Inspection on 02/07/07 for Martindale Road, 329

This inspection was carried out on 2nd July 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Martindale Road, 329 15/12/06

Martindale Road, 329 30/05/06

Martindale Road, 329 31/01/06

Martindale Road, 329 08/09/05

Martindale Road, 329 15/11/04

Martindale Road, 329 14/07/04

Martindale Road, 329 05/02/04

Martindale Road, 329 05/08/03

Martindale Road, 329 21/07/03

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 Martindale Road, 329 Hounslow Middlesex TW4 7HG Lead Inspector Robert Bond Key Unannounced Inspection 2nd July 2007 10:00 Martindale Road, 329 DS0000022896.V340616.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 Martindale Road, 329 DS0000022896.V340616.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. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martindale Road, 329 Address Hounslow Middlesex TW4 7HG 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) 0208 577 6031 martindaleroad@lot-uk.org.uk www.lifeopportunitiestrust.org.uk Life Opportunities Trust Nicholas Horton Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Physical disability (0) of places Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2006 Brief Description of the Service: 329 Martindale Road, Hounslow is a purpose built seven place care home for adults with learning disabilities. Although a two storey property, the service users are all accommodated on the ground floor. Only the office is upstairs. Communal rooms are of a good size and there is a large and secure garden to the rear. All downstairs areas have level access and are accessible to people in wheelchairs. The locality is a residential area near a bus route to Hounslow town centre. Life Opportunities Trust (LOT), who operate the home, is a not for profit organisation. The current fees charged for a place at the care home are £1,308.60 per week. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a ’key’ inspection that considered mainly those standards that are the key standards within the National Minimum Standards (NMS) for care home for younger adults, as published by the Department of Health. The Inspector sent out questionnaires in advance to relatives and to professionals who visit the home. Six responses were received back. The feedback from visiting professionals was very positive, as was most of the feedback from relatives but two relatives felt they were not sufficiently informed about the progress of their relative residing in the home, or about any changes within the home such as staffing. The Registered Manager of the care home completed in advance of the inspection a detailed Annual Quality Assurance Assessment (AQAA). The Inspector spent over 3 hours at the home during which time he interviewed the Registered Manager, met staff and residents, toured the premises, and examined a range of records. The Inspector assessed the home’s success at meeting 25 anticipated outcomes, and found that 1 was exceeded, 19 were fully met, whereas 5 were only partly met. This led to the Inspector making 6 requirements and 2 recommendations. The home is full and no new resident has moved in recently. All the residents are of white British ethnicity, and equality and diversity issues in terms of disability are appropriately addressed by the management of the home. The home is fully staffed except that the deputy manager post remains vacant. All the requirements except one from the previous CSCI inspection have been met. Standards within the home have continued to improve overall. What the service does well: What has improved since the last inspection? The extent and content of risk assessments has improved in terms of the residents and in terms of the building. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 6 The home’s Protection of Vulnerable Adults policy and procedure has been extended. Some additional refurbishment of the home has been undertaken. Staff training needs have been identified on an individual basis. A quality assurance exercise has been undertaken and the views expressed have been summarised. A start has been made in the introduction of resident friendly documents in picture format. An activity board that uses photographs has been set up. The recording of activities and residents’ appointments has been improved. The home now has two senior support workers. What they could do better: The Service Users’ Guide must be produced in a format that is suitable for the people for whom the home is intended. Once the pictorial format has been introduced, residents should sign their agreement to their care plan where possible in order to demonstrate that consultation has taken place. It is recommended that residents without relatives to look after their interests should have an advocate. It is recommended that newsletters about the home generally should also be produced at regular intervals, for the benefit of relatives and other interested parties. The parking area at the front of the home must be repaired to make it safer for residents and staff. The closing of all fire doors must be checked and adjusted as necessary to ensure the protection of residents and staff from fire. To facilitate the regular checking of the contents of first aid boxes, an approved list of their contents must be kept in each box. Regulation 26 visits by a senior manager in order to inspect the operations of the home, and to supervise the Registered Manager, must take place at least monthly. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 7 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. Martindale Road, 329 DS0000022896.V340616.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 Martindale Road, 329 DS0000022896.V340616.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): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need but it is not in a format that is suitable for them. There are no prospective residents to be assessed at the present time. Existing residents have individual written contracts that contain the required information. EVIDENCE: The Inspector examined the home’s existing Service Users’ Guide and found it to be well produced, informative, and containing the required information. However it was not in a format that prospective residents would be able to understand. The Registered Manager responded that a pictorial version was being considered. The home is fully occupied and no-one has moved in recently. The assessments of existing residents were inspected at the previous CSCI inspection and found to be of a good standard. The Inspector examined the contract of one existing resident and found that it contained the required information in a clearly laid out format. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 10 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. Residents know that their assessed and changing needs and personal goals are reflected well in their individual care plans. Residents are enabled to make decisions about their lives with assistance as needed but further work is necessary concerning the use of advocates. Residents are sufficiently supported to take risks as part of an independent lifestyle. EVIDENCE: The Inspector examined in detail (case-tracked) the care file of one resident chosen at random. The file contained a detailed care plan that was clearly written, and which contained assessment information and goals for all appropriate aspects including culture and religion. The files also contained guidance for staff completing care plans, identified priority needs, action plans, and a photograph of the resident. Care plans are reviewed monthly and the key worker system is in use. A manual handling assessment and relevant risk assessments were also on file. These are also reviewed regularly. Care Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 11 management reviews of all residents have been booked to take place in August 2007. The resident whose care was case-tracked had not signed his/her agreement to the care plan, but records showed that the resident had been involved in drawing up the care plan, and the Registered Manager reported that a signature would be obtained where possible once the intended pictorial care planning system had been introduced, which was imminent. He added that staff members were being trained in an improved person-centred planning system. In terms of decision making, residents are now involved with care planning, residents attend review meetings, and monthly group meetings are held. The Inspector read several sets of minutes that contained evidence of discussions about meals, outings and holidays. The Registered Manager reported that two residents were under the Court of Protection, and a further four residents were going through the process of registration with the Court of Protection. He added that links had been made with a local advocacy group. It is recommended that residents without relatives to look after their interests should have an appointed advocate. The Inspector checked the financial records of all the residents to make sure that their personal monies held by the home were being spent only on extra items that would not be provided by Life Opportunities Trust. The records were well maintained, and the expenditure was appropriate with the possible exception of a birthday cake purchase. The Registered Manager agreed to investigate further as on the face of it the expenditure had been miscoded and should be recharged to the home’s catering budget. In terms of independence and responsible risk taking, the Inspector found that appropriate risk assessments had been undertaken, and were kept on file. The Registered Manager reported that independence was promoted by offering choices, as evidenced by the residents meeting minutes. He added that selffeeding was promoted in the home, as seen by the Inspector, and that residents were encouraged to walk, with the provision of physiotherapy. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to take part in appropriate activities to a satisfactory extent. An adequate number and range of activities take place in the local community. Residents are enabled to maintain family relationships. Residents’ rights and responsibilities are suitably recognised. Residents are provided with a good diet in very pleasant surroundings. EVIDENCE: The Inspector examined the home’s activity programme that now covers evenings and weekends. A pictorial version has been started that displays photographs of residents against picture symbols for activities. This is a good development that can be improved by producing the activity timetable in a larger format. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 13 The activity programme is primarily home based as no residents attend day centres or college. However on the day of the inspection, three residents were taken out to lunch by a member of staff. Other outings specifically mentioned by the Registered Manager were Woburn Zoo, Richmond Park, and Syon House, with trips planned on the canal, and to Brighton. Residents have had a chalet holiday this year within the United Kingdom, and a future foreign holiday is being considered. The home has two vehicles to take residents out in, and the Registered Manager reported no shortage of drivers. The Registered Manager reported that the involvement of relatives in the home is limited. Two relatives returned completed questionnaires to the CSCI, and their comments were generally favourable. However one relative said, “They don’t tell us when new staff have been hired or about what is happening to (resident)”. The other respondent said, “I have asked if we could have more information on (resident’s) progress, and general well being.” The same criticism has been picked up via the home’s own quality assurance surveys and as a result some action has been taken in that informative letters are now being sent to relatives by the home. The Inspector read a copy of a letter that had been sent but the style used was as if the letter was from the resident him/herself. This approach could lead to misunderstandings particularly as feelings were being ascribed to residents without the evidence that they were true. It was therefore agreed with the Registered Manager that future letters to relatives about individual residents would be written by key workers in their own names, and would contain only verifiable facts. It is recommended that newsletters about the home generally should also be produced at regular intervals for the benefit of relatives and other interested parties. The Inspector observed good interactions between staff and residents, and saw both breakfast and lunch being served. The Registered Manager reported that residents are given the opportunity to have a key to their bedrooms, but none had taken this up. The Inspector noted the contents of the home’s menu, which uses a four-week cycle. A record is also kept of what residents actually eat. A dietician is used as an advisor. The dietician wrote in her response to the CSCI that “the home has been excellent at contacting her with nutritional queries and concerns”. The dining area has been recently decorated and is a very pleasant room to eat in. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 14 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good personal support in the way they prefer and require. Residents’ physical and emotional health needs are well met. The home’s medication records are very well maintained. EVIDENCE: The Inspector examined a sample care plan in detail and noted that personal care actions for the support staff were recorded within it. The Inspector also examined the daily record on the same resident and noted that the record was informative and well maintained. The Inspector noted that the care file contained an OK Health Check, a monthly weight chart, and a record of health appointments. The home makes good use of dietician, physiotherapist, speech therapist, optician and dentist services. The Registered Manager reported that staff had been trained in Person Centred Planning, and that the system would be revamped in future, using the Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 15 computer to produce and update the plans. Pictorial Health Action Plans are also going to be introduced, he added. Recent staff training has included incontinence, bereavement and loss, and mental health of older people. One relative who responded to the CSCI said, “The local manager ensures that each person is well looked after.” The physiotherapist who responded said, “Well organised and good team work approach, well led by management and very caring towards residents.” The Inspector examined a sample of the medication storage arrangements, and the medication administration and returned to pharmacist records. All were in good order. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 16 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. Residents can feel that their views are fully listened to and acted upon. Residents are well protected from abuse, neglect and self-harm. EVIDENCE: The Registered Manager reported that no formal complaints had been received by the home during the period since the previous CSCI inspection. No formal complaints have been received by the CSCI either during this period. The Inspector noted that the home’s policy and procedure on the Protection of Vulnerable Adults had been updated to include instructions to staff on how to report any suspected abuse. Some staff members are awaiting updated training on Safeguarding Adults from the London Borough of Hounslow. The Registered Manager reported that twice this training had been cancelled by the trainers at the last minute. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 17 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. Residents live in a very homely and comfortable environment, but it is not sufficiently safe at present. Residents live in a home that is very clean and hygienic. EVIDENCE: The Inspector toured the premises in the company of the Registered Manager. The ‘romper’ room and some bedrooms have been redecorated. Further redecoration is planned. The home was seen to be clean, tidy and hygienic throughout. There were no malodours. Some repairs to the front drive are awaited. As this work will remove a trip hazard, urgent action is necessary to make the area safe for residents and staff. It was noted that a cupboard that had a notice ‘fire door, keep locked’ had the key left in the lock. The Registered Manager locked the door and removed the key. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 18 The door to the ‘romper’ room, which is also a fire door, did not close securely. A check must therefore be made to ensure that all fire doors close securely in order to protect residents and staff from fire and smoke in the event of a fire starting. The home was seen to be well decorated and furnished. Specialist furniture and equipment was provided. Residents now have the use of a computer. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 19 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. Residents are well supported by staff members who have received substantial training. Residents are well protected by the home’s recruitment procedures that are fully implemented. Residents’ individual and joint needs are well met by the specialist training that staff receive. EVIDENCE: The Inspector examined the current staff rota. Sufficient staff were seen to be on duty. The Registered Manager reported that the home has a complete staff team, with the exception of a deputy manager. This post is to be readvertised. The home does now have two senior support workers however. The Registered Manager reported that 5 out of 17 support staff have an NVQ level 2 or 3 in care, two support staff are currently undertaking the award, and a further four members of staff have expressed an interest. At this rate the required 50 of staff being NVQ qualified will eventually be attained. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 20 The Inspector examined the recruitment records for a recently appointed member of staff. All necessary recruitment checks had been undertaken. The Registered Manager reported that the probationary period assessment and reporting system was in the process of being improved. The Inspector examined induction training records for the new member of staff, and training records generally. A substantial amount of training has recently been provided including communication skills, management and leadership, supervision, and report writing. The range and extent of training is commended. Planned future training sessions were reported to include managing diversity, non-violent crisis intervention, Makaton, and dysphasia. Training needs are identified in supervision, and appropriate training sessions are then identified and booked. Martindale Road, 329 DS0000022896.V340616.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 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home. The views of residents, relatives and other stakeholders are ascertained and taken into account. The health, safety and welfare of residents and staff are not sufficiently promoted and protected. The frequency of visits and hence oversight of the home by senior management of the organisation is inadequate. EVIDENCE: The Registered Manager has obtained the Registered Manager’s Award, the NVQ level 4 in care, and the NVQ Assessor’s Award. Under his management standards within the home have improved, and the number of requirements made by the CSCI have fallen. All except one of the requirements from the previous CSCI inspection have been fully met. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 22 The post of Deputy Manager is currently vacant, but is soon to be readvertised. The home has an internal quality assurance system in place. The Inspector read a sample of the questionnaire responses received back. The responses go to the head office of Life Opportunities Trust (LOT), who summarise the findings and advise the local Registered Manager of any action necessary. The Inspector checked the home’s hot water temperature, call bell system, hoist servicing record, and health and safety monthly audit. A previous CSCI requirement that the first aid boxes must contain an approved list of their contents has not been met, and is therefore restated. Two requirements have also been made in the Environment section of this report that have potentially serious health and safety implications. The Inspector has received in the last eight months Regulation 26 reports from LOT dated 30th November 2006 and 31st March 2007 only. He asked the Registered Manager if reports for other months were in his possession and was told they were not. The Registered Manager added that he was receiving monthly supervision from his line manager but that as she had 14 homes to look after, he often travelled to see her as opposed to her visiting the home at least monthly as required by Regulation 26. Some other arrangement is necessary in order to meet the Regulation. Martindale Road, 329 DS0000022896.V340616.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 2 2 3 3 x 4 x 5 3 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 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 x 3 x 3 x x 2 2 Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 24 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 5 Requirement The Service Users’ Guide must be produced in a format that is suitable for the people for whom the home is intended. Once the pictorial format has been introduced, residents should sign their agreement to their care plan where possible in order to demonstrate that consultation has taken place. The parking area must be repaired to make it safer for residents and staff. The closing of all fire doors must be checked and adjusted as necessary to ensure the protection of residents and staff from fire. To facilitate the regular checking of the contents of first aid boxes, an approved list of contents must be kept within the box. This requirement is restated as the original timescale of 01/02/07 has not been met. Regulation 26 visits must take place at least monthly. Timescale for action 01/12/07 2. YA6 15(2) 01/10/07 3. 4. YA24 YA24 13(4)(a) 13(4)(a) 01/08/07 01/08/07 5. YA42 12(1)(a) 01/09/07 6. YA43 26 01/08/07 Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 25 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 2 Refer to Standard YA7 YA15 Good Practice Recommendations Residents without relatives to look after their interests should have an advocate. Newsletters about the home generally should be produced at regular intervals for the benefit of relatives and other interested parties. Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Martindale Road, 329 DS0000022896.V340616.R01.S.doc Version 5.2 Page 27 - 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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