Inspection on 07/06/05 for Endymion Road, 2

This inspection was carried out on 7th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Endymion Road, 2 02/10/08

Endymion Road, 2 14/11/07

Endymion Road, 2 01/08/06

Endymion Road, 2 21/02/06

Endymion Road, 2 25/01/05

Endymion Road, 2 22/07/04

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 2 ENDYMION ROAD London N4 1EE Lead Inspector Caroline Mitchell Unannounced 7 June 2005 @ 5.00 pm 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 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 Stationary 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. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 2 Endymion Road Address London, N4 1EE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8693 6088 020 8299 4818 Mr Charan Singhe & Mrs Margaret Badu of Choice Support Vacant Post PC Care Home 6 beds Category(ies) of LD - Learning Disability registration, with number of places 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25 January 2005 Brief Description of the Service: 2 Endymion Road is a large converted terraced house situated in the Finsbury Park area of North London. The home is registered to provide personal care for up to six service users of either sex and over the age of 18 who have a learning disability. The stated aim of the home is to provide a supportive environment where service users can live their lives according to their individual wishes and needs with the assistance of staff. There are three floors and all service users have single rooms. There are six single bedrooms and one sleep in room for staff; none of the rooms are en -suite. There are three bathrooms, and four toilets, a kitchen and a lounge. The accommodation is not suitable for service users with physical mobility problems. Choice Support, a large organisation that provides residential services for people with learning disabilities nationally, operates the home. The housing management is provided by London and Quadrant. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on an unannounced basis and took around three hours to complete. The inspector arrived in the early evening and the manager, who was newly appointed, was kind enough to stay on after the end of his shift to aid the inspector throughout the visit. The inspector toured the building and reviewed a number of the records kept in the home. The inspector also had the opportunity to speak with three staff members and took the opportunity to spend some time sitting in the lounge with the service users. Due to the nature of their disability, and their communication difficulties it is difficult to gain their opinions about life in the home. However, the inspector observed that they were relaxed and comfortable, in each other’s company and with the staff and there was a lot of laughter between staff and service users. What the service does well: What has improved since the last inspection? What they could do better: 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 6 The main concern for the registered provider is the state of the house, which is deteriorating, and there is a need to ensure that the maintenance issues are addressed in the home as a matter of priority. A number of requirements are restated under standards 26, 27 and 28. In addition the practice of propping open bedroom doors could leave service users at risk in the event of a fire. The service user plans and risk assessments are in need of review in order to ensure that they keep pace with the service users’ changing needs. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 1, 2 & 5 Prospective users have the information they need to make an informed choice about where they live as both a statement of purpose and a service user guide are available. Service users can be confident that their aspirations and needs will be properly assessed. EVIDENCE: Both the statement of purpose and the service user guide are in place and these are included in each service users’ file. Each service user has lived at Endymion Road for several years. It was evident on each file examined that each person had a full assessment undertaken prior to moving into the home. Information about the assessed needs of service users was detailed and included how all aspects of care and development are met. Examples include communication methods particular to individual service users. There is a copy of the service user individual contract that has been introduced by Choice Support included in the service users’ written records. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 6, 7, 9 & 10 A new Person Centered Planning format is being introduced. Service user plans and risk assessments are detailed and informative. Service users are encouraged to make decisions about their lives and supported to take risks as part of an independent lifestyle. However, both the plans and the risk assessments are in need of review. There are a number of restrictions placed on service users, and these are generally for their own safety, and are documented appropriately. EVIDENCE: Three service user plans were examined. Each had individual plans in place. These are in need of review. Choice Support are introducing a new way of planning for service users’ needs, which is called person centred planning (PCP) and the manager is undertaking training as a facilitator in order to start the process of involving the key workers in reviewing each service user’s plan in the new format. He said that he aims to ensure that all service users’ plans are completed in the new format by the end of August. A requirement is made in respect of this. There were comprehensive risk assessments in place both for individual service users and for tasks and activities that service users engage in or are exposed to. The risk assessments include the level of risk identified and the action taken to minimise the risk. If 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 10 necessary members of the multi-disciplinary team are involved in risk management strategies. Risk assessments contain information, clearly gained from the experience of staff. This ensures that staff learn from each other and provide a consistent approach to the care of service users. However, these have not been reviewed for over a year and a requirement is made in respect of this. Because of the nature of the service users’ disabilities (they do not communicate in conventional ways) it is difficult to be sure of their opinions. There are a number of restrictions placed on service users, for their own safety, such as not having keys to their front door. They are assessed as at risk if they were to go out without staff supervision. These restrictions are agreed by all relevant stakeholders and are documented appropriately as part of service users’ plans and risk assessments. However, as previously stated, the risk assessments have not been reviewed and a requirement is made in respect of this. It was evident that service users are encouraged to be as independent as possible and to make decisions that are meaningful to them. This includes choices about what they wear, choices of activities, and bedtimes. The acting manager talked about the choices and regularly made by the service users and the ways in which they make their preferences known. The information regarding service users is kept appropriately in the home. The organisation has previously provided evidence to the inspector of the exemption in place for charitable organisations in relation to registration with the Data Protection Agency. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14, 15 & 16 The home provides opportunities for personal development and service users do take part in a good range of social and leisure activities, both in the home and in their local community. Service users’ families have involvement in their lives. Service users’ rights are recognised and staff work proactively to support service users to reach their potential. EVIDENCE: There is evidence in the day-to-day records that the service users are assisted and supported to develop on a personal level. Specific plans and strategies are in place and staff work proactively with service users to ensure they develop to their full potential. Staff members told the inspector about the various skills service users have learned and the responsibilities that they each take on around the house. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 12 Records reflect that service users take part in various activities including going shopping, for walks in the park and attending a specialist day centre for people with learning disabilities and taking part in a variety of activities there. Service users are fully assisted to take part in the life of the local community. All service users have freedom passes for public transport and are encouraged to use this, with staff support, in preference to the home’s own transport. Supporting service users to access community activities and local facilities is given a high priority. There was evidence from service users’ plans that religious and spiritual needs of service users are being addressed. Service users have specific plans which detail how their social and recreational needs are met. Planned activities take place both during the day and the evening and weekends. Service users are encouraged to access recreational activities. One service user’s records reflected that they had been to the stables and been out for lunch that week, as part of their regular scheduled activities. Another had been bowling, sight seeing and swimming in the previous month. The home employs a sessional reflexologist, who was visiting the home and providing massage therapy for each service user at the time of the inspection. Evidence was seen in the service users’ files that staff support them to maintain family involvement and to make friends and develop relationships. There was evidence on file and there were examples seen of how the house routines support and promote the individuality and independence of service users. Some controls have been established because of some of the rituals service users engage in and these are documented as part of individual plans and risk assessments. Only one service user can manage their own mail. Staff assist the other service users to open and attend to their letters. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 19, 20 & 21 Service users are assisted and supported to access appropriate health care. The arrangements that are in place in the home for the storage and administration of medication were acceptable and safeguard service users interests. Service users can be confident that their ageing, illness or death would be handled sensitively and appropriately in the home. EVIDENCE: Evidence was seen on service users plans that they are assisted and supported to access appropriate health care facilities and each one is registered with a General Practitioner. The service users are supported to attend the surgery, and outpatient hospital appointments when necessary. One service user had recently had an accident and hurt his finger, and it was evident that the staff had taken all necessary action to ensure that he received the appropriate medical treatment. The inspector reviewed the arrangements that are in place in the home for the storage and administration of medication and these were acceptable. The staff had undertaken training in the Boots system the day prior to the inspection and the manager said that the system would be installed at the beginning of the following week. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 14 The service users’ families have been consulted about their wishes in relation to funeral arrangements are these are recorded in service users’ records. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 22 & 23 Service users and their representatives can feel their views are listened to and will be acted on, and that service users are protected from abuse, neglect and self-harm. There are written procedures for handling complaints a policy on adult protection and whistle blowing exists that is in line local adult protection procedures. EVIDENCE: The inspector saw a copy of the guidance for service users about how to make a complaint. It is written in accessible language and includes “widget” pictures to help service users to understand the process. No complaints had been recorded in the home since the previous inspection. Choice Support has developed an adult protection policy to comply with the Department of Health guidance “No Secrets” and this is available in the home along with a whistle blowing policy for staff. There have been no adult protection issues since the previous inspection. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 The home provides an environment that service users can regard as their home and their bedrooms are personalised to reflect this. However, the standard of the repair and décor is poor, and is becoming a less comfortable environment for service users to live in and these issues must be addressed as a matter of priority. EVIDENCE: 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 17 The home has an uncared for feel and is need of decoration in most areas. The manager showed the inspector written evidence of the maintenance tasks that have been identified by Choice Support to be undertaken by the organisation responsible for the maintenance of the home, London and Quadrant. However, there has been very little improvement in the decorative state of the home since the last inspection. A number of requirements are restated in respect of the environment under NMS 26, 27 and 28 of this report and must be addressed as a matter of priority. The bedrooms were not measured during this inspection and the figures above are based on a visual assessment and information from the registered persons. The home provides appropriate accommodation for the service users who live there, although some of the bedrooms are quite small. It is evident that effort has been put into ensuring that service users’ bedrooms are decorated and equipped to reflect the personalities and interests of each occupant. However, the decoration is beginning to look quite tired and there is a need to re-decorate most of these rooms. This excludes the service user who has a bedroom in the basement, who has now moved back in his bedroom, which has been refurbished following a leak from the room above. At the previous inspection the inspector noted that the vanity units in most service users’ bedrooms had suffered water damage and needed to be refurbished. This issue has not been addressed and this requirement is restated for a second time. There are sufficient bathrooms and some separate toilets in the home. However, at the previous inspection, the toilets and bathrooms needed to be redecorated and the floor covering needed to be replaced. The pedestals of two wash hand basins were cracked. A light fitting was coming away from the ceiling and the shade was melted. At this inspection, it was noted that these issues had not been addressed. The light fitting remained without a cover, the pedestals remain broken and the bathrooms and toilets are not of an acceptable standard and still need to be refurbished. Several requirements are restated in relation to these issues and need to be addressed as a matter of urgency. There is one lounge and a large sensory room. However, the sensory room is in the basement, is rarely used and had an unlived in feel. There is also a large kitchen / diner. The decoration in the shared areas has deteriorated since the previous inspection and the lounge is now quite badly in need of re-decoration. The floor covering in the lounge are not in a good state of repair and also needs to be replaced. The hallway, stairs and landing had recently received a coat of emulsion, but the woodwork is in a poor state and needs to be repainted. The kitchen also needs re-decorating and the carpet needs to be replaced on the stairs and landings and requirements are restated in respect of this. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 18 There are no service users who require specific aids and adaptations at present. There are magnetic fire door closures on some of the doors to communal areas, which automatically close when the fire alarm sounds. The washing machine and dryer are sited in a laundry room in the basement and the washing machine has a sluice cycle. There are written policies and procedures in place regarding infection control. Although the home was reasonably clean, as it is badly in need of re-decoration, it did not feel particularly comfortable to be in. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 & 33 The home is adequately staffed in terms of the hours provided. The needs of the service users in the home were seen to be met by the numbers, competence and skills of the staff employed. An improvement in the consistency of staff is expected now that a number of new, permanent staff have been recruited. EVIDENCE: All staff have a job description which is relevant to their role and responsibilities and which is linked to assisting and supporting service users to attain individual goals. The main aims and values of the home are covered in the induction period and staff read and sign all policies and procedures. Choice Support has provided a copy of the General Social Care Council Code of Conduct to staff. There was evidence that staff have the skills, competencies and experience to meet the assessed needs of service users. Interactions between staff and service users were observed to be appropriate, professional and relaxed. It was apparent that the staff team are committed to working with individual service users to enable them to live as they wish and to fulfil their individual goals and aspirations. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 20 The inspector was provided with a copy of the staff rota for the period in which the inspection was undertaken and noted that this indicated that there was sufficient numbers of staff rota’d on duty to ensure that all shifts were covered. There have been a number of staff vacancies and some new staff have recently been recruited in order to ensure that there are sufficient numbers of staff to support service users’ assessed needs at all times and to ensure continuity of care on a day by day basis. Most new staff were due to start the following week. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 & 42 Service users benefit from the ethos and leadership of the home. The record keeping in the home safeguards the service users’ best interests. Service users can be confident that the home protects their physical safety through a reasonably proactive approach to health and safety in general, although the practice of propping open bedroom doors could leave service users at risk in the event of a fire. EVIDENCE: A new manager has been appointed to run the home since the last inspection. He has submitted an application to the Commission for registration. From discussion with staff at the home it was evident they felt the management approach to the home is open and positive. Staff meeting minutes that were examined also reflected this. The records seen by the inspector were well organised, in good order and kept securely. Service user records included a recent photograph and weekly 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 22 activities schedule. During the tour of the building the inspector noted that the certificate of registration was properly displayed. A number of the doors in the home are fitted with magnetic closures that are linked to the fire alarm system and close automatically in the event of a fire. However, the service users’ bedroom doors are not linked to this system and it was evident that they are being propped open regularly, in order to help air the rooms. As stated in the home’s own fire risk assessment, fire doors must not be wedged open in this way, and a requirement is made in respect of this. It is recommended that the service users’ bedroom doors are fitted with magnetic closures of the same type that are currently in place in the rest of the house. The lock has been changed and an alarm has been fitted to the basement door by recommendation of the fire officer, to ensure a more effective route of escape in the event of a fire. The inspector noted that there are sufficient staff who are trained first aiders to ensure that a person qualified in first aid is on duty at all times, satisfactory portable appliance testing (PAT) has been undertaken and the record of fridge and freezer temperatures were acceptable. There was evidence that the registered provider has ensured that equipment such as gas and fire alarms have been serviced appropriately. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 2 ENDYMION ROAD Score Standard No Score Version 1.20 Page 23 G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc 1 2 3 4 5 3 3 x x 3 22 23 ENVIRONMENT 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 1 1 1 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 2 x 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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 6 Regulation 15 Requirement The manager must ensure that all service users plans are completed in the new PCP format. The registered provider must ensure that the service users risk assessments are reviewed and updated. The registered provider must ensure that the floor coverings in the bathrooms and toilets are replaced where necessary. (Timescale of 12/12/04 not met)This requirement is restated. The registered provider must ensure that the broken pedestals to the wash hand basins are replaced. (Timescale of 12/10/04 not met)This requirement is restated. The registered provider must ensure that the light fitting in the bathroom on the first floor is repaired or replaced. (Timescale of 12/09/04 not met)This requirement is restated. The registered provider must ensure that the woodwork in the hallway, stairs and landing is redecorated. Timescale for action 31/08/05 2. 9 13 (4) 31/08/05 3. 27 23 [2] [c] [d] 31/10/05 4. 27 23 [2] [c] 31/10/05 5. 27 23 [2] [c] 31/10/05 6. 28 23 [2] [d] 31/10/05 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 25 7. 26 23 [2] [c] 8. 27 23 [1] [a] [d] 9. 26 23 (2) (d) 10. 27 23 [2] [c] 11. 28 23 (2) (d) 12. 28 23 (2) (d) 13. 28 23 (2) (d) 14. 28 23 (2) (d) The registered provider must ensure that the vanity units in service users’ bedrooms that have suffered water damage are refurbished. (Timescale of 12/01/05 not met)This requirement is restated. The registered provider must ensure that the bathrooms and toilets are redecorated and suitable accessories are provided to ensure that they are more pleasant and homely. (Timescale of 12/01/05 not met)This requirement is restated. The registered provider must ensure that the service users’ bedrooms are re-decorated as necessary. (Timescale of 30/05/05 not met)This requirement is restated. The registered provider must ensure that the toilet on the first floor is repaired.(Timescale of 28/02/05 not met)This requirement is restated. The registered provider must ensure that the kitchen is redecorated.(Timescale of 30/06/05 not met)This requirement is restated. The registered provider must ensure that the carpets in the hall, on the stairs and landings are replaced. (Timescale of 30/07/05 not met)This requirement is restated. The registered provider must ensure that the lounge is redecorated. (Timescale of 30/05/05 not met)This requirement is restated. The registered provider must ensure that the floor covering in the lounge is repaired or replaced. (Timescale of 30/05/05 not met)This requirement is restated. 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 26 15. 42 23 (4) The registered person must ensure that fire doors are not wedged open. 07/06/05 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 42 Good Practice Recommendations It is recommended that the service users’ bedroom doors are fitted with magnetic closures of the same type that are currently in place in the rest of the house. 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection Solar House, 1st Floor, 282 Chase Road, Southgate, London, N14 6HA 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 2 ENDYMION ROAD G59 S60622 2 Endymion Road V222871 07.06.05 Stage 4.doc Version 1.20 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. 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