Inspection on 17/06/08 for Horse Leaze (5)

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Good service.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Horse Leaze (5) 27/10/07

Horse Leaze (5) 02/08/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Horse Leaze (5) 5 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 17th June 2008 12:10 Horse Leaze (5) DS0000066791.V364134.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 Horse Leaze (5) DS0000066791.V364134.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. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horse Leaze (5) Address 5 Horse Leaze Beckton London E6 6WJ 020 7473 2391 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) shortbreaks.london@heritagecare.co.uk www.heritagecare.co.uk Heritage Care Nicola Jane Larsson Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2007 Brief Description of the Service: 5 Horse Leaze is a six-bedroom bungalow located in a residential area in Beckton, East London. The home is operated and managed by the Heritage Care organisation. The home provides respite care and short break accommodation to six adults who have learning difficulties. Each person who uses the service has a private bedroom and shares the bathroom and shower facilities. There is a communal lounge, dining area, conservatory and kitchen. The home blends easily into the surrounding area. Since the last inspection the number of people using the respite care service provided by the home as risen from 12 to 23. There is ample free parking in the vicinity. Public transport links include the Docklands Light Railway (DLR) and several bus routes. Local amenities include a large supermarket, community centre, pub and retail park. Cinema complex, and local shopping centres at Stratford and East Ham are accessible by bus. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried this inspection over the course of two half-day visits to the home. During the Inspection we spoke with the Registered Manager and with one member of staff. Both of the residents receiving respite care at the home were engaged in community activities during both of our visits. We looked at a range of documentation relating to the running of the home including resident’s personal files, staff personnel files and health and safety records. The home completed an Annual Quality Assurance Assessment (AQAA) within the timescales set by the Commission. The quality rating for this service is ** stars. This means the people who use the service experience good quality outcomes. Residents come to stay at the care home for short breaks. An Inspector visited the care home to find out what it was like to stay there. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 6 What the service does well: A respite care service is provided to learning disabled men and women from diverse backgrounds within the London Borough of Newham. The home promotes equality and diversity by ensuring that its premises are wheelchair accessible. The home also operates “women only” respite weeks. The home assesses the needs of potential residents. The home supports residents to make decisions about their lives and helps them manage their finances during their visit. Residents are supported to maintain contact with their families. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 7 Staffs promote dignity and respect whilst assisting with personal care. The home has an easy to understand complaints procedure. The home is comfortable and generally well maintained. It is clean and free from offensive odours. The home carries out checks on staff before they start work. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 8 Staffs receive regular training and supervision and the Manager is suitably qualified. In surveys residents and their families gave positive feedback about the service. The home maintains many of the health and safety records required by legislation. What has improved since the last inspection? Each resident has an individual plan. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 9 People who use the service are part of the local community and the home organises an activity each day. The home provides good meals and keeps a record of is provided. The home has improved its medication practise. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 10 The home has learnt from past incidents and changed some of the ways it does things. There is enough staff on duty to meet the needs of residents. Personnel information is available for inspection. The home notifies the Commission of any significant events. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 11 The home listens to residents and their families. The home has improved the way it records some health and safety checks. What they could do better: Five requirements were made as a result of this inspection, two of which were restated. A good practise recommendation was also made. Individual plans must be regularly reviewed and possible risks addressed. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 12 Plans must also contain information about how the residents healthcare needs will be met during their stay. The home must improve some of the health and safety records it keeps. Some minor repairs and maintenance must be carried out. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 13 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 14 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 Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 15 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information about the service it provides and assesses potential residents before their initial stay. EVIDENCE: The home has produced a statement of purpose and service users guide that outline the service provided. We sampled the personal files for two residents receiving respite care at the home at the time of the inspection. This evidenced that each had been assessed by the home before receiving a service. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 16 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home involves residents and their families in the development of an individual plan that is person centred and easy to read. However, the home must ensure that plans are regularly reviewed and that potential risks are appropriately assessed. EVIDENCE: Each of the residents we case tracked had an individual plan that had been developed by the home as a result of an assessment. The plans included information about the person’s personal, social and healthcare needs. Both of the plans we looked at were person centred and contained life history information. The Manager told us that since the last inspection the service has been developing its links with day services and social work teams to improve the homes role in wider care planning for people who use the service. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 17 The plans we saw were undated and unsigned and we were unable to evidence from the available documentation that individual plans are reviewed at least every six months or as needs change. The plans we saw addressed how residents should be supported to make decisions about their lives. We also looked at the records the home maintains relating to finances for the residents currently receiving a service. These evidenced that the home logs monies bought into the unit by each resident, and that these are held in a safe in the staff office. A record of the date, amount and reason for each withdrawal or deposit is subsequently recorded and signed by staff, along with a record of the amount of monies the resident is discharged home with. At the time of our first visit to the home, no risk assessment was available on file the file of one resident. For the other, a brief risk assessment addressing a visual impairment was available on file. This was however undated and unsigned. When we returned 48 hours later, the Manager informed us that they were in the process of developing and placing on file comprehensive risk assessments for both residents. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 18 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful activities of their choice at home and in the community, according to their interests and abilities. A variety of wellbalanced meals are provided and staffs have received training to assist residents who need support with eating. EVIDENCE: The people using the service at the time of this inspection were engaged in a range of community, leisure and occupational activities. In addition to participating in activities within the home both were attending day services five days per week, where they are supported to access a range of community activities. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 19 The home has a timetable of structured activities. Sampling of the activity log and discussions with the Manager and a care worker evidenced that this is flexible in line with the abilities and preferences of the residents receiving respite care each week. Activities available within the home include a facilitated music session, a craft session, games night, film night, relaxation session and discussion group. Discussions with care staff and sampling of the activity log evidenced that residents choose when to join in an activity. The Manager and care worker also told us that weekend day trips had been instigated within the home and that these had proved very popular. The home offers respite care and residents are supported to maintain contact with their families during their stay in accordance with their individual plan. None of the residents at the time of this inspection had any specialist dietary requirements. Discussion with the Manager and care workers evidenced that the home provides a fixed menu made up from “firm favourites” and that this always includes a meat and vegetarian option. We were told that individual residents preferences are taken into consideration and additional meals provided in addition to the set menu. We sampled the daily logs for the two residents using the service at the time of this inspection. These evidenced that a record of meals taken was recorded as part of the entry. The meals provided were varied, balanced and nutritious. In their AQAA the home states that the meals provided can also be varied to address the cultural and religious needs of people who use the service. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 20 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive sensitive support with personal care that promotes their dignity. The home has improved its medication practise and developed links with specialist healthcare services. However the home should develop the way it records healthcare information in the individual plan. EVIDENCE: The individual plans we looked at included information on resident’s preferences for personal care. Discussions with care staff evidenced that residents choose their own clothes. The Manager told us that a female care worker will always assist female residents with their personal care, but that it was not always possible to provide a male care if requested by male residents. Our discussions with one care worker evidenced that they promote dignity and respect whilst assisting with personal care. The carer was able to tell us the practical steps they take, such as ensuring privacy by shutting doors, Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 21 explaining what they were going to do, seeking permission, and encouraging the resident to do what they are able to themselves. For both of the residents we case tracked their assessments and plans both contained information relating to healthcare. However, this information was brief, for one resident a long list of medication suggested a range of healthcare issues, however, outside of their visual impairment there was no information relating to particular conditions this person experienced, how they impacted upon their daily living, or the appropriate assistance they may require during their stay. For a second resident a brief healthcare history detailing their current situation was available. However, this resident uses a medical device at certain periods of the day, and information on how and when this equipment should be used was not contained within the plan. The homes AQAA states that since the previous inspection the home has developed links with the local physiotherapy and speech and language therapy departments. The Manager told us that nobody who uses the respite care home is currently self-medicating. None of the residents at the time of this inspection were using controlled drugs. We had looked at the homes medication policy and procedure at an earlier inspection and found that this complied with National Minimum Standards. We looked at the actual medication stored in the home and compared this with what was recorded on the Medication Administration Record (MAR). All the available medication was listed on the MAR sheet, and appropriate stock levels of medication had been maintained. The MAR sheets were properly completed and found to be in good order. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 22 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. The home has reviewed the way it works and made some changes to ensure that residents are safeguarded. Care staffs demonstrate a good understanding of safeguarding issues and there responsibilities. EVIDENCE: We had previously viewed the homes complaints and safeguarding policies and procedures and found that these complied with National Minimum Standards. We looked at the homes complaints log and saw that no complaints had been received since the last inspection. Several residents and their families had left compliments on the service they had received. There have been no adult protection issues since the previous inspection, and as a result of two earlier adult protection matters the home has reviewed its admission processes to ensure that residents are only admitted once funding for appropriate staffing to meet their needs has been agreed and provided. The home evidenced that appropriate disciplinary action had been taken against an agency care worker on duty at the time of one of the earlier adult protection matters. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 23 The care worker we spoke to during the inspection was able to demonstrate a good understanding of safeguarding issues. The care worker was able to describe a range of abuses vulnerable people might experience, and was clear about their responsibilities to report any adult protection concerns they may have. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a comfortable, well maintained home. Each resident has their own room and specialist aids and equipment are available. EVIDENCE: The home is situated in a modern, purpose built bungalow in a residential area. All areas of the home are wheelchair accessible. The home is generally well maintained and provides a comfortable, homely environment. From the main entrance there is a hallway, which has the staff office, utility room and large bathroom/wet room situated off. A large open plan lounge and dining area can also be accessed from this hallway. The lounge area has a range of comfortable seating and space for wheelchair users. A TV and stereo are available. Several small tables are located in the dining area, and there is also access to a large conservatory with games area and access to a lawned Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 25 garden. The kitchen is also sited off the dining area and this has a range of fitted units and appliances. From an inner hallway three residents bedrooms and a shower room can be accessed. From a separate hallway at the opposite end of the bungalow a further three residents bedrooms, a storeroom and a WC can be accessed. The home has recently been repainted throughout and new flooring fitted in the communal areas. New bedroom furniture has been purchased and televisions and CD players are provided in each room. Since the last inspection the home has also improved wheelchair access to the shower room. Some minor maintenance issues were identified during this inspection and these are detailed in the requirements section of this report. On both occasions that we visited the home during this inspection we found it clean, hygienic and free from offensive odours. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 24, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staffs undertake external qualifications and receive in house training and regular supervision. Staffs are employed in sufficient numbers to meet the needs of residents. The homes recruitment procedure safeguards people who use the home. EVIDENCE: All of the homes permanent staff and one of the homes regular bank staff have obtained at least NVQ level 2. The home displayed a current staffing roster, and this accurately reflected the staffing situation found in the home at the time of the inspection. The Manager told us that the home ordinarily has two care workers on duty during the day and one at night. When individual residents require higher levels of care additional staffing is provided. The Manager also told us that the home is building up its own core of heritage care bank staff to ensure continuity and consistency. Discussion with care workers and the Manager evidenced that Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 27 bank staff also receive supervision from the Manager and are invited to team meetings and away days. At the time of this inspection the home has four permanent members of staff, and two regular bank staff. Other floating bank staff also covers some shifts within the home. The home has developed a condensed induction programme for bank staff working within the home, and copies of a completed induction record were available for the bank staff appearing on the current staffing roster Since the last inspection Swallowing and Feeding and Moving and Handling refresher training have been provided to staff. In addition some staff have completed access to management and first aid training. We sampled the available supervision records for two members of staff and also spoke with one care worker and the Manager. This evidenced that staff receive regular supervision. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is suitably qualified and experienced. They have demonstrated an understanding of person centred care and promote equality of opportunity. The home listens to residents and their families. The home maintains health and safety records required by legislation, however some health and safety checks are not always completed at the appropriate frequency. EVIDENCE: The Manager has obtained the Registered Manager Award (RMA) and NVQ level 4 award. They have recently completed their registration with the Commission for Social Care Inspection and have been employed by Heritage Care within learning disability homes as a Manager for some years. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 29 The home has promptly notified the Commission of any occurrences that affect people who use the service in line with regulations. Records we looked at evidenced that since the last inspection the home had held a team-building day to look at service development. An evaluation of the homes strengths and weaknesses had also been developed. The home has also developed an easy read picture format questionnaire for people who use the service and their families. A number of completed surveys were available for the Inspector to look at, although the outcomes had not been collated. The Manager told us that they were planning to hold an open day and receive further responses to the questionnaires, which would then be collated and published. We looked through the completed questionnaires the home had already received. These were generally very positive in the feedback provided. Many people who use the service and their families commented on staff, noting that they were “hospitable”, “approachable”, “efficient” and “friendly”. Residents and their families also commented that there was “good communication”, “nice environment” and “a good service”. We looked at a range of health and safety records. These evidenced that the home has obtained a portable appliance-testing certificate, a hoist testing certificate and a gas safety certificate. A general environmental risk assessment for the home was also available. We also looked at the homes accident and incident logs and found these to be in order. The home also records the results of weekly water temperature tests, and the results were found to be within acceptable limits. However, the homes record of fridge and freezer temperatures evidenced that no entries had been made on nine occasions during May and June 2008. The home was not evidenced as having carried out a fire evacuation drill since the last inspection. The homes fire alarm call point testing records evidenced that the system was serviced in April 2008. Tests were generally carried out and recorded on a weekly basis, however there was one occasion in March 2008 where a twoweek period elapsed between tests. The home displayed a valid insurance certificate with appropriate cover. Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 30 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 X 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X X 2 X Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 31 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 Timescale for action 30/12/08 2. YA9 13 The home must evidence that individual plans are reviewed every six months or as needs change. The home must ensure that it 30/12/08 adequately and regularly assesses potential risks to people who use the service. This is a restated requirement. The previous target of the 30/01/08 was not met. The home must ensure that individual plans detail the healthcare needs of the resident and include information on how these will be met during their stay. The following repairs and maintenance must be carried out: The broken window in the lounge must be replaced. Items such as hoists and stepladders must be appropriately stored when not in use. 3. YA19 12 30/12/08 4. YA24 13, 23 & 39 30/12/08 Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 32 Curtains in the conservatory must be properly fitted. Broken toilet roll holders must be replaced. Fridge and Freezer temperatures 30/12/08 must be recorded on a daily basis. These are restated requirements. Previous targets of the 15/01/06, 30/04/06, 30/01/08, 30/11/06 and 30/01/08 were not met. Weekly fire alarm call point tests must be carried out and recorded. Records of fire evacuation drills must include timings. These are restated requirements. The previous target of the 30/01/08 was not met. Fire doors must not be wedged open. 5. YA42 16 & 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Horse Leaze (5) DS0000066791.V364134.R01.S.doc Version 5.2 Page 34 - 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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