Inspection on 26/10/07 for Essex Park 49

This inspection was carried out on 26th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Essex Park 49 30/09/09

Essex Park 49 21/10/08

Essex Park 49 04/07/06

Essex Park 49 02/11/05

Essex Park 49 17/05/05

Essex Park 49 02/11/04

Essex Park 49 03/06/04

Similar services:

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Edenvale

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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 Essex Park 49 Finchley London N3 1ND Lead Inspector Tom McKervey Key Unannounced Inspection 26 & 31st October 2007 11:00 th Essex Park 49 DS0000010437.V337221.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 Essex Park 49 DS0000010437.V337221.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. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Essex Park 49 Address Finchley London N3 1ND 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) 020 8346 3860 020 8346 3860 Walsingham ** Post Vacant *** Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Essex Park is a home for six adults of either gender who have learning disabilities. The home is owned and managed by Walsingham Community Homes; an organisation, which provides special needs housing in other parts of the U.K. The home is a detached, two storey building, located in a pleasant residential area of Finchley in North London. It is close to shops and many other amenities. Service users bedrooms are located on the ground and first floor. The communal lounge, dining rooms and kitchen are located on the ground floor. There is a large attractive garden at the rear of the property which is accessible to service users. A car is provided for the purpose of taking service users out on various shopping trips and excursions. Information about the home including service users’ guide and the CSCI inspection reports are available from the home by contacting the provider. The fees for the service average £1195 per week, depending on the assessed needs of the residents. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and was completed in six and a quarter hours. The visit was part of the Commission’s inspection programme to check compliance with the key standards and to look at how the home was progressing in meeting requirements from the last inspection, which took place in July 2006. On the first day of the inspection I was assisted by a team leader, as the manager was absent from the home. I made an appointment to return and complete the inspection two days later, when she was available. Before this inspection, the manager sent me an AQAA, (Annual Quality Assurance Audit), which is a self-assessment of how the home meets the National Minimum Standards. Against each standard, the manager is asked to provide evidence about what the home does well, what they could do better, how they have improved in the last 12 months and what their plans are for improvement. This document is referred to in the body of this report. The inspection process included visiting all areas of the home, reading residents’ case files and other records, and discussing with those who were verbal about their experiences of living in the home. Staff were also interviewed about their work and how they were supported, and their records were examined. What the service does well: Potential users of this service will have their needs thoroughly assessed to ensure that the home is suitable for them and they have tenancy agreements that protect their rights as residents. Each resident is involved in writing their care plan, which sets out their health, social and personal needs and there are good guidelines for staff about how to minimise any risks to residents. Residents are able to exercise a wide range of choice about their lives and are consulted about how the home is run. There is a good range of educational and social activities available and the residents enjoy full access to the local community. Residents are supported to choose their own meals, which are nutritious and varied. The residents are treated with dignity in their personal care and they are supported to access a full range of health services. Medication is administered safely, which protects residents from harm The home’s complaints procedure is written in a format that the residents can understand and staff are trained in adult protection procedures. There are thorough recruitment procedures used to screen staff in order to protect residents’ best interests. There is an experienced and competent manager in charge of the home who provides clear leadership and sets high standards for the care of the residents. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 6 There are good systems in place to ensure that the health and safety of people who live and work in the home are safeguarded. 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. The summary of this inspection report can be made available in other formats on request. Essex Park 49 DS0000010437.V337221.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 Essex Park 49 DS0000010437.V337221.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): 2&5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential users of this service can be confident that their needs will be thoroughly assessed to ensure that the home is suitable to meet their needs. People who live in the home have written terms and conditions that protect their rights as residents. EVIDENCE: At the time of this inspection, there were five people living in the home and there was one long-term vacancy. The manager informed me that there had been several referrals to the home but after assessing the referrals, she had decided that the home was not suitable for their needs. The most recent admission to the home was in 1999, so the current residents have lived together for a long time. The three case files seen, contained evidence of needs assessments by care managers from the local authority and the home manager at the time, before people were placed at the home. A resident had recently had a serious accident, which resulted in problems with their mobility. All bedrooms are upstairs; however, this person was assessed by an occupational therapist who agreed that they could manage the stairs with the support of the staff. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 9 All the residents are funded by the local authority who carry out care reviews annually to ensure that the home continues to meet residents’ needs. Each resident has a licence agreement that provides information about the terms and conditions of residency. Essex Park 49 DS0000010437.V337221.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including observation and examining residents’ records. Residents’ health, social and personal needs are set out in care plans in which they have been involved, and there are good guidelines for staff about how to minimise risks to residents. However, the care plans do not always reflect significant changes in the person’s needs. Residents are able to exercise a wide range of choice about their lives and are consulted about how the home is run. EVIDENCE: I examined three care plans. It was evident that the home is adopting a person-centred approach to individual care planning, which enables the resident and their relatives to be fully involved in the process. The care plans cover issues such as communication, mobility and health. Pen pictures of the individuals are provided that record their likes and dislikes. The care plans are also written in the first person; for example, “I am 42 years old and love Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 11 people to be friendly towards others. I love to chat to people”. Another example was; “I need encouragement to wash myself”. Thorough risk assessments were also documented in the care plans; for example, lack of road sense and incidents that might occur when travelling in the home’s vehicle. The risk assessments were accompanied by good guidelines for staff about how best to support the person; for example, “Use the downstairs shower, rather than the bath”. I noted that generally, the care plans were up to date. However, in one instance, there was no reference in one resident’s care plan that they had recently sustained an injury that seriously affected their mobility. This accident was appropriately recorded in the accident book, but the manager is required to ensure that care plans are reviewed regularly to ensure that any changes in a resident’s needs are recorded. Not all residents are verbal, but I saw several examples of residents being consulted by the staff and people exercising choice. For example, I observed one resident being asked about what they would like to eat for lunch. Another resident said they had changed their mind about going out, which was respected by the staff. A resident who is blind, has an advocate who visits them monthly. I was shown pictures of meals that enable non-verbal residents to choose menus. I saw minutes of meetings that are held between the staff and residents, to discuss day-to-day issues in the home and important events. Pictures are used at these meetings to help residents participate and make suggestions, which were acted on as appropriate. Essex Park 49 DS0000010437.V337221.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): All these standards were assessed. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including discussions with staff and residents. Residents have a good range of educational and social activities and they have full access to the local community. The meals that residents choose are nutritious and varied. However, their rights are being infringed by staff opening their personal mail. EVIDENCE: All the people who live at the home attend a day centre or college. it was evident in the case files that staff from day centres attend residents’ care reviews and provide reports about their progress. Residents attending colleges are awarded certificates of achievement. The home has its own vehicle but as there is only one approved staff driver, I was told the car was not used very often. In any case, staff support the residents to use public transport as much as possible. There is a range of outings such as going to shops, cafés and pubs and residents are supported to use local amenities like bowling and swimming. Some residents attend places Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 13 of worship. It was pleasing to note that three residents attended Walsingham’s annual general meeting in Croyden this year. Most of the residents have close contact with their families and sometimes have overnight stays at home. I was concerned that while I was at the home on the first day, a letter arrived for a resident, which a member of staff put in the manager’s in-tray, rather than giving it to the resident. I was informed that this was the practice in case there was important information, in the post, for example, a health appointment. When I discussed this issue with the manager at my second visit, she stated categorically, that she did not approve of this practice and stated that she would ensure that staff are reminded that mail should be given to residents unopened, but obviously, in the presence of staff so that important information is not lost. Residents are supported to choose the menu for the week and to accompany staff to do the weekly shopping. The menus showed a good variety of meals that were well balanced and nutritious. The people I spoke to, said that they were happy with the food and they had enough to eat. I examined the fridges and freezers and was satisfied that the food was being labelled and stored safely. All staff had attended training in food hygiene. Essex Park 49 DS0000010437.V337221.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents are treated with dignity in their personal care and they are supported to access a full range of health services. Residents’ can be confident that their welfare is protected by safe administration of their medicines. EVIDENCE: There is good information for staff about how to best support residents with their personal care, particularly those who are non-verbal. I noted that all the residents were clean and appropriately dressed for the time of year. The residents with whom I spoke, said that staff treated them with dignity and respect. I was informed that personal care is always provided discreetly in residents’ bedrooms or in locked toilets/bathrooms. Each resident’s file contains important health information for staff to take with them if they need to accompany a resident to A&E in an emergency. There is a good standard of healthcare records that show appointments for residents when they are seen by the G.P, dentist, optician etc. Residents have “Healthcare Plans” which give complete medical histories of the individuals. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 15 Female residents had cervical and breast screens this year and all residents had the flu’ vaccine. A resident who is diabetic, has their blood monitored by staff each week and charts are kept to record seizures for those who have epilepsy. I noted that staff were diligent in supporting a resident who had recently sustained a fractured femur. This consisted of regular exercises, in accordance with advice from an occupational therapist. Special adaptations and a new chair had been also provided for this resident to make life more comfortable. The residents also have regular appointments with a consultant psychiatrist who also reviews medication. I examined the medication standards and found no deficiencies in the storage and administration of medicines, and there were no gaps in the MAR sheets. Staffs’ signatures were attached to show they had been trained in the administration of medicines. Essex Park 49 DS0000010437.V337221.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including looking at documents and interviewing staff. Residents are protected from abuse by the home’s complaints procedure, and staffs’ awareness and training about adult protection. EVIDENCE: The home has a procedure on complaints, which is written in pictorial format so that the residents can understand it. In her AQAA submission, the manager states that she also intends to put the complaints procedure on audio. In the past year, only one complaint had been logged, which was from a neighbour about the behaviour of a resident. This was responded to appropriately and resolved. There is a copy of the local authority’s procedure on Protection of Vulnerable Adults, and a policy in place about whistle blowing. The staff records show that all staff had attended training on adult protection with the exception of two, for whom training has been booked. In discussion with individual staff, they demonstrated a good knowledge and awareness of issues of abuse. Essex Park 49 DS0000010437.V337221.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, 27, 28 & 30 People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including visiting all areas of the home. Because of the poor standard of maintenance and decoration, the residents do not have an attractive home to live in and a specific resident’s bedroom needs major refurbishment to improve their comfort and wellbeing. The home is generally clean and tidy. EVIDENCE: I inspected all areas of the home, including the residents’ bedrooms and communal spaces. Since the last inspection, the kitchen has been redecorated. The standard of decoration in the majority of the bedrooms was good. However, in one person’s bedroom, the dresser was broken, there was no bedside locker, the ceiling lights did not have lampshades, and a full length mirror did not have a stand and/or was not fixed to the wall. I was informed that this resident was only supposed to use this bedroom temporarally while their own bedroom was having work done. However, this arrangement has Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 18 been in place for six months and now must be addressed. Appropriate window restrictors were in place in bedrooms. The front door was very marked and gave a poor impression of the home. The downstairs toilet was blocked and the hall and stair carpets were very stained and worn. With these exceptions however, the home was generally clean and tidy and there were no offensive odours. I have made requirements for all these issues to be addressed. The lounge and dining furniture was in good condition and the garden was well maintained.. Staff have disposable gloves and aprons available to them when supporting residents with personal care and they have been trained in infection control. Essex Park 49 DS0000010437.V337221.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, 34 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service and interviewing staff. There are sufficient numbers of staff on duty to meet residents’ needs and they are supported by a well trained and supervised group of staff. EVIDENCE: The staff rota showed that there is normally three staff on the morning shift, two in the evening and one awake at night. The staff to whom I spoke, said that the staffing levels were sufficient to support the five residents. At the time of the inspection, vacancies were being covered by agency staff who have worked for some time in the home and know the residents well. They manager told me that she has advertised to fill the current staff vacancies. Two staff have attained National Vocational Qualification level 2 and one was currently training on NVQ level 3. The manager is a NVQ assessor. All staff have undergone an induction that covers policies and procedures and health and safety subjects. The manager told me that even staff who worked at the home for a long time, had gone through this programme again to ensure that their knowledge was up to date. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 20 Walsingham Community Homes has an agreement with the Commission for Social Care Inspection for staff recruitment records to be retained at their head office, therefore these records were not seen. I was assured by the manager that robust recruitment procedures are followed, including Criminal Records Bureau screening and references. I saw records of staff supervisions and those staff I spoke to, said they valued these one-to-one sessions as an opportunity to discuss their work and identify their training and development needs. Essex Park 49 DS0000010437.V337221.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, 38, 39, 41 & 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including discussions with the manager and staff and examining records and documents. The residents benefit from having an experienced and competent manager to run the home effectively. Residents are supported to air their views at meetings, but this could be further improved by actively seeking their views and that of other stakeholders, about the quality of the services to identify areas of improvement. There are good systems in place to safeguard residents’ financial interests and their health and safety. EVIDENCE: The manager has extensive management experience, having been a manager at another home owned by the Walsingham. She has NVQ level 4 (Manager) Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 22 qualification and expects to complete the registered manager’s award in December 2007. She is also an NVQ assessor and has registered with the Commission for Social Care Inspection as the manager. I discussed the AQAA with the manager and suggested areas where the information could be improved upon. There was a relaxed atmosphere in the home and the staff told me they were confident in the manager’s ability and that she was approachable, supportive, and gave clear leadership about the standard of care and quality of the service to be provided. Regular meetings are held between staff and residents about menu planning and the day to day running of the home. However, a formal audit of residents’, relatives’ and other stakeholders’ views of the quality of the service has not been done this year, which is a requirement. Senior managers make monthly visits to the home to monitor the service and they provide a report of their findings and areas that need improvement. I sampled records of residents’ financial transactions and found that these were satisfactory. Receipts for purchases were kept and the cash balanced with the accounts. Accidents and incidents were recorded accurately, but these records would benefit from being kept in separate folders for ease of reference. There were good health and safety procedures, including regular testing of temperatures of the water, fridges and freezers and the area where the medicines are kept. Records also showed that the gas boiler and all portable electrical appliances had been tested and safe to use. Fire alarms are tested weekly and drills are carried out. There is a valid insurance certificate on display. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X 3 3 X Essex Park 49 DS0000010437.V337221.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 YA6 Regulation 15(2)b) Requirement A specific resident’s care plan must be reviewed to ensure that recent changes to their mobility are documented and addressed. Staff must support residents to open their personal mail themselves. The front door of the home must be redecorated or replaced to improve the appearance of the property. The registered person must ensure that the carpets in the halls and the stairs are cleaned or replaced. This requirement is restated from the last inspection. The timescale for compliance was 30/09/06 The blockage in the downstairs toilet must be cleared. A appropriate bedroom furniture and fittings must be provided for a specific resident, including, lampshades, bedside locker and dresser. The mirror must DS0000010437.V337221.R01.S.doc Timescale for action 15/12/07 2. 3. YA16 12(4)(a) 23(1)(2) 15/12/07 30/12/07 YA24 4. YA24 23(1)(2) 30/12/07 5. 6. YA24 YA25 23(2)(b) 16(1)(c) 30/11/07 15/12/07 Essex Park 49 Version 5.2 Page 25 7. YA39 be secured to the wall or have a stand fitted. 24(1)(a)(b)(3) The registered person must put in place effective quality assurance and quality monitoring systems, which seek the views of service users, visitors and professionals. The outcome of the surveys must be published and made available to all parties including the CSCI. This requirement is restated from the last inspection. The timescale for compliance was 30/09/06 31/01/08 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 YA41 Good Practice Recommendations The records of accidents and incidents should be kept in separate folders for ease of reference. Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Essex Park 49 DS0000010437.V337221.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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