the COSSH regulations must be stored securely. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 7 Hot water temperature 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. The summary of this inspection report can be made available in other formats on request. Colham Road, 3 DS0000032552.V335936.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.V335936.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective user’s individual aspirations and needs have been well assessed in advance of moving in. EVIDENCE: The Registered Manager reported that one new long-term resident had moved into the care home since the previous CSCI inspection. The Inspector therefore case-tracked the procedure followed for assessing the care needs of that particular resident. The Registered Manager reported that the resident in question had been living in another care home and had been referred by his care manager to live at 3 Colham Road as his care needs had increased to an extent where it was appropriate for him to move. This was confirmed by the Inspector examining the papers on the resident’s care file. The Registered Manager had visited the prospective resident in his former care home, and had undertaken her own assessment in addition to the care management assessment. A series of trial visits to 3 Colham Road had been arranged before the new resident moved in. Colham Road, 3 DS0000032552.V335936.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will know that their assessed and changing needs and personal goals are reflected in their individual plans once the new resident-friendly care plans have been produced for everyone. Residents are appropriately encouraged and assisted to make decisions about their lives. Within the limitations imposed by their multiple needs, residents are appropriately encouraged to take risks as part of an independent lifestyle. The use of risk assessments that contain photographs enhances this approach. EVIDENCE: The Inspector case-tracked a second care file. A detailed ‘client profile’ was present. The care plan was seen to be very good in terms of production, clarity and contents. The care plan had been signed and dated by the resident’s link worker, and was reviewed at least six monthly. Care plans were noted to be based on the assessment of needs that had been undertaken prior to the resident moving into the care home. The file examined also contained a detailed ‘daily routine’. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 11 The Registered Manager explained that a computer software programme called Board Maker has been used to prepare the care plan in a format that is resident-friendly and makes substantial use of photographs. This approach is commended. At the present time only resident has a care plan using this format, but the intention is to use it for all the long-term residents, and then extend it to respite care residents also. Risk assessments are in the course of being similarly improved. The care files of two residents so far have been updated in this way. The use of photographs within the risk assessments is also commended as the photos demonstrate to staff exactly which items of equipment for example are being referred to in the text. In terms of decision making, the care files examined demonstrate the involvement as far as possible of the residents despite their profound and multiple care needs. The Registered Manager reported that parent/carer meetings are now held quarterly. Colham Road, 3 DS0000032552.V335936.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part to a satisfactory extent in an expanded range of appropriate leisure activities in the home, and in the wider community. Most long-term residents maintain links with their families to a good extent. Residents’ rights are well recognised. An appropriate diet is provided and good records are kept of food and drink consumed. EVIDENCE: The Registered Manager reported that all residents attend day centres and that the extent of activities provided have been increased both within the home and within the local community. The home has two vehicles to take residents out in. The Registered Manager reported that one has recently been replaced by the Friends of Colham Road and there are plans to purchase a third vehicle that can be driven by staff who Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 13 have not obtained the licence necessary for driving the larger vehicles. Two relatives of residents responded in their questionnaires that a lack of staff who could drive the larger vehicles was a constraining factor. The situation is likely to improve also when temporary agency employees working in the care home have been replaced by permanent Council employees who are willing and able to take the driving test for the larger vehicles. One relative wrote, “Involvement of parents/carers is very good.” The care plans examined by the Inspector confirmed that day centres were being attended, and a variety of activities undertaken. Activities highlighted by the Registered Manager included trips to the zoo, to Birdworld, pub visits, cinema and garden centre. Two residents were going away on a holiday. The Registered Manager reported an increase in art, swimming and cookery activities. An aromatherapist is about to commence a fortnightly service. The Inspector examined a sample food menu, and the records that were being kept of food and drink consumed. PEG feeding records were also examined. One relative wrote in their survey response that the home ensures a good standard in areas such as food. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive excellent personal support in the way they prefer and require. Residents’ physical and emotional health needs are met but the system for recording residents’ weights must be reviewed. Residents are well protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The care plans examined by the Inspector contained excellent detailed instructions for the care staff concerning exactly how personal care tasks should be undertaken in ways that the residents preferred. These instructions were supplemented by the use of photographs, which is commended. Health Action plans were seen to be in place for all long-term residents. Each long-term resident also has a ‘hospital book’ to be taken to hospital with them when a hospital admission proves necessary. The book provides hospital staff with all the information that they would need to know about the resident. The use of this technique is also commended. The Registered Manager reported that hospital books are going to be prepared for respite care residents of the home also. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 15 The Inspector examined residents weight records. Mostly these are done monthly, but the record of a resident requiring PEG feeding was kept quarterly. This is acceptable but the record itself was inadequate as entries for 2007 were being made on the form that had been used to record other data during the year 2006, thereby creating confusion about which year the data related to. See Requirement 1. The Inspector examined the medication storage facilities and records of administration in one of the units of the home. The Inspector also examined the home’s records of medication returned to the pharmacist. No errors or omissions were noted. No residents are able to look after their own medication. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives of residents can feel that their views are fully listened to and acted on. Residents are well protected from abuse, neglect and self-harm in terms of the training that staff have received. EVIDENCE: Ten relatives sent back completed survey responses. No complaints as such were made to the Inspector or the CSCI but two expressed concern about the lack of transport in certain situations. One relative wrote in their survey response that the home should consider ways to make time spent in the care home more stimulating. Another relative however wrote “I am very grateful to Colham Road as the respite care is a lifeline.” The Inspector examined the complaints record kept within the care home and found that two relatives had complained officially within the last 12 months. One complaint had been about medication. The other was concerning agency staff and a problem over communication. In both cases the home had responded appropriately and made any necessary changes. Records show that all existing staff have been trained in the Protection of Vulnerable Adults, and that arrangements are in hand to train the new staff about to be recruited. Colham Road, 3 DS0000032552.V335936.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment but one that will not be sufficiently safe until the washing facilities in the respite care unit, hoist storage facilities and kitchenette facilities throughout the home have been improved. Residents live in a home that is sufficiently clean and hygienic. EVIDENCE: The Registered Manager reported that she had recently heard that funding had been made available for this financial year to improve the respite care unit of the home. She had not yet seen the plans but she believed that bedroom sizes would be increased, and that shared bathrooms would be created that opened directly off the three bedrooms affected. The Registered Manager added that funding was also available to refurbish the kitchenettes throughout the home. She hoped that further funding would become available to improve other aspects of the building in due course such as providing additional storage space for hoists. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 18 Until the building work is finished, requirements 2, 3 and 4 remain and are restated from the previous CSCI inspection report. The Registered Manager reported however that all soft furnishings have been replaced and the Inspector noted that many bedrooms, bathrooms and corridors had been decorated since his last inspection. One relative wrote in their survey response that the home ensures a good standard in areas such as cleanliness. This was confirmed by the Inspector during his tour of the building. Colham Road, 3 DS0000032552.V335936.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported by staff who are competent and in the case of the permanent staff, very well qualified. The staff team relies too heavily on temporary agency staff at present to the detriment of residents. Residents are believed to be well supported and protected by the home’s recruitment policy and practices. Residents’ needs are being met by well trained staff. EVIDENCE: On the day of the Inspector’s first visit, recruitment interviews were taking place. The Registered Manager reported that staff selected that day had not yet been cleared to start work, and a second recruitment drive was planned. As at the date of the Inspector’s second visit to the home, the staff vacancies remained as: 2 Team Leaders, 4 Care workers, and 1 Night Care Worker. There is therefore still a high dependency on temporary agency staff but the situation is about to get better. However Requirement 5 concerning recruiting more permanent staff is restated pending the new staff actually taking up their posts. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 20 The dependency on agency staff continues to have adverse implications. For example one relative wrote in their survey response, “Due to lack of staff, they are unable to take respite users out at weekends.” The Inspector understands this relates to agency staff not having the necessary driving licences to drive the larger buses that the home uses. The Registered Manager reported that she had increased the weekend staffing levels by one care worker per shift in order to improve the number of activities and outings that could be provided then. The Inspector examined the home’s training records, which were satisfactory. The Registered Manager said that excluding the nurse-trained member of staff, all permanent staff members have NVQ’s in care. This is commended. All senior members of staff are first aid qualified. The Inspector was unable to check recruitment procedures and records as all the files were at the Head Office. At previous inspections all recruitment checks were seen to have been undertaken satisfactorily. Colham Road, 3 DS0000032552.V335936.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is very well managed. Relatives can be confident that their views are sufficiently taken into account when the operation of the home is being reviewed. However Regulation 26 reports are not being sent to the CSCI on a regular basis. The health, safety and welfare of residents and staff members are not sufficiently promoted and protected. EVIDENCE: The Registered Manager reported that she had completed her Registered Manager Award qualification in January 2007. The Registered Manager has been successful in meeting almost all of the requirements made at the previous CSCI inspection that are within her power to achieve. Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 22 The Registered Manager reported that customer surveys are sent out to relatives on a six monthly and that the results are summarised by Head Office and made available to her. Although Regulation 26 visits and reports are undertaken by the manager from another care home, and the Inspector saw copies of the reports at 3 Colham Road, the last Regulation 26 report received by the CSCI Hammersmith office is dated December 2006. The Registered Manager agreed to send on the missing reports. Health and Safety concerns will not be fully met until the remodelling and reequipping of the home has been completed. In addition, the Inspector found oven cleaner kept on a shelf in one kitchenette instead of being locked away as required. The Inspector also noted that although hot water temperatures are being monitored and recorded by the home’s handyperson, instances of excessively cool or hot water are not being reported or adjusted. On a positive note however, the Inspector found that fridge and freezer temperatures were being recorded and were within the acceptable range, and the call bell system was also heard to be working correctly. Colham Road, 3 DS0000032552.V335936.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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 2 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 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 2 3 x 4 x 2 x x 2 x Colham Road, 3 DS0000032552.V335936.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. Standard YA19 Regulation 12(1)(a) Requirement The system for recording the weight of residents must be reviewed to avoid any confusion over dates. Kitchenettes must be properly maintained and equipped in order to provide a safe service for residents. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT MADE TWICE PREVIOUSLY. Adequate storage must be provided for electric hoists and other equipment to assist mobility. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT. All bedrooms must have adequate facilities for residents to wash. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT. 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 DS0000032552.V335936.R01.S.doc Timescale for action 01/11/07 2. YA24 13 (4) (a) 01/06/08 3. YA24 23(2)(l) 01/12/08 4. YA24 23(2)(a) 01/06/08 5. YA33 18)1)(a) 01/12/07 Colham Road, 3 Version 5.2 Page 25 6. 7. YA39 YA42 26(5) 13(4) 8. YA42 13(4) health and welfare of residents. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT THAT HAS BEEN MADE THREE TIMES BEFORE AS SUFFICIENT PERMANENT STAFF MEMEBERS HAVE NOT BEEN RECRUITED WITHIN THE TIMESCALE SET. Regulation 26 reports must be provided to the CSCI on a monthly basis. Cleaning materials that come under the COSSH regulations must be stored securely. Hot water temperature must be recorded, and if necessary adjusted, at least monthly. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT. 01/11/07 01/10/07 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Colham Road, 3 DS0000032552.V335936.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Colham Road, 3 DS0000032552.V335936.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!