Inspection on 02/08/06 for Horse Leaze (5)

This inspection was carried out on 2nd 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Horse Leaze (5) 17/06/08

Horse Leaze (5) 27/10/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Horse Leaze (5) 5 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Key Unannounced Inspection 2nd August 2006 11:30 Horse Leaze (5) DS0000066791.V305358.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.V305358.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.V305358.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) www.heritagecare.co.uk Heritage Care Mr David Roberts 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.V305358.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th February 2006 Brief Description of the Service: 5 Horse Leaze is a six bed roomed bungalow located in a residential area in Beckton, East London. The home is operated and managed by the Heritage Care organisation. The home accommodates six adults who have learning difficulties and are predominantly non-verbal in their communications. Each service user has their own 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. 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.V305358.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 inspection carried out by one Inspector over the course of a day. The Inspector met with the Manager and spoke privately with a staff member. Records and documentation relating to the running of the home including service users personal files and staff personnel files were sampled. This was the Inspectors third inspection of the home. What the service does well: The home benefits from an experienced Manager and currently accommodates three male and three female service users from diverse cultural backgrounds. The home employs eight care staff in addition to the Manager. A central training log for staff is maintained and periodic refresher training offered. The home has produced a statement of purpose and service users guide and has contracts with individual service users. The home carries out its own assessments and develops comprehensive individual plans. The home also assesses and regularly reviews potential risks to service users. Appropriate financial records are maintained and service users are supported to manage their personal allowance. Service users are supported to engage in a range of community, leisure and occupational activities. One to one staffing is available to support service users to engage in these activities. A range of activities and entertainment is also available inside the home. Staffs were observed to interact with service users who make their own decisions about when to join in or when to be alone. A range of nutritious meals that meet service users cultural needs is provided. Service users are also supported to maintain links with their families. Support with personal care is provided in a manner that recognises service users preferences and abilities and promotes dignity. Service users are supported to attend regular healthcare appointments. The home implements a range of corporate policies including complaints and adult protection. Complaints are appropriately addressed and details of complaints along with the action taken are recorded in a log. Staff demonstrated a good understanding of adult protection issues and their responsibilities. The home provides a comfortable, homely and well-maintained environment for service users. There is a range of private and shared space. Service users have their own bedroom that reflects their personality and interests. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 6 The home conducts and records regular fire tests and maintains accident and incident records. 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. Horse Leaze (5) DS0000066791.V305358.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 Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home assesses service users needs and has a produced a guide to help service users make decisions about where they live. EVIDENCE: Previous inspections have evidenced that the home has produced a statement of purpose and service users guide that comply with regulations and provide up to date information to service users. The Inspector was advised by the Manager that the statement of purpose and service users guide are in the process of being revised to reflect that the building and care service are now both the responsibility of Heritage Care. There have been no new admissions to the home since the last inspection in February 2006. The Inspector sampled the personal files for two service users currently living at the home. This evidenced that the home assesses service users and develops individual plans to meet identified needs. It was also evidenced that the home has developed contracts with service users and copies of these were also available on the personal file. The home currently accommodates 3 male and 3 female service users from diverse backgrounds including Asian, Afro-Caribbean and White British. Horse Leaze (5) DS0000066791.V305358.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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has developed individual plans and risk assessments for service users. However, individual plans should be reviewed at least every six months. EVIDENCE: The Inspector sampled two service users personal files and evidenced that both contained individual plans addressing how the service users health, personal and social care needs will be met. These plans are generated from the homes own assessments and address needs including personal care, mobility and communication. The homes “personal profile” tool is a comprehensive document that assesses service users needs and plans how to meet these. It was evidenced for one service user that their personal profile and plan of care had been reviewed on a six monthly basis. However for a second service user a period of nine months had elapsed between reviews of their profile and plan. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 10 Sampling of service users personal files evidenced that the home retains all correspondence regarding service users benefits. Service users receive support to manage their personal allowance. Service users monies are retained in individual locked boxes and each has a log recording expenditure that is signed, and receipts are retained. Sampling of service users personal files also evidenced that the home has developed a risk assessment tool and has appropriately applied this. Risk assessments addressing service users activities in the community, personal care and lifting and handing had recently been reviewed. Horse Leaze (5) DS0000066791.V305358.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to engage in a range of community, leisure and occupational activities. EVIDENCE: The home supports service users to engage in a range of valued and fulfilling activities. Sampling of service users files evidenced that they are supported to visit local places of interest including museums, local shops, the cinema, the city airport and the city farm. Some service users have been supported to have train rides and to take part in gardening activities. Visits to local cafes and pubs for lunch also occur frequently. Service users are also supported to engage in culturally appropriate activities including visits to a local Asian shopping centre and a referral to an Asian women’s group for one service user. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 12 The homes staffing rota has been developed to facilitate one to one support for service users on a regular basis in order that they can engage in activities outside of the home. In addition there are a range of activities and entertainment available in side the home including a TV and DVD player, a range of DVD’s, a stereo and appropriate games. An aroma therapist visits the home on a weekly basis and all service users are able to access this service if they choose. The home has access to a mini bus and is considering organising day trips and short breaks away for service users. Discussion with the Manager and sampling of service users personal files evidenced that service users are supported to maintain family links and that family and friends are welcomed and encouraged to visit the home with service users agreement. Some service users are also supported to have visits to their families. Throughout the course of the inspection the Inspector observed that staff talk to and interact with service users and that service users choose when to be alone or when to join in an activity. The Inspector sampled the homes log of meals served. A range of nutritious meals that aim to meet service users dietary and cultural needs are served. At a previous inspection it had been noted that on days when beef dishes were served, no alternative had been recorded as being offered to the two service users who do not eat beef as a result of their religious background. The Inspector noted that this issue had been addressed, and that clear alternatives had been recorded for these service users on days when beef was served to other service users. A notice had also been attached to the fridge door advising staff not to purchase or give yoghurts that contain beef derivatives to these two service users. The Inspector sampled the personal file for a service user who had previously been in receipt of mobility allowances and noted that since the last inspection appropriate paperwork and copies of correspondence was available to evidence their current entitlement to motability benefits. Horse Leaze (5) DS0000066791.V305358.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 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive personal care in the way they prefer and are supported to attend regular healthcare appointments. However, the home must improve its medication recording and its practice for disposing of medications. EVIDENCE: The Inspector sampled the individual plans for two service users. These included detailed information on the assistance required with various aspects of personal care and how the service user prefers to receive their support. The individual plan for one service user identified how they required support to select their clothes, and how the service user prefers them to be laid out on the bed in order that they can dress themselves with only verbal prompts. The Inspector also spoke with a staff member on duty who was able to identify how they would promote respect and dignity for service users by knocking on the door before entering, by explaining to service users what you wanted to do and seeking their permission and by encouraging service users to do for themselves what they are able to. One service user has been assessed and provided with a motorised wheelchair in order that their independence can be maintained. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 14 Both of the service users personal files sampled contained a record of healthcare appointments attended, the date and the outcome. The records available records evidence that service users have been supported to access their GP, optician, specialist clinics and the podiatrist in recent months. The home implements a corporate Heritage Care Medicines Policy. This includes guidance to staff on completing the Medication Administration Record (MAR) and administering medication. There is also guidance for staff on the procedure for receiving and disposing of medication. The policy also addresses the storage and administration of controlled drugs and provides a framework for service users to self-administer within a risk management framework. The Inspector checked the actual medications available in the home against those recorded on the current MAR sheet for two service users. One service users available medication and MAR sheet were found to match. For the second service user two discontinued medications had not been disposed of, and an “as required (PRN)” medication was not listed on the MAR sheet. Horse Leaze (5) DS0000066791.V305358.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 & 23. 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 from harm and their views are listened to and acted upon. EVIDENCE: The home operates the corporate Heritage Care complaints policy. This includes a formal and informal system of making complaints and states that all complaints will be dealt with within 15 days. The home has a pictorial summary of the complaints procedure available for service users. The Inspector viewed the homes complaints log. The most recent entry was made in November 2005 and details of the complaint and the action taken were appropriately recorded. The Inspector also sampled the homes adult protection policy. This is also a corporate Heritage Care policy and contains information for staff on the definitions of abuse, and key principles for staff to consider. The policy makes appropriate reference to local adult protection guidelines and outlines the procedure for staff to follow should they have any adult protection concerns. The policy also makes clear reference to a separate corporate whistle blowing policy. The Manager advised that no adult protection concerns had been raised. The staff member interviewed by the Inspector demonstrated a good understanding of adult protection issues and was able to clearly identify their responsibilities should they have any concerns. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 16 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, 26, 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a comfortable, homely and well maintained environment. EVIDENCE: The Inspector toured the premises, including some service users bedrooms. The home was found to be accessible, safe and generally well maintained. There was a homely and comfortable atmosphere. Service users have their own bedroom, and these were redecorated in 2005, with service users choosing their own colour schemes. Individual service users rooms contained a bed, chair, built in wardrobe, chest of draws and washbasin. Service users had personalised their own rooms with pictures, photographs and other personal mementos. The home is bungalow style accommodation with all areas of the home being wheelchair accessible. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 17 The home has a bathroom with sink and WC, shower room with sink and WC and a separate toilet. The inspector noted that the bathroom was generally very clean and well presented. The shower room curtain was ripped and requires replacement. The home provides comfortable, accessible shared spaces for service users in the form of a lounge, dining area, kitchen, conservatory and garden. The Manager advised the Inspector that a project to renovate the garden is planned to start later in the year. Several minor repairs identified at the last inspection have been completed to a good standard, and carpets and bathroom linoleum have been replaced. One service user currently uses a hoist for transfers and has this equipment fitted in their bedroom. A second hoist that is not currently in use is stored in the hallway. The home has separate industrial style laundry and drying facilities. The Inspector found the premises to be clean, hygienic and free from offensive odours. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 18 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, 34, 35 & 36. 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 appropriately trained staffs. However, staff must be regularly supervised and evidence of satisfactory pre employment checks must be available for inspection. EVIDENCE: In addition to the Manager the home employs six day and two night support workers. Throughout the course of the inspection staffs were observed to be accessible to and approachable by service users. The Manager advised that three support workers have obtained NVQ level 2 and a further staff member is currently studying for their NVQ level 2. The Manager also told the Inspector that an audit of staff training had recently been carried out and staff referred for refresher training where appropriate. The home maintains a staffs training file where details of training completed and the date is recorded. The home has a structured induction programme that all staffs complete. Heritage Care operates a centralised Human Resources Department that retains all details of pre employment checks. A summary sheet detailing the type of check is held locally at the home and is available for inspection. The Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 19 Inspector sampled two staff personnel files. One of these was for a member of staff who joined the home earlier in 2006. A record of the induction process was available in the local file and the summary sheet had been completed to evidence two satisfactory references and proofs of identity had been obtained. However, there was no reference number or date recorded for his or her Criminal Records Bureau (CRB) check. A copy of their letter of employment was available and supervision records evidenced that this had occurred on two occasions in a four-month period. The second personnel file sampled by the Inspector was found to be incomplete, as it did not evidence that two satisfactory references had been obtained. The Inspector noted that this staff member had returned to work from long term sick in March 2006. Available supervision records evidenced that supervision had occurred on only one occasion in the intervening period. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 20 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 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home must develop its quality assurance practices and ensure that all records required by health and safety is appropriately maintained. EVIDENCE: The home Manager advised the Inspector that they have previous experience of managing a care home and have recently completed their NVQ level 4 studies. However, although the Manager has been in post for some time they have yet to register with the Commission for Social Care Inspection, as required by regulation. At the last inspection the home were required to develop their quality assurance processes to include the views of service users, their families and other interested parties. At the time of this inspection the Manager advised the Inspector that the home are looking to develop a 3 monthly forum to Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 21 obtain feedback from service users families and involve them in the running of the home. The Inspector examined a number of health and safety records required by regulation. The homes own guidance on fridge temperatures states that the fridge must be maintained below 4 degrees. The record of fridge temperatures seen by the Inspector evidenced that the actual temperature had exceeded this on consecutive days between the 1st and 23rd July. The homes guidance on freezer temperatures states that the freezer must be maintained between – 18 and –23 degrees. The record of actual temperatures was outside of these parameters on two occasions. Neither the fridge or freezer temperature records recorded any action taken to return them to acceptable limits. Additionally no freezer temperatures were recorded on two dates. The Inspector viewed the homes fire records. The homes fire register had been updated to reflect the current service user group. Weekly fire call point and emergency lighting tests had been carried out and were found to be in order. A fire evacuation drill complete with timings was evidenced as being carried out in November 2005. The Inspector also viewed the record of water temperatures within the home. The Inspector noted that this is ticked to evidence that the water temperature is acceptable, but does not state the actual temperature recorded during testing. An incident reporting sheet is maintained on each service users personal file. The home maintains separate accident reporting books for staff and service users. During a tour of the premises the Inspector noted that all fridge and freezer contents were appropriately labelled. However, a potentially hazardous cleaning substance was found on open display in the homes laundry area. Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 22 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 2 X 2 X 2 X X 2 X Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4,5 & 7. Requirement The statement of purpose and service users guide must be revised to reflect the transfer of the building to Heritage Care. Service users individual plans must be reviewed at least six monthly or as their needs change. All discontinued medications must be disposed of in an appropriate and timely manner. All medications including “as required (PRN)” medications must be listed on the MAR. The ripped shower curtain in the shower room must be replaced. The home should consider how to support staff to achieve the required level of staff qualified to NVQ level 2. Personnel information required by regulation, including pre employment checks must be available for inspection. This is a restated requirement. The previous target of the 30/04/06 was not met. Timescale for action 30/11/06 2. YA6 15 30/11/06 3. YA20 13 & 17 30/10/06 4. 5. YA24 YA32 23 12 & 18 30/10/06 30/11/06 6. YA34 Sch 2 30/11/06 Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 24 7. YA36 18(2) Staff must receive a minimum of six supervisions per annum. 30/11/06 8. 9. YA37 YA39 8 24 This is a restated requirement. The previous target of the 30/06/06 was not met. The Manager must apply to be 30/10/06 registered by the Commission for Social Care Inspection. The home must develop its 30/11/06 quality assurance process to include service users views, the views of their relatives and other professionals involved in their care. This is a restated requirement. The previous target of the 30/06/06 was not met. Fridge and Freezer temperatures must be recorded on a daily basis. Fridge and Freezer temperatures must be obtained within acceptable limits and appropriate action taken and recorded if they are not. These are restated requirements. Previous targets of the 15/01/06 and 30/04/06 were not met. When recording the outcome of water temperature testing the actual temperature must be recorded. Potentially hazardous cleaning materials must be stored in a locked cupboard. 8. YA42 16(2) & 23(4) 30/11/06 Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 25 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 Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Horse Leaze (5) DS0000066791.V305358.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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