Inspection on 09/06/05 for Mallow Crescent (25-30)

This inspection was carried out on 9th June 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mallow Crescent (25-30) 04/05/07

Mallow Crescent (25-30) 19/10/05

Mallow Crescent (25-30) 15/12/04

Mallow Crescent (25-30) 05/07/04

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

CARE HOME ADULTS 18-65 Mallow Crescent (25-30) 25-30 Mallow Crescent Guildford Surrey GU4 7BU Lead Inspector Vera Bulbeck Unannounced 09 June 2005 10:00 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. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mallow Crescent (25-30) Address 25-30 Mallow Crescent Guildford Surrey GU4 7BU 01483 455879 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) South West Surrey Adults & Community Care Services, Grosvenor House, London Square, Cross Lanes, Guildford, Surrey, GU1 1FA Rosemary Ellen Broomer Care Home (CRH) 35 Category(ies) of Learning disability (LD), 35 registration, with number Physical disability (PD), 1 of places Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Accommodation and services may be provided to named persons aged 65 years and over with prior written agreement of the CSCI. 2 Respite care may be provided to a maximum of 6 persons at any one time, these persons should be grouped into the same unit, House 28 3 To accommodate one service user with a Physical Disability. Date of last inspection 15 December 2004 Brief Description of the Service: 25-30 Mallow Crescent consists of six purpose built houses situated in Burpham. The houses are set at the end of a crescent in a quiet residential area, which is well kept. Each house has a front garden and a medium sized garden at the rear of the house. There is adequate car parking for several cars at the front or side of each house. Five of the houses are for long-term placements, with the sixth house offering respite care for five places. Each house has a large and airy lounge/dining room, appropriately furnished, with access to the rear garden. An open plan kitchen is adjacent to the dining room. All the bedrooms are single occupancy and are nicely decorated and meet the needs of the service users. The home is registered to accommodate thirty-five people with a learning disability. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Vera Bulbeck, and Mrs Sandra Holland Regulation Inspectors for the Commission undertook the unannounced inspection on The 9th June 2005, for Social Care Inspection. The purpose of the inspection was to obtain a full understanding of the extent to which the home meets the 43 standards of The National Minimum Standards for Younger Adults; it will be necessary to review both inspection reports for 2005-06. The aim of the unannounced inspection was to provide an opportunity to meet and speak with residents and staff and to follow up the requirements and recommendations made as a result of the last inspection. It was disappointing to note that a number of requirements have been carried forward since the previous inspection. It is highly recommended these requirements be attended to immediately. Residents with whom the inspectors spoke were complimentary about life at Mallow Crescent. The homes were clean and tidy, tastefully furnished and in good decorative order. Staff was seen to be interacting with the residents in a manner that respected privacy and dignity. As identified at the previous inspection in December 2004, further development of the service is required before it fully meets the requirements of the Care Home Regulations 2001. Details are noted in the main body of the report. It is important that the registered manager continues to monitor the performance of the individual homes. A number of recommendations were also made. The staff were observed to be courteous and approachable and the atmosphere within the homes was relaxed and friendly. The inspectors wish to thank the residents and staff for their cooperation and hospitality during the inspection. What the service does well: It was pleasing to note the home has introduced a complaints system enabling residents to voice their concerns and to make a complaint, some with the help of staff if required. The complaints form has been produced in a symbols style to enable residents to complete the form. This method has proved to be working well. The inspector has received copies of the complaints via the registered manager and it was noted the response to residents by the manager is in symbol form. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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 Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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, 3 and 5 Comprehensive assessments of prospective residents are carried out to ensure the home can meet their needs and introductory visits are considered essential. EVIDENCE: Team leaders advised that the manager or assistant team leaders, in conjunction with care management, carry out, assessments of prospective residents. Some residents have complex needs, including communication difficulties and these are all assessed prior to moving into the home to ensure that specific needs can be met. It was stated that many of the residents have lived at the home since opening and very few permanent vacancies occur, although one house is specifically arranged for respite care. A team leader advised that any prospective resident would be very gradually introduced to the home, over a series of visits. This would ensure that existing residents have the opportunity to get used to a new housemate, and enable staff to assess the prospective residents needs. Contracts between the home and residents are in place for most, but not all, residents. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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, 8 and 9. An individual plan is in place for each service user. Service users are actively involved in the running of the home. EVIDENCE: It was evident that each resident’s plan had been drawn up with reference to the pre-admission assessment and with the involvement of the resident and their representative. Where able, residents have signed the plan to show their participation. Changing needs and goals and monthly reviews of the plan, are noted and care management reviews are recorded. Residents are involved in the day-to-day running of the home. Residents commented they assist with household shopping, with menu-planning, cooking and household tasks. Residents were observed to be supported when cooking the evening meal, making refreshments for visitors and helping staff to write a shopping list. Residents meetings are held and an agenda was displayed on a notice board. The manager advised that a staff recruitment day had been held recently and that residents had been actively involved. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 10 Wherever possible, risks to the health and welfare of residents are identified and assessed. Risk assessments were seen in individual plans, including the risks to residents having seizures, cooking activities, vulnerability, horse riding and self administration of medication when out at activities. Some of the risk assessments need to be reviewed or updated. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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) 11, 12, 13, 14, 15, 16 and17. Residents appear to lead happy and fulfilling lives and are supported to develop their life skills. Some residents have successfully moved from the home to live independently in a house nearby. EVIDENCE: It was pleasing to observe residents living contentedly with their housemates and being suitably supported by staff. Residents were seen going off to and arriving back from their various daily activities, including work, classes at a local adult education centre and a day centre. A small number of residents work locally and are able to walk to work independently. Another resident is a member of staff on a grounds maintenance team and was working in the home’s grounds on the day of the inspection. A resident who no longer wishes to attend regular, outside activities, was able to remain at home and was spending her time with craft activities. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 12 Many residents have contact with their family and friends and some residents have short stays with them. This was confirmed by their individual plans and by residents. Residents are supported to maintain friendships and are protected from inappropriate relationships. Two residents formed a relationship, which became potentially dangerous to one of them; measures have been put in place to provide protection, whilst still enabling them to meet. Holidays are arranged for individual residents or very small groups, and photographs were seen of previous trips. Two residents had been shopping on the day of inspection, to buy new clothes for their holiday. The evening meal was seen being prepared in two of the houses and residents were being supported to cook the meal, lay the table and clear up afterwards. The meal is taken as a family group with staff joining in and is served at family sized dining tables, attractively set. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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 and 20. Personal support is provided appropriately and resident’s healthcare needs are well met. EVIDENCE: It was evident from observation, that residents are supported with their personal care in a manner that promotes their choice, privacy and dignity. Individual wishes regarding the gender of staff giving personal support is recorded in individual plans. A key-worker system is in place to ensure continuity and consistency of support and most residents were able to name their key-worker. Healthcare needs are met by a number of healthcare professionals, including general practitioners (G.P.’s), district nurses, community psychiatric nurses (CPN’s), speech and language therapists and psychologists. Contact with these professionals is recorded in individual plans. The majority of residents require support with their medication administration, although one resident takes his own medication when he goes out to an evening social event. A risk assessment has been carried out to minimise any risks to him or others. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 14 A small number of shortfalls in medication administration were noted: • The receipt of all medications into the home had not been recorded • Hand written transcription of medication onto the medication administration record (MAR) sheet had not been signed, countersigned and was incomplete • Social leave medication issued to a resident, had not been signed for by two staff, as required by the risk assessment. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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 and 23. All required policies and procedures are in place to ensure that residents feel their views will be listened to. Policies are in place to protect residents from abuse and neglect. Staff training and recruitment procedures are up to date and well-documented, ensuring residents are safe from any possible risk of harm and abuse. EVIDENCE: The recording of complaints and action taken was found to be well documented and actioned appropriately. The complaints system was designed for the residents to voice their concerns or worries and in a format that is in symbol form to enable residents to complete themselves or to seek the help and support of a member of staff. Residents confirmed they are able to speak freely with staff and would know how, or speak with their key worker to make a complaint if necessary. It is pleasing to note that resident’s complaints are taken seriously in Mallow Crescent. The inspector has received a number of resident’s complaints with the action taken by management of the home. All complaints have been dealt with appropriately. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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, 27 and 30. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet resident’s individual and collective needs in a comfortable and homely way. EVIDENCE: The home is homely and residents confirmed they enjoy living in the home. One resident has recently purchased new bedroom furniture and is very proud of her bedroom. Another resident also stated she is happy in the home but it is very noisy, with doors slamming and in the resident’s bedroom above, music is played very loudly. In one of the toilets/shower room, a wash hand basin hot water supply was found to be very hot. This was made an immediate requirement. Another bathroom on the ground floor was found without a lock. The premises were found to be clean and hygienic. The laundry areas were domestic in style and a number of residents are able to do their own laundry, some with assistance from staff. However in one of the laundries, in an unlocked cupboard, a tin of paint was found with some firelighters. This was made an immediate requirement. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 17 Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 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, 34 and 36. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual resident’s at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: A number of staff has been on recent training courses. Two care assistants are in the process of completing NVQ Level 2 and some have completed NVQ Level 2 and 3. It was noticed that staff respect residents and are good listeners and communicators. They have the skills to meet residents individual needs and dealing with anticipated behaviours. Recruitment procedures were checked and management were found to be operating a through recruitment procedure. References, criminal records bureau (CRB) checks are undertaken on all staff before employment commences. There has recently been a recruitment programme for a number of new staff, which is in process at the present time. Residents have been actively involved the recruitment process. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 19 Staff stated they receive regular supervision. Evidence of the format used and the records seen, confirmed that supervision takes place on a regular basis. Staff are appraised annually. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 41,42 and 43. The resident’s benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. Action must be taken to ensure the health, safety and welfare of residents is covered at all times. EVIDENCE: A number of records were seen to be well documented. However, a number of records need to be reviewed and streamlined. Particularly building checks, where staff should be responsible for ensuring the home is meeting all the standards. Staff should also be aware of how often a fire drill needs to be undertaken. A risk assessment needs to be undertaken on the whole house, and an emergency plan needs to be in place. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 21 The accident book currently records any accident in the home but the inspector was unable to trail the record of which resident has had an accident in the house. The registered manager keeps a copy of the form in her office. Under the Data Protection Act copies should be kept on the residents file. An up to date building insurance certificate was not displayed in all the houses. This must be in place. And the check for Legionella was out of date being 15/03/04. In house 30, paint and firelighters were found in an unlocked kitchen cupboard, and bleach and cleaning spray-containing bleach was found under the kitchen sink unlocked. Cereals must be stored in a plastic container with a lid. In house 28, Oven cleaner was found under the kitchen sink unlocked and a lid needs replacing on a bin in the laundry. The upstairs toilet extractor fan was not working and the inspector was informed it has been out of order for some time. The toilet is an internal room, without a window. In house 29, a ground floor bathroom was without a lock on the door. Houses 29 and 30 have cupboards under the stairs which require shelves, as both cupboards are full of a variety of items including food storage and some of the items at the back need to be sorted out. At present one can hardly open the door for hoovers and everything piled high on the floor. All communal bathrooms and toilets require paper hand towels. The conference room visitors should not be using the resident’s facilities, the toilet for example. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mallow Crescent (25-30) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 1 2 H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 23 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 YA1 Regulation 4 Requirement That the registered person must compile in relation to the care home a written statement (the statement of purpose) which shall consist of the aims and objectives; a statement as to the facilities and services; a statement as to the matters listed in Schedule 1; this statement of purpose to be specific for each house (timescale 28/02/05 not met). That the registered person shall so far as practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. Specifically the registered person must ensure that all service users not yet assessed to hold their own door keys must now be assessed and the outcome of that assessment must be recorded in their care plans. (timescale 28/02/05 not met). That the registered person must make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home; that H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Timescale for action 16/09/05 2. YA16 12 15/07/05 3. YA30 13 17/06/05 Mallow Crescent (25-30) Version 1.30 Page 24 4. YA42 16 17(2) Schedule 4 5. YA42 13 & 23 6. YA43 25 s/he must ensure that unnecessary risks to the health and safety of service users are identified and as far as reasonably practical eliminated; that specifically the missing lid to rubbish bin must be replaced and dried food, including cereals, must be stored in sealed containers (timescale 15/01/05 not met). That the registered person must 17/06/05 ensure that food is properly prepared as evidenced by the availability of records demonstrating that cooked meat has been probed to determine it has reached a safe temperature. (timescale 15/01/05 not met). That the registered person must 09/06/05 ensure that all parts of the home to which service users have access are so far as reasonably practical free from hazards to their safety and that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated; specifically materials that are hazardous to health should be stored in a locked cupboard at all times. (timescale 15/12/04 not met); The temperature of the hot water supply must be controlled to ensure the safety of service users; Assessments of identified risks must be maintained, be reviewed and kept up to date. That the registered person shall, 17/06/05 as requested, provide to the Commission for Social Care Inspection (Surrey office) a copy of the current certificate of insurance for the registered person in respect of liability which may be incurred by him in relation to the care home in Version 1.30 Page 25 Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc 7. YA5 17 (2) Schedule 4 8. YA9 13 9. 10. YA27 YA41 23 17 11. YA42 23 12. 13. 14. YA42 YA42 YA42 17 23 13 respect of death, injury, public liability, damage or other loss; this is required for the purposes of considering the financial viability of the home. (timescale 31/01/05 not met). The registered person must maintain in the care home the records specified in Schedule 4. Specifically, a record of the care homes charges to service users (contract) must be maintained, be kept up to date and be available for inspection in the home. Arrngements for the safe administration of medication must be made. Specifically, all medication received into the home must be recorded, hand written transcriptions of medication directions must be signed, countersigned and completed fully and medication issued to service users for periods of social leave, must be checked and signed for by two members of staff. A two way lock to be fitted to the bathroom currently without a lock. A number of records need to be reviewed and updated particuarly records relating to checks on each house. A fire risk assessment must to be undertaken on each house including every room and an emergency plan needs to be implemented. An up to date insurance certificate must to be displayed in all houses. The water must be tested for Legionella in all houses. Hazardous substances must be kept in a locked cupboard at all times. 8/7/05 24/6/05 30/06/05 22/07/05 22/07/05 22/07/05 22/07/05 09/06/05 Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 26 15. 16. 17. 18. YA42 YA42 YA42 YA42 16 13 23 13 All dried foods including cerals must be stored in a sealed plastic container. A bin needs replacing in the laundry of house 28. The extractor fan in a toilet without a window needs urgent attention. shelving required under the stairs of houses 29 & 30 the current practice is a health and safety hazard. 16/06/05 22/07/05 16/06/05 22/07/05 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 YA30 Good Practice Recommendations It is good practice and recommended by the Health & Safety Executive that paper hand towels are provided in all communal toilets and bathrooms. Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mallow Crescent (25-30) H58-H09 S34879 Mallow Crescent V222967 090605 Stage 4.doc Version 1.30 Page 28 - 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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