Inspection on 23/10/07 for Jude House

This inspection was carried out on 23rd October 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Jude House 92 Randall avenue Neasden London NW2 7SU Lead Inspector Sarah Middleton Key Unannounced Inspection 23rd October 2007 09:15 DS0000069586.V346778.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 DS0000069586.V346778.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. DS0000069586.V346778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jude House Address 92 Randall avenue Neasden London NW2 7SU 020 8452 0336 020 8830 7258 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) Lucille Rabor Amanda Rabor Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places DS0000069586.V346778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered person may provide the following category 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: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 4 N/A Date of last inspection Brief Description of the Service: Jude House is a four bedroomed home on a quiet residential street close to the North Circular Road and local amenities. It is a registered home for four adults whose primary needs are mental health. It has three floors, with one bedroom on the ground floor, two bedrooms on the first floor and one bedroom on the top floor, this bedroom has its own en-suite facilities, with a toilet and shower. On the first floor there is a bathroom and a small separate shower room. There is parking to the front of the house and a garden and patio area to the rear of the home. The home has a part-time Registered Manager, General Manager, Assistant Manager and a small team of support workers. Registered General and Mental Health Nurses and an Occupational Therapist also work part-time in the home. The Registered Provider owns three other registered care homes in the same area and some staff work between these homes. The fees range from £800- £850 per resident per week. Residents make contributions towards various items such as their personal toiletries and taxis. DS0000069586.V346778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection was from 9.15-5.45pm. The Registered Manager had completed the Annual Quality Assurance Assessment and this assisted with the planning and inspection process. “We” is the term used to describe the Inspector and “residents” refers to the people living in the home. We spoke with three members of staff and three residents. Two relatives and one resident had completed a postal survey. The Registered Manager was present for some of the inspection and other Managers assisted with the inspection process. We would like to thank the staff and residents who spoke with us and contributed to the inspection. As this was the home’s first inspection since registering there were no previous requirements. All of the Key National Minimum Standards were inspected and three requirements were made. What the service does well: What has improved since the last inspection? This is the home’s first main inspection carried out by the CSCI. DS0000069586.V346778.R01.S.doc Version 5.2 Page 6 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. DS0000069586.V346778.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000069586.V346778.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. 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 assessed prior to moving into the home. EVIDENCE: The home opened a few months ago and residents have been moving in over a period of time. The home seeks to obtain as much information from the referrer, such as a care plan and risk assessment prior to meeting and assessing the prospective resident. We looked at the pre-admission assessment used in the home. Two members of staff meet with the prospective resident and begin to assess the prospective resident’s needs. The assessment considers the support the resident will need, their health and social needs and if there are any identified risks. The home recognises it can take time to obtain relevant information as this can be sought from various sources such as the prospective resident, relatives and professionals. Once a new resident has moved into the home an initial care plan is developed. This will inform the staff team on how to support the resident. DS0000069586.V346778.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect residents assessed needs. Residents are supported and encouraged to make decisions about their lives. Residents can take risks and these are identified and recorded onto risk assessments. EVIDENCE: We looked at a sample of care plans. Overall these were comprehensive and provided clear information about the resident. These look at a range of areas such as building relationships with staff and others, the type of support the resident will need regarding their mental health needs, daily living skills and general abilities. Where possible residents are involved in the development of the care plan and all members of staff make contributions to the care plans. DS0000069586.V346778.R01.S.doc Version 5.2 Page 10 The home also provides a summary of the residents needs and this is used to provide a quick overview of the support and needs of each resident. Care plans are monitored on a monthly basis and main reviews take place every six months. Care plans are also updated as and when changes occur. The Occupational Therapist completes reports on the work she has been doing with the residents. We also saw notes that are taken when the Registered Mental Health Nurse meets with the residents. These individual meetings are held once a week and are an opportunity for the resident to discuss any issues. The Nurse also uses this time to assess the residents’ current mental health. Samples of daily records were viewed and these recorded any significant behaviour or activity that took place. Discussions took place regarding recording informative and accurate information about each resident. The home is mindful that staff need to use appropriate language and this is looked at on a regular basis. Staff stated that residents are encouraged to make daily decisions. For some of the residents, who have lived in hospitals for sometime, this could be a big step for them. Staff explained that for one resident having choices and freedom was an exciting and new experience. One resident spoken with confirmed she could make decisions but that the home continuously checked up on her whereabouts. This is due to the resident’s needs and potential risks, however the staff recognise that residents need to be able to have certain levels of freedom. The four residents living in the home do not have advocates. The Registered Manager said that all have some contact with family who could represent the residents’ views should the need arise. The home encourages residents to manage their own finances and provides various levels of support to ensure the resident can safely manage their money. Samples of risk assessments were seen and as with the care plans, these were comprehensive and informative. These are reviewed on a monthly basis. Risk assessments are individual to the resident and cover areas such as risk of falling, substance and alcohol misuse and challenging behaviour. The risk assessments highlight the risk and ways to support the resident to minimise and manage the identified risk. DS0000069586.V346778.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to take part in meaningful activities both in the home and in the community. Residents are supported to maintain contact with relatives and friends. Residents’ rights are respected and recognised in the home. Residents receive a well balanced and culturally appropriate diet. DS0000069586.V346778.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home records the activities the residents have taken part in each day. An Occupational Therapist visits the home on a part-time basis and provides individual and group sessions to all of the residents. Activities could include going shopping or cooking a meal. Those residents asked said they enjoyed seeing the Occupational Therapist. Other places accessed are the shops, luncheon club, the library and flower arranging classes. A new resident is keen to join a gym and possibly enrol at College next year. The home seeks to understand the residents’ interests and abilities and work to support them in keeping them occupied and stimulated. Those residents who can go out independent of staff do so. For some residents, this might be going to the local shops, for others it could be going further away from the home. The home does not have its own form of transport and so residents are encouraged to walk or use public transport. Where residents feel unable to access public transport taxis are used. Photographs were seen of residents attending Jamaica day. Holidays and day trips are being considered for 2008. Residents confirmed they have contact with relatives and/or friends. One resident has a mobile phone and she explained this enables her to keep in contact with relatives whenever she chooses. The residents have access to a public telephone that is located near to the front door. Residents have difficulties in keeping keys and this is recorded in their files. Those residents who are able to have keys to their bedrooms and to the front door of the home have these given to them. Residents confirmed they receive their personal mail. Residents were seen during the inspection either alone in their bedrooms or with other residents. Those residents asked confirmed they could choose when to spend time away from others. Staff were seen to talk with residents and not exclusively amongst themselves. We viewed the kitchen. Fresh produce was seen in the fridge and temperatures are taken of the fridge and freezer on a daily basis. These were within an appropriate range. The flooring needs some attention (see Standard 24 in the report). Samples of menus were seen. These are planned each month and take into consideration residents’ preferences and cultural needs. Due to the diverse background of the staff team, residents are able to receive the meals they prefer or are familiar with. Overall the residents said they liked the food. One resident said she would cook her own meals if she didn’t like the meals on offer. Residents usually make their own breakfast and lunch, with the evening meal usually cooked by staff. One resident is diabetic and his diet is monitored. Residents can choose to eat together or alone. DS0000069586.V346778.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Residents receive personal support in their preferred way. Residents’ health needs are identified and were being met. To safeguard residents, evidence of checks and counts on medication need to be in place. EVIDENCE: Overall the residents living in the home are able to carry out personal care tasks independent of staff. Staff stated there are times they need to prompt and encourage some residents to carry out specific personal care tasks, such as changing their clothes. Residents confirmed they choose what they want to wear and can decide when they get up and go to bed. DS0000069586.V346778.R01.S.doc Version 5.2 Page 14 Health needs were seen to be recorded onto care plans. This outlined supporting residents with various health needs such as managing diabetes and weight management. All residents have a GP and other health professionals, such as Psychiatrist, Psychologist and Chiropodist. Health appointments are documented on separate medical forms so that staff can easily see any treatment or advice given. As stated earlier there are Registered Mental and General Nurses working in the home and the health needs of the residents can be monitored and acted on if there are any concerns. Samples of the medication were looked at. There were no residents selfmedicating at the time of the inspection. The medication was kept in a locked cupboard in the office. There were no controlled drugs in the home. The home returns unwanted or discontinued medication to the Pharmacist thus avoiding an over stock of medication. Staff receive accredited training on handling and administering medication. In addition, staff receive regular updates on medication from the Registered General Nurse. Medication is delivered weekly and is checked by a member of staff. Some medication is in a monitored dosage pack, whilst other medications are in boxes and bottles. One of the Registered General Nurses said she makes regular checks on the medication. This was not evidenced and a requirement was made for this to be evidenced so that any errors can be identified and rectified. The medication in boxes and bottles that was counted was correct at the time of the inspection. DS0000069586.V346778.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of how to complain and feel any issues would be listened to. Systems are in place to safeguard the residents. EVIDENCE: We saw the home’s complaints procedures in the residents’ bedrooms. Those residents asked said they would talk to the Registered Manager if they had any concerns. Overall residents felt staff listened to them and would respond to comments made. The home has not received any complaints since registering. A book was available where complaints and concerns would be recorded. There have been no adult protection referrals or investigations since the home registered. There are some concerns regarding one resident and her finances. We were told this had been investigated prior to the resident moving into the home. Staff explained there was no evidence to confirm that financial abuse was occurring. We discussed with staff the need to take action should there be any evidence that a resident is being abused. Informing Social Services, the CSCI and the Local Authority’s Safeguarding Adults Co-ordinator would need to take place so that appropriate investigation could then take place. Those staff asked said they would report any concerns immediately to the Registered Manager. All staff receive training on adult abuse and the next training course has been planned in January 2008. DS0000069586.V346778.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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. To ensure the home is homely and appealing the shortfalls need to be addressed. The home was clean and free from unpleasant odours. EVIDENCE: We carried out a tour of the home. The home has a person who carries out maintenance work on the home. Overall the home was well maintained, however some shortfalls were identified. • The first floor bathroom there were marks on the floor and several floor tiles were cracked. • There was tile missing around a pipe under the bathroom sink. • The first floor shower room flooring had a cracked tile. • The kitchen flooring was marked and cracks were seen. DS0000069586.V346778.R01.S.doc Version 5.2 Page 17 A requirement was made for the environmental shortfalls to be addressed. Staff and residents maintain the cleanliness of the home, with residents cleaning their own bedrooms. Staff assist those residents who need support and encouragement to maintain a safe and clean standard in their rooms. The laundry room is located on the top floor and residents are supported to carry out this task. The home was clean and free from odour at the time of the inspection. DS0000069586.V346778.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team support the residents. Robust recruitment procedures safeguard the residents. To ensure residents are supported by appropriately trained staff, the training programme needs to be available to all staff. EVIDENCE: We were informed that all staff working in the home have an NVQ level 2 and/or level 3. As noted earlier the staff have a variety of experiences, such as qualified nurses and support workers who have experience in working in care. Those staff asked said the staff team work well together and in the interests of the residents. The staff spoke in detail regarding the needs of the residents and were committed to offering a quality service. Furthermore staff were aware of the individual mental health needs of the residents. DS0000069586.V346778.R01.S.doc Version 5.2 Page 19 The rota was viewed. This was confusing; as it did not clearly reflect the hours the Registered Mental Health Nurse works in the home. Some staff work across the four registered care homes, owned by the same Registered Provider and we were informed that some hours are covered on a day- by- day basis, depending on the needs of the home and any appointments on that specific day. We discussed the need to accurately reflect who is working in the home. However we were satisfied that there were sufficient numbers of staff working in the home, as there is always a core group of staff working on the rota. Additional staff then work the extra hours needed. At times there are at least two members of staff working on each shift, with only a few hours early evening where there is one member of staff. There is always a Manager on call and the Registered Manager lives very near to the home. The Registered Manager and other Managers acknowledged that there needed to be clearer evidence as to who worked in the home. The home has a small number of bank staff who work covering the vacant hours. The home has not used external agency members of staff. The home has a Registered Manager, General Manager, Assistant Manager and an administrator, who work to ensure the home runs smoothly and effectively. The General Manager and Assistant Manager, who were spoken with, were aware of their roles and responsibilities. Staff said that team meetings are held on a regular basis and a meeting was due to be held on the day of the inspection. Three staff employment files were viewed. These contained all the necessary documentation, such as application form, Criminal Record Bureau Checks, health declarations and two references. The completed Annual Quality Assurance Assessment stated that at the 2nd stage staff interviews, residents are involved in meeting the potential staff member and this also enables existing staff to observe the person interacting with residents. Those staff asked confirmed they had received an induction to the home. We viewed the induction, and saw that this is broken down and considers areas such as health and safety and getting to know the residents. All new staff shadow existing staff in order to see how the home runs and how staff interact with residents. The individual training files viewed showed that the Registered Mental Health Nurse had not attended the mandatory training, but had attended protection of vulnerable adults in 2006 and leadership and management in 2007. The Registered General Nurse said she attended and observed the training but had not actually taken part and received certificates. This was discussed with the Registered Manager and other Managers and a requirement was made for this shortfall to be addressed. Other files viewed showed that overall staff receive training within the required timescales. The home currently does not have an overall staff training plan showing the training booked and planned for the staff working in the home. This was discussed and will be considered and developed for future inspections. This could be beneficial as at a glance it could be assessed the members of staff who are up to date with the required training and who needs to attend training courses. DS0000069586.V346778.R01.S.doc Version 5.2 Page 20 The Mental Capacity Act 2005 was discussed. The General Manager was aware of this legislation and it was stressed that all staff need to have access to information on this subject and training where it is deemed appropriate. The home should be considering how this legislation might be used in the home and how the home will evidence when it has been used. DS0000069586.V346778.R01.S.doc Version 5.2 Page 21 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. Systems are in place to monitor the care in the home and to obtain the views of residents. Regular maintenance checks safeguard the residents. EVIDENCE: The Registered Manager works seventeen hours in the home and manages another care home on the same road. She has an NVQ level 4 and is currently studying for a degree in Psychology. A General Manager and Assistant Manager also work in the home, to ensure the home is well managed at all times. DS0000069586.V346778.R01.S.doc Version 5.2 Page 22 Those staff asked said they felt able to approach and talk with the Registered Manager. The home had surveys that are sent out to residents and relatives. These ask for comments on the home and staff. Surveys are also completed when visitors come to see the residents. They are asked about the care the resident receives. We had not received any monthly Regulation 26 reports and this was requested for future inspections. These reports are important as they are carried out by someone who is not working in the home and can be another way of examining the care provided in the home and can highlight any shortfalls. Discussions took place with regards to devising an overall quality assurance summary or short report that is made available to residents and for inspection. This should provide an overall view of the progress of the home, where work has been made to improve the home and areas still to be addressed. It is important for the home to reflect on its practice and to consider future aims and objectives, which could be highlighted in the report. Samples of maintenance records were viewed. The Gas Safety record, Portable Appliance test and fire equipment had all been serviced and were up to date. The home had held weekly fire drills, although had not recorded the names of the staff and residents who had attended. This will be addressed and checked at the next inspection. The fire risk assessment was viewed. This outlined the main fire risks. A fire officer had visited the home and had been satisfied with their inspection of the home. The water temperature is controlled by thermostatic values, however it was advised that as this can fail, water temperatures should be taken in all areas of the home where residents have access. Furthermore discussions took place with regards to the radiators, as currently these are not covered. If the needs of the residents become frail or residents needs change, the home would then need to ensure the radiators are covered. DS0000069586.V346778.R01.S.doc Version 5.2 Page 23 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 3 34 3 35 2 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 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x DS0000069586.V346778.R01.S.doc Version 5.2 Page 24 N/A 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 YA20 Regulation 13(2) Requirement Timescale for action 26/10/07 2. YA24 3. YA35 To ensure residents are safeguarded evidence that regular checks and counts regarding the medication in the home must be available. 23(2)(b)(d) To ensure residents live in a 31/01/08 hygienic and welcoming home attention must be paid to the environment, such as flooring in the bathroom, shower room and kitchen. 18(c)(i) To ensure residents are 31/03/08 supported by a competent and qualified staff team, the training programme must be available to all members of staff. 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 DS0000069586.V346778.R01.S.doc Version 5.2 Page 25 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 DS0000069586.V346778.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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