Inspection on 01/11/05 for Norwood 30 Old Church Lane

This inspection was carried out on 1st November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 30 Old Church Lane 31/07/07

Norwood 30 Old Church Lane 04/04/06

Norwood 30 Old Church Lane 20/01/05

Norwood 30 Old Church Lane 11/05/04

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 30 Old Church Lane 30 Old Church Lane Stanmore Middlesex HA7 2RF Lead Inspector Judith Brindle Unannounced Inspection 1st November 2005 07:55 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 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 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 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. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 30 Old Church Lane Address 30 Old Church Lane Stanmore Middlesex HA7 2RF 020 8954 6566 020 8385 7697 oldchurchlane@norwood.org.uk 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) Norwood Mrs Bridget Ann Iannotta Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: 30 Old Church Lane is a Jewish care home registered to provide personal care, and accommodation for 8 adults with learning disabilities. The proprietor is Norwood. The home is located on the outskirts of Stanmore. The shops, banks, restaurants, and other amenities of Stanmore are within a short drive or walk from the care home. Bus and train public transport services are located close to the home. The home was opened in 1997, and consists of a large detached two-storey building, within a residential area. All the homes bedrooms are single. The home includes a flat where two service users are accommodated. The home has an accessible well-maintained enclosed garden. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 4.75 hours during a day in November 2005. During the inspection the inspector focused on spending time talking with residents, observation of interaction between staff and residents, and assessment as to whether previous inspection requirements and recommendations had been met. The inspector was pleased to meet, and speak to all the residents. Several residents have varied verbal communication needs, and use signs, gestures and a few words to communicate. Other residents spoke at length with the inspector. Care records, staff personnel records, health and safety records were among a variety of records inspected. A tour of the premises took place. During the inspection 17 National Minimum Standards for Adults where assessed. All the National Minimum Standards assessed during the unannounced inspection had been met or almost met. All requirements, except one, (which was partially met), from the previous inspection had been met. The registered manager was on duty during the unannounced inspection. What the service does well: The care home has a welcoming, and friendly atmosphere. Residents who kindly spoke to the inspector reported that staff were caring, kind, and supportive. Observation of staff during their interaction with residents confirmed that they enabled residents to make choices and were respectful and supportive of the resident’s varied needs. Training includes staff training to meet resident’s specialist needs. Resident’s have the opportunity to participate in a wide-range of chosen activities. Residents spoke of the many activities provided by the service that they enjoy. The care home is set within a Jewish cultural environment, and residents are encouraged and supported to participate in religious activities if they so wish. Residents spoke of recent religious festivals that they had celebrated and enjoyed, and of planned celebrations, which they were looking forward too. The care home is particularly inclusive in that it supports and encourages involvement of others; examples of furniture and other items donated to the care home were evident. There is clear evidence that the service is keen to continue to improve standards. Support and advice from health and social care professionals in meeting resident’s needs is regularly sought. Residents spoke of the care home as being their home, and all those that kindly spoke with the inspector reported that they were happy living in the care home. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Arrangements are in place to ensure that all prospective residents receive an assessment of their needs, which are reviewed regularly. EVIDENCE: The care home has an admission procedure. There have been no new admissions to the care home for several years. Staff informed the inspector during a previous inspection that a care manager from a Local Authority generally refers a prospective resident. The registered manager, and the allocations officer from Norwood then complete a comprehensive assessment of the prospective resident’s needs, with the resident’s involvement (if able) and family/significant others participation. This assessment includes health, social, cultural and welfare needs, and this forms the basis of the resident’s care plan. . There is then a transition period of visits to the care home from the prospective resident. Then a ‘settling in’ period followed by a comprehensive review (with the resident’s involvement) of the resident’s needs prior to the placement being confirmed. Care plan information and documentation confirmed that resident’s needs are comprehensively assessed, and that recorded action by staff to meet those needs is in place. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 and 9 Arrangements are in place to ensure that resident’s assessed needs, and their changing needs, and goals are reflected in their individual plan of care. Assessment of residents needs include assessment of risk, which supports and enables individual residents to have an independent lifestyle as possible. EVIDENCE: All the residents have an individual plan of care. The three care plans inspected recorded evidence of having been regularly reviewed. The registered manager, and records inspected informed the inspector, that all the care plans had or were in the process of being comprehensively reviewed. The manager informed the inspector that the some care plan documentation had been archived to ensure the accessibility of recent up to date information in regard to resident’s needs. This was evident in care plans inspected. The three care plans inspected included a photograph of each resident, and also recorded evidence of comprehensive assessment of individual resident’s needs, including assessment of individual personal care needs, and specialist needs of residents. Recorded staff guidance is in place to ensure that these assessed needs are met, and individual goals recorded. Records informed the inspector that some staff guidance had been further developed since the previous inspection. There should be evidence that resident’s, as far as possible are 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 10 involved in the monthly review of their plans of care. There was recorded evidence that residents participate in multi-disciplinary review meetings of their care plans. All the residents have a key worker. Two residents spoke positively about their key workers. Records confirmed that residents have potential risks assessed. It was evident that staff have worked hard in the development, and the review of resident’s risk assessments. This documentation was accessible, and included staff guidance to meet assessed needs of risk, and in managing behaviours from residents that might challenge the service. Other risk assessments included bathing risk assessments, and independent mini cab travel, kitchen safety and road safety. Records informed the inspector that staff had signed as having read the risk assessments. This is good practice. Records confirmed that advice, and support from specialist services, which include psychology services are accessed by residents (with staff support) as and when needed. Daily individual resident’s progress records were comprehensive, and included reporting in regard to their welfare, health, and social needs. Behaviour from resident’s that at times challenge the service is monitored, and staff guidance to manage this behaviour is recorded. The care home has a missing persons procedure. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 14 Arrangements are in place to ensure that residents have the opportunity to participate in a variety of leisure activities, which include accessing community, based facilities. EVIDENCE: Residents kindly informed the inspector of the varied and numerous activities that they participated in, and were aware of the activities that they had planned for the day of the inspection, and of other intended future cultural/religious, social, leisure and educational activities. Each resident has an activity programme, and residents participate in a variety of activities during the day. A resident spoke of gardening employment that she was involved in and enjoyed. Certificates obtained by residents following completion of a variety of college courses were available for inspection. Activities included accessing day resource services, college, swimming, cinema, meals out, music sessions, watching television (residents spoke of soap opera programmes that they regularly watched and enjoyed) pottery, sailing, and art activity sessions. These activities were varied, and there was evidence from residents, staff, and records that residents participated as far as they are able in choosing these activities. Residents spoke of a resident having had a birthday recently, and that they had enjoyed a party celebration. Records, 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 12 residents, and staff informed the inspector that residents choose as far as possible (depending on ability) a wide range of appropriate activities, including the participation in some household duties. Residents kindly spoke to the inspector about their interests and hobbies, which they confirmed they could participate in. The care home enables in house sessions for residents, from outside specialists, such as art and music workers to take place. The care home has a music room. Residents were observed to choose activities during the inspection. Residents spoke of recent holidays that they had enjoyed, which included vacations abroad with family members. Staff informed the inspector that all the residents had had a holiday this year. Records, staff and residents confirmed that the religious needs of the residents are facilitated. A resident spoke of his participation in some recent Jewish celebrations, and that he was looking forward to Hanukkah. Staff receive training in regard to the ‘Jewish way of life’. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18,19 Arrangements are in place to assess and meet the personal care, and the individual health needs of residents. Residents’ health care needs are assessed, and there are procedures in place to address them. EVIDENCE: The three care plans inspected, recorded evidence that resident’s personal care needs, and their health needs are assessed, and that these assessed needs are reviewed regularly. Staff guidance in regard to meeting these needs were recorded in the care plans. Records, and residents confirmed that specialist support, and advice is sought when needed. This specialist support includes continence advice from the continence advisor, and assessment and guidance from a speech therapist, and also psychiatric care and treatment. A resident attended an appointment with a psychiatrist during the inspection. Staff were observed to be sensitive and respectful when providing support and assistance with resident’s personal care needs. A resident spoke of choosing her own clothes, and of being supported to manage her own personal care needs. Residents are all registered with a GP. Records informed the inspector that residents are provided with chiropody treatment, dental services and appointments with optician services. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 14 Records confirmed that residents health needs are closely monitored and that residents have access to specialist hospital appointments as and when required by them. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22, 23 Arrangements are in place to ensure that complaints are listened to, taken seriously and acted upon, and handled objectively. Arrangements are in place to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints procedure, in written and pictorial format. This was displayed, and accessible in a communal area of the care home. It includes the stages of, and timescales for the complaints process. The care home has appropriate recording procedures for complaints. Records confirmed that the registered manager has developed further recording procedures to ensure that all ‘concerns’/complaints communicated by residents, visitors and significant others are recorded and acted upon. This is positive. Complaints are monitored on a monthly basis. A resident confirmed that they were aware of the procedure for making a complaint. Residents have the opportunity to attend residents meetings. Several residents had recorded risk assessments in regard to being vulnerable to risk of abuse. All residents need to have these in place (see standard 33). The care home has appropriate protection of vulnerable adults policies and a whistle blowing procedure, which had recently been reviewed. Records confirmed that support and advice from professionals/specialists was sought as and when required, and that residents had access to this support. Staff have received abuse awareness training. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 and 30 Residents live in a homely, comfortable and safe environment, which is generally well maintained. Arrangements are in place to ensure that the care home is kept clean, and hygienic. EVIDENCE: The inspection included a partial tour of the premises, which particularly focused on inspection of the communal areas. The home was clean, airy, warm, and well decorated, and free from offensive odours. The furnishings were judged to be of quality. The registered manager informed the inspector that some new furniture, and other furnishings had been donated to the care home recently. Other homely features in the communal areas included pictures, ornaments and houseplants. Residents were observed to access the communal facilities freely. Residents spoke of liking the décor, and furnishings of the care home. The registered person should consider having the stairway walls repainted, and the stair carpet cleaned or replaced. This was a previous recommendation. The registered manager reported that this maintenance is planned. A broken drawer in a kitchen cabinet needs to be repaired. The manager reported that there are plans to replace the kitchen units. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 17 The laundry facilities are located away from food storage, and food preparation areas. There is an industrial washing machine and also an industrial dryer. The electric clothes dryer needs repair. The manager reported that this was planned. The registered manager informed that a domestic staff member is employed on a part time basis. Bathrooms, the kitchen, and the toilet facilities have appropriate hand washing amenities. Appropriate protective clothing was accessible to care staff. The laundry floor in the flat of the care home is stained and should be cleaned or replaced. The registered manager reported that a person responsible for health and safety in Norwood had assessed the laundry in regards to the possible need for an extractor fan, and it was assessed as not being required. It is recommended that the registered person should seek advice from the Environmental Health service in regard to whether an extractor fan needs to be in place in the laundry room, as the laundry room was very warm during the previous inspection. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32,33, 34 and 35 Arrangements are in place to ensure that an effective staff team supports residents. Arrangements are in place to ensure that residents are protected by the care home’s recruitment policy and procedures. Staff receive appropriate training to enable them to carry out their role and responsibilities in the care and support of residents. EVIDENCE: The staff rota was available for inspection. There are four staff on duty during the day (three staff at the weekends), a part time domestic staff member, and one staff on duty at night. . The night staffing needs, were discussed with the registered manager. The home has night care risk assessments for some service users; the manager informed the inspector that the relevant local purchasing authorities had completed or were in the process of completing individual risk assessments in regard to the care and support needs of residents at night. The registered person needs to ensure that there have been individual risk assessments/assessment (including personal care needs) completed for each resident, and that they conclude that the each resident would be of low risk if there was not a wake staff on duty, prior to wake night staff being discontinued and being replaced by a ‘sleep in’ staff. The registered manager reported that there were three staff vacancies, and that their hours are covered by contracted bank staff that generally knows the residents well. Staff have access to a clearly recorded comprehensive shift 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 19 planner. This information was displayed in the office, so accessible to residents, and staff. On call procedures were assessable, and staff had signed that they had read them. Records informed the inspector that staff participate in regular staff meetings. The care home has a recruitment and selection policy. Three staff personnel files were inspected. These confirmed that required safeguards including a satisfactory enhanced Criminal Record Bureau check is carried out for each staff recruited. Records confirmed that staff receive a statement of terms, and conditions, a code of conduct and practice, and that at least two references are obtained prior to their employment. The registered manager described the staff induction programme that all new staff complete. The staff induction format including a partially completed staff induction record was available for inspection. During the inspection, all the care staff attended training conducted a specialist service in regard to sexuality issues, related to the service user group. A staff training plan was available for inspection and a copy of the documentation was supplied to the inspector. The three training records that were inspected recorded varied and appropriate training for staff. The training included of health and safety training, first aid, food and hygiene training and medication training. Records confirmed that specialist training was also provided and included epilepsy training, training in regard to behaviour that might challenge the service, and also sensory impairment training. Records, and the registered manager informed the inspector that several staff had completed NVQ level 2 and 3 care courses, and that one staff was in the process of completing NVQ level 4. Also that two staff were planning to commence NVQ level 2 in care courses in January 2006. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): Standard 37, 39 and 42 Resident’s benefit from a well run home. The health, safety, and welfare of the people living in the care home are promoted and protected. EVIDENCE: The registered manager has managed the care home for several years and has obtained the Registered Manager Award qualification, and also has a registered nurse qualification in regard to the learning disabilities service user group. She informed the inspector that she was shortly leaving her employment as manager of the care home, and that her manager’s post had been advertised. Following the registered manager leaving her post. The registered provider needs to ensure that an individual is appointed to manage the care home, and also needs to give notice to the Commission of the name of the person appointed and the date on which the appointment is to take effect. Until the appointment of the manager has been made, the registered person needs to inform the Commission for Social Care Inspection of the arrangements for the management of the care home, and the qualifications, skills and experience of that person. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 21 Records, and the registered manager informed the inspector of quality assurance systems in regard to Norwood that had been developed, and a general service review had taken place, which had included participation from residents. An action plan for London Norwood services was recorded. The registered manager confirmed that a business plan for 30 Old Church was in progress of being developed and includes quality assurance monitoring issues in regard to the service. This business/annual development plan documentation in regard to 30 Old Church needs to be supplied to the CSCI. The home has a health and safety policy, and risk assessment. Required fire checks are carried out. The home has an up to date fire risk assessment. Fire drills take place regularly and include participation from the residents. Fire safety equipment has received up to date checks. Food stored in the fridge was appropriately covered and dated. Required electrical and gas service checks were up to date, and certificates available for inspection. The door in the ground floor passageway of the care home needs adjustment, to ensure that it closes fully. The home has an accident reporting procedure. The Employers Liability Insurance certificate was displayed and up to date. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 30 Old Church Lane Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000017550.V262231.R01.S.doc Version 5.0 Page 23 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 YA24 Regulation 23, (2) • Requirement Timescale for action 01/01/06 2 YA33 3. YA37 4 YA37 A broken drawer in a kitchen cabinet needs to be repaired. • The laundry clothes dryer needs repair. 12,13(4)(6) The registered person needs to ensure that all the residents needs have been assessed, including personal care needs, and risk assessment, before consideration of having a ‘sleep in’ staff instead of a wake night staff. 8(2) Following the registered manager leaving her post. The registered provider needs to ensure that an individual is appointed to manage the care home, and also give notice to the Commission of the name of the person appointed and the date on which the appointment is to take effect. 9(2)(b) Until the appointment of the manager has been made, the registered person needs to inform the Commission for Social Care Inspection of the arrangements for the management of the care home, DS0000017550.V262231.R01.S.doc 01/01/06 01/12/05 01/12/05 30 Old Church Lane Version 5.0 Page 24 5 YA39 6 YA42 and the qualifications, skills and experience of that person. 24(2) There needs to be an annual development plan in regard to the service in place, and available for inspection. A copy of this needs to be supplied to the CSCI. 13(4) 23(4) The door in the ground floor passageway of the care home needs adjustment, to ensure that it closes fully. 01/03/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard YA6 YA24 YA24 YA24 Good Practice Recommendations There should be evidence that residents, (as far as possible) are involved in the monthly review of their plans of care. The registered person should consider having the stairway walls repainted and the stair carpet cleaned or replaced. The registered person should seek advice from the Environmental Health service in regard to whether an extractor fan needs to be in place in the laundry room. The laundry floor in the flat of the care home is stained and should be cleaned or replaced. 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 30 Old Church Lane DS0000017550.V262231.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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