CARE HOME ADULTS 18-65
Mencap (Chasewood Avenue) 3 Chasewood Avenue Enfield Middlesex EN2 8PT Lead Inspector
Tony Brennan Key Unannounced Inspection 22nd February 2007 11:00 Mencap (Chasewood Avenue) DS0000010572.V322994.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 Mencap (Chasewood Avenue) DS0000010572.V322994.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. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mencap (Chasewood Avenue) Address 3 Chasewood Avenue Enfield Middlesex EN2 8PT 020 8342 1568 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) www.mencap.org.uk Royal Mencap Society Paula Jean Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1 specific service user who is over 65 years of age may continue to be accommodated in the home. This condition must be reviewed at such times as the specific service user vacates the home. 8th December 2005 Date of last inspection Brief Description of the Service: The home is a large detached house in a quiet road near Enfield. The home has three floors. On the ground floor there is the kitchen, lounge and laundry. There is also one large en-suite bedroom for a service user who uses a wheelchair. On the first floor there are five bedrooms and two accessible shower rooms. On the top floor there is a further bedroom, which is currently unoccupied and the staff office. The home is very comfortable and there has been a great deal of effort made to ensure the bedrooms are comfortable and reflect the tastes and preferences of the service users. There is a large, attractive garden to the rear of the house, which has seating and is used by the service users. The aims of the home are to affirm and enhance the dignity and self-respect of the service users and to pay due regard to their wishes and preferences. The service also aims to support the service users to share in and contribute to the community, and to lead an ordinary life with the assistance they require. The home is for six service users. Most of the service users attend day services in line with their individual needs. The home uses local transport to access community activities. The home has established links with local professionals so that the service users specialist needs can be responded to. The fees range from £600 to £650. Copies of this report are available from the Commission Website. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection programme. The inspector also sought to confirm that the quality of the service is being maintained. There were five areas for improvement identified at the last inspection. The inspection took place over one day. Steven Challis, the deputy manager, assisted the inspector with the inspection. The inspector spoke with the three people who live at the home, and two members of staff. The inspector observed care practice and interaction between the service users and staff. The inspector toured the building and examined a number of records relating to the care, health and safety and management of the home. The inspector would like to thank the deputy manager and staff who assisted him by answering questions about the running of the home. The inspector would also like to thank the people who live at the home who discussed their views of the service they receive. What the service does well:
The inspector case tracked people living at the home and found that there were assessments from the home and care management of their needs prior to coming to live at the home. These were used as the basis on which detailed care plans were based. Personal preferences were integrated into the assessment and care plan to ensure these were met. The inspector found that care plans had been developed with the involvement of people living at the home. The deputy manager explained that these detailed care plans were to be used as the basis for person centred planning. Care plans on positively supporting people living at the home had been further developed. These provided a specific programme and guidance for the individuals and how to handle their behaviour. Risk assessments were found to cover all areas that affected people living at the home in their daily life. Risk assessments were cross-referenced with care plans. This ensured people living at the home are supported in ways that maximised their independence and choice. The inspector observed that people living at the home did their washing. They were supported to use the washing machine. Other service users were supported to wash up and tidy the kitchen. The preferences of people living at the home to be involved in domestic tasks were recorded. People living at the home were supported to choose what they wanted to eat. The menu is prepared weekly at the service user meeting. The menu is prepared in a pictorial format. This assists people living at the home to know what meals are available each day. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 6 Staff spoken to understood the support that people living at the home needed with their personal care. Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. Medication had been reviewed regularly to ensure the continued well being of people living at the home. Daily notes showed that health professionals had been consulted to ensure that people living at the home were receiving the medicines they required. Medication profiles were in place and had been updated to reflect any changes in medication. Both the complaints and adult protection policies were available to service users in pictorial formats to assist them to raise concerns. Advocates confirmed that they supported people living at the home to raise issues when necessary. The inspector found that the rota showed that a consistent staffing level was maintained. The rota showed that extra staff were rotared to provide cover for social events and other activities. All staff are supported to do some form of training that meets their professional and personal development needs. Staff and people living at the home spoken to confirmed that they felt that the registered and deputy managers were supportive and approachable. There are also weekly meetings when people living at the home can discuss the quality of the service they receive. People living at the home also have access to advocates supporting them to share their views of the care they receive. The home provides a safe environment for people who live there. What has improved since the last inspection?
Five areas for improvement were identified at the last inspection and all had been met. There are now detailed care plans that give guidance that ensures the needs of people living at the home are met. Since the last inspection the carpet on the fist floor had been replaced. The inspector also found that the communal areas of the home had been redecorated. The kitchen has been redesigned and redecorated. People living at the home had chosen the colour scheme and work tops for the kitchen. The kitchen is more accessible for people living at the home. This has made the home bright and more pleasant for service users. Since the last inspection there has been a recruitment drive. Three new staff have been recruited. Staff spoken to felt that this had made a significant difference to the support and range of activities available. Since the last inspection a number of policies that people who live at the home need regular access to have been produced in pictorial formats. The deputy manager explained that some of the people living at the home would find an audio format of policies easier to access. He is currently developing this so that policies are available in a number of formats that people at the home can access. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mencap (Chasewood Avenue) DS0000010572.V322994.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 Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ needs are assessed prior to admission to the home to ensure they receive the care and support required. EVIDENCE: The inspector case tracked service users and found that there were assessments from the home and care management of their needs prior to coming to live at the home. These identified the needs of service users prior to admission to the home. These were used as the basis on which detailed care plans were based. Service users’ personal preferences were integrated into the assessment and care plans to meet their needs. Staff spoken to understood the needs of service users and could explain the specific needs of service users case tracked. The inspector observed staff interaction with those who use the service and found this demonstrated that staff understood their needs. When service users returned from their day centres the inspector observed that they were greeted and offered a drink. The needs of the service users case tracked had been reviewed. Appropriate professional support had been obtained to ensure the needs of service users could be met. There were assessments detailing behavioural needs relating to
Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 10 service users learning disabilities. Where necessary multi disciplinary reviews had been held to ensure that appropriate professional support for service users was obtained. One service user case tracked who recently had two epileptic seizures had been reviewed by medical professionals. Changes to her care had been made. The care plan and risk assessment had been reviewed and updated to provide detailed information on her support needs with regard to epilepsy. Another service user had requested an extra day at the Day Centre. Staff at the home had discussed this with the social worker and the Day Centre to ensure that the service user’s request was met. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans do provide detailed information on the needs of service users. Service users are supported to make decisions about their lives. Risks to service users are assessed to ensure their safety. EVIDENCE: The inspector case tracked three service users who live at the home. The inspector found that care plans had been developed with the involvement of service users. The deputy manager explained that these detailed care plans were to be used as the basis for personal plans of the needs of service users. Care plans had been reviewed and contained detailed information on the needs of service users. Care plans provided clear information on how to support service users in ways that reflected their personal preferences. Where service users preference was for same gender care this was recorded. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 12 Care plans on positively supporting service users behaviour had been further developed. These provided a specific programme and guidance for the individual service users and how to handle their behaviour. There was also guidance on when it was appropriate to administer ‘when required’ medications. Service users spoken to confirm they had been involved in reviewing their care plans. One of the service users case tracked had behaviour that challenges due to his being verbally abusive towards staff and service users. The inspector found that his care plan provided detailed guidance on how this behaviour should be managed. This guidance was based on professional advice on how this behaviour should be addressed. The deputy manager explained that this review had resulted in a change of approach. This was proving to be more effective in meeting the needs of the service user. The inspector observed and spoke with staff. They knew how to support service users with their behaviour. This was in line with guidance provided in care plans. Risk assessments were found to cover all areas that affected the service user’s daily life. Risk assessments identified the specific risk facing individual service users. Risk assessments were cross-referenced with care plans. This ensured service users are supported in ways that maximised their independence and choice. Staff were able to describe how they prevented risks to ensure that service users were safe and were supported to exercise control over how they live. Risks relating to behavioural issues were identified and actions to prevent or lessen the level of risk were discussed. The risk assessments had been agreed with service users or their advocates. Risk assessments had been reviewed to ensure changes to the level of risk were addressed. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are supported to engage in a range of activities that meet their needs. Service users have community contacts and are supported to maintain personal relationships. Service users are supported to maintain a nutritious diet that reflects their personal choice. EVIDENCE: The deputy manager explained that since the last inspection, more activities were taking place. This was due to more staff being available. The inspector found that service user records showed that all service users are involved in activities both in the home and in the wider community. The inspector observed one of the service users case tracked and found that she asked staff to go on a shopping trip. The member of staff agreed to accompany her and the service user was able to go out. A number of service users attend day centres. Service users said that they could choose from a range of activities.
Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 14 The deputy manager explained that service users had all been on holiday. A service user spoken to by the inspector said that the holiday had been “good”. The inspector observed that service users were supported to put their washing in the washing machine. Other service users were supported to wash up and tidy the kitchen. Care plans recorded service users preferences to be involved in domestic tasks. The deputy manager explained that service users involvement in domestic tasks was recorded so that they could be supported to learn new daily living skills. Care plans and risk assessments outlined the support service users needed to maintain personal relationships. Daily notes recorded that staff had supported service users on visits to families and friends. The registered person explained that the menu is prepared weekly at the service user meeting. The inspector saw minutes of these meetings and service users’ suggestions for meals were recorded. The menu had been prepared in a pictorial format. This will assist service users to know what meals are available each day. The inspector observed service users prepare a meal. Staff assisted by ensuring that service users followed appropriate hygiene and safety measures. Service users were supported to choose what they wanted to eat. The inspector observed that there were fresh vegetables and fruit available. The inspector saw that meals were well presented and were provided in a relaxed and supportive environment Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are supported with their personal care needs to ensure that they maintain their independence. Service users are able to access the medical care they need. Service users are protected by safe procedures for handling medication. EVIDENCE: Care plans outlined the support service users require and how they could be supported to maintain their independence in doing their personal care. Staff spoken to understood the support that service users needed with their personal care. This included information on same gender care where this was appropriate. Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. Staff at the home had supported them to attend appointments. The support needed was recorded in the service users care plan. Daily records showed that one of the service users had access to professional support with hearing and sight. Another service user had been given support by a dietician to maintain a fat free diet for health
Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 16 reasons. This had been recorded as part of the service user’s care plan. The service user’s agreement to this had been recorded. The medication policy contained all the required information. The inspector found that records for the administration of medication were complete. Records of medication received and returned were also complete. All medication was held securely. Service users medication had been reviewed regularly to ensure their continued well being. Daily notes showed that health professionals had been consulted to ensure that service users were receiving the medicines they required. Medication profiles were in place and had been updated to reflect any changes in service users’ medication. Where medication had been reviewed the relevant professional had signed to show they made the changes. The inspector checked the medication for the service users case tracked and found that this corresponded with the medication administration record. Training records and discussions with staff confirmed that they had received training on the safe administration of medicines. This included training on the administration of rectal diazepam. Records showed that this training is repeated yearly to ensure all staff follow practices. Detailed guidance on when this medication should be administered to service users was recorded in their care plans. This provided guidance for each individual. The inspector observed staff administering medication and found that this was done safely. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users can be confident that their complaints are listened to and acted upon. Adult protection procedures protect service users from abuse. EVIDENCE: The complaints policy explained how to make a complaint and how it would be dealt with. Service users told the inspector that they understood how to make a complaint. The complaints record showed that there had been no complaints. There were comprehensive policies on handling abuse and adult protection. Training records showed that staff had received training in adult protection. The inspector spoke with staff and they demonstrated their understanding of adult protection issues. Both the complaints and adult protection policies were available to service users in pictorial formats to assist them to raise concerns. Advocates confirmed that they supported service users to raise issues when necessary. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users live in a safe and comfortable environment that is adapted to meet their needs. The home is a clean and hygienic environment for service users to live in. EVIDENCE: The inspector toured the home and found that it was in a good state of repair. Service users’ bedrooms were decorated and furnished in a manner that reflected their personal preferences. There were areas for service users to sit and relax. The inspector found that since the last inspection the carpet on the first floor had been replaced. The inspector also found that the communal areas of the home had been redecorated. This has made the home bright and more pleasant for service users. The inspector observed that service users were able to access the kitchen and other facilities without restrictions. In consultation with service users the kitchen has been redesigned and redecorated. The inspector found that the home was clean and hygienic. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 19 Equipment was provided for this purpose. The home has an infection control policy. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Sufficient staff are always available to meet the needs of service users. Staff do have all the skills to support service users. Service users are protected by the home’s recruitment procedures. EVIDENCE: The inspector found that the rota showed that a consistent staffing level was maintained. Since the last inspection there has been a recruitment drive. Three new staff have been recruited. Staff spoken to felt that this had made a significant difference to the support and range of activities available. The rota showed that extra staff were rotared to provide cover for social events and other activities. The deputy manager explained that the home also has access to a regular bank of workers so that the home’s own staff are able to concentrate on providing more individualised care and support to service users. Service users daily notes showed an increasing variety of activities. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 21 All staff are supported to do some form of training that meets their professional and personal development needs. Training records confirmed that all staff were up to date with, and had all the statutory required training. Training records showed that 50 of staff have either level 2 or 3 in the National Vocational qualification in care. The inspector examined staff files and found that all the required information was available relating to the recruitment and appointment of staff. Staff had gone through an interview process and there were notes to confirm this. Applicants had been invited to the home to meet with service users. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 40 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The registered manager has the skills and understanding to manage the service in the best interests of service users. Service users views of the service are sought and used as the basis for improvement. Service users and staff health and safety is always promoted and safeguarded. EVIDENCE: Staff and service users spoken to confirmed that they felt that the registered and deputy managers were supportive and approachable. Training records showed that the registered manager has the skills and experience to manage the home to meet the needs of service users. The records showed that staff receive regular supervision from either the registered or deputy managers. The inspector also found that staff meetings were held to discuss practice Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 23 issues in the home. This ensured that staff are able to support service users’ needs effectively. The home has a system to monitor the views of the service users on the service that is provided. Ideas for improvement are sought. Action to improve the service had been agreed with service users. There are also weekly meetings were service users can discuss the quality of the service they receive. Service users also have access to advocates supporting them to share their views of the care they receive from the home. Since the last inspection a number of policies that service users need regular access to have been produced in pictorial formats. The deputy manager explained that some service users would find an audio format of policies easier to access. He is currently developing this so that policies are available in a number of formats that service users can access. The registered person ensures that the safety risks to service users and staff are identified. Measures are put in place to provide a safe living and working environment. Records showed that fire equipment was tested regularly and maintained. Drills were taking place. The fire risk assessment provides details of potential risks of fire. All health and safety policies were available. Certificates for gas and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. Training on health and safety topics was complete. Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 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 3 X 3 X Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 25 No 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. Standard Regulation Requirement Timescale for action 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 Mencap (Chasewood Avenue) DS0000010572.V322994.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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
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