Inspection on 11/07/06 for Drayton Road

This inspection was carried out on 11th July 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drayton Road 06/10/05

Drayton Road 24/05/05

Drayton Road 18/11/04

Drayton Road 15/06/04

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 Drayton Road 2 Drayton Road Leytonstone London E11 4AR Lead Inspector Rob Cole Key Unannounced Inspection 11th July 2006 10:00 Drayton Road DS0000007262.V302871.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 Drayton Road DS0000007262.V302871.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. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drayton Road Address 2 Drayton Road Leytonstone London E11 4AR 020 8556 2550 020 8988 1491 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) Outward Mr Thomas Boyle Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Drayton Road is a residential home, registered to provide personal care and support to eight adults with learning difficulties. The home is situated in a residential area of Leytonstone, in the London Borough of Waltham Forest, close to local amenities and transport networks. The home was purpose built over three floors. The home is privately run and managed by Outward. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 11/7/06 and was unannounced. The inspector had the opportunity of speaking with service users and staff, and the homes manager was present for part of the inspection. Overall the inspector was satisfied that this is a well run home. Service users spoken to informed the inspector that they are happy with the level of care and support provided, one commented “I really like living here”. 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 contacting your local CSCI office. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 6 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 Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 7 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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that prospective service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and visits to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are subject to regular review. The Statement includes details of the organisational structure and the aims and objectives of the home. The Service User guide includes a copy of the homes complaints procedure and details of the services and facilities provided. All service users are provided with their own copy of the Guide. Both documents have been produced in written English, pictorial form and on audiotape to help make them accessible to service users. A new service user has been admitted to the home since the last inspection. There was evidence that a comprehensive pre admission assessment was carried out by the homes manager and deputy manager. This included needs associated with health, medication, family and social and leisure needs. The service user and their next of kin had the opportunity of visiting the home prior to moving in, and the service user was able to have overnight stays. They informed the inspector that they were pleased to have moved in to the home. At the time of inspection they had only been living at the home for two weeks, Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 8 and a placement review meeting had been planned for the near future. The home had an admissions procedure, and the inspector was satisfied that the service user had been admitted in line with the homes procedure. All service users have been provided with a contract/statement of terms and conditions. These include details of services and facilities provided and fees payable, and were in line with national Minimum Standards. Contracts have been signed by service users and a representative of the organisation. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users have control and choice over their daily lives, and that care planning is of a good standard. EVIDENCE: Clear and comprehensive care plans are in place for all service users. These are drawn up with the involvement of the service user, their family, social worker and keyworker, and the homes manager. There was evidence that they are subject to regular review. Plans cover needs associated with personal care, mobility, medication and social and leisure needs. Daily logs are also maintained, and these are clearly linked to care plans. Plans are produced in a written and audio format. Risk assessments were in place for seven of the eight current service users. These were of a satisfactory standard, and covered risks associated with smoking in the home, accessing the community and using kitchen implements. Risk assessments were subject to regular review. Assessments identified risks, and included strategies to manage and reduce these risks. However, there was no risk assessment in place for the most recent service user to move in to the Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 10 home, and it is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. There was evidence that service users have a large degree of control and choice over their daily lives. On the day of inspection service users were observed to get up and go to bed as they wished, choose when and what to have for meals and choose their own clothes to wear etc. The home holds regular service user meetings, the agenda is set jointly by staff and service users. Minutes are maintained of these meetings, these evidenced discussions on house rules, for example around visitors, and also discussions around holidays and activities. Service users also have regular one to one meetings with keyworkers, were they are able to discuss house issues. Since the last inspection the home has had a new kitchen fitted, and service users were involved in choosing this. Service users spoken to informed the inspector that they were very happy with the new kitchen. The home has a confidentiality policy in place, which makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. All confidential information is stored securely, and staff and service users can access their records as appropriate. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users are supported to live valued and fulfilling lives. They have regular access to the community, and a wide range of social and leisure activities are provided. EVIDENCE: There was evidence that service users have regular access to the local community, through various day services, adult education classes, shops parks markets etc. One service user recently completed an NVQ in Food Preparation at college, while another two service users are studying drama at an adult education centre. They informed the inspector that they are currently working on a production of the musical Oliver. Two service users are studying numeracy and literacy skills, while another is studying IT skills. Two service users work for Outward, where they are involved in the recruitment process for new staff to the organization. They receive a salary for this. One service user attends, POISE, a group run by MENCAP. They are on the committee of this group, and help arrange social events such as discos. Two service users Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 12 regularly attend church. Service users access public transport, including tubes and mini cabs, and the home has its own unmarked transport. There was evidence that service users have access to a variety of social and leisure activities, both in house and in the community. On the day of inspection service users were observed to be playing games and puzzles, listening to music, watching television and painting. The home holds occasional parties, for example to celebrate birthdays. In the community there was evidence that service users are supported to go to football matches, the cinema, pubs, restaurants, discos and on day rips. Service users are offered an annual holiday away from the home as part of their basic contract price. Service users are booked to go on holidays to Kent and Wales later this year. Service users informed the inspector that they have been involved in choosing and planning their holidays, and that they were very much looking forward to going on them. The home has a visitor’s policy, and service users are able to see visitors at any reasonable time, and in private if they so wish. The home helps to facilitate contact with families, and service users are able to visit family members. Service users are given their own mail to open, and are able to use a telephone in private. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. As part of programmes in place to help develop independence, service users are involved in food preparation, including buying and preparing food. The inspector was pleased to note the wide degree of choice on offer over mealtimes, for example at lunch five different meals were provided, in line with individual service users choice. Service users were able to help themselves to drinks and snacks throughout the day, and expressed satisfaction with both the quality and quantity of food provided. Fresh fruit was available on the day of inspection. The kitchen was clean and tidy, and food was stored appropriately. Records were maintained of fridge and freezer temperatures. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 this service. It is the view of the inspector that the home is able to meet the health and personal care needs of service users. Medications are stored, administered and recorded appropriately, and service users have access to relevant health professionals. EVIDENCE: Clear guidelines on supporting service users with their personal care are in place on individuals care plans, and these indicated that service users are encouraged to do as much for themselves as possible. Service users choose their own clothes, and on the day of inspection all were appropriately dressed. Service users were observed to be involved in the homes daily routines, for example cleaning the kitchen and washing up, and this was in line with care plans. All service users are registered with a GP. Records are maintained of medical appointments, including any follow up action necessary. Records indicated that service users have access to health professionals as appropriate, including dentists, dieticians and physiotherapists. The home makes use of the Continence Advisory Service, who supply advice and continence products to the home. Used continence products are disposed of appropriately. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 14 One service user was observed to have some bruising on their arm, they informed the inspector that this occurred when they fell out of their bed. However, no accident/incident form had been completed around this, and it is required that the home completes accident/incident forms as appropriate. The home has a comprehensive medication policy, and all staff undertake training before they are able to administer medications. Medications are stored in a locked cabinet inside the office. Records are kept of medications entering the home, and since the last inspection of those that are returned to the pharmacist. Guidelines have also been introduced since the last inspection on the administration of medications prescribed on a PRN basis. No service users currently self medicate or are on any controlled drugs. Medication Administration Record charts are maintained, those checked by the inspector appeared to be accurate and up to date. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 this service. Overall the inspector was satisfied that the home has taken reasonable steps to help safeguard service users from the risk of abuse, although the home must obtain an up to date copy of the Local Authorities adult protection procedures. EVIDENCE: The home has a complaints log, although the inspector was informed that no complaints have been received since the previous inspection. There is also a complaints procedure. All service users are given a copy of this, included in the Service User Guide. The procedure includes timescales for responding to any complaints received, and contact details of the CSCI. The complaints procedure was on display within the home, and has also been produced in video format, to make it more accessible to service users. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home has an adult protection procedure in place, this appeared to be in line with current legislation. However, the home did not have a current version of the Local Authorities adult protection procedures, and must obtain one. Since the previous inspection all staff have now received training in adult protection issues, and staff spoken to demonstrated a good understanding of their roles responsibilities with regard to adult protection issues. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 16 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to its physical environment. Service users are provided with adequate communal and private space, and the home was generally well maintained. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest, close to shops, transport links and other local amenities. The home is purpose built over three floors. Not all of the communal areas are accessible to all service users, due to mobility issues. At the last inspection several maintenance issues were raised, noticeably that the kitchen was in a poor state of repair, and their were also instances of peeling wallpaper and cracked paintwork around the home. The inspector was pleased to note that all of this has been addressed, and the home is now in a good state of repair, and well maintained, both internally and externally. Further, it was noted at the last inspection that some of the windows were dirty, these were all found to be clean at this inspection. All service users have their own bedrooms, these have locks fitted and service users have been offered keys to their rooms. Bedrooms have recently been Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 17 decorated, and service users informed the inspector that they were involved in choosing the new décor. Rooms have been personalised to service users individual tastes, for example with family photographs and televisions. Rooms had appropriate furniture, including table and chairs, wardrobes and chest of draws. Bedding, carpets and curtains were all well maintained, and domestic in character. Bedrooms had adequate natural light and ventilation. Bedrooms meet National Minimum Standards on size requirements. However, the protective guard around the heating system in one of the first floor bedrooms was damaged, and this must be repaired or replaced. One service user has ensuite facilities in their bedroom, and all other bedrooms have hand basins in them. There is a shower room on the ground floor and a bathroom on the first floor. The ground floor shower room was specifically designed to meet the needs of one of the service users. Grab rails are in place in communal areas, and there are sufficient toilets to meet service users needs. On the day of inspection bathrooms were found to be clean, tidy and free from offensive odours, and all had locks fitted to them. The home’s garden was well maintained, and service users were observed to enjoy spending time there during the course of the inspection. The home has various means in place to help prevent the spread of infection, including an infection control policy. Staff are provided with protective clothing, such as aprons and gloves. The laundry facilities are adequate to meet service users needs, and hand washing facilities are situated throughout the home. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 18 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): 31,32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that staff are sufficiently competent and experienced to carry out their roles and responsibilities, however, it is the inspectors judgement that staffing levels are currently inadequate to meet service users assessed needs at all times. EVIDENCE: The home provides 24-hour staff support including an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. However, the inspector was disappointed to note that staffing levels have not increased since the last inspection, nor was the home able to demonstrate that staffing levels had been reviewed to determine how the needs of service users can be met at all times. For much of the time the home operates with just two staff on duty, who have responsibility for supporting eight service users, with very differing needs. On the day of inspection one service user asked staff on several occasions to support them to go to local shops, but due to staffing levels this was not able to happen. Staff themselves informed the inspector that they believed current staffing levels to be too low. When there are only two staff on duty they have responsibility for assisting with all necessary personal care, domestic duties including cooking, cleaning and laundry, administering medications, completing Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 19 all required paperwork, answering phones, dealing with any visitors and supporting service users with any appointments they may have. This leaves very little time for any meaningful interaction with service users. It is a repeat requirement that the home carries out a review of staffing levels to determine how it can meet the assessed needs of service users at all times. All staff receive a copy of their job description, and a copy of the General Social Care Council codes of conduct. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and have built up good relations with individual service users. All staff receive a structured induction programme on commencing work at the home, which covers service user and health and safety issues. Staff have regular on-going training opportunities, and records are maintained of staff training. Recent training has included adult protection, sexuality, food hygiene and dementia. The inspector was informed that three of the six care staff employed at the home have achieved a relevant care qualification, and that it was planned that the remaining three will have the opportunity of working towards such a qualification in the near future. Staff receive regular formal supervision, records are maintained, and staff get a copy of the records. The home also holds regular staff meetings, all staff are able to contribute to the agenda. The home has policies in place on recruitment and selection and equal opportunities. The inspector was informed that service users are given the opportunity of been involved in the recruitment of staff at an organisational level, but not necessarily in the recruitment of staff to the home. It is recommended that service users from the home are given the opportunity of been involved in the recruitment of all staff to the home. Staff employment records are held centrally by the organisation. The home keeps a sheet for each staff member which records what employment checks the organisation holds for them. This has been agreed with the CSCI. Sheets checked indicated that the home has carried out all checks on staff as appropriate, including references, proof of ID and CRB checks. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 20 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): 37,38,39,40,41,42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that this is a well run home, appropriate quality assurance systems are in place, and health and safety issues are well managed. EVIDENCE: The homes manager is currently working towards the Registered Managers Award, and is a registered nurse for people with learning difficulties. The manager has extensive experience of working with adults with learning disabilities, including in a managerial role. The home also employs a deputy manager. Staff and service users spoken to said that they found the manager to be accessible and approachable. Care plan reviews, service user and staff meetings and staff supervisions all contribute to quality assurance within the home. Copies of previous inspection reports were available to view in the home, and there was evidence that monthly unannounced Regulation 26 visits take place. The home issues Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 21 questionnaires to service users to gain their views on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback. The home had appropriate policies and procedures in line with National Minimum Standards, those checked by the inspector, including complaints and adult protection appeared to be satisfactory. Record keeping was of a generally good standard. The home has various health and safety policies in place, including on COSHH and fire safety. Staff undertake health and safety training as appropriate, such as on first aid and manual handling. Fire extinguishers were situated around the home, these were last serviced in March 2006. Fire alarms are tested weekly, and were last serviced on the 16/5/06, the home holds regular fire drills. The home had in date certificates for PAT testing, gas safety and electrical installation. COSHH products were stored securely, and hot water and fridge/freezer temperatures are tested appropriately. The home had in date employer’s liability insurance cover. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 22 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 3 3 3 3 Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA33 Regulation 18 Requirement The registered person must ensure that the home carries out a review of staffing levels to determine how it can meet the assessed needs of service users at all times. (Timescale 31/01/06 not met) The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. The registered person must ensure that the home maintains a record of all accidents/incidents that occur in the home. The registered person must ensure that the home has a current copy of the Local Authorities adult protection procedures. The registered person must ensure that the broken protective fireguard in the first floor bedroom is repaired or replaced. Timescale for action 31/10/06 2 YA9 13 31/10/06 3 YA19 17 31/10/06 4 YA23 13 31/10/06 5 YA26 23 31/10/06 Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 24 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 It is recommended that service users who live at the home are given the opportunity to be involved in the recruitment of all staff to the home. Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Drayton Road DS0000007262.V302871.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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