Inspection on 30/01/07 for Elm Cottage

This inspection was carried out on 30th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Cottage 17/07/08

Elm Cottage 25/01/08

Elm Cottage 21/02/06

Elm Cottage 09/09/05

Elm Cottage 30/03/05

Elm Cottage 07/12/04

Elm Cottage 26/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 7 Lucerne Road Elmstead Market Colchester Essex CO7 7YB Lead Inspector Brian Bailey Key Unannounced Inspection 30th January 2007 09:30 7 Lucerne Road DS0000017739.V328500.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 7 Lucerne Road DS0000017739.V328500.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. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7 Lucerne Road Address Elmstead Market Colchester Essex CO7 7YB 01206 822794 01206 822794 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) Partnerships in Care Limited Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require by reason of a learning disability (not to exceed 3 persons) 21st February 2006 Date of last inspection Brief Description of the Service: 7, Lucerne Road is a registered care home providing accommodation for three people under the age of 65 years who have an acquired brain injury. It is one of two homes in the area owned by Partnership in Care An acting manager is currently managing both homes following the resignation of the registered manager during 2005. The home runs two programmes of care: one for community rehabilitation and the other being long term supported living assistance for service users requiring maintenance of their rehabilitative state, who may also have behavioural problems, which can be managed within the home. 7 Lucerne Road is small, detached bungalow situated in a small residential cul de sac in the village of Elmstead Market, approximately five miles from the town of Colchester. The home is within walking distance to local village amenities, which includes a shop, a pub and the local GP surgery. The village is on the main bus route to the town of Colchester and the seaside town of Clacton on Sea. Single accommodation is provided and a communal shower room. The home has a lounge and dining/sitting room for shared activities. The home has a comfortable, safe and fully accessible dining room, lounge and sitting room for shared activities or private use and a small back garden. Car parking for visitors at the front of the house is good. Previous inspection reports are available from the home, Partnerships in Care and our website www.csci.org.uk. As at February 2007, the fees for accommodation were stated as ranging from £295 to £322 per day. The stated extras to the fees include toiletries, clothing and leisure pursuits. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection looking at the core standards for the care of adults. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home that took place on 30th January 2007 at 9.30am, discussions and observations with residents, staff, a questionnaire issued by CSCI and from checking the records kept at the home. A copy of the previous inspection report dated 14th February 2006 is available from the home and can be seen on our website at www.csci.org.uk Service users accommodated at this home have sustained an Acquired Brain Injury (ABI) and have varying degrees of permanent cognitive disability following the early stages of recovery. This includes changes in concentration, awareness, perception and insight and in some cases long term and/or shortterm memory loss. What the service does well: What has improved since the last inspection? What they could do better: As at January 2007, no progress had been made to improve the office and laundry facilities despite the last three inspections of this home, the most recent being February 2006, requiring action to be taken to improve the facilities. This is clearly a situation that cannot be ignored. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 6 The organisation subsequently informed us in February 2007 that they have reassessed the room and must now decide which of the options for improvement is preferred. The past three inspections of this home have required the home’s Quality Assurance system to be developed to ensure that the views of service users and all other people with an interest in their well-being are obtained. This has not been achieved. All staff must be provided with formal supervision on a regular basis, which again was a requirement at the last inspection. Evidence of all checks made when staff are recruited must be available at the home for inspection. The Registered Person will need to ensure that all standards rated below level 3 receive attention since some of these have failed to meet a satisfactory level as indicated above. 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. 7 Lucerne Road DS0000017739.V328500.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 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Quality in this outcome area is good. The home operates a thorough pre admission process, giving care and attention to ensuring the home is admitting individuals whose entire assessed needs could be fully met. The home promotes the opportunity to visit the home as an essential part of the admission process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and a Service User Guide (Residents’ Information and Handbook), which was revised in January 2007. The home has admitted one new service user since the last inspection. The admission for a trial period was part of a planned programme of care and the manager and staff were well aware of the person’s needs and how these could be met. Previous inspections of this home have commended the service for its thorough, comprehensive pre-admission process. Care records checked at this inspection contained detailed and relevant assessment information. Lucerne Road operates an admission policy that requires the prospective service user to make a number of visits to the home in progressive duration, covering introduction, compatibility with other service users and the opportunity to meet the staff and see the facilities available. The home does not accept unplanned or emergency admissions. The home’s procedure is for 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 9 the manager and the multidisciplinary team, together with the service user and/or their relative and/or advocate, to carryout pre-admission assessments, which also included assessments from various specialists. 7 Lucerne Road DS0000017739.V328500.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, 8, 9 & 10. Quality in this outcome area is good. Care plans were service user focused, developed according to needs, including rehabilitation processes and achievable goals, care and maintenance of health, lifestyle and well-being. Service users were supported within an individualised risk management approach. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of two service users were checked. These were detailed, up to date and provided a wide range of information about the needs of the person and how these were to be addressed. Staff spoken with were knowledgeable about each service user’s needs and of how they were to be supported. Records showed that care plans are reviewed at regular intervals. Care plans were linked to the Care Programme Approach (CPA) and the home worked in partnership with the multidisciplinary team, the service user and/or relative/advocate enabling care to be delivered in an agreed organised way. Comprehensive risk assessments were evident in each service user’s plan with clear risk management strategies to reduce potential risks that individuals with an ABI face on a daily basis, due to impaired memory and concentration. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 11 Any infringements and limitations to service user’s choice were made through the assessment process and in the service user’s interests to prevent harm to themselves and others. This was recorded in the service user’s plan. Service users’ individual records were appropriately maintained, although the facilities for storage of files in the office are poor. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. Service users were given the opportunities and support to maintain and develop social, emotional, communication and independent living skills in and outside the home. Family and friends links with the service were strongly encouraged and well developed. The home offered opportunities to establish a structured and purposeful lifestyle, respecting service users rights and choices. The home supplied sufficient quality of food and provided a well balanced diet that met individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: None of the current service users were in any form of employment or fulltime education. One service user was being supported in maintaining their rehabilitative state following recovery. One service user was on the community rehabilitation programme looking towards a more independent outcome and was participating in community based activities and maintaining a daily living programme such as shopping, changing the bedclothes and keeping own room tidy. One person spoken with said they liked the home and 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 13 staff and added that they wouldn’t hesitate to speak up if they had any concerns. They described their days as being busy, which they preferred. A service user was observed preparing to go with a staff member to a local fitness centre and to the hairdressers in the afternoon. Shopping for clothes was said to be a favourite pastime. One service user was observed relaxing in the lounge listening to a member of staff reading a book. It was evident from the care records that service users are facilitated to make decisions with regard to their own life. Freedom of movement within the home was observed and staff were observed giving support to service users to make choices insofar as was practicable to exercise control over their life in accordance to their risk management plan. It was evident the home viewed community access and inclusion essential to the rehabilitative process and was incorporated in accordance with the service users assessed needs and individual plan. Service users were supported on a one to one basis by staff in the community. Important dates were recorded in individual care plans for staff to support the service users in maintaining links with family and friends on birthdays and anniversaries. One service user has regular contact with family. The staff had worked closely with the service users producing menus looking at more healthy options and fresh produce incorporating choice, likes and dislikes. Mealtimes were seen to be flexible around service users choice. Good food stocks were available and individual food selections were recorded. 7 Lucerne Road DS0000017739.V328500.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 & 20. Quality in this outcome area is good. The service users were looked after well in respect of their healthcare and personal needs. Staff were patient, communicative and engaged positively with each individual and demonstrated a good understanding of the service users they were supporting and treated them with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were unable to retain or self-administer medication. The medication policy reflected all areas of safety. All staff had received accredited training in the safe handling and administration of medication. Care plans reflected individual medication prescribed and included information relating to the side effects and adverse reactions of medicines being taken by the service user, which is good practice. Medication continues to be dispensed from the GP surgery into Dossett boxes, which is a system normally used for self- administration. The system provides medicines for seven days. The previous inspection identified a possible hazard with the system as all medicines for a particular time are placed together within the same compartment, making it difficult for the care staff to identify what medication is being administered or even refused. Staff had looked into 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 15 adopting a monitored dosage system but felt this was not feasible for three people only. In the circumstances the manager had agreed to replace the Dossett boxes with an improved version that provide clearer information to the staff. The manager must monitor the system and ensure that the risk to service users of staff making an error when administering medication is assessed and any action taken to minimize the risk. Observation of care records showed that service users were enabled to access health care professionals when required. 7 Lucerne Road DS0000017739.V328500.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 &23. Quality in this outcome area is good. The home has appropriate arrangements in place to protect residents and to respond to their concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints policy and procedure was in place and accessible to the service users’ representatives. Senior staff spoken with were aware of the procedure to take in the event of a complaint being made. Staff indicated that the current service users were not able to make a written complaint but any verbal concerns or complaints would be listened to, taken seriously and acted upon appropriately. The home did not have a formal system for complaints to be recorded along with records of action taken, the outcomes of the investigation and detail of the complainant’s satisfaction. The home and CSCI had not received any complaints since the last inspection. The home had good policies with regard to preventing abuse through good practice and staff and management support systems and how to recognise abuse. Guidance for staff on what to do in the event of a suspicion or allegation of abuse incorporating Local policy and Essex Social Services alert forms and contact numbers were available. The staff had received Protection of Vulnerable Adults (POVA) awareness training and the one staff member who had not been trained was to attend a course on 20/2/07. 7 Lucerne Road DS0000017739.V328500.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, 25, 26, 27, 28 & 30. Quality in this outcome area is adequate. Service users benefit from being able to live in a clean, well furnished and decorated property although there are some features of the house that detract from this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 7 Lucerne Road is small, detached bungalow situated in a small residential road in the village of Elmstead Market. The home is ideal in many respects and blends in well with the neighbouring properties; however, there are some drawbacks as far as service users and staff are concerned, which have been highlighted at previous inspections and at least since February 2004. These relate to the layout, the size of rooms and corridors, no bath and the inadequacies of the laundry/office. No progress has been to implement the requirements imposed and no up to date plan of action has been provided to CSCI. Whilst service users are able to live in a clean, comfortable and safe environment, all of the above issues do impact on the lives of service users and therefore they can expect improvements to be made in these areas. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 18 Several rooms have been redecorated and staff were in the process of trying to make the rooms look more homely. The main light fittings in the lounge and dining room are institutional in appearance. Single accommodation is provided, but the smallest of the three bedrooms did not meet National Minimum Standards with regard to size and the ability to furnish with required minimal furnishings. Due to the layout and small passageways of the bungalow, the home is not suitable for wheelchair users. One current service user requires the use of a walking frame; the service user and staff indicated this proved difficult to manoeuvre at times. The home has a lounge and dining/sitting room for shared activities. The service users share one bathroom, which did not have a bath – only a shower is provided. Consideration has still not been given to installing a bath so that a choice is available. It was noted that some radiators were not guarded to protect service users. These must be assessed for the risk they present to service users and action taken to minimise any identified risk The kitchen was domestic in style, clean and well equipped. 7 Lucerne Road DS0000017739.V328500.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): 31, 32, 33, 43 & 36. Quality in this outcome area is adequate. A team of experienced staff supports service users however the staff have not been supervised adequately over the past year. Evidence that the staff recruitment procedures have been followed needs to be available at the home to demonstrate that service users are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently three service users accommodated at Lucerne Rd. One person, who was admitted more recently on a trial period, is taken each day to the sister home at Wivenhoe Road as part of a rehabilitation programme to use the kitchen facilities available for the purpose. Staff indicated that two members of staff per shift were required to meet the assessed needs of the service users. The recruitment files of staff are held at Wivenhoe Road as the facilities at this home are inadequate and confidentiality cannot be guaranteed. Three files were checked. All the files held evidence of the required checks undertaken including two satisfactory references, a completed application form, employment history, a written record of the interview, record of induction and a copy of the Contract of Employment, Statement of Terms and Conditions and a job description. CRB and POVA first disclosures were not available, as they 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 20 had apparently been returned to Elm Park for safekeeping. Evidence must be available at the home to show that these have been obtained for all staff. Information provided by the manager confirmed that over 50 of the support staff had obtained a National Vocational Qualification at level 2, which means the home has met the target set in the National Minimum Standards. From the sample of staff files examined, induction and statutory accredited training in health and safety subjects such as Food & Hygiene, Infection Control, First Aid, Managing Challenging Behaviour and Medication Administration is provided. Formal staff supervision sessions have still not been implemented although the manager has now completed a staff appraisal with each member of staff. Plans to introduce staff supervision have been agreed with the seniors who will be responsible and they attended a supervision and leadership course in 2006. 7 Lucerne Road DS0000017739.V328500.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, 40, 42. Quality in this outcome area is adequate. Service users benefit from living in a home that is well managed, although some aspects of health and safety need to be addressed and a comprehensive Quality Assurance system introduced to ensure people’s views about the service are sought. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The appointment of a manager in September 2006 to manage this home and the sister home at Wivenhoe Road, Aylesford, brought a period of stability and improved the level of support to the home and to the senior staff who had been running the homes on a daily basis. The manager was aware of the need to apply to the CSCI for registration as manager and to take an appropriate training course. The manager and staff had made progress in dealing with some of the requirements made at the last inspection but were unable to progress the much-needed changes to the office/laundry environment because of the financial implications. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 22 Information provided by the manager confirmed that Health & Safety matters at the home are taken seriously. Services and equipment are serviced at the appropriate intervals and were up to date. Policies and procedures were in place and evidence was available to show that some of these had been revised and updated as part of the organisations Quality Assurance system. There was however no evidence at the home that a survey of service users, relatives and health care professionals had been carried out to obtain their views about the service. 7 Lucerne Road DS0000017739.V328500.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 1 29 X 30 1 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 3 X 2 X 7 Lucerne Road DS0000017739.V328500.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 YA20 Regulation 13 (2) Requirement The system used for the administration of medication must be assessed for the risk it presents to service users and action taken to minimise any identified risk. A record must be kept of all complaints received that include the date received, a brief description of the complaint, the outcome and whether the complainant was satisfied. The Registered Person must provide suitable laundry facilities to include sluicing facilities and a hand washbasin. Fourth repeat requirement not met within timescale. 4 YA28 YA30 23 The Registered Person must 01/07/07 provide the option of a bath for the service users. Fourth repeat requirement not met within timescale. 5 YA28 17,19. The Registered Person must 01/07/07 provide suitable and secure office facilities for the staff and storage of records required by DS0000017739.V328500.R01.S.doc Version 5.2 Page 25 Timescale for action 01/04/07 2 YA22 22 (8) 01/04/07 3 YA27 23 01/07/07 7 Lucerne Road regulation to be kept within the home for inspection purposes and for the effective and efficient running of the business. Fourth repeat requirement not met within timescale. 6 YA34 19 (1) a Evidence that Criminal Records Bureau (CRB) disclosure checks have been obtained for each member of staff must be available at the home to confirm that the necessary recruitment procedures have been taken to protect service users. The Registered Person must ensure that staff receive the support and supervision they need to carry out their jobs. Second repeat requirement not met within timescale. The Registered Person must ensure effective quality assurance and monitoring systems are in place to review care outcomes and inform future practice. This is a fourth repeat requirement not met within previous timescales of 30/1/07, 31/01/06, 31/03/05 & 1/09/05. The lack of radiator guards must be assessed to determine the risk of an injury to service users and action taken to remedy any identified risks. The responsible person must carryout Regulation 26 visits on a monthly basis and ensure reports are available for inspection at the home. These visits provide residents with the confidence that external management are monitoring the home. 01/04/07 8. YA36 13 01/05/07 10. YA39 24,12. 01/05/07 11. YA24 YA42 13 (4) a 01/04/07 12. YA40 26 (2) 26 (3) 17 (2) 01/04/07 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA25 Good Practice Recommendations The Registered Person must consider how this standard will be met with regard to adequate available floor space. Recommendation carried over from previous inspection. 2. YA26 The Registered Person must consider how this standard will be met with regard to the provision of two armchairs and a table in the bedroom, which does not have available floor space. Recommendation carried over from previous inspection. 7 Lucerne Road DS0000017739.V328500.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 7 Lucerne Road DS0000017739.V328500.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!