Inspection on 12/04/06 for Nicholas Court (1-5)

This inspection was carried out on 12th April 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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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 Nicholas Court (1-5) 1-5 Nicholas Court 2a Tunmarsh Lane Plaistow London E13 9NA Lead Inspector Sharon Lewis Unannounced Inspection 12th April 2006 12:35 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nicholas Court (1-5) Address 1-5 Nicholas Court 2a Tunmarsh Lane Plaistow London E13 9NA 020 8552 0043 020 7350 4858 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.heritagecare.co.uk Heritage Care *** Post Vacant *** Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: 1-5 Nicholas Court is a purpose built home for younger adults who have learning disabilities and challenging behavioural needs. The home consists of five individual flats. Service users benefit from residing in individual flats where their independence and choice is promoted. Newham Registration and Inspection Unit originally registered Nicholas Court in November 1995. Heritage Care is the care provider and they have recently taken over ownership of the building and now have registered provider responsibilities. The home is located in a residential area in Plaistow, close to shops, services and amenities. A range of bus routes along the Barking Road and Greengate Street serve the home. The nearest underground stations are Plaistow and Upton Park on the District Line. The home has a small car park and unrestricted street parking is available in adjacent roads. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken on a Wednesday afternoon and lasted four and a half hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. In addition to checking the home’s compliance with the legal requirements made at the last Inspection. Individual discussions were held with the Acting Manager and four Support Workers including the Designated Responsible Person on duty. The Inspector spoke to four of the five service users currently living at the home. All service users indicated they were happy living at the home and were comfortable in their surroundings. Service users files, medication and medication administration records, all health and safety records and other relevant documentation were also examined. A tour of the premises was additionally undertaken. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well: Detailed ‘person centered ’ care plans have been developed for service users. The new care plans actively promotes each service users individual needs and wishes. Activity plans and favourite recipes have been incorporated to fully promote individual lifestyles. Service users are able to take part in age, peer and culturally appropriate social and leisure activities. It was good to see that a service user is currently enjoying a holiday in Las Vegas. Service users had individual daily activity programmes designed to address their particular interests, personalities and needs. This included attendance at a Men’s Group, social groups, sensory, relaxation and pampering sessions, massages, music therapy, art, gardening, drives out, rambling, swimming, bowling, karaoke, football, video nights, puzzle solving and board games. Service users engage in their local community by going shopping in Galleons Reach, East Ham, Barking and Stratford. Services users regularly enjoy eating Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 6 out and going to the pub. Service users additionally access local services, which includes their bank, barber, hairdresser and nail parlour. During the Inspection a service user was out at a rambling session. Service users are actively encouraged to develop their independent living skills. The home evidenced service users taking responsibility for their shopping, meal preparation, clearing the table, laundry and housework. What has improved since the last inspection? What they could do better: Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 7 During this Inspection ten legal requirements were highlighted. The Statement of Purpose must be updated to include recent developments. Service users and their relatives must have adequate up-to-date information regarding the home. General maintenance must be further addressed. Service users must reside in comfortable, well-maintained environments. The home must ensure all staff have regular recorded supervision meetings at least six times a year. Staff must consistently date all records. Service users must be better protected by the home’s staff supervision and record keeping practices. Staff must ensure medication administration records are appropriately maintained. A copy of the employer’s liability insurance certificate and the portable appliances testing certificate must be forwarded to the Commission for Social Care Inspection. Fluff must also be regularly removed from all tumble driers. Service users must be protected by the home’s health and safety practices. 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. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-3 1 – 5 Nicholas Court demonstrated the ability to meet service users individual needs. Documentation must be further developed to inform service users choice and promote their rights. EVIDENCE: The Statement of Purpose is currently being updated to include all new developments concerning the home. Service users and their relatives must have adequate up-to-date information regarding the home. The current service users have resided at the home for a significant period of time. There have been no recent admissions. The home is able to offer support to adults with a moderate to severe learning disability and additional physical or sensory disabilities. The home is unable to offer support to people who require nursing care, have a drug or alcohol dependency or have a primary mental health need. The home recognises the benefits of moving people on to receive individualised support in the community. Plans are in progress for a service user to move into more independent accommodation in the community. The organisation has a commitment to appropriately moving people on where possible to maximise their independence. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 10 1 – 5 Nicholas Court evidenced that they are able to meet the assessed needs of individuals. All service users were comfortable in their surroundings and indicated that they were happy living at the home. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 1 – 5 Nicholas Court actively promotes service users individual needs and wishes. EVIDENCE: All service user files were examined during this Inspection. Detailed ‘person centered ’ care plans have been developed for service users. Care plans detailed service users communication, personal care, daily living, health care, , behavioural issues, beliefs/emotional needs and finances. Activity plans and favourite recipes have been incorporated to fully promote individual lifestyles. Currently care plans are evaluated on a six monthly basis. Service users are allocated key workers who provide guidance, support and monitor their progress. Staff demonstrated that assistance and support was given to service users to make decisions about their own lives. Observation, examination of daily logs and discussion with service users evidenced that they exercised choice in their daily lives. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 12 Service users are supported to take risks as part of an independent lifestyle. Service user benefit from better risk management systems. Evidence was seen of risk assessments being updated and dated. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17 Service users lifestyle needs are individually promoted at 1 – 5 Nicholas Court. EVIDENCE: Service users have opportunities for personal development within the home. Service users’ files, observation and discussions with service users and staff evidenced that independent living skills are actively encouraged. Service users take responsibility for their shopping, meal preparation, clearing the table, laundry and housework. Their house keeping tasks are specified in their individual plan. Service users are able to take part in age, peer and culturally appropriate social and leisure activities. It was good to see that a service user is currently enjoying a holiday in Las Vegas. Service users had individual daily activity programmes designed to address their particular interests, personalities and needs. This included attendance at a Men’s Group, social groups, sensory, relaxation and pampering sessions, massages, music therapy, art, gardening, drives out, rambling, swimming, bowling, karaoke, football, video nights, puzzle solving and board games. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 14 Service users engage in their local community by going shopping in Galleons Reach, East Ham, Barking Market and Stratford. Services users regularly enjoy eating out and going to the pub. Service users additionally access local services that includes their bank, barber, hairdresser and nail parlour. Service user and staff discussions and documentation evidenced that service users maintain family and personal relationships. This included visits by relatives to the home, telephone contact and enjoying day trips and holidays with their respective family members. The home demonstrated that service users’ rights are respected and responsibilities recognised in their daily lives. The home evidenced that birthdays are celebrated, service users related they had a birthday party and photographs confirmed their experience. Service users were observed during the Inspection exercising their individual choice and participating in their own daily routines. Documentation and observation evidenced that service users choose when to get up, get dressed, and be alone or in company, and when not to join an activity. The home evidenced that meals are healthy, nutritious and reflected various cultures. Fruit is readily available and service users regularly enjoy eating out. Kitchen premises were inspected and were found to be clean. Fridge and freezer temperatures are monitored and recorded daily. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 20 Service users personal and health needs are generally promoted at 1 –5 Nicholas Court. Greater care however must be taken when maintaining medication administration. EVIDENCE: Service users receive personal support in the way they prefer and require. Times for getting up/going to bed, baths, meals and other activities are flexible and dependent on service users needs and preferences. Service users choose their own clothes and their appearance reflects their age and personality. Evidence was seen were service users had been supported with a weightloss programme and healthy eating is actively promoted. The respective General Practioner (GP) additionally confirmed this success. Documentation, observation and staff discussions evidenced that service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Evidence was seen of proposed medical review with psychiatrist and psychologist involvement. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 16 Service users have regular dentist, optician, chiropodist, and specialist health appointments. Files additionally evidenced that service users also benefit from alternative therapies. These included aromatherapy, foot massages, relaxation sessions and shiatsu. Medication policies and procedures are in place. Only staff with medication assessment training, administer medication. Medication and medication administration records were examined in four of the five flats. Medication is appropriately stored in locked cabinets. Boots chemist are currently undertaking quarterly reviews. Medication administration records evidenced more than five discrepancies were gaps were noted. Staff must ensure medication administration records are appropriately maintained. Service users must be protected by the home’s medication procedures. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 1- 5 Nicholas Court has policies and procedures to address service user concerns, complaints and promote their protection. EVIDENCE: The home has produced a complaints policy. The complaints book was examined; there have been no service user complaints in the last year. The Commission for Social Care Inspection however received an anonymous complaint from an agency staff member. Part of this complaint was investigated during the Inspection was found to be unsubstantiated. The organisation will investigate and report on the areas relating to staffing and care of a particular service user. The home currently has an outstanding Adult Protection allegation. Adult Protection protocols are currently being developed with Newham Social Services. The aim being to clearly identify the home’s and Social Services respective responsibilities. The home was noted to have managed all adult protection allegations in a satisfactory manner. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Service users benefit from having their own individual flats. General maintenance however must be further addressed. EVIDENCE: 1-5 Nicholas Court consists of five purpose built flats. The home is located in the Greengate area of Plaistow in the London Borough of Newham. Being purpose built the home does not blend unobtrusively into the neighbourhood. The premises is further separated from the local community, due to a large surrounding wall. There are plans however to knock down this wall to promote greater integration with the wider community. A homely atmosphere is promoted by accommodation in individual flats. Currently all service users have their own individual flat. Each flat has its own lounge/dining area, kitchen, laundry and bathroom. All service users share a large courtyard garden. There are additional surrounding gardens and patio areas with outdoor seating. Flat 5 has Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 19 developed their own vegetable garden. The home is close to shops, services and amenities situated on the Barking Road. Canning Town, Stratford, Green Street and East Ham shopping areas are accessible by bus. A range of bus routes are available along Barking Road and Greengate Street. The nearest underground stations are District Line, Plaistow and Upton Park stations. The home has a small car park and unrestricted street parking is available in adjacent streets. Service users’ bedrooms had adequate storage space and reflected their individual tastes and needs. Shared spaces complement and supplement service users’ individual rooms. Flat 5 benefits from having a spare room, which is a designated activity room. Service users artwork is on display in the activities room and throughout the flat. The maintenance of the property is a continual issue. The organisation have produced a list of all maintenance issues. Redecoration of the premises is in progress and there are plans to fit new kitchens in all flats. In Flat 1 the bathroom toilet cistern must be boxed in and the area retiled. This requirement is repeated from the last two Inspections. The bath panel must additionally be secured. In Flat 2 the area above the radiator must be repainted in the bedroom. In Flat 3 the bedroom radiator and the bedroom walls must be repainted. The home has until July to meet this requirement. In Flat 4, the zips on the lounge sofas must be repaired or replaced. This requirement is repeated from the previous Inspection. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 - 36 1 – 5 Nicholas Court has adequate staffing however staff must benefit from regular supervision. EVIDENCE: Staff discussions and observations demonstrated that staff were respectful of service users and were aware of their individual needs and communication patterns. Examination of the staffing rota, staff discussions and observations evidenced that the home was sufficiently staffed to meet the individual and collective needs of service users. The Deputy Manager is now in post. Service users benefit as the appointed person has previous management experience at the home. The organisation is currently recruiting a second Deputy Manager on a three month Acting basis. The organisation has a central human resources department and a corporate recruitment policy and procedure. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 21 Staff confirmed they had regular team meetings, team days and had attended a range of training. This included Multimedia training, Protection of Vulnerable Adults (POVA), Person Centered planning. Staff have completed the necessary National Vocational qualification (NVQ) training. Staff have benefited from Managing Challenging Behaviour training. Guidelines have been developed and need to be consistently implemented to respond to the racist and sexually inappropriate behaviour of the identified service user. The Acting Manager stated there are plans to hold specific individual Away Days dedicated to each service user and their needs. Staff confirmed they have had individual development days. Staff discussions evidenced that all staff had not received regular recorded supervision. Informal supervision and adhoc advice had however been given by management. The home must ensure staff have regular recorded supervision meetings at least six times a year. The Acting Manager confirmed staff supervision would be shared with the Deputy Managers having responsibility for Flats 1 & 2 and Flats 3 & 4 respectively. The Manager would have supervisory responsibility for the staff in Flat 5. There are plans to rotate support staff every six months, to enable them to work in different flats. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 & 43 1 – 5 Nicholas Court is adequately managed however service users welfare, health and safety must be better promoted. EVIDENCE: The home has not had a Registered Manager since January 2003. Various Acting Managers have been employed during this period. The current Manager is currently going through the Commission for Social Care Inspection registration process. Staff described the Acting as “very nice”, “very supportive” “tries her best and tries to find solutions.” The current Acting Manager has worked previously at Nicholas Court and has proven management experience within Heritage Care. During this Inspection it was evidenced that standards and practice had improved to promote a more individualised service user focused, transparent service. The process of managing the home was seen to be open and transparent. Staff interviewed related they feel valued and are able to use their initiative. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 23 Staff were noted to be consulted on a range of issues, which included service and policy development. The home has a quality assurance policy and quality assurance systems are in place. The Registered Provider in accordance with regulations undertakes monthly visits. These reports are routinely sent to the Commission for Social Care Inspection. The monthly reports effectively highlighted the home’s strengths, shortfalls and appropriate plans of action. The organisation has produced an action plan to address service development. The Primary Care Trust (PCT) have cut the home’s budget in favour of individual budgets per service user. This has resulted in a loss of staffing hours, which has decreased the designated responsible person role. The Manager is also off the rota and is more administration based. The draft financial budget was examined and discussed with the Acting Manager. The home is financially viable and there are plans to fill the current placement voids. A new record keeping system had been introduced which incorporates individual service users daily reports, menus, incidents, fire safety and health issues. This assists management to efficiently monitor the progress of each service user. Examination of daily reports however highlighted that staff did not consistently date these reports. Staff must consistently date all records. Service users must be better protected by the home’s record keeping practices. Fire safety was examined. A fire risk assessment has been produced. The home evidenced that regular fire drills were held, alarms were tested every week and fire equipment was annually serviced. Further work is needed to safeguard against fires. In Flat 5 a large amount of fluff was found in the tumble drier. Fluff must be regularly removed from all tumble driers. Service users must be protected by the home’s fire safety practices. The home evidenced that the majority of health and safety certificates and policies are in place. The current employers liability insurance was not on display, although Head Office confirmed the policy had been renewed. A portable appliances testing certificate is also outstanding. A copy of the employer’s liability insurance certificate and the portable appliances testing certificate must be forwarded to the Commission for Social Care Inspection. Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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 2 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X 2 2 2 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 25 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 (1) Requirement The Statement of Purpose must be updated to include recent developments. Staff must ensure medication administration records are appropriately maintained. In Flat 2 the area above the radiator must be repainted in the bedroom. Timescale for action 01/09/06 2. YA20 13 (2) 01/05/06 3. YA24 23 (2) (d) 01/10/06 4. YA24 16 (2) ( c) In Flat 4, the zips on the lounge sofas must be repaired or replaced. Timescale of 01/01/06 and 01/04/06 not met. 01/08/06 5. YA27 23 (2) (b) & (j) In Flat 1 the bathroom toilet cistern must be boxed in and the area retiled. Timescale of 01/01/06 and 01/04/06 not met. The bath panel must additionally be secured. 01/08/06 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 26 6. YA36 18(2) The home must ensure all staff have regular recorded supervision meetings at least six times a year. Staff must consistently date all service user records. Fluff must be regularly removed from all tumble driers. 01/07/06 7. 8. 9. YA41 YA42 YA42 17 (1) (a) 23 (4) (a) 23 (2) (c) 01/06/06 01/05/06 A copy of the portable appliances 01/06/06 testing certificate must be forwarded to the Commission for Social Care Inspection. A copy of the employer’s liability insurance certificate must be forwarded to the Commission for Social Care Inspection. 01/06/06 10. YA43 25 (2) (e) 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 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Nicholas Court (1-5) DS0000066792.V289311.R01.S.doc Version 5.1 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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