Inspection on 29/07/05 for Horse Leaze (7)

This inspection was carried out on 29th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Horse Leaze (7) 30/11/07

Horse Leaze (7) 25/05/06

Horse Leaze (7) 19/01/06

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

CARE HOME ADULTS 18-65 7 Horse Leaze 7 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 29th July 2005 at 2.15 pm 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 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 Stationary 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. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 7 Horse Leaze Address 7 Horse Leaze, Beckton, London, E6 6WJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7473 1945 Heritage Care Mr Warren Spencer Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 11th January 2005 Brief Description of the Service: 7 Horse Leaze is a care home for adults with mental health support needs. Since the last inspection Heritage Care have taken over as the Registered Provider from English Churches Housing. As Heritage Care were previously providing day to day staffing and management of the home this change has not been disruptive to service users. The home is a single storey building located within a residential area of Beckton. There are bus routes and the Docklands Light Railway is accessible closeby. The home aims to provide a supportive enviroment within which service users can develop confidence, dignity and personal responsibility. Each service user has their own bedroom and access to communal lounge, dining, kitchen and bathroom facilities. The home has four male and two female service users in residence. The home is culturally reflective of the local community with service users from African Caribbean, Asian, Irish and White British backgrounds. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 an afternoon. The main focus of the inspection was to review progress on the eight requirements and five recommendations made at the previous inspection. During the course of the inspection the inspector sampled several service users personal files, the homes policies and procedures and other relevant documentation. In addition a member of staff was privately interviewed, as were four service users. The Inspector also spoke with the senior support worker on duty. The Inspector was unable to sample staff personnel files as these were properly secured in the Managers absence. What the service does well: What has improved since the last inspection? What they could do better: The home has been required over several inspections to hold and record progress meetings with service users to review their individual plans and goals. This requirement has again been repeated as a result of this inspection. Similarly shortfalls relating to the homes medication administration and recording practises have resulted in requirements again being made. Risk assessments must be completed to address areas such as self-medication and non-compliance with medication. These must be regularly reviewed. During maintenance works staff on site must ensure that risks from potential trip hazards are addressed. Service users bathing needs should be assessed by an Occupational Therapist and the homes current bathing provision reviewed in light of these. Bathrooms and toilet areas must be maintained and properly 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 6 cleaned. The home must review how to support one service user to maintain his room free from offensive odours. The complaints log must record all relevant information relating to the investigation, action taken and outcome. 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. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 2. The home has developed good practise in obtaining information from other agencies when considering a new service user. The home did not complete its own assessment or prepare an individual plan for a new service user. EVIDENCE: The Inspector sampled the personal file for one service user who moved into the home in January 2005. From paperwork available on this file it was evidenced that the service user had been assessed as requiring residential care by their community mental health team. A Care needs assessment and care plan reflecting this need were seen. The service at this home had been identified as most appropriate as the service user had previously lived there and was happy to move back. A completed referral from his then support workers had been completed and identified the types of support this service user requires assistance with. The Inspector noted that the current support plan is dated September 2004 and transferred with the service user from their previous placement. The home must ensure that new service users are assessed by the home and an up to date support plan to address their needs drawn up. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 & 9. The home has developed comprehensive service user planning documentation and tools. Plans are easy to follow and service users participate in their development. Service users are supported to make individual choices and develop in areas of need. Individual plans are not being regularly reviewed and may not be an accurate reflection of current service user needs. The home must develop its practise in relating and reviewing risk assessments as part of the individual planning process. EVIDENCE: The Inspector sampled three service user personal files and noted that these contained detailed individual service users plans that address personal health and social well-being. The information contained in the plan included: * * * * The service users past. Their assessed needs with regard to medication, communication, finance, activities of daily living and personal care. Educational and leisure needs. Short term and long-term goals for areas of identified need. G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 10 7 Horse Leaze The information recorded was detailed but easy to access. Service users strengths as well as areas where support is required were identified. The individual plans were drawn up by the key worker and service user and signed by both to evidence this. The Inspector noted however that individual plans are not being reviewed regularly. These plans must be reviewed at six monthly intervals, or earlier if the service users need change. The Inspector noted that individual service user plans identify areas where service users can independently make choices, for example, choosing clothes. The home encourages service users to manage their own finances, with support where needed. For one service their individual plan identified that support is needed with budgeting as the service user tends to overspend at the early part of the week leaving her short of money towards the end and prone to ask other service users for loans and cigarettes which they do not like. The Individual plan identifies short and long term goals for this area and identifies the support and action required by care staff. The Inspector viewed the minutes of service user meetings. Four have been held this year and they appear fully recorded with the names of all attendees their comments and a record of the minute taker. The Inspector noted that one recent discussion at a service user meeting had addressed what to do if a visitor calls to see a service user who is not at home. After a general discussion each service user stated their views as to how to deal with this type of situation. From this a consensus was developed and agreed and is now recorded as the homes policy. This demonstrates how service users are being supported to participate in the day-to-day running of the home and to contribute to the development of policies and procedures. The Inspector noted that a number of standardised risk assessments had been completed for service users including safe access to cleaning materials and access to kitchen knives. Annotations on these assessments suggest that they had been reviewed annually in 2003 and 2004 but that no review had occurred in 2005. The Inspector noted that these review dates did not correspond with the dates of review for the individual plan. Some individual risk assessments were completed; an example was the risk assessment for one service user on keeping paracetomol medication in her bedroom. The Inspector again noted that this had not been recently reviewed and that there was no risk assessment addressing self-medication of which the paracetomol keeping is an element. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16 & 17. The home is promoting service users well being by supporting access to a range of educational, community and therapeutic work opportunities. The home also supports service users to maintain contact with family and friends in the way they choose. EVIDENCE: The Inspector noted that individual service users leisure and educational preferences were included in the individual care plan. One service users plan identified that the service user likes to listen music and write letters. The service user plan also identifies the community and educational activities the service user is currently involved in. One service user attends adult education classes and a day service where there are opportunities for therapeutic work and additional earnings. For another service user it was identified that they would like to pursue a course in cookery and support staff had obtained information on classes available locally. Another service user advised that he likes to visit the local pub with other service users once a week. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 12 Staffs support service users to maintain contact with family and friends. One service users plan identifies how they like to maintain regular phone contact with their family. Service users are able to choose their own visitors and whether to see them in a communal area or in private. Service users preferred form of address is noted on their individual service user plan and used by staff. Service users are able to choose when to be alone or when to spend time in the communal areas or be involved with activities. During the inspection staff were observed to be sat with service users and interacting with them. Each service user has a range of chores they are responsible for in the home, and are given appropriate support to carry these out. Service users choose the meals they would like to eat each week and then choose which of these they will prepare. Whilst some service users are able to cook independently, others require support from staff. During this inspection the home was in the process of having a new kitchen fitted. Service users are therefore receiving funds each day and choosing a take away meal to eat. At least one service user has special dietary requirements and the Inspector noted that this was included in the individual service user plan along with the support required by staff to follow a diabetic diet. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20 & 21. By supporting service users to attend healthcare appointments and monitoring there outcomes the home is promoting service users wellbeing. However, the home must address some shortfalls in its risk assessment and management framework to address self-medicating and non compliant service users. EVIDENCE: The Inspector noted that care plans identified how service users prefer to be supported. For example, one service user who is self-medicating likes to be verbally reminded by staff when tests are due. Each service users personal file includes a healthcare section that includes records for GP, chiropody and other medical appointments. The Inspector viewed the homes medication file. This includes a comprehensive policy relating to medication and service users who self medicate. The Inspector noted that at least one service user is currently selfmedicating. A risk assessment and management plan that is regularly reviewed must be developed for self-medicating service users. The Inspector viewed the medication records and compared the medication actually available against the list of medication taken by each service user; the medication administration record (MAR) and the record of medications obtained and disposed of. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 14 Generally these were found to be in order, the medication actually available did tally with the MAR and records of medication obtained and disposed of. The Inspector did however note that one service users list of medication contained an item that was not recorded as discontinued and did not appear on the MAR. The Inspector noted that the MAR sheet had been correctly completed. The Inspector noted that the missed medication record for one service user indicated that he had missed his medication on six occasions in the last four months. This was also identified as an area of concern at the previous inspection. The Inspector viewed the personal file for this particular service user and noted that compliance with medication was not covered in the care plan and had not been risk assessed. The Inspector viewed the homes policy and procedures file and noted that a local protocol regarding the ageing and death of service users had been developed. This included information on how the home aims to support ageing service users and the circumstances when a move to more supported accommodation might be needed. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 22 & 23. To ensure all complaints are appropriately investigated and the most applicable course of action taken, all relevant information must be included in the complaint log. Appropriate handling and recording of financial transactions protects service users as does staffs knowledge and understanding of adult protection issues. EVIDENCE: The Inspector viewed the homes complaints log and noted that recent complaints centred around one service users badgering of others for cigarettes. The service users individual plan recognised this behaviour as a potential result of poor money management. From discussion with the service user the Inspector established that this service user has now given up smoking. This was not recorded as part of the complaint investigation or outcome. The Inspector noted that one service user receives high levels of support with managing his finances. A locked deposit box containing his monies is kept in the staff office and a log for all withdrawals and deposits into the box. The service user and staff sign each entry. The service user advised the Inspector that he was happy with this arrangement. The Inspector checked the log balance with the actual monies available and found that they matched. The Inspector also checked the petty cash ledger and safe deposit and found these to be in order. From discussions with staff the Inspector was satisfied that those on duty had an awareness of adult protection and the types of abuse vulnerable adults may experience. Staff were also able to locate and homes adult protection policy and outline what they would do if they were concerned about adult protection issues. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30. Despite the disruption from the installation of a new kitchen the home is generally homely and comfortable. To promote service users independence their bathing needs and the homes bathing provision needs reassessment. Service users must be appropriately supported to maintain their bedrooms free from offensive odours. EVIDENCE: The home is a single storey bungalow that blends with other accommodation in the locality. At the time of this inspection the home were in the finishing stages of having a new kitchen installed. This is obviously causing some disruption. However the Inspector noted that the communal lounge and dining areas were generally homely, safe and comfortable. The senior support worker was advised to move paint cans and toilet rolls stored on the floor in the hallway to service users rooms as these pose a potential trip hazard. The Lounge area has doors out onto the garden and has comfortable sofas and armchairs as well as more upright seating. There is a unit housing the TV and stereo. The adjacent dining area accommodates a large dining table and chairs and display shelves which house service users handicrafts and art works. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 17 The home has a separate laundry room which houses and industrial type washing machine and tumble dryer. The Inspector noted that potentially hazardous cleaning substances were being kept on open shelves in the laundry room. Hazardous cleaning materials were also being kept in the WC. Each service user has their own bedroom and several service users showed the Inspector their bedrooms. These contained a sink, wardrobe, bed, chair and chest of draws. Service users have been able to personalise their rooms by bringing in extra furniture where space permits, hanging pictures and photographs on the walls, and choosing how they would like their rooms decorated. The previous inspection had recommended that service users sinks be fitted with a light over. The senior on duty advised that this had been reported to the landlord and remained outstanding works. One service user whose room was visited smelt strongly of urine, and the Inspector noted that his care plan stated he was incontinent. Whilst the care plan identified strategies for staff to support with continence management the care plan did not address how the service user would be supported to maintain his environment. The care plan must be revised to include this. The home has one bathroom with a tub and no toilet, an adapted shower room with WC and hand basin and a toilet with hand basin. The Inspector noted that the large bathroom was being used to store materials and tools being used in the kitchen refurbishment. The Inspector spoke with the Senior Support Worker on duty and was advised that this room was being used for storage as only one service user uses it, and the others prefer to use the shower. The Inspectors tour of the shower room found that there was a leak behind the toilet area. The handrail next to the toilet was marked with faeces. The Inspector noted that this is the smaller of the bathrooms and is not adequate to cope with the five and indeed currently six service users who are using it. The home must ensure that the personal care needs of service users are reviewed by an Occupational Therapist, and the outcome of these assessments should form the basis of a review and possible reprovisioning of bathing facilities in the home. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 & 35. Service users seem supported by staff that are accessible, approachable and comfortable with them. EVIDENCE: As the manager was not on site the staff personnel files were properly secured and were not able to be accessed by the Inspector on this occasion. During the course of this inspection the Inspector noted that staff on duty were accessible to, approachable by and comfortable with service users. The Inspector interviewed a member of bank staff on duty. She confirmed that the she had received and induction upon joining the home earlier this year, and that she had received a copy of her completed induction checklist. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42. The home is promoting service users safety by regularly testing fire alarms and holding fire drills. Service users are however being put at risk by the homes failure to satisfactorily store substances potentially harmful to health. EVIDENCE: The Inspector viewed the homes record of fire alarm testing and found that this is now occurring weekly and the outcome and any required action are recorded. Three fire drills including evacuation have been held since the last inspection. Evacuation times for service users have been recorded on two occasions. The Inspector noted on the third occasion that service users had not responded to the drill. The manager had subsequently called a service uses meeting to address this and remind service users of the importance of fire drills for their safety. During the site inspection the Inspector noted that potentially hazardous cleaning substances were being kept on open shelves in the laundry room. Hazardous cleaning materials were also being kept in the WC. The home must 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 20 ensure that all substances potentially hazardous to health are properly and securely stored. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Horse Leaze Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 15(1) Requirement New service users taking up residence at the home must have an individual plan drawn up to identify their current needs. Individual service user plans must be reviewed at least every six months or more frequently if service users needs change. This is a restated requirement. Previous targets of the 01/11/04 and 01/03/05 were not met. The home must develop its risk assessment practises. (1) In addition to generic risk assessments individual service users should be risk assessed in relation to their individual support plan. (2) Risk assessments must be reviewed as part of the review of the individual plan. The home must develop its medication administration practise. (1) The list of medications taken by service users must match the medications recorded on the MAR, or be annotated to indicate a medical review resulting in stoppage. (2) The home must ensure that service users are Timescale for action 29/10/05 2. 6 15 29/10/05 3. 9 13(4) 29/10/05 4. 20 13(2) 29/10/05 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 23 5. 24 13(4)a 6. 42 13(4)a 7. 29 23(2)n 8. 27 23(2)n 9. 30 23(2)d 10. 30 16(2)k 11. 22 22(3) supported to comply with their medication and that needs associated with this are included in the service user plan and are risk assessed. (3) Self medication regimes must be subject to a risk assessment and management framework. Part (2) of this requirement is a restated requirement, the previous target date of 01/02/05 was not met. Paint cans and toilet rolls stored in the hallway must be removed as they pose a potential trip hazard. Hazardous substances must be securely stored in line with Control of Substances Hazardous to Health (COSHH) guidelines. Occupational therapy assessments must be completed for each service users bathing needs, and identified aids obtained. When all Occupational Therapy assessments are completed the home should review its current bathroom provision and consider what alterations need to be made. Bathrooms, shower rooms and wcs must be clean and properly maintained. (1) Grab rails and lino in the bathrooms and toilets must be cleaned or replaced. (2) Leaks in bathroom and wc areas must be investigated and repaired. The home must review the care plan for one incontinent service user and include the support and monitoring needed to maintain an hygienic and odour free bedroom. The complaints log must adequately record details of the complaint investigation, any Effective from time of inspection. Effective from time of inspection 29/10/05 29/10/05 29/10/05 29/10/05 29/10/05 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 24 action taken and the outcome. 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 26 Good Practice Recommendations The home should consider providing lights over the sink area in service users rooms. This is a restated recommendation. 7 Horse Leaze G57 G06 S63910 Horse Leaze V241755 290705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Gredley House 1-11 Broadway 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. 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