Inspection on 28/06/07 for Flat A 12 Hyde Close

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Hyde Close 12A High Barnet Hertfordshire EN5 5TJ Lead Inspector Margaret Flaws Key Unannounced Inspection 28 June 2007 08:30 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 Hyde Close 12A DS0000069196.V336502.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. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Close 12A Address High Barnet Hertfordshire EN5 5TJ 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) 020 8441 5278 020 8364 8083 www.sense.org.uk Sense, The National Deafblind and Rubella Association Kristel Nicol Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 5 Date of last inspection New Service Registration Brief Description of the Service: 12a Hyde Close is managed by Sense. It is a service for adults who have sensory impairments, mobility problems and severe or complex learning difficulties. The four flats in the building at Hyde Close which, although always managed separately, were originally under one registration but now, each flat has its own registration. This is the first inspection of 12a Hyde Close under its own registration. 12a Hyde Close accommodates 5 people in their own rooms and has a kitchen/lounge area and two bathrooms. Each person has his or her own single bedroom with a washbasin. There is a large shared sensory garden area and a patio. The laundry facilities are shared between the flats. The staff team work two day shifts and at night, there is one waking night and one sleep-in staff member. Opposite the home on the same site, there is a specialised day service, which Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 5 is separately managed. The residents have access to all these facilities and other community resources. The flat has its own eight seater minibus, which accommodates wheelchairs. The home is situated in High Barnet, in a pleasant residential area, close to shops, restaurants, pubs and other local amenities. The area is well served by public transport. The stated aims of the service are to provide support to the residents to achieve their optimum potential in social, emotional, developmental and educational activities, and enjoy a good quality of life. Following ‘Inspecting for Better Lives’, the provider must make information available about the service, including inspection reports, available to service users and other stakeholders. The fees for the home range between £1461-£2115. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, commencing early in the morning. It was part of the CSCI normal inspection programme and the newly Registered Manager and the Deputy Manager assisted throughout. Three staff were also on duty but went out with residents during the inspection. Two staff were later spoken to by telephone. The inspection consisted of interviews with the Registered and Deputy Managers, interviews with staff, inspection of the resident and staff files, home records, a tour of the premises and a brief visit to the day centre on the same site. It was not possible to talk to the residents because of their lack of verbal skills. However, observation of staff interactions with them made it possible to form an impression about the quality of the service. What the service does well: What has improved since the last inspection? Of nine requirements made at the last inspection, three were specific to other flats now separately registered. Five out of six outstanding requirements have been met. The new separate registrations are now completed and the home now has its own Registered Manager. Only female staff members provide personal care to female residents. Missing lampshades have been replaced; old furniture and builders rubble has been removed. The home has a clear business and financial plan. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are thoroughly assessed to ensure that the home can meet their needs. EVIDENCE: The home is purpose built to provide specialised care and support to people with learning difficulties and physical and sensory impairments. Staffing levels in the flat reflect the high level of support required by the residents. There is excellent pre-admission information available to prospective residents and their families and trial visits are part of the process. No new people have been admitted to the home since the last inspection. However, all files contained in-depth assessment information for those already living there. The assessment information forms the basis for comprehensive care planning to meet the residents’ needs. All residents have had a six monthly review by their social work care managers and a full review by their purchasing local authorities. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 10 Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs constantly reviewed and met; they are supported through appropriate communication to make decisions and helped to take risks that improve their quality of life. EVIDENCE: Two care plans and files were sampled. These included draft Person Centred Plans. Because the people living in the home are non-verbal, most are blind and/or deaf, there is very detailed information on file to help staff to communicate with them, to help understand their needs and provide care and support them in their decision-making. For example, the Registered Manager described how the home is developing a new system of person centred healthcare planning into action. This will involve developing picture book tools to interact with each resident about their health issues and producing a person centred ‘health passport’. The Registered Manager said that they are closely considering the implications of the Mental Capacity Act to see how the people living in the home could be further empowered in decision making. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 12 Each person’s file contains very detailed guidelines outlining what their needs are and how these can be met, for example, dealing with challenging behaviour and bathing. New ‘trailing’ guidelines have been producing to support the residents to move safely and independently around the home. Most staff have advanced training in the methods of communicating with people who are severely disabled, including training in British Sign Language. Staff were observed communicating with residents using BSL and it was clear that they were understood. There are good systems for protecting residents’ privacy, for example, flashing light doorbells for each room for deaf residents. Risk assessments are in place for identified risks and these were updated regularly. The Registered Manager gave good examples of risks taken that expand the quality of the residents’ lives: supporting one person to go surfing while on holiday; supporting others to go on fairground rides and to go boating. She said that, in all cases, the residents loved these experiences and flourished with the challenges, despite the limitations of their disabilities. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are provided with a wide range of activities and options to enhance their lives. Their relationships with family and community are supported; their rights and responsibilities valued and their wellbeing is maintained by a healthy diet. EVIDENCE: Activities inside and outside the home are excellent and each person has a detailed weekly activity plan. Staff described how they take the residents out as much as possible. For example, in the previous few days, they had been to the pub, to cooking sessions, to art and swimming sessions and out for dinner. In addition, they had been to Kew and Hampton Court on a trip up the Thames. These visits were documented in the residents’ files and in shift plans. Two members of staff drive and the home has its own eight-seater minibus (wheelchair accessible). This gives the home considerable flexibility in what can be offered. Those residents that are able assist with cleaning and cooking. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 14 Holidays are also prioritised and the most recent holidays have been to Centre Parks. One person regularly visits the Caribbean because he loves hot weather and beaches. Despite physical limitations, he participates in activities like surfing and swimming with dolphins. Staff always accompany the residents on holiday. The Anne Wall Day Centre is alongside the home on the same site and residents attend regularly, in some cases, daily. It is a big specialist centre for people with dual sensory impairment and multiple needs, including learning disabilities. I briefly toured the centre with the Registered Manager. The centre has excellent facilities including a large sensory room, an art room, a kitchen for cookery classes, swimming and hydrotherapy pools, a fully equipped gym, an allotment garden and facilities for massage, aromatherapy, drama and music therapy and for IT. Most residents regularly visit their families at home and staff support them with transport to and from home, and advice to relatives during their visits. Food is of a very good standard and people’s choices are sensitively canvassed and recorded. Menus are rotated on a six-week cycle, in consultation with the residents (using visual menus boards), and packed lunches are provided when people go out. There were plenty of fresh fruit and vegetables available on the day of the inspection. These are bought regularly at Barnet market. Specific dietary needs are addressed in menu planning and staff were able to describe how they ensure that the residents received a healthy diet. One staff member has specific responsibilities for food planning. The home has recently purchased a new fridge/freezer. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home know that their healthcare and social care needs will be considered and met; that personal support will be provided sensitively and that they are protected by the home’s medication policies and procedures. EVIDENCE: Healthcare records were extensive and detailed. Depending on the person’s needs, appointments are held with a wide range of consultants, specialists and other healthcare services. Check-ups are routine and documented, for example, with dentists and opticians. The Registered Manager described how the home managed and met the healthcare needs of the residents – for example, through dietary support for one person with a dietary disorder. Health information cards for emergencies are being developed from existing (somewhat bulky) material that staff take out with them and the residents. Staff accompany the resident to the doctors and make a report on the persons’ file after the visit. As described under Standard Seven, the home is putting person centred healthcare planning in place. An issue where a male carer provided emergency personal care to a resident was quickly resolved after the last inspection. The home has a clear Gender Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 16 Sensitivity Procedure, rota cover has been carefully risk managed and a requirement given at the last inspection is met. Staff described how they provided personal care in line with the needs and wishes of the people living in the home. Three residents who use wheelchairs have had them replaced with new electric wheelchairs in the past six months. Accidents and incidents are appropriately recorded and monitored for actions to be taken. Medication policies and procedures were inspected and found to be excellent. No errors were found in the MAR charts and medication was safely stored and accounted for. Surplus medication is stored safely in a locked cupboard and each person’s medication is kept in a locked cupboard in his or her rooms. Medication checks are done three times a day. If medication needs to be taken while a resident is out, this is taken in a travel dispenser. Side effects of particular medications are detailed in each person’s file. Controlled drugs are stored and handled correctly. However, some policies were not dated and a requirement is given. All staff are doing new medication training at an advanced level, with ongoing competency assessments. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home are protected by sound complaints and adult protection policies and procedures, which are put into practice professionally by staff. EVIDENCE: Since the last inspection, one complaint was received. This was satisfactorily reported, investigated and resolved to the satisfaction of those involved. CSCI was kept informed throughout the process and social services informed. The Registered Manager acted appropriately to deal with the situation. One adult protection investigation was initiated and an allegation not substantiated. Staff are trained annually in adult protection and how to report incidents of suspected abuse. I was happy with the way in which staff responded in discussion on reporting allegations of abuse Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living in the home are disadvantaged by the lack of urgency by the landlord in attending to maintenance and refurbishment in the bathrooms and kitchen. The home is kept very clean and tidy. EVIDENCE: I toured the flat and gardens with the management staff. The rear garden is very attractive, with sensory features and plants. There is also a rabbit living there. The Registered Manager describe an ambitious fundraising plan she has initiated with other staff, including the staff of other flats, to redesign the garden with the support of volunteers. The plan is very focussed on making a high quality and accessible space for the residents. At the back of the flat, there is a covered, paved area for barbeques. This area has recently been painted and decorated. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 19 In response to requirements made at the last inspection, missing lampshades have been replaced and old furniture and builders’ rubble disposed of. The bedrooms are very nicely personalised and have lots of sensory stimulation, for example, aromatherapy and hanging mobiles. Room furniture is designed specifically for each person’s abilities and needs. One person has sensory massage chair and another has specialist high-fi equipment because of his love of music. New flooring has been laid in the communal areas, and new blinds and new cupboards installed. The home uses textural flooring and different surfaces to help guide blind residents around the home. The home has a new fridge/freezer and dishwasher. The bathrooms are shabby compared to the rest of the home, where ongoing improvements are making it a brighter and more enjoyable place to live. Stonham Housing Association maintains the building. The Registered Manager said that this organisation has been asked repeatedly by Sense to improve the bathrooms, which need new bath and shower facilities and redecoration, but so far, Stonham has not actively responded. This is disappointing for both the residents and the staff. A requirement is given that the bathrooms be upgraded. The kitchen units still need replacing and a requirement given at the last inspection is restated. Additionally, there needs to be a clear refurbishment plan in place, with dates for work to be completed by and indications of who is responsible. A requirement is given. The home was very clean and tidy. A cleaner comes in regularly but staff do most of the cleaning on a rotational basis. There are very good policies and procedures for infection control and all staff have been trained in this area. The home now has a new maintenance person with responsibility for all the flats at Hyde Close. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are supported by a sufficient well trained and well managed staff. EVIDENCE: The staff rota was checked and staff on duty observed. There were sufficient staff on duty to meet the needs of the people living in the home. The Registered Manager said that one person effectively is provided with one to one support, even though the purchaser turned down funding for this level of support. This person sometimes has challenging behaviour. Staff have been trained to work with challenging behaviour. I was unable to inspect the new staff records on this inspection as they were held centrally but no new staff have been recruited since the last inspection. The home has excellent induction and shadowing procedures for new staff. Two staff have been promoted to senior roles. Staff training and systems to record training are good. Annual mandatory training has been rolled out throughout the year. Staff have been trained in Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 21 infection control, fire safety, adult protection, first aid, food hygiene, sexuality awareness, medication, sexuality and relationships, British Sign Language and deaf-blind awareness. Most staff either have NVQ3 or are close to completing this qualification. Staff supervision is good. Staff spoken to had all received supervision monthly from the Registered Manager or Deputy. The Deputy Manager is due to be trained in supervisory skills in August. Staff were positive about the value of supervision: “it’s a good opportunity to speak in-depth to my manager about my performance and how I can improve.” Staff were also positive about the team’s cohesion and way of working together. Staff meeting minutes supported this. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 22 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): 37,39, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home will benefit from the flats now being separately registered, with good devolved responsibilities to managers. The health and safety and welfare of people living in the home is well protected by policies and regular checks. EVIDENCE: Since 12a Hyde Close has been registered separately, management has improved considerably. The Registered Manager explained that it is much easier now to take action on improvements and outstanding issues because her line of authority is clear. During the inspection that she demonstrated how she has been proactive in making improvements and supporting staff through her enabling management style. Staff said that they were enjoyed working in the home and felt well supported by the Registered Manager. I also spoke at length to the Acting Deputy Manager during the inspection, who had a sound Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 23 understanding of the role and was observed to work well with the Registered Manager. The annual quality assurance audit has been completed and distributed. This meets an outstanding requirement. A further external audit found that the quality systems in place were stringent. The home has its own operational plan and own budget, which are clear and meets a requirement from the last inspection. However, requirements are made under Standard Twenty Four to ensure that a refurbishment and maintenance plan is produced. Personal money is held for each flat for the residents’ use. Records were clear and balanced. A recent financial audit was very positive about the protections in place for resident’s personal money. The home has recently updated policies and procedures on communicable diseases and clinical procedures. Health and safety certificates were checked and were up to date. These covered fire, gas, water, lifts, bath chair and hoists, and electrical installations and portable appliances. An environmental health officer last visited in February 2007 and found the home to be safely run. The home has created role with health and safety responsibilities and a staff member is being trained up to do this. Health and safety records and monitoring were found to be good. Fire drills are carried out quarterly, fire equipment regularly inspected and staff regularly trained in fire safety. The emergency call system has been replaced. Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 x 3 x Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 25 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 YA40 Regulation 17(2) Requirement The Registered Persons must ensure that all new policies and procedures are dated and signed. The Registered Persons must ensure that a clear refurbishment plan is produced, including timelines and lines of responsibility. The Registered Persons must ensure that bathrooms upgraded. The Registered Persons must ensure that the kitchen units are replaced. Timescale of 30/09/07 not met. Timescale for action 30/08/07 2 YA24 23 30/09/07 3 4 YA24 YA24 23 23 30/11/07 30/11/07 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 Hyde Close 12A DS0000069196.V336502.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area Office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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