Inspection on 08/02/06 for Hitchin Road (9)

This inspection was carried out on 8th February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hitchin Road (9) 10/12/07

Hitchin Road (9) 24/07/07

Hitchin Road (9) 12/07/06

Hitchin Road (9) 28/10/05

Hitchin Road (9) 08/03/05

Hitchin Road (9) 12/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hitchin Road (9) 9 Hitchin Road Stevenage Hertfordshire SG1 3BJ Lead Inspector Hazel Wynn Unannounced Inspection 8th February 2006 10:00 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 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 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 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. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hitchin Road (9) Address 9 Hitchin Road Stevenage Hertfordshire SG1 3BJ 01438 352 395 01438 742 865 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) Life Opportunities Trust Audrey Alldrick Care Home 7 Category(ies) of Learning disability over 65 years of age (7), registration, with number Physical disability over 65 years of age (7) of places Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: The home was first registered with Hertfordshire County Council on 1st April 1998. 9 Hitchin Road is an Edwardian family home that has been renovated and adapted to provide care for seven elderly people who have learning and or physical disabilities. The home consists of seven single bedrooms, two on the ground floor and five on the first floor. A passenger lift is installed to access the upper floors. There is hoist tracking fitted to the main lounge, all bedrooms, bathrooms and toilets. The communal facilities on the ground floor include a large family style lounge overlooking the gardens to the rear of the house, dining room with interconnecting hatch to a well-equipped kitchen. There are also two assisted bathrooms, toilet facilities, a sluice room and a laundry room. The home is situated close to the town of Stevenage, on a busy trunk road leading to the A1(M) and Hitchin. There is access to various community services. The staff use their cars and the home has its own specially adapted minibus to escort residents to various facilities and services in the community. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, the 2nd inspection of the year was carried out by one inspector and took place during the afternoon of 8th February 2006. The inspection presented as positive although two requirements were made. This was a snapshot of the day. Time was spent with the manager and a brief time with several staff members who provided positive feedback. Several of the service users were enjoying a music therapy session, which was observed for a few moments. The last report was discussed and progress has been made. A tour of the premises included the garden area, dining room and the lounge where the music therapy was taking place. What the service does well: The home has a key worker system that works well and ensures that each person’s needs are provided for with an individual approach. The keyworkers ensure all documents that are relevant to the service users they ‘keywork’ are well maintained. Coordinator meetings occur in which staff receive support in the effective management of care plans, ensuring that all files are well organised. The service users have a board in their bedroom identifying their link worker and keyworker. At the last inspection it was established that all staff had received the General Social Care Council Code of Conduct. These were also available in the home for agency staff. The management structure provides for senior cover on all days of the week including weekends. All bank and agency staff are provided with a basic induction and the home provides a quick reference ‘need to know’ file ensuring that specific needs of the service users are being met at all times. The documentation makes it clear that positive working relationships are maintained with other relevant professionals. Health records were well maintained and showed a clear path of intervention and support. One service user is being supported with a specialist diet and appropriate support and advice is received from the dietician who is working closely with the staff. There is a signed copy of the contract, which is issued to all service users and a copy retained on their file. A clear and comprehensive assessment tool is completed for all new service users and this forms the basis of the initial care plan. Established during the last inspection was the fact that: each member of staff holds a defined role and responsibility. In addition to the core roles that they hold each person is delegated an additional internal system to monitor. These systems appear to be very effective and ensure that the management of the home is maintained to a high standard. Each member of staff has received food hygiene training. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 6 Complimentary therapy is promoted and includes art therapy, aromatherapy and sensory sessions. The home also actively promotes the involvement of outside advocacy support services and volunteers to empower, promote and enable service users to maintain external support and links. At the last inspection, the service user bedrooms were well maintained and each was decorated to the individual service users preference. Staff should be commended for their efforts. One part of the garden has been developed into a sensory section with sensory plants and flowers, including wind chimes and ornaments specially chosen for special effects to meet the needs of the service users. With the passing of years most of the service users are now bereaved of their loved ones but two of the service users are supported to maintain contact with their family. The service users have known one another for many years and have made friends within the group and grown close to individuals they identify with. What has improved since the last inspection? What they could do better: Due to the death of a service user, progress on reviewing care plans has been delayed and this now needs to be one of the priorities and a requirement has been brought forward. There were gaps in medication recording and this part of the system must receive attention and not be allowed to continue – a requirement was formally made. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 7 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. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 8 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 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 9 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- 5 Prospective service users are able to make informed choices about where to live. Visits and a planned transition period aid choice, empowering user selfdetermination. Individual aspirations and needs are fully assessed ensuring that care is tailor made for the service user. Each service user has a detailed written statement of terms and conditions ensuring that their individual rights are supported and protected. EVIDENCE: During the last inspection, it was established that a comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The content is suitable to meet individual needs. Full assessments, carried out by a competent person, of each service users needs and aspiration are made before the service user moves into the home and these are reviewed (there had been a delay in reviews due to the death of a service user who was supported at home to the end of life). All assessments include the input of significant others involved in the care of the service users and when the assessment is completed it forms the basis of the individual care plan. The admissions procedure to the home includes trial visits for the service users to make an informed choice about where to live. Prospective service users make trial visits enable them in making positive choices through active Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 10 empowerment about whether they are happy with the home and also for the home to determine if they are able to meet the service users assessed needs. A contract is then drawn between the home and the service user. The contract includes the terms and conditions within the home and the rights of the service user. At the last inspection, contracts were examined in the service users files and were signed by the manager of the home and the service user and / or representative. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 11 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 – 10 Through advocacy and various forms of communication service users know that their assessed and changing needs and personal goals are reflected in their care plan. Individual needs and choices within the home are being promoted to encourage and empower service user self-determination, participation and consultation. Service users are supported to take risks within a risk management framework as part of an independent lifestyle. Service users can be assured that their confidences are kept and that information about them is appropriately stored. EVIDENCE: During this inspection, the manager confirmed the outcome of the last inspection in that every effort is made to actively seek individual and group views. Due to the complex needs of the service users, each person has an allocated link worker and coordinator. Many of the service users have access to external advocacy services, which support them in making empowering choices in their lives. Relative and family and/or friend involvement is encouraged were possible, many of the service users have been bereaved of their family members. Regular service user meetings occur where feedback is sought and Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 12 minutes are recorded. Clear actions are taken following the meetings to monitor the viewpoints of the service users and for the staff to ensure that wherever possible they are meeting their individual aspirations and needs. Individual daily notes and guidelines for the service users were seen on the sample of files seen during this inspection. All service users are supported within the Care Management Framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed (although in-house reviews, which are needed have been delayed due to the illness and death of a service user). The ethos within the home is that the care plans of each individual are ‘owned’ by the individual. The system appears to be effective as a working document and focuses on service users individual goals and aspirations. In house reviews were overdue by reason that staff had been providing committed support to a service user whose preference was to die at home and this preference had been met. The documents held within the individual files demonstrated that the choices and the desires of service users had been sought. During the last inspection, the service users and staff were able to provide confirmation that they were aware of their individual care plans and that their consent had been sought for a variety of processes within the home, this includes the administration of medication. Confidentiality training forms part of staff induction and the Life Opportunities Trust organisation has policies on confidentiality and data protection which are made available to service users and their relatives/carers. All information within the home is handled with care and respect. All personal notes and files detailing information on the service were seen to be appropriately stored. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 13 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 - 17 Opportunities are provided for personal development and also for age, peer and culturally appropriate activities. The service users are part of their local community and engage in appropriate leisure activities. Personal relationships are actively supported and rights and responsibilities recognised and respected. The service users enjoy a healthy and nourishing diet with relaxed routines in pleasant surroundings. EVIDENCE: Personal development opportunities are planned for each service user and were observed to be included in the plans and progress notes in a sample of files seen at this inspection. Service users are supported appropriately to take part in activities in the home. Individual needs, choices and preferences are always considered as discussed with the manager and apparent from the documentation sampled. A record of activities was maintained within the daily recording system. The home has access to a mini bus and allocated drivers. Staff support and encourage all service users to maintain and develop social, emotional, communication and independent living skills. The involvement and Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 14 encouragement of the service users to enjoy a structured activity and for one service user to get ready to go out to an activity was observed during the inspection. The home is centrally located, and is within a short distance from shops and the local community amenities and service users regularly enjoy the benefits of these resources. The home values and seeks to reflect racial and cultural diversity of service users through celebration of, and awareness of different cultures, religions and festivities. Care staff have developed a user friendly activities board so that service users can know what is on offer for the day ahead, this uses pictures to portray the activity. A detailed timetable was available for the activities that are provided at the day centres. Activities include: art therapy, aromatherapy and sensory sessions on a weekly basis. Day care provision is in place for the service users, providing a number of different sessions, tailored to meet service users individual preferences, needs and choices. One service user has now managed to access a cookery course due to the perseverance of the care staff. The service users are all aged over 65 years and over the years most have been bereaved of the their loved family members; two service users have surviving relatives and the manager explained how the service users are supported to maintain contact. The majority of the service users know one another extremely well, having been resettled together, and have forged friendships, with individuals, within the group. The dietician provides input to support staff and service users in the assurance of a healthy and nutritious diet with variety and choice. The dining room provides for very pleasant area to enjoy meals. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 15 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 - 21 Service users are appropriately supported with medication and are protected by the homes policies and procedures although there were gaps in recording resulting in a requirement. The ageing, illness and death of a service users is handled with respect and as the individual would wish. EVIDENCE: Although standards 18 and 19 were more fully assessed with satisfactory outcome during the previous inspection, a sample of files seen at this inspection provided evidence that this was being maintained. See the previous section regarding a service user who has managed to access a cookery course through the determination of the home’s care staff. Service users are supported with their medication in accordance with policies and procedures and according to their ability and needs. The medication administration record showed several gaps and a requirement was made for this not to reoccur. The home has policies and procedures in place with regard to supporting service users relatives and friends during ageing, illness and death of a service. A service user who recently died at the home had been well cared for and supported as death drew imminent and as was the preference, the committed staff team supported the service user to the end of her life. Staff Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 16 are commended for the tremendous and tireless support that they have provided to this individual both during life and at the end of life. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 17 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 complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened too. Robust policies, procedures are in place to ensure service users are protected and safe. Staff must receive full training in order to ensure a consistent approach EVIDENCE: The complaints procedure is included in the user friendly Statement of Purpose and the Service User’s Guide, which has been circulated to service users. At the previous inspection ascertained that the information contained within the documents was accurate and well structured meeting individual service users needs. All staff receive training in issues around abuse and the recognition of abuse and the home has available copies of Hertfordshire County Council’s adult protection procedure. Five of the staff have recently attended the adult abuse training and have created an information training session for the remainder of the staff team to cascade the training to them in staff meetings and in house training sessions. The staff that have not yet attended the adult abuse awareness external training are enrolled and are awaiting dates for the training as they become available through Adult Care Services. Every effort has been made to place staff on the course, however places were limited. Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Protection of Vulnerable Adults (POVA) training, which is currently occurring within the home. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). The personnel files for staff more recently recruited were examined during this inspection and found to contain all required information for robust recruitment and adult protection. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 18 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 - 30 The environment is homely, comfortable, safe and well maintained. All necessary resources and equipment is provided within the home ensuring all specialist and individual needs can be met and the promotion of independence supported. Shared space compliments and supplements service users personalised individual space. Toilets and bathrooms provide sufficient privacy and meet individual needs. The home is clean and hygienic. EVIDENCE: The fabric of the building both externally and internally recently underwent major refurbishment, which has led to a home that presents well, is safe and comfortable and the maintenance programme assures its upkeep. The home has retained many of its original features and has a grand entrance hallway with original tiles to the floor. The home was well maintained and clean and hygienic throughout. A maintenance person supports the staff in the up keep of the garden area, which is currently well maintained. The garden has been landscaped to meet the needs of the service users; providing a sensory garden and chimes that provide stimulating sounds. The service users were very involved with the developments of the landscaping to the garden. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 19 Bathrooms and toilets are well equipped to provide for specialist needs and to promote independence, safe support and privacy. All bedrooms within the home are extremely well maintained and decorated. All service users are supported and empowered to decorate their individual rooms according to their individual preference. The home was observed to be fresh and clean and had an inviting atmosphere. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 20 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 - 36 There is clarity of staff roles and responsibilities. Staff are competent and qualified and are robustly recruited. An appropriately trained supervised and supported staff team meets the individual and joint needs of the service users. EVIDENCE: Each staff member has a clear job description detailing their role and responsibility and a copy of this is maintained in the policy and procedures manuals. Additionally staff are providing with training to manage other tasks and when competent take on these additional responsibilities as part of their ongoing development. All staff are adequately and suitably trained and experienced in order to meet the complex needs of the service users. An annual training plan is in place within the home to ensure staff development is maintained. The manager explained that a good programme of NVQ II, III and IV is in place. The home has a full and consistent team. Reviews of care plans have been delayed due to the recent care given to a service user right up until the time of death; this had naturally become a priority but the manager did state that she recognised that reviews now need to progress. During this inspection staff confirmed that they are well supported and receive formal supervision on a regular, as appropriate, basis. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 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 - 43 The home appears well run and with an ethos, leadership and management style that benefits the service users. The service users can be confident that their views underpin all self-monitoring, review and development by the home. The service user’s best interests and rights are safeguarded by the home’s policies, procedures in relation to record keeping (see medication recording, earlier commented on in this report). The health, safety and welfare of service users and staff are promoted and protected. Staff were able to demonstrate an awareness of their roles and responsibilities, thus ensuring that the service users benefit from a well structured and organised home. EVIDENCE: From records, observation, discussions with staff and management and some contact with the service users, (the contact with service users was limited due to an afternoon of in-house music therapy in which the service users were engaged). During the previous inspection there was ample opportunity to mingle with the service users and reported outcomes were favourable. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 22 It was observed (albeit briefly) during this inspection that the relationship between the staff and service users was professional, supportive and enabling. The ethos and management approach creates an open, positive and inclusive atmosphere, staff spoken to stated that they feel well supported and they feel the home is well managed. A clear commitment is made to equal opportunities, with staff and service users expressing positive views with regards to this. The service users appeared to benefit from this well structured and well run home. Service users spoken appeared to be happy, content and relaxed in their environment as they participated in a music therapy session. During the previous inspection it was ascertained that the home has a vast range of policies and procedural guidelines in place. All records are secure within the home and samples seen at this inspection were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. The medication administration record, as mentioned and addressed earlier in this report, showed several gaps in recording resulting in a requirement being made. A requirement was brought forward in respect of the review of care plans. The home has a maintenance person who ensures that all servicing is carried out in a timely manner and that a safe environment is maintained. Serving records were maintained and up to date. The home employs a competent manager and has good management support structures in place. Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 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 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 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 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 4 3 3 3 3 3 2 3 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 24 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 YA6YA42 Regulation 15 (1) & 13 (4) Requirement All care plans must be individually reviewed, ensuring that guidelines for the safe administration of medication and information are reflective of the details in the care plans. (This requirement has been brought forward. It is acknowledged that there has been good reason for delay but this must now be a priority). The administration of medication must be recorded accurately. There must be no gaps on the Medication record for medication prescribed for a service user. Immediate. Timescale for action 30/03/06 2 YA20 13 (2) 08/02/06 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 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Hitchin Road (9) DS0000019431.V282178.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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