Inspection on 01/08/06 for Hart Lodge

This inspection was carried out on 1st August 2006.

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

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

Other inspections for this house

Hart Lodge 04/09/07

Hart Lodge 23/01/06

Hart Lodge 30/06/05

Hart Lodge 19/11/04

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

CARE HOME ADULTS 18-65 Hart Lodge 10 Whalebone Grove Chadwell Heath Romford Essex RM6 6BU Lead Inspector Mrs Sandra Parnell-Hopkinson Key Unannounced Inspection 1st August 2006 09:00 Hart Lodge DS0000059918.V301188.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 Hart Lodge DS0000059918.V301188.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. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hart Lodge Address 10 Whalebone Grove Chadwell Heath Romford Essex RM6 6BU 020 8590 7077 020 8500 9339 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) R Hart Care Ltd Mr Gerald Rueben Mhlanga Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Hart Lodge is a registered care home for nine people of either sex who have mental health needs. Hart Lodge opened in the latter Part of 2004. The care home is situated in a residential area of Chadwell Heath and can be reached by road via the A12 and A13 or by bus routes, and is within easy reach of central Romford shopping amenities. The building has been converted from a family house to a nine-bedroom care home. The home provides a high standard of accommodation with all bedrooms being single with en suite, and some with shower en suite. There is a lounge/dining room with a rear garden which has been decked and has seating for residents. Residents are encouraged to be independent and to be part of the local community. Hart Lodge is owned by Hart Care Ltd which owns and operates another care home for people with mental health needs in the Southend area. At the time of the inspection the minimum fee is £850. per week up to an unspecified maximum which is dependent upon the needs of the individual. The statement of purpose and the inspection report are available in the lounge area of the home, and a copy of each can be obtained from the home upon request. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which took place from 08.30 hours on the 1st August, 2006. The information for this inspection has been gathered from a visit to the service, a pre-inspection questionnaire, Regulation 37 notifications, Regulation 26 reports, questionnaire responses from service users, staff and health professionals, discussions with some service users, some staff members and the manager. Service user files were viewed, together with maintenance records and other documents relating to the service. At the time of the inspection there were no visitors to the home. Staff on duty were very pleasant and interacted well with the service users. During the inspection a service user went shopping with the support of a member of staff. Service users are encouraged to be a part of the local community and to participate in community activities. Some activities are provided within the home and these are being reviewed by the new manager and the service users. Emphasise is placed on the rehabilitation of the service users, some of whom have been discharged from hospital under various sections of the Mental Health Act. Service users are encouraged to be self-sufficient with regards to medication, personal hygiene, maintaining a clean home, cooking, shopping and clothes laundering. Staff training is given a high profile with all of the current staff having achieved either NVQ level 2 or 3. Since the last inspection, a new manager has been recruited and she is in the process of submitting her application to the Commission for registration as the manager of Hart Lodge. What the service does well: Feedback from service users was that staff are very supportive and encourage them to be self-sufficient. Staff training is given a high profile with all of the current staff having achieved either NVQ level 2 or 3. The proprietors are very supportive and have a good understanding of the needs of people with mental health problems, and the need to offer a flexible service. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 6 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. Hart Lodge DS0000059918.V301188.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 Hart Lodge DS0000059918.V301188.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): 2, 4 and 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users can be assured that their individual aspirations and needs will be assessed and that they will have the opportunity to visit and stay overnight at the home prior to making a definite decision to move in. Each service user has an individual written contract containing the terms and conditions of residency at Hart Lodge. EVIDENCE: From discussions with the manager and from viewing the file of a prospective new resident, it was evident that a full assessment of his needs has been undertaken and he has made several visits and stayed overnight at Hart Lodge, prior to him deciding to move into the home on a permanent basis. Files of other residents were viewed and each contained a copy of the licence agreement for residency at the home. It was evident from the files that a copy of the summary of the single Care Management assessment integrated with the Care Programme Approach had been obtained by the manager for the individual service users. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and staff benefit from having a detailed care plan but these must be reviewed on a regular basis. However, service users are consulted on and participate in all aspects of life in the home and are supported to take risks as part of an independent lifestyle. EVIDENCE: Four residents were case tracked and as part of this process their files were inspected. All four residents’ had been generated from the single Care Management Assessment and covered all aspects of personal and social support and healthcare needs. The plans set out how current and anticipated specialist requirements would be met and described any restrictions on choice and freedom in accordance with the Care Programme Approach or the Mental Health Act 1983. Plans established individualised procedures for residents who were likely to be aggressive or cause harm or self-harm, and focused on positive behaviour, Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 10 ability and willingness. It was evident from discussions with some residents that they had been involved in the drawing up of the care plans together with other relevant people/agencies. All residents have an allocated key worker, and as all residents are on the Care Programme Approach all have a social supervisor/co-ordinator. Of the four files inspected, it was evident that the internal care plans for two had been regularly reviewed but two files did not evidence that reviews had been undertaken. However, the statutory reviews had been done. One resident’s care plan indicated that she had an appointment for an eye operation but that this had been cancelled by the hospital, but there was no evidence of a follow up appointment. Discussions were had with the new manager regarding the importance of regular reviews being undertaken and the outcomes being recorded on the files so that these remain updated to reflect changing needs. It was possible to speak to four residents and they all said that they were happy at the home, and were given support to make decisions about their own lives. Wherever possible residents are enabled to manage their own finances with the necessary support and tuition. On the day of the inspection one resident went shopping with the support of a care worker. The new manager had held a residents’ meeting on the 31st July, 2006 and this was confirmed by notes and from talking to the residents. One resident said “we talked about activities that we wanted to do.” Following this meeting the manager will be organising a current affairs group and a barbecue has been arranged for this weekend. Risk assessments were in place and again the manager must ensure that these are reviewed and updated. From discussions with the staff it was evident that they were aware of the need to respect information given by residents in confidence, and to handle information about residents in accordance with the home’s written policies and procedures, the Data Protection Act 1998 and in the best interests of the residents. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are given the opportunity to maintain and develop social, emotional and independent living skills, and are encouraged to keep appropriate jobs, and to continue education and/or other training and to maintain community links and take part in leisure activities. Service users are supported in maintaining and developing personal, family and sexual relationships, subject to restrictions agreed in the individual plan and contract. Daily routines promote independence, choice and freedom of movement, and the registered persons ensure that the health and wellbeing of service users is maintained by the provision of nutritious, varied and balanced meals. EVIDENCE: Some residents are self-catering and are given money to purchase their own food requirements but they have to provide necessary receipts, and their diet is monitored by the key worker to ensure that the meals are nutritional. These Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 12 residents are provided with their own store cupboard in the kitchen and each has a separate small refrigerator. The care plans viewed indicated that dietary intake and weight were being monitored where appropriate. Generally Sunday lunch is arranged for all of the residents so that they and staff can enjoy a meal together. One resident spoken to is self-catering and has undertaken a food hygiene course and he was very proud to tell the Inspector that “I have a certificate to show this.” With regard to food which is open in any of the fridges, it is essential that these are appropriately stored and labelled with the contents and date. It was evident from discussions with a resident and from viewing several files that staff are enabling residents to have opportunities to maintain and develop social and independent living skills. A new resident is due to move into the care home in the very near future, and the new manager has already enrolled this person at a local college. Residents are also given opportunities to fulfil their spiritual needs in accordance with their wishes. Information is given to residents about the local community facilities such as shops, library, cinema, pubs and places of worship. Some of the residents often go to a local pub for lunch, and on the day of the inspection a resident went out to do her grocery shopping accompanied by a support worker. The new manager is very aware of the need to encourage residents in their choice of lifestyle and the proprietors enable a flexible staff regime to ensure that support workers are available when needed. The daily routines promote independence and individual choice unless a resident is subject to restrictions that have been agreed in the individual’s care plan. Residents are involved in ensuring that the communal areas and their own bedrooms are kept clean and they are responsible for doing their own laundry. It was apparent during the inspection that residents and staff interact very well with each other. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in a sensitive and flexible way which maximises their privacy, dignity, independence and control over their lives, and they can be sure that their healthcare needs will be met by the involvement of the appropriate professional. However, the administration of medication still requires attention to ensure that all residents are protected by the home’s policies and procedures. EVIDENCE: It was evident from the case files that residents are registered with a local GP, and visit the dentist, optician, hospital and other health care services when required. All of the current residents are on the Care Programme Approach and have regular access to mental health specialists, therapists and their social supervisor/co=coordinator. Medication administration remains an issue at Hart Lodge, and the inspection report produced by the Commission’s Pharmacy Inspector had not been passed to the new manager. During this inspection a copy of this report was given to the new manager and it is essential, and a requirement, in this report that all of the requirements stated by the Pharmacy Inspector are complied with. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 14 Failure to comply with these by the end of August, 2006 may result in enforcement action being taken. However, the inspector is confident that the new manager will ensure compliance as she has already made arrangements for staff training from Britannia Pharmacy, and for this company to take over responsibility for the supply of medication at Hart Lodge. All medication administration records will be provided by Britannia Pharmacy and all medication will be in monitored dosage systems or blister packs where appropriate. With regard to those residents who are able to self-administer their medicines, the manager is strongly recommended to ensure compliance with the SAM programme left at the home during that inspection. During the inspection the new manager was given a copy of the Commission’s latest guidance on various aspects of medicine administration/training in care homes. Also it was noticed that whilst there is a requirement, clearly labelled above the medicines fridge, that the temperature of this must be taken and recorded daily, this is not being complied with. There were several days during the week beginning the 24th July, 2006 where records were missing and again those for the 30th and 31st July, 2006 were missing. It is essential that the temperature of the medicines fridge is recorded daily, and if no medication is being stored at any time then this should be indicated on the records. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users feel that their views are listened to and acted upon and that they and their families will not be victimised for making a complaint. EVIDENCE: From viewing the complaints log the inspector was satisfied that the management takes all complaints seriously and deals with these in a positive manner for the benefit of the complainant, other residents and staff. In discussions with some residents they expressed their ability to raise concerns or make a complaint if they felt they needed to, and were confident that the manager and the staff would listen and deal with the matter appropriately. The residents’ meetings are also a forum which enables residents to express any area of concern or complaint. Staff have undertaken training in adult protection, and a member of staff was able to demonstrate a clear understanding of adult protection, what was meant by adult abuse and the procedure for dealing with any allegations which might be made to her. The home’s policies and practices regarding residents’ money and financial affairs ensure that they have access to their personal financial records, safe storage of money and valuables and private consultation on financial issues. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 16 Hart Lodge DS0000059918.V301188.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, 25 28 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a homely, comfortable and safe environment which is clean and hygienic, and they have bedrooms which suite their needs and lifestyles. EVIDENCE: During a tour of the premises the inspector was able to observe that the communal spaces were well furnished and decorated. The new manager is planning to discuss with residents a proposal that more pictures be put onto the walls of the lounge and corridors. The home was clean and well maintained, and the COSHH materials were kept in a locked cupboard in the laundry room. Residents spoken to said that the home “was very nice and they were happy with their bedrooms.” All bedrooms are single with an ensuite toilet and handbasin, and some also have an ensuite shower. Bedrooms have been personalised by each resident to suit their own needs and preferences. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 18 An issue identified at the previous inspection with regards to the telephone appears to have been resolved and the “telephone room” was unlocked on the day of the unannounced inspection and residents were able to use the telephone when they wanted to. The residents spoken to also said that the issue around those who were selfcatering accessing the kitchen has also been resolved, and the system is now working much better. The garden area which has been laid to decking, was well maintained and there was a seating area for residents, some of whom were enjoying the sunshine during the inspection. 1. Hart Lodge DS0000059918.V301188.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): 32, 33, 35 and 36. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected by the home’s recruitment procedures and benefit from a supportive and effective staff team who are supervised and appropriately trained. EVIDENCE: Several staff records were viewed and these were found to be in accordance with the statutory requirements and had application forms, references and enhanced criminal records bureau disclosures. New staff undertake an initial induction which is supported by a further in depth induction in line with the Learning Skills Council. All new staff have to serve a probationary period of six months at the end of this time the employment is reviewed and either confirmed or not. All staff receive regular supervision and all have achieved or undertaking either the NVQ level 2 or 3. Staff spoken to said that training is always available and that arrangements are being made for additional training in various aspects of mental health. Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 20 Staff rotas were inspected and the staffing levels were adequate to meet the current needs of the residents. Staff meetings are held on a regularly basis, that is every 4-6 weeks. Hart Lodge DS0000059918.V301188.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, 39, 40, 42 and 43 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from living in a home which is run in their best interests, and can be sure that their financial interests are safeguarded. The health, safety and welfare of service users are promoted and protected. The acting manager has not been registered with the Commission, and it is therefore not possible to make a judgement as to her fitness. However, during the inspection it was evident that service user benefited from her management approach to the home. EVIDENCE: Since the last inspection the registered manager has resigned and the acting manager has been in post since the beginning of July, 2006. The Care Standards Act 2000 and the Care Home Regulations 2001 require that a registered premises has a registered manager. The organisation will be required to submit an application for registration of the new manager as soon Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 22 as the necessary criminal records bureau disclosure has been received so that this can accompany the application. In discussions with the acting manager, who has worked at other care homes, is a RMN and has achieved the Registered Manager’s Award, it was evident that the interests and needs of the service users were paramount. She has already made some changes at the home and staff and residents spoke highly of her. She is keen to ensure the rehabilitation of residents to a “normal” community life and will be organising appropriate activities, in discussion with residents and other interested parties, to this end. Residents’ and staff files are kept secure and in accordance with the Data Protection Act 1998. Maintenance records for gas, electric, water and fire were checked and in order. The fire alarms are tested weekly from a different point in the home. Regulation 26 visits and reports are being undertaken by the responsible individual. Also as part of this inspection process questionnaires were sent to residents (3 of whom replied), staff (6 of whom replied) and to visiting health professionals and social workers (4 of whom replied). All of the responses were very positive as to the care being delivered at Hart Lodge, and it is to be hoped that the new manager will continue this to the benefit of residents and staff at Hart Lodge. Hart Lodge DS0000059918.V301188.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 4CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 3 X 3 2 Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person is required to ensure that care plans are reviewed and updated regularly and at least six monthly (This is a repeated requirement timescale 01/04/06 not met) The registered person is required to ensure that risk assessments are reviewed and updated on a regular basis. (This is a repeated requirement timescale 01/04/06 not met) The registered person is required to ensure that self-medicating service users have this clearly identified and supported by a care plan. (This is a repeated requirement timescale 01/04/06 not met) The registered person must ensure that all opened food in the refrigerators are appropriately stored and labelled with the contents and the dates The registered person is required to ensure that all requirements and recommendations as DS0000059918.V301188.R01.S.doc Timescale for action 31/08/06 2. YA9 15 31/08/06 3. YA9 13 31/08/06 4. YA17 12 (1) (a) 31/08/06 5. YA20 13 31/08/06 Hart Lodge Version 5.2 Page 25 detailed in the Pharmacy Inspector’s report are complied with (This is a repeated requirement timescale 01/04/06 not met) 6. YA43 23 (2)© The registered person must ensure that the temperatures of the medicines refrigerator are recorded daily as required by the home’s policies and procedures. The registered person must ensure that an application is made to the Commission for the registration of the new manager. 12/08/06 7. YA43 9 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hart Lodge DS0000059918.V301188.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Hart Lodge DS0000059918.V301188.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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