Inspection on 09/01/07 for Positive Community Care

This inspection was carried out on 9th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Positive Community Care 23/05/06

Positive Community Care 13/12/05

Positive Community Care 07/07/05

Positive Community Care 30/09/04

Positive Community Care 11/05/04

Positive Community Care 01/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Positive Community Care 174 Petts Hill Northolt Middlesex UB5 4NW Lead Inspector Robert Bond Key Unannounced Inspection 9th January 2007 09:30 Positive Community Care DS0000027713.V324519.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 Positive Community Care DS0000027713.V324519.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. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 174 Petts Hill Northolt Middlesex UB5 4NW 0208 621 1724 0208 248 8496 pcc707@aol.com 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) Ms Charmaine Watson-Mattis Mr Leisel Alian Vaiphei Suantak Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (9), of places Physical disability (1) Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) place for a service user with a physical disability can be accommodated. 23rd May 2006 Date of last inspection Brief Description of the Service: Positive Community Care (PCC) is a care home for nine adults with mental health needs and/or a learning disability. The overall aim of the service is to support service users in maintaining and developing their independence and integrating into the community as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. The home was established in 1997, was initially two small homes operating side by side, which were later combined into one. A third house (166 Petts Hill which is next to 170) is operated by PCC as a supported living scheme (SLS). There is a throughput from the Care Home to the SLS. The care home’s bedrooms are all singles but containing double beds. One bedroom is en-suite. Two bedrooms have been created within the loft space. The home has adequate communal areas including a conservatory and large rear garden. The home is in a residential area, next to a convenience store/petrol station, and is on a bus route. The home has its own small minibus, but this is not used at present. The fees range from £600 to £1,000 per week. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key inspection of the inspection year and this report considers the home’s success in meeting the anticipated outcomes of the key National Minimum Standards (NMS) for younger adults living in care homes. Since the previous key inspection undertaken on 23rd May 2006, additional inspection visits have taken place on 10th July and 9th October, and a CSCI pharmacist inspection was undertaken on 29th November 2006. For the current key inspection, the Inspector sent out questionnaires in advance, and toured the premises, interviewed the Registered Manager, met staff and service users, and examined a variety of records. Two relatives of service users returned completed questionnaires. On the day of the inspection, the home was fully staffed and there was one potential service user vacancy due to a service user failing to return to the home from his Christmas leave. The Inspector found that 16 anticipated outcomes were fully met, whilst 6 were only partly met. This led the Inspector to make 7 requirements and 1 recommendation. Sixteen requirements were made in the previous key inspection, 21 requirements were made in the two additional visit inspections, and 5 new requirements were made in the Pharmacist inspection. All of these requirements have been met. In general, there have been substantial improvements since the previous key inspection, and in particular to the premises, the records and the staffing levels but there is still considerable room for improvement in terms of cleanliness of the premises, and in staff recruitment procedures. What the service does well: A personalised individual service is provided to service users in a way that promotes their independence. Some service users benefit from rehabilitation to the extent that they are able to move next door into the supported living scheme there, which is also operated by PCC. A similar second scheme has recently opened further up the road. The managers and staff communicate well with service users who feel able to come to them with their concerns knowing that they will where possible be assisted. The Statement of Purpose and Service Users Guide are well produced. The care plan format is sufficiently detailed and a thorough assessment is undertaken before a prospective service user move in to the home. Staffing levels have been increased. The gardens are nicely landscaped. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The views of a nutritionist should be sought concerning the suitability of the current menu choices. The downstairs bathroom is not sufficiently clean and hygienic and contained items that were broken, soiled or damaged. A complete refurbishment is required. Additional staff members must obtain NVQ level 2 or 3 qualifications in Care. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 7 The home must maintain an up to date record of staff members’ qualifications and training. A satisfactory reference should be obtained from the last employer when recruiting new staff members for the care home. New members of staff must not commence their employment duties until a clear POVA First declaration has been obtained. A business or development plan is required for the year ahead. 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. Positive Community Care DS0000027713.V324519.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 Positive Community Care DS0000027713.V324519.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. Prospective service users’ individual aspirations and needs are assessed well. EVIDENCE: The Inspector examined in detail (case-tracked) the care records of the most recent service user to move into the care home. The Inspector found that the file included a previous hospital discharge summary, a hospital Occupational Therapy assessment, a health and social needs assessment from Hillingdon Mental Health Services, and the care home’s own pre-admission assessment. The home’s assessment report had been typed up using a format that not only identified the service user’s needs but also identified how those needs would be met; in effect this was an initial care plan. The Inspector made recommendations on how the documentation could be improved further and the Registered Manager agreed to change his template. The file examined did not contain a copy of the contract terms and conditions that should have been issued to the service user when he first moved in to the care home. The Registered Manager, who had been abroad at the time of the admission, investigated and subsequently informed the Inspector that new service users were subject to a one month probationary period and hence no Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 10 contract had yet been issued by the care home. In this case, the placement will be terminated as the service user failed to return from his Christmas leave. Positive Community Care DS0000027713.V324519.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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users should be aware that their assessed and changing needs are well reflected in their care plan. Service users are well empowered to make decisions about their lives. Service users are well supported to take appropriate risks as part of an independent lifestyle. EVIDENCE: The Inspector noted that the home’s assessment of the care needs of the prospective service user, whose care file the Inspector case-tracked, amounted to an initial care plan, as means of meeting identified needs were documented. The Registered Manager reported that the care plan would be updated monthly and be subject to a formal six monthly review. The Inspector checked that appropriate daily report notes were also kept. For this service user a daily record of his outings was kept as he was subject to a curfew time. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 12 The file examined also contained a Care Plan prepared following the Care Programme Approach. This care plan identified the need for a placement in a care home. The service user had a named Key Worker, and signed completed ‘monthly key working forms’ were noted by the Inspector. The care plan format in use had risk management issues incorporated within it, and there was on the file case-tracked a risk management form completed by the referring hospital. The Registered Manager confirmed that the home promotes the independence of service users and responsible risk taking. One of the relatives who completed their questionnaire praised the skill of the key worker and the success the home was having in preparing her relative for subsequent independent living. Apart from their involvement in care plans and reviews, service users are consulted in meetings such as the monthly residents’ meeting, as evidenced by minutes examined by the Inspector. Positive Community Care DS0000027713.V324519.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 and 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 sufficiently encouraged to engage in activities that are appropriate. Adequate in-house activities are provided. Service users are assisted in a satisfactory manner to access community facilities. The maintenance of personal, family and sexual relationships is sufficiently promoted. Services users’ rights and responsibilities are satisfactorily respected and promoted. Service users are considered to be provided with an adequate diet, subject to a nutritionist’s views on the matter. EVIDENCE: The Inspector examined the home’s activity timetable. This showed adequate in-house activities, use of day centres and college, one to one time, counselling time, and weekend trips out. The Inspector observed one service user being Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 14 given bus fare to go to a day centre, and another service user settling down to watch a dvd. The Registered Manager reported that one service user attends Creative Writing classes. The Inspector noted that service users’ activity interests are assessed and are recorded in their care plans. The Inspector noted that at least one service user had gone home to his relatives over the Christmas period, and that at least one service user has his partner to stay overnight. Service users are offered keys to their bedroom doors, which have had the service users’ names written on them. Staff members knock on bedroom doors before entering. The Inspector examined in detail a sample food menu for the home, and saw evidence that service users had been consulted about what should be on the menu. Vegetarian and non-vegetarian menus were available. The Inspector considered that the diet was probably adequately healthy and varied. However the Inspector received a questionnaire response from a relative of a service user that alerted him to the amount of ‘junk food’ served. The Registered Manager when asked confirmed that food was cooked on the premises and was not brought in from take away shops. He did however think that possibly chips were on the menu too often. See Recommendation 1, which suggests that the views of a nutritionist should be sought on the matter. Positive Community Care DS0000027713.V324519.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good personal care support in the ways they prefer and require. Service users’ physical and emotional health needs are met to a satisfactory extent. The homes policies and procedures for administering medication adequately protect service users. EVIDENCE: The Inspector noted from the care file case-tracked that a full health assessment had been undertaken and provided to the care home by the referring hospital. The Inspector also noted that weight records and where appropriate blood pressure records were kept monthly. A record was also kept of all health care professional visits to the home, and the professionals were encouraged to write and leave behind their own notes concerning the actions they had taken, etc. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 16 The Registered Manager reported that now two GP practices share responsibility for service users in the care home. A District Nurse visits the home, as do Community Psychiatric Nurses, as necessary. The Inspector checked the home’s storage of medication. A proper refrigerator is now in place for the storage of medication that must be kept cool. Both the temperatures of that fridge, and the room that medication is stored within, are monitored daily. A random check of medication administration records by the Inspector did not disclose any errors. Positive Community Care DS0000027713.V324519.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users, relatives and neighbours can feel that their views are fully listened to and acted upon. Service users are satisfactorily protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints record and noted that no formal complaints had been recorded since before the previous CSCI inspection. No complaints have been received by the CSCI directly either during this period. The Registered Manager showed the Inspector email correspondence between a neighbour and himself that demonstrated that concerns raised by the neighbour about noise on two occasions had been resolved satisfactorily. The Inspector examined the home’s Protection of Vulnerable Adults policy and procedure, which are good. The Inspector also examined training records that indicated that staff had been adequately trained in the procedure. Positive Community Care DS0000027713.V324519.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is sufficiently homely, comfortable and safe with the exception of the downstairs bathroom. The home are sufficiently clean and hygienic with the exception of the downstairs bathroom. EVIDENCE: The Inspector noted many improvements to the premises since the last key inspection. In particular the refurbishment of the two upstairs bathrooms had been completed, bedrooms, kitchen and non-smokers lounge had been decorated, and new chairs had been placed in the conservatory. The landscaping of the front and rear gardens had also been finished. In general the home was seen to be adequately clean and hygienic on the day of the inspection. The exception is the downstairs bathroom where the following were noted: a broken shower, missing sink and bath plugs, unpainted and dirty wooden cupboard door, damaged paintwork, and missing grouting to Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 19 certain tiles. The room did not smell sufficiently fresh. The Registered Manager reported that he thought the Proprietors intended to replace the large bath with a shower suitable for service users in wheelchairs. However, the whole room, its contents and decoration must be refurbished in order to achieve the required standard of cleanliness and hygiene. See Requirements 1 and 2. One of the relatives who responded by questionnaire commented on ‘a lack of cleanliness’ generally in the home. A dedicated cleaner is not employed. Positive Community Care DS0000027713.V324519.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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of qualified staff members available to support service users is not sufficiently high. Service users are not adequately protected by the home’s recruitment practices. Further evidence is required to judge whether staff are adequately trained to meet service users’ individual and joint needs. EVIDENCE: The Inspector examined the home’s staffing rota that demonstrated that two support staff members are on duty all day and every day. The Inspector also examined the staff rota for the next-door supported living scheme that demonstrated that a separate member of staff was employed to assist the residents of that home. The Registered Manager confirmed that the staffing, management, medication and financial arrangements for the supported living had now been separated from those of the care home. The Inspector also observed a notice in the conservatory that informed visitors from the supported living scheme that they did not have the right to enter noncommunal parts of the care home unless invited to. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 21 The Inspector examined the home’s training records and ascertained that 4 out of 9 support staff have NVQ level 2 or 3 qualifications. The NMS target is 50 . See Requirement 3. The computerised training record the Inspector was shown was not up to date as several staff whose names appeared in the record have now left their employment, and two new staff members have joined. A new training profile for the home as a whole is required. See Requirement 4. The Inspector noted evidence of induction training of the new staff members. The Inspector examined the recruitment records for the two staff members who had recently commenced work in the care home. The Inspector found that although two references had been sought for each employee, in the case of one employee, a reference had not been taken up from his last employer as required by the Care Home Regulations (as amended). Requirement 5. The Inspector also found that although Criminal Record Bureau disclosure checks had been requested by the care home for the two potential new employees, the employees had been allowed to commence their duties before the CRB disclosures had been received back. At the time of writing these are still outstanding. The Registered Manager explained that although the CRB requests had been made to the umbrella organisation the home uses in sufficient time, an unaccountable delay had arisen in that the CRB office had only recently received the applications. The new employees had been allowed to start work as they were rostered to work, were not working alone, and existing employees could not cover the shifts. Temporary agency employed staff member had not been used in their place as perhaps should have happened. The Regulations indicate that where there is a delay in obtaining a CRB disclosure that has been requested by the new employer, new staff members must not start work until a clear POVA First check has been obtained. Pending subsequent receipt of a satisfactory CRB disclosure, employees who are working directly with service users must not work alone and must be supervised at all times. The Registered Manager said he was aware of the POVA First process and that the umbrella organisation applied it. The Registered Manager, in the presence of the Inspector, telephoned the umbrella organisation and requested that the POVA First checks be undertaken straight away on the two new employees. The CSCI requires evidence of those checks having been undertaken. Requirement 6. Positive Community Care DS0000027713.V324519.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is run in a satisfactory manner. Service users views are sufficiently taken into account and these views must be used to inform a development plan for the year ahead. The health, safety and welfare of service users are adequately promoted and protected. EVIDENCE: The Registered Manager reported that he is continuing to work towards obtaining The Registered Managers’ Award, which he hopes to complete by mid 2007. The Registered Manager (and the Proprietors) have been successful in meeting all the requirements made by the CSCI during the four inspections already undertaken during this financial year. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 23 The Inspector examined sample minutes of Residents’ Meetings that are held on a regular basis. The latest Regulation 26 report the Inspector had received a copy of was dated 5th October 2006. A more recent report was seen in the home, and one dated 10th January 2007 was subsequently faxed to the Inspector. The CSCI requires these reports to be submitted directly to the Hammersmith Office on a monthly basis. The issue of a service user absconding (failing to return from Christmas leave and being subsequently reported to the Police as a missing person) should have been reported to the CSCI at the time as a Regulation 37 issue. The necessary report has been faxed to the Inspector subsequently. Service users views are periodically gathered by questionnaire and the Inspector read a summary of their views dated August 2006. The Inspector asked to see the home’s Business Plan and was shown one that related only to 2006. A development plan for the year ahead is therefore required in line with NMS 39.2. See Requirement 7. The Inspector checked the home’s hot water supply, a sample first aid box, fridge temperature records, and evidence that fire precaution checks were regularly made. All were found to be in order. Positive Community Care DS0000027713.V324519.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 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 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 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 2 x x 3 x Positive Community Care DS0000027713.V324519.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. 1 Standard YA24 Regulation 23(2)© Requirement Timescale for action 01/03/07 2 YA30 3 YA32 4 YA35 5 YA34 6 YA34 The equipment and fittings in the downstairs bathroom must be adequately maintained. 23(2)(d) The downstairs bathroom must be adequately decorated and kept hygienically clean. 18(1)© In order to achieve the target of 50 support staff with NVQ 2 or 3 qualifications, addition NVQ training is necessary. 18(1)(a) Up to date training records are necessary. A revised list of staff qualifications and training to be sent to the CSCI. Sch2(5),19(1bi) The registered person shall not employ a person to work in the care home unless he has obtained two written references relating to the person including one from the last employer. Sch2(7),19(1bi) No new employee may start work without a clear POVA First check having been obtained. The CSCI requires to see evidence of these DS0000027713.V324519.R01.S.doc 01/04/07 01/09/07 01/03/07 01/02/07 01/02/07 Positive Community Care Version 5.2 Page 26 7 YA39 24 belated checks for the two new employees. A development plan for 2007 01/03/07 is required. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA17 Good Practice Recommendations The views of a nutritionist should be obtained concerning the menu choice currently available. Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Positive Community Care DS0000027713.V324519.R01.S.doc Version 5.2 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. 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