Inspection on 11/04/06 for Deepdene House

This inspection was carried out on 11th April 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deepdene House 21/12/07

Deepdene House 11/10/05

Deepdene House 14/04/05

Deepdene House 25/11/04

Deepdene House 01/07/04

Deepdene House 26/02/04

Deepdene House 30/10/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Deepdene House 55-57 Stanthorpe Road Streatham London SW16 2EA Lead Inspector Lynne Field Unannounced Inspection 11th April and 4th May 2006 11:00 DS0000022723.V289258.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 DS0000022723.V289258.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. DS0000022723.V289258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deepdene House Address 55-57 Stanthorpe Road Streatham London SW16 2EA 020 8769 6297 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) Mr Sam Vindalon Mrs C Vindalon Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places DS0000022723.V289258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Deepdene House is a private care home that at the time of this inspection provides up to 20 places for adults with mental health problems and aims to rehabilitate them. The home is made up of 2 interconnecting Victorian houses with a large rear garden. There is parking at the front of the houses and on street. Accommodation at the present time is both single and double rooms. Deepdene House is situated in a quiet suburban street within easy walking distance of Streatham High Street, which has good transport links as well as leisure, community and shopping amenities. On the day of the inspection there were four service user vacancies. DS0000022723.V289258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over two days covering part of the afternoon and early morning of a weekday, and lasted nearly eight hours. The inspection methods included a tour of the building on both days of the inspection. A service user and the manager gave their views of the home as the tours progressed which was very informative. The inspector met and spoke to ten service users and five members of staff over the two days. Both the proprietor and the Director of Operations came to meet the inspector. A number of records held at the home were inspected. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by DS0000022723.V289258.R01.S.doc Version 5.2 Page 6 contacting your local CSCI office. DS0000022723.V289258.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 DS0000022723.V289258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have information about the home before they move, and can visit. Their needs are assessed at referral stage and they are given a contract when they move in. EVIDENCE: The inspector met and spoke to two service users who had moved into the home in since the previous inspection in October 2005. They said they had information about the home before they visited and had visited prior to making a decision to move in. One service users said would like to get their own place in a couple of year’s time. Records that were inspected showed that appropriate assessments had been done before admission. This includes assessing service users aspirations and needs, with risk assessments and care plans in place. Licence agreements were in place that had been signed by the service user, their Social Worker, and a representative from the home. One service user’s records inspected showed that they had been an emergency admission. Records on the file showed there was a copy of the previous placement assessment on file and an assessment of needs was completed by the home as soon as the service user moved in. DS0000022723.V289258.R01.S.doc Version 5.2 Page 9 On the day of the inspection the inspector met three professionals from a local hospital who had come to see if the home would be suitable for one of their service users. The manager told the inspector if they thought the home was suitable, the service user be assessed by the manager of the home to see if the home could meet the service users needs. Then the service user would be invited to spend some time at the home before making a decision to come to live there. The home’s Statement of Purpose and Operational Policy has been sent to the Commission and has been updated to reflect changes in registered person, number of rooms, and facilities. DS0000022723.V289258.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): 6,7,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual care plans and are involved in making decisions about their lives. Service users, relevant care professionals and their family (where appropriate) are consulted in planning and reviewing care. Risk assessments are in place, and records are kept securely in the home. EVIDENCE: The inspector examined four services user files, which are kept in a locked cupboard in the main office. These were very well organised, and clearly showed that care plans were generated from comprehensive assessments and referral information. Care Plans are agreed between staff and service users, with specific ‘Agreements’ being drawn up that are signed by both, which set out how problems will be addressed by them together. For example, a service user has challenging behaviour, the inspector was shown a management plan relating to this behaviour and how it is to be managed. This has been reviewed with the service user and signed by them and other professionals involved. Other files showed that regular reviews were held, attended by the user and the multi-disciplinary team involved in their care. DS0000022723.V289258.R01.S.doc Version 5.2 Page 11 Risk assessments and management plans are in place with care plans and risk assessments reviewed and updated. The inspector was shown records of key worker meetings that are held and recorded, which showed how staff consult with service users about progress in their care and issues relating to the home. Three service users self medicate. Service users were supported to do this. It was risk assessed over a number of months and monitored at key worker meetings the service users have each month. There are records of social workers meeting with service users on file and copies of placement reviews are held in the service users files that were inspected. The inspector spoke to ten service users during the course of the inspection. They confirmed that they were able to make choices about their life, with support from staff. Two service users told the inspector they had just come back from voting in the local elections. Each service user has a key to the front room as well as their bedroom, and can enter and leave the home freely. There are restrictions placed upon service users, relating to the assessed risks or their individual needs. One service user had agreements in place that restricted unsafe behaviour, relating to illegal drug taking and there was a rehabilitation program for social and personal skills in place. The inspector observed staff supporting the service user when they had failed to comply with the agreement and put into action the alternative strategies that are in place to respond to problems (other than Warnings and ultimately termination of placement). The clinical leader is training and working with staff to improve their skills in dealing with non-compliance behaviour. DS0000022723.V289258.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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual programmes of activities that reflect their interests and wishes. They are offered some opportunities to participate in routines in the home as well as in activities outside, but there needs to be continuing work done by the home to continue to change the culture of the service users attitude about their own responsibilities in their life and home. Rights and responsibilities are respected. Meals at the home are of a very high standard. EVIDENCE: The four service users’ files that were examined by the inspector showed that assessments and care plans refer to service users’ interests and social networks. Service users are supported to attend activities, and maintain links with friends and family unless there are clearly indicated reasons not to do so – in which case, appropriate documentation was in place explaining why. Several service users were out at day centres, or appointments at the time of DS0000022723.V289258.R01.S.doc Version 5.2 Page 13 the inspection. Service users are able to spend time with friends and relatives in the privacy of their rooms. The stated aim of the home is to promote rehabilitation. Care plans were seen that aimed to promote personal hygiene or management of personal finances. There is a small kitchen on the lower ground floor. The inspector observed service users making drinks for themselves. The inspector was told that service users could make snacks for themselves in the kitchen. One of the recently refurbished rooms has a kitchenette area, which will allow a service user to prepare meals and be quite self-sufficient. The manager told the inspector that this was not happening as the home felt this could isolate service user and the service user preferred to eat in the dining room with others. The inspector observed one person going out to get supplies of bread for the home during the inspection. Service users said they helped with preparing meals and this was evident on the day of the inspection when the inspector observed a group of service users preparing vegetables for the main meal of the day. The home continues to provide two cooked meals a day, which are eaten communally. A domestic cleans the communal areas. As stated in the previous report in October 2005, there continue to be limitations to the extent to which service users can or do experience independent living routines. Some service users are happy to participate in the running of the home. One person, who did not live in the home, made the observation to the inspector, that part of the culture of being a mental health patient is that there is not an expectation that service users should help around the home and all service users should do is sit around smoking and drinking cups of tea, watching television and expect everything to be done for them. The home has appointed a clinical leader who oversees the clinical and therapeutic aspects of the service users care who along with the manager and staff has been tackling this attitude of service users. This is also being done through individual key worker meetings and at service reviews where service users agree social care programs. At service users meetings group decisions are discussed and made about allocating chores and other issues relating to the home. There is a programme of group activities scheduled for half an hour each day On the day of the inspection this was not evident. The inspector was told most service users did not want to join in. The inspector was told that a member of staff works what the home calls the middle shift to enable service users to be supported in a variety of activities. In reality if this is to be achieved there will have to be more work done with individual service users to enable the culture of the home and service users to take place and change and more staff will need to be employed to do this as this is time consuming. DS0000022723.V289258.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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way that they prefer and require, and this is undertaken in a respectful and professional manner. EVIDENCE: The inspector observed interaction between staff and service users, which was respectful and appropriate. Each service user is registered with the GP of their choice and Community Psychiatric Nurses visit regularly to work with the service users and support the staff. The inspector noted that the manager and staff conveyed a clear sense of commitment to the delivery of a flexible service. Service users’ medication is stored securely in a locked medication cabinet in the staff office. The inspector inspected three of the service users medication at random. All medication stocks checked were in order. The inspector was told that no member of staff is allowed to administer medication until they have completed the homes medication training. The inspector was told by the manager each member of staff has Handling and Administration of Medication DS0000022723.V289258.R01.S.doc Version 5.2 Page 15 training. This is followed up each year with refresher training given by the local pharmacist who comes in twice a year to check the homes medication. Three service users are self-medicating which was agreed at a meeting with the Community Psychiatric Nurse. Each service user was assessed and monitored in a program over eight weeks. After the eight weeks the service user is monitored weekly by checking the medication kept in the service users room and observing their behaviour as part of the risk assessment. Each service user has a medication agreement form that has been signed by the service user, the manager or key worker. The home’s Operational Policy contains a statement that sexual and racial harassment will not be tolerated. There was evidence on file that culture and ethnicity of service users was assessed, and addressed in care planning. There are three female service users at the time of this inspection. One had been allocated a bedroom with en-suite facilities. This promotes privacy, which can be a particular issue for females sharing communal facilities with men, and is to be commended. It was recommended that a review is undertaken to ensure that the home is appropriately addressing issues relating to gender and sexuality. This has been reinstated. DS0000022723.V289258.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know their views are listened to and acted on. EVIDENCE: The manager of the home said she would deal with complaints as they arose by following the home’s complaint policy and procedure. The manager said they had a complaint box that service users could put complaints in anonymously and this was checked every day. No complaints have been made since the inspection before last when the registered proprietor followed the homes complaints procedure. Service users informed the inspector that they had no complaints or concerns but if they did they would tell the manager of the proprietor and “they would sort it out”. Service users meetings are held monthly and all service users are invited to attend. Service users told the inspector they felt their views were listened to and acted upon. The manager told the inspector a service user questionnaire had been sent out. The results from that were in the process of being collated by the provider. The inspector was told by the manager that if any adult protection issues were raised the home would follow its adult protection policy. The manager said that DS0000022723.V289258.R01.S.doc Version 5.2 Page 17 the registered provider had provided training for staff in adult protection and this was discussed in staff meetings and supervision. DS0000022723.V289258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that they find comfortable. Bedrooms are personalised. There are numerous communal areas for service users to use, including lounges that are either smoking or non smoking lounges. Improvements have been undertaken in the home to provide single rooms with en-suite facilities. The home was clean. EVIDENCE: The inspector had a tour of the home, and saw all communal areas, eight service users’ bedrooms, and two rooms that had recently been converted to have en-suite facilities. These had been refurbished to a high standard. The lower ground floor consists entirely of communal areas. There is a large dining room, kitchen, a smoking and non-smoking lounge with a small kitchenette for making snacks. Lounge areas have been refurbished recently making the rooms bright and clean. The manager told the inspector the home had ordered new dining tables and chairs to make dining area more homely. DS0000022723.V289258.R01.S.doc Version 5.2 Page 19 Meals are served by staff from a trolley, and there are locked units for the fridge and cutlery. There is access through the lounges to a large and attractive paved garden area. There is an administrative office at the home, which serves both homes owned by the company. On the day of the inspection several service users were assisting the gardener to develop the garden. The Ground level floor accommodates staff offices, as well as newly refurbished bedrooms, with en-suite facilities (and one with a small kitchenette). Refurbishment had been carried out to a high standard, and the en-suite facilities meant the home now meets National Minimum Standards in respect of provision of bathrooms, showers and toilet facilities for the number of service users. Access to the lower ground floor and upper floors is via flights of stairs. There are toilets and bathrooms on all floors, which have locks on the doors. Areas were clean and fresh looking. Equipment and furniture were in a good state of repair throughout the home. The service users who showed the inspector their bedrooms said that they were happy with them, and that they had everything that they needed and wanted. Each was personalised to reflect their own tastes and interests. DS0000022723.V289258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are supported by an effective staff team, who have access to training. Policy relating to the recruitment of staff is good, but records of checks were incomplete. EVIDENCE: Copies of the job descriptions have been sent to the CSCI and contain all the information specified in Schedule 4(6). This requirement has been met. Four staff files were inspected. The inspector had been led to believe the home had received satisfactory CRBs and POVA checks on all the staff,on the day of the inspection the inspector found there was a delay in one member of staff’s CRB check. The operations director explained the member of staff had requested and paid for a CRB and POVA check be carried out by an agency in Peckham and although both the individual and the home had continually chased up this check it was not forthcoming. Subsequently the member of staff applied to another agency. Since the inspection the inspector has been informed the CRB had come the next day. A copy of the CRB was faxed to the inspector as evidence. DS0000022723.V289258.R01.S.doc Version 5.2 Page 21 Staff told the inspector they had access to a range of training and are encouraged to attend training courses. Eight staff have NVQ level two or above. Staff had recently had training in challenging behaviour to help staff support service users to comply with agreements and other actions that could be taken to help service users who had histories of non-compliance with such agreements, which had contributed to previous placements failing. Staff have also had training in “General welfare and well being of clients: Physical, Spiritual and Psychological” and Rehabilitation and Activates of ADL skills. DS0000022723.V289258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Senior management roles in the organisation promote clarity, accountability and promote the best interests of users. EVIDENCE: The home is well run. Staff and service users said they have confidence in the manager and there is a relaxed feel about the home. The new manager who was appointed in October 2005, has worked at the home since 2001 where she held a senior role. She has a BA in Psychology and a MA in Psychotherapy. The manager has started the process of applying to be the registered manager and has started to work towards gaining the RMA/NVQ4. The inspector observed the manager dealing calmly and confidently with a difficult situation DS0000022723.V289258.R01.S.doc Version 5.2 Page 23 of a service user being suspected of smoking illegal drugs who responded well to how the manager dealt with the situation. Service users said they felt safe in the home and did not want to move on. They said when they had their key worker sessions and service user meetings where they were able to say what they felt and it was acted on as well as listened to. The home is in the process of monitoring the on - call system of the organisation. Times and the issue is being recorded and will be collated to look at how staff could have dealt with anything that has arose in the home could have been dealt with by the team leader without calling the manager. At the present time the team leader is the one to make any decision and is on call. The home needs to ensure the team leaders have knowledge, training and skills to make any decisions that may be the responsibility of the manager. Records indicated that all fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. At the previous inspection, the Director of Operations for the company spoke to the inspector. She had explained that the company was undergoing some review. Mr & Mrs Vindalon, who own Deepdene House have a second home called Prema House. They say they formed the company, Deepdene Limited in 1989. The Director of Operations was a new post, and she is responsible for reviewing all aspects of operation of both homes, and is developing a new Business Plan. The issue discussed with the Director of Operations following that inspection, is that the home’s Operational Policy and Registration details need to be reviewed and updated to reflect recent changes including the status of the organisation (Deepdene Ltd, rather than as individual proprietors). The home still needs to submit copies of its revised business plans. DS0000022723.V289258.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 3 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 2 3 x 3 3 2 DS0000022723.V289258.R01.S.doc Version 5.2 Page 25 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 YA14 Regulation 16(2)n Requirement The Registered Person must review the arrangements regarding the programme of activities in the home, including how service users are consulted about activities, and how group activities can be arranged. Consideration must be given to identify funding to support this. Previous requirement of 01/02/06 not met. Timescale for action 01/07/06 2 YA38 10(1) 12(1) 18(1)(2) 3 YA43 10, 24 01/07/06 The registered person must review and monitor the on-call rota, and out-of-hours support to the home, to ensure that this is adequate, appropriate, and avoids staff fatigue. The outcome of the review, with timescales for any action agreed, to be notified to the Commission in writing. Previous requirement of 10/11/05 not met. The Registered Person must 01/07/06 submit revised Business Plans to the Commission, with information relating to any changes in organisation or operation. This is to include DS0000022723.V289258.R01.S.doc Version 5.2 Page 26 details of the organisational structure and roles of the senior management team and Directors. Previous requirement of 10/01/06 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA8 Good Practice Recommendations The Registered Person should produce a report detailing the results of the previous User Satisfaction Questionnaire, and/or consider repeating the consultation The Registered Person should arrange for a review to be undertaken to ensure that the home is appropriately addressing issues relating to service users’ gender and sexuality. 2. YA18 DS0000022723.V289258.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022723.V289258.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. 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!