Inspection on 21/09/06 for Harefield Road, 156

This inspection was carried out on 21st September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Harefield Road, 156 21/09/09

Harefield Road, 156 08/11/07

Harefield Road, 156 22/12/05

Harefield Road, 156 02/06/05

Harefield Road, 156 09/02/05

Harefield Road, 156 24/06/04

Harefield Road, 156 12/02/04

Harefield Road, 156 09/10/03

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Ashlong House

Norbury Crescent (30)

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 Harefield Road, 156 Uxbridge Middlesex UB8 1PP Lead Inspector Simon Smith Key Unannounced Inspection 21st September 2006 3.15 Harefield Road, 156 DS0000027063.V310029.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 Harefield Road, 156 DS0000027063.V310029.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. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harefield Road, 156 Address Uxbridge Middlesex UB8 1PP 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) 01895 254803 Ealing Consortium Limited Miss Kirsten Hadleigh Care Home 4 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of registration for one Service User, who is over 65, as approved by the NCSC on 08/04/03 22nd December 2005 Date of last inspection Brief Description of the Service: 156 Harefield Road is home to four men with learning disabilities who also have mental health needs. The home is owned by Notting Hill Housing Association and the service is managed by Ealing Consortium, a not-for-profit organisation. In addition to registered care and support, Ealing Consortium also provides supported living, a short break service and activities for people with learning disabilities. The home is situated in a pleasant residential area and has good access to public transport networks and good shopping and community facilities. A good standard of decoration has been achieved throughout the home and the property has a well maintained garden. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector used evidence from a wide range of sources when making judgements about the home. These included visiting the home and talking to residents, the manager and staff. The inspector also looked at residents’ files and health and safety records. Surveys were given to residents, relatives and professionals who visit the home. Two residents and two relatives returned surveys. The inspector was made welcome during the visit and would like to thank all those who gave their views about the home. The home met 25 of 30 National Minimum Standards assessed at this visit. Five Standards were almost met. It is important to note that three of these Standards relate to action that must be taken by the housing association responsible for maintenance. Residents’ said that staff treat them with respect and that carers listen to them and act on what they say. One resident said, “I like going out in the community, going to shops and eating out”. Another resident said “I like it here – its good”. Relatives said that they are made welcome when they visit and that staff provide good care and support. One relative said, “I find the staff at the moment and also the new manager very caring towards all the residents”. Another relative said, “I could not wish for a better home for my son. The staff are kind and caring and support him in every possible way”. A new manager has started work since the last inspection. Staff said that the new manager listens to their ideas and encourages them to think about how the home could improve. Staff on duty knew residents’ needs well and were positive about their work. Staff feel that Ealing Consortium is a good organisation to work for and that they get good training and support. What the service does well: Supports residents to access social, leisure and employment opportunities. Supports residents’ involvement in their local community. Supports residents to maintain positive relationships with their families. Involves residents in the life of the home and consults them about decisions. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 6 There are good systems in place to capture residents’ views about the services they use. There is a commitment to monitoring and improving the quality of the home. Staff understand their roles and communicate well with one another. The manager encourages staff to contribute their views to the development of the home and provides good support to the staff team. 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. Harefield Road, 156 DS0000027063.V310029.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 Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Information about the home is available to residents, although some details need updating. Residents’ individual needs are effectively assessed at the time of admission. Residents are issued with a written agreement that sets out their rights and responsibilities. EVIDENCE: Ealing Consortium has produced a Statement of Purpose, which gives details of the services provided and sets out the home’s aims and objectives. A Service User Guide is issued to all residents. Some of the information in the Statement of Purpose and the Service User Guide, such as the manager’s details, needs updating. Two residents’ files were examined. Both contained evidence that residents’ needs were assessed at the time of their admission. Assessments addressed areas including self care and independent living skills, leisure and social interests. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 9 Residents have a tenancy agreement with Notting Hill Housing Association that clarifies their rights and responsibilities. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents’ care plans reflect their needs and preferences and are regularly reviewed. Residents receive good support to make decisions and choices about their lives. Residents are consulted about issues that affect them in the home. There is a commitment to supporting residents in taking manageable risks. EVIDENCE: There is a commitment to person-centred planning and to delivering a service that reflects residents’ needs and aspirations. Implementing person-centred planning is an organisational objective for 2006 and the manager said that a pilot project is in progress within the organisation to introduce Essential Lifestyle Plans for residents. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 11 Two residents’ care plans were examined. Care plans reflected residents’ individual skills, strengths, needs and goals and recorded preferences in terms of daily routines and leisure activities. Both care plans had been recently reviewed, providing evidence that residents’ needs are regularly assessed and monitored. Residents choose not to meet formally but confirmed that their opinions and preferences are reflected in their daily lives, such as choosing the menu and the activities in which they are involved. One resident has expressed a wish to consider moving to another care home. The manager was able to demonstrate that the resident is receiving support to make choices in this area and that the home has liaised with the resident’s care manager about this issue. There is a commitment to supporting residents to take manageable risks in their day-to-day lives and risk assessments are in place addressing specific activities undertaken by residents. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents are encouraged to develop the skills required for independent living. Residents are involved in their local community. Residents are supported to maintain relationships with their families and friends. Residents are encouraged to involve themselves in the routines of the home. The home should consider how to keep the home’s communal facilities available to all residents. Residents are involved in choosing the home’s menu. EVIDENCE: Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 13 Residents are encouraged to develop the skills required for independent living and receive support from staff with household tasks. One resident said that he participates in the routines of the home such as cleaning and laundry. Another resident said that he has a part-time job, which he enjoys, and that he does some of his own cooking. Residents are involved in their local community and make use of local shops, cafes, pubs and other neighbourhood resources. The manager said that increasing residents’ participation in their local community is a focus for the home. Staff support residents in maintaining relationships with their friends and families. Two residents said that their relatives visit them at the home and one resident said that he goes out for a meal with a family member and a member of staff each week. Another resident said that he often spends weekends with his family. Interaction between staff and residents was positive during the inspection. Observation during the visit confirmed that residents are comfortable and relaxed in their home environment and that they are able to choose how they spend their time at the home. However the kitchen is locked at night and therefore is not available to residents during this period. Staff advised that this is because one resident has a tendency to drink too much at night. Whilst this resident’s needs must be taken into account, the home should also consider how to keep the home’s communal facilities available to other residents. For example the majority of items stored in the kitchen could be locked away at night but the area could remain accessible to residents for the preparation of snacks and drinks. The rationale underpinning the reasons for restrictions on access must also be recorded on the resident’s care plan. Residents are consulted about the home’s menu. Care staff have responsibility for cooking and preparing food, which is appropriate given the size of the home. Residents are encouraged to involve themselves in meal preparation. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents receive personal support in the way they prefer. Residents’ healthcare needs are met. Residents are supported to access community and specialist healthcare resources where necessary. Residents’ medication is appropriately stored and accurately recorded. Where residents control their own medication, this must be supported by an appropriate risk assessment and reflected in their care plans. EVIDENCE: The home’s induction programme provides detailed information about how to provide individual support for each resident. This means that staff adopt a consistent approach in their work with residents. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 15 The inspection provided evidence that long term healthcare conditions, such as epilepsy, are managed well and that appropriate specialist advice is sought where necessary. There was also evidence that the home responds appropriately when residents’ needs change. For example the home had reassessed the appropriate staffing ratio for one resident following a recent incident. The home is required to manage some challenging behaviour. Staff have attended de-escalation training to equip them with the skills to manage this de-escalation effectively. The manager advised that she needs to attend a refresher course in de-escalation techniques. Monthly Quality Assurance reports (see the ‘Conduct and Management of the Home’ section of this report) monitor any accidents/incidents affecting residents, including incidents of challenging behaviour. There is an appropriate system for the storage and administration of medication. All medication coming into or leaving the home is recorded. There are clear procedures governing the administration of medication. The manager said that all staff attend appropriate training before being authorised to administer medication. Inspection of medication records for two residents revealed no omissions or errors. The manager was able to demonstrate that the home had taken action to make the improvements in this area required by the CSCI, including the training of agency staff, checking medication at handovers and creating a record of sample staff signatures. An audit of the home’s medication by the supplying pharmacist was due the day after inspection. Staff said that one resident self medicates at weekends when he is often away from the home, although this is not reflected in the resident’s care plan. Whilst it is positive that residents are encouraged to manage their medication, the home must be able to demonstrate that any potential risks arising from this activity have been considered and that measures have been put in place to address them. The resident’s care plan should also reflect that he administers his own medication when away from the home. See Requirements 1 and 2. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Appropriate procedures are in place for the management of complaints. Residents feel confident about raising concerns if necessary. Training is provided for staff in the Protection of Vulnerable Adults, although some staff should attend refresher training in this area. EVIDENCE: The home has an appropriate Complaints procedure. There have been no complaints made about the home since January 2004. Residents said that they would know who to speak to if they were not happy about something at the home and that they would feel confident about approaching staff with a complaint if necessary. The home works within the local authority‘s Protection of Vulnerable Adults (POVA) policy, which provides guidance for staff in the recognition and reporting of abuse. The home’s training records indicate that POVA training was last delivered in June 2004, although staff that have joined the service since that time will have attended a one day session on this topic during their induction. It is recommended that those staff who have not attended POVA training since June 2004 attend a refresher session. Harefield Road, 156 DS0000027063.V310029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Some areas of the home have been improved since the last inspection but a number of issues still need to be addressed. The lighting on the first floor must be improved and the toilet replaced. The home must obtain evidence that the water supply complies with the Water Supply Regulations (1999). EVIDENCE: The home is situated in a pleasant residential area and has good access to public transport networks and good shopping and community facilities. A good standard of decoration has been achieved throughout the home and the property has a well maintained garden. The manager said that, since the last inspection, the home’s heating system has been repaired and redecoration of the interior and exterior of the property Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 18 completed. The manager also advised that new double glazing has been installed where necessary. Although some areas of the home have improved since the last inspection, a number of issues still need to be addressed. The toilet on the first floor is in a poor condition, is a source of unpleasant odours and should be replaced. See Requirement 3. Lighting on the first floor landing is inadequate and must be improved. See Requirement 4. Staff advised that there were initially two wall mounted lights in this area but that one had been accidentally broken. The subsequent repair did not include replacing the light unit. The remaining light unit is the same design as that which was broken. The design is not ideal for residents’ needs and it is recommended that both units are replaced by a more appropriate design. The manager said that the home’s water supply has been inspected and certified as meeting relevant standards but that the certificate of inspection has yet to be received. This certificate must be obtained by the home as evidence that the water supply complies with the Water Supply Regulations (1999). See Requirement 5. Harefield Road, 156 DS0000027063.V310029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staff understand their roles and communicate well as a team. Staff attend training appropriate to their roles. Staff receive effective supervision and support. New staff receive good support when they start work. EVIDENCE: The staffing structure of the home comprises a manager, senior support worker and five support workers. There was one full-time vacancy at the time of inspection, which is covered by bank and agency staff. The inspector spoke to the manager and members of permanent and agency staff. All were positive about their work at the home and about Ealing Consortium as an employer. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 20 Staff said that they are encouraged to attend training relevant to their work and to contribute ideas for developing the service. Staff also said that they receive regular one-to-one supervision and that they meet as a team weekly. Although staff confirmed that they receive sufficient training to do their jobs well, the home’s training records could be improved. This issue was identified as an area for improvement in the most recent Quality Assurance report. Staff confirmed that they had been required to produce references and a Criminal Records Bureau disclosure prior to staring work at the home. The manager advised that Ealing Consortium holds staff records (including references and Criminal Records Bureau disclosures) centrally and confirmed that these records had been obtained for all those employed at the home. New staff said that they had a formal induction and good support when they started work at the home. There is an expectation that new staff will register with the Learning Disabilities Award Framework unless they have already completed this training. Harefield Road, 156 DS0000027063.V310029.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The manager is experienced, enthusiastic and provides good support to the staff team. There are effective Quality Assurance systems in place. Residents’ views are sought about the services they use. Residents’ financial records were clear and accurate. The health and safety of residents and staff is maintained. EVIDENCE: The home’s registered manager left in July 2006. The new manager must therefore submit an application to register with the CSCI. See Requirement 7. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 22 The new manager has a good deal of relevant experience and advised that she had had a two week handover from her predecessor when she took up the post. The manager is working towards the Registered Managers Award and has achieved the NVQ assessors’ award. The manager is enthusiastic and has a commitment to involving staff in the development of the service. As highlighted in the previous section of this report, staff feel that their views and contributions are valued by the manager. Staff also said that the manager is approachable and provides good support to the staff team. Ealing Consortium has a commitment to Quality Assurance and systems are in place to capture residents’ views about the services they use. In addition the Consortium’s service users have opportunities to contribute to the organisation’s development. For example service users have been involved in the recruitment of staff. The organisation also monitors quality regularly through the organisation’s managers. The home manager completes and submits a quarterly Quality Assurance report, which addresses all areas of service delivery. The service (area) manager visits the home weekly and compiles monitoring reports quarterly. There is a ‘business strategy’ for the period 2005-8, which addresses quality and service development. Ealing Consortium achieved the Investors in People award in 1999. The organisation was re-accredited in 2003 and a further re-assessment was planned for September 2006. There are appropriate systems for recording residents’ income and expenditure. Monthly reconciliations are completed and sent to Head Office. Staff check residents’ monies daily. Financial records for two residents were examined. Cash balances were correct and records of expenditure were accurate and up to date. The home has an appropriate fire detection system and fire procedures. Fire alarms and call points are checked by staff weekly. Inspection of records provided evidence that the fire alarm system was checked by an engineer in July 2006 and that the last fire drill was held in August 2006. Harefield Road, 156 DS0000027063.V310029.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 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 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X 3 3 X Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 2 3 4 5 6 Standard YA20 YA20 YA24 YA24 YA30 YA37 Regulation 13(2) 13(2)(4) 23(2) 23(2) 13(3)(4) 8 Requirement Where residents self medicate, this must be reflected in their care plans. Demonstrate that residents’ self medication is supported by an appropriate risk assessment. Replace the toilet in the first floor bathroom. Provide adequate lighting on the first floor landing. Obtain evidence that the water supply complies with the Water Supply Regulations (1999). The manager must submit an application for registration. Timescale for action 30/11/06 30/10/06 30/11/06 30/11/06 30/11/06 30/11/06 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 2 Refer to Standard YA1 YA16 Good Practice Recommendations Update the information in the Statement of Purpose and Service User Guide where necessary. Consider how to keep the home’s communal facilities available to all residents. DS0000027063.V310029.R01.S.doc Version 5.2 Page 25 Harefield Road, 156 3 4 5 6 YA16 YA19 YA23 YA35 The rationale underpinning the reasons for any restrictions on access should be recorded on resident’s care plans. The manager should attend a refresher course in deescalation techniques. Staff who have not attended POVA training since June 2004 should attend a refresher session. Improve records of staff training. Harefield Road, 156 DS0000027063.V310029.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Harefield Road, 156 DS0000027063.V310029.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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