Inspection on 27/10/07 for Horse Leaze (5)

This inspection was carried out on 27th October 2007.

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 13 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) 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 09/07/2008.

CARE HOME ADULTS 18-65 Horse Leaze (5) 5 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 27th October 2007 10:00 Horse Leaze (5) DS0000066791.V353582.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.V353582.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.V353582.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) horse.leaze5@heritagecare.co.uk www.heritagecare.co.uk Heritage Care ** post vacant ** 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.V353582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 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 accommodates six adults who have learning difficulties, and since the last inspection the home has moved from providing permanent residential care to a short breaks respite care service. 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. 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.V353582.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of a day. They had visited the home on several occasions previously. The Inspector met with the Manager, and spoke privately with one person who uses the service and one care worker. They also sampled a range of records and documents relating to the running of the service. Since the last inspection the home has undergone a significant change, the former residents and staff have all moved onto supported accommodation and a short breaks respite care service moved into the premises. An Inspector visited the home to find out what it is like to live there. They spoke to people who use the service. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 6 They also spoke to staff. What the service does well: The home is able to meet the needs of people of different ages and different backgrounds. People who use the service told the Inspector that they liked staying here. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 7 The home is comfortable and well maintained. People who use the service are assessed before they come to stay. Residents are supported to look after their money during their visit. Staff support people who use the service to make decisions about their every day lives. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 8 Residents have flexible routines and proper equipment. The home listens to residents’ worries. The Manager and staff are professionally qualified. What has improved since the last inspection? The home’s information such as service users guide and statement of purpose has been updated to show what happens at the home now. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 9 The home reviews the needs of people who use its service. The home properly disposes of medication that is no longer needed. The home has finished some minor repairs. Care workers study for NVQ level qualifications. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 10 Staffs receive regular supervision to help them do their job. The home keeps all its cleaning materials in a safe place. What they could do better: Each resident must have their own plan that looks at their personal, social and healthcare needs. The home must assess possible risks to people who use the service. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 11 The home must support people who use the service to join in the local community. The home should provide more activities within the house. There should be a record of all the meals that residents are given. The home must meet the healthcare needs of people who use the service. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 12 The home must make sure that it has good medication practise and procedures. The home must do all it can to keep people who use the service safe. There must always be enough staff on duty to meet the needs of people who use the service. The home must have information about staff and how they are recruited to show the Inspector. The home must make sure it tells everybody who needs to know about changes that affect the lives of people who use the service. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 13 The home needs to find ways to listen to people who use the service and their families so that the service can get better. The home must make sure it keeps proper health and safety records. 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.V353582.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.V353582.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 has produced a statement of purpose and service users guide that reflects the service currently being offered, and potential service users are assessed prior to a service being offered. EVIDENCE: The Inspector viewed the home’s statement of purpose and service users guide. These have been reviewed and updated to reflect the service now being offered by the home. The Inspector sampled the personal files for two people who use the service. One person was currently in residence, and the other had recently used the service. This evidenced that both people who use the service were assessed prior to their short break starting. Horse Leaze (5) DS0000066791.V353582.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make their own decisions. Whilst the home gathers information from other professionals it does not develop, review and update its own individual plan with people who use the service. The home does not regularly assess or review potential risks to people who use the service. EVIDENCE: The Inspector sampled the personal files for two people who use the service. One person was currently in residence and they had been admitted several days previously in an emergency situation and were not known to the service. Basic information such as health, mobility, activities, relationships and food preferences had been recorded, and the Manager advised the Inspector that a more detailed individual plan would be developed and agreed with them during their stay. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 17 A second person who uses the service was evidenced as being initially assessed in March 2003, and having an undated and unsigned personal planning book that addressed communication, important people, activities and preferences. It was not clear whether the home had developed this book or s it had been obtained from another professional or agency. A separate care plan developed by the Primary Care Trust dated October 2005 was also on file. There was also a “health matters” document on file. It was evidenced that reviews of this service users needs had taken place in June 2003, April 2005, April 2006, September 2006 and February 2007. The Inspector noted that information in different parts of the personal file indicated a change in need from April 2007 which meant that the service user required 1:1 support at all times. In other sections of the file it was evidenced that this service user is an insulin dependant diabetic, however there was no information on the arrangements for administering this injection or monitoring blood sugar during the respite placement. It was not evidenced by the Inspector that this information along with that obtained from other professionals had been compiled into an accessible, individual plan developed by the home. The home supports service users to manage small amounts of money they bring with them and will need during their stay. The Inspector sampled the records maintained by the home relating to residents finances. This evidenced that a log of the money bought in by each service user is maintained, and that an entry for each expenditure including the date, amount and reason are logged and signed by staff. Sampling of the daily logs for two people who use the service evidenced that care workers encourage and support people who use the service to make decisions about their daily lives, for example their daily routine and activities they would like to engage in. The home had completed a risk assessment for the longstanding service user, and this was dated October 2005 with no evidence of update or review. The second service user who was not previously known to the service had no risk assessment on file. Horse Leaze (5) DS0000066791.V353582.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to engage in their usual activities during their short break, and to maintain appropriate contact with their families. However, the home needs to develop opportunities for residents to engage in the local community and activities within the home. EVIDENCE: The Registered Manager told the Inspector that the home supports people who use the service to engage in their usual activities during their period of respite care. Sampling daily logs which evidence that residents continue their attendance at day service and other activities during their short break supported this. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 19 The Manager acknowledges that the home needs to develop its role in supporting people who use the service to participate in the local community. They advised the Inspector that they planned to develop outings for people who use the service to places of interest. The Manager also told the Inspector that the home is developing activities for people who use the service to engage in within the home. At the time of this inspection an outside facilitator organises a music night once per week. In addition the home aims to develop craft evenings, film nights, a range of garden and indoor games and aromatherapy sessions. People who use the service are receiving respite care from their families who are their main carers. Sampling of personal files evidenced that the home develops links with families and supports people who use the service to maintain appropriate contact during the period of their respite care. During the course of the inspection care staff were observed talking and interacting with people who use the service. The Inspector viewed the log of meals provided, and noted that there were gaps in this and that it was not clear what food and meals had been recently provided. The Manager told the Inspector that the home is now moving to a system of providing a four week rolling menu with a choice of two meals, one of which is vegetarian each day. The Manager further stated that this menu will be flexible and will take into account the personal preferences of the people using the service that week. The Inspector was shown sample menus for this new system and these evidenced a variety of nutritious meals being provided. The service user spoken to by the Inspector said that the meals provided were “okay”. During the course of the inspection the Inspector noted that the meal preferences and timings of one resident had been recorded and made available to staff in the office. Horse Leaze (5) DS0000066791.V353582.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 adequate. This judgement has been made using available evidence including a visit to this service. The home appropriately meets the personal care needs of people who use the service. However, there are gaps in the homes recorded information relating to healthcare needs and some poor practise in the administration and recording of some residents’ medicines. EVIDENCE: Discussion with one care worker evidenced how staff supports people who use the service to make choices around the clothing that they wear. Sampling of daily logs evidenced that people who use the service have flexible routines for getting up, going to bed, baths and mealtimes. At the time of this inspection the home has a mobile hoist that staffs have been trained to use. Sampling of the personal plan for one resident evidenced that the home had developed a “health matters” plan. The Manager advised the Inspector that Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 21 the home is able to support residents to attend healthcare appointments if they notified of them in advance of the short break. As mentioned in a previous section of this report, one of the residents case tracked is a diabetic who requires insulin injections and blood sugar monitoring. Whilst there was information on file on diabetic diet and accessing the local diabetic clinic, it was not clear how the blood sugar was monitored or the insulin administered during the short break. The Inspector sampled the medication records and actual medication available for two people currently using the service. For one of these people the available medication corresponded with the Medication Administration Record (MAR), and the MAR sheet had been appropriately completed. This person also uses a controlled medication and the Inspector found that appropriate records and storage facilities were in place to address these controlled medicines. The second resident whose medication was sampled by the Inspector was not previously known to the service, and they had been admitted as an emergency one-week previously. On admission they had arrived with a pre-loaded dossett box that was not labelled and a variety of boxed medication. A MAR sheet had also been drawn up for this person and the Inspector noted that the medicines listed on the MAR did not correspond with the boxed medication actually available. There was no evidence that the home had made contact with the residents GP to establish what medication they should be taking. Inspection of the medicines cupboard evidenced that no discontinued medicines had been retained. Horse Leaze (5) DS0000066791.V353582.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views. The home has fully implemented its policy and procedure to report adult protection concerns, however it must ensure that it appropriately considers the findings of these meetings and takes necessary action to minimise identified risks. EVIDENCE: The home operates corporate Heritage Care Complaints and Safeguarding Adults policies and procedures. These have been inspected on previous occasions and have been evidenced as complying with National Minimum Standards. The Inspector sampled the home’s complaints log. This evidenced that a record of the date and nature of complaints are recorded. No complaints had been received by the home since the last inspection. One adult protection issue had been highlighted prior to the Inspectors site visit, and another adult protection concern was received shortly after the site visit. The home was evidenced as taking appropriate action in response to these concerns, including notifying Social Services and the Commission for Social Care Inspection. A strategy meeting has been held for one matter, and a second issue is ongoing at the time of writing this report. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 23 The Inspector was concerned to note that the first adult protection issue identified that whilst the person using the service had been assessed as requiring 1:1 support, there were insufficient staff on duty to meet this identified need. The second ongoing matter also includes concerns relating to levels of staffing within the home. Horse Leaze (5) DS0000066791.V353582.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. The home provides a well-maintained environment that meets the needs of people who use the service, including the provision of specialist aids. EVIDENCE: The home is situated in a modern, purpose built bungalow in Beckton. All areas of the home are wheelchair accessible. The home is well maintained and provides a comfortable, homely environment. From the main entrance there is a hallway with the staff office located off this. A large bathroom with tub, WC and hand basin is also located off this entrance hallway, as is a small utility room that houses a large washing machine and tumble dryer. Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 25 There is a large open plan lounge and dining area. There is a range of comfortable seating and space for wheelchair users. A TV and stereo are available. Several small tables are situated in the dining area. A large carpeted conservatory can be accessed from the dining area, and this has double doors to a lawned garden. The kitchen is also situated off the dining area and this has a range of fitted cupboards and appliances. From an inner hallway three service users’ bedrooms and a shower room can be accessed. To the other side of the bungalow another inner hallway gives access to a further three service users bedrooms and a WC. The premises were found to be clean, hygienic and free from odours. Horse Leaze (5) DS0000066791.V353582.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, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service recognises the importance of training and regularly supervises staff. However, the home must ensure that sufficient numbers of staff are on duty at all times to meet the identified needs of people who use the service. EVIDENCE: At the time of this inspection the home employs a Manager, Deputy and four care workers. The Manager advised the Inspector that three workers, including the Deputy Manager had obtained NVQ level 3, and that a fourth care worker is currently studying for their NVQ level 2. The Inspector was advised that the remaining care worker has qualified as a registered nurse. The Registered Manager told the Inspector that the make of the staff group reflects the cultural backgrounds of people who use the service. Heritage Care operates a centralised Human Resources department. They are responsible for the recruitment of staff and pre employment checks. The Inspector sampled the files available on site for two staff members. These Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 27 included photocopies of documents retained by Human Resources. Available records evidenced that an Enhanced Criminal Records Bureau (CRB) check was obtained for each, and that proofs of identity and entitlement to work were sought. However, no written references were available for either. Sampling of available personnel records evidenced that since the last inspection range of training had been provided to the staff sampled. These included Adult Protection, Supervision and Fire Safety. One of the staff sampled had recently transferred to the home, and a record of their induction was available. Supervision records seen by the Inspector evidenced that one staff member sampled had received four supervision sessions in the current year, and a second had received three. The home is therefore on target to provide a minimum of six supervisions to staff in a year. Horse Leaze (5) DS0000066791.V353582.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a Manager who is qualified and experienced. However, the home must develop its quality assurance procedures and ensure that all basic health and safety checks are carried out and recorded. Significant events that affect the lives of service users must be notified to the Commission for Social Care Inspection. EVIDENCE: The current short breaks service has moved into the premises previously occupied by a residential care home. Heritage Care operated both services and both aimed to provide a service to adults with learning disabilities. The Manager of the short breaks service advised the Inspector that they are in the Horse Leaze (5) DS0000066791.V353582.R01.S.doc Version 5.2 Page 29 process of registering with the Commission as Manager. The Manager has previous experience of working as the Manager of a care home and they have completed their NVQ level 4 and Registered Managers Award studies. As previously stated, the former staff group and residents have moved on from the care home since the last inspection. However, the Commission did not receive correspondence from Heritage Care relating to this change, and was not included in the discussions relating to the move on of former residents. The Registered Manager advised the Inspector that the home uses a range of methods to ensure the quality of the service provided including visits by the Responsible Individual, reviews and summary reports for each stay. However, the home does not currently have a forum for service users or their families and there is no formal process for obtaining feedback, collating outcomes or publishing this to interested parties. The Inspector sampled a range of health and safety records. These evidenced that a record of water temperatures was only available from October 2007. Sampling of the homes fridge and freezer temperature records evidenced that whilst these were within acceptable limits, they were not routinely recorded on a daily basis, with no records available at all from 31st July to 29th September 2007. Sampling of the home’s fire logbook evidenced that no fire alarm call point testing took place between August and October 2007. There were records to evidence that the system had been serviced on the 10th October 2007, and that a fire evacuation drill had also taken place, however there were no timings recorded for this. A tour of the premises evidenced that potentially hazardous cleaning materials were securely stored. The Inspector also sampled the homes accident and incident logs and found these to be in order. Horse Leaze (5) DS0000066791.V353582.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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 2 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 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 1 2 X X 2 X Horse Leaze (5) DS0000066791.V353582.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 14 Requirement The home must develop an individual plan with each person who uses the service that addresses all aspects of personal, social and healthcare support. Timescale for action 30/01/08 2. YA9 13 The home must ensure that it 30/01/08 adequately and regularly assesses potential risks to people who use the service. The home must support people who use the service to participate in the local community. A range of appropriate leisure activities must be provided within the home. The home must maintain a log of the meals provided to people who use the service. The Registered Person must ensure that the healthcare needs of people who use the service are assessed and that procedures are in place to DS0000066791.V353582.R01.S.doc 3. YA13 16 20/02/08 4. YA14 16 20/02/08 5. YA17 16 30/01/08 6. YA19 12 30/01/08 Horse Leaze (5) Version 5.2 Page 32 address them. 7. YA20 13 & Sch 3 The Registered Person must ensure that accurate medication records are available for each person who uses the service. The medication available must correspond to that listed on the MAR sheet. The Registered Person should liaise with the GP and Pharmacist to ensure that supplies of medication are available in good time. 8. YA23 13 The Registered Person must ensure that the findings of strategy meetings are fully implemented to ensure the safety of people who use the service. The home must ensure sufficient staff are on duty at all times to meet the identified care needs of people who use the service. Personnel information required by regulation, including pre employment checks must be available for inspection. This is a restated requirement. Previous targets of the 30/04/06 and 30/11/06 were not met. 11. YA38 37 The home must notify the Commission of significant events that could impact upon the lives of people who use the service. The home must develop its quality assurance process to include service users views, the views of their relatives and other DS0000066791.V353582.R01.S.doc 30/01/08 30/01/08 9. YA33 18 01/12/07 10. YA34 Sch 2 20/02/08 01/12/07 12. YA39 24 20/02/08 Horse Leaze (5) Version 5.2 Page 33 professionals involved in their care. This is a restated requirement. Previous targets of the 30/06/06 and 30/11/06 were not met. 13. YA42 16 & 23 Fridge and Freezer temperatures must be recorded on a daily basis. These are restated requirements. Previous targets of the 15/01/06, 30/04/06 and 30/11/06 were not met. Weekly fire alarm call point tests must be carried out and recorded. Records of fire evacuation drills must include timings. Water temperatures must be tested on a regular basis and maintained within acceptable parameters. 30/01/08 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.V353582.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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