Inspection on 04/09/06 for Sampson Avenue

This inspection was carried out on 4th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sampson Avenue 13/08/07

Sampson Avenue 08/12/05

Sampson Avenue 23/05/05

Sampson Avenue 04/01/05

Sampson Avenue 30/09/04

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 Sampson Avenue 27 Barnet Hertfordshire EN5 2RN Lead Inspector Anthony Lewis Key Unannounced Inspection 4th September 2006 09:00 Sampson Avenue 27 DS0000010537.V310351.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 Sampson Avenue 27 DS0000010537.V310351.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. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sampson Avenue 27 Address Barnet Hertfordshire EN5 2RN 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) 020 8449 0142 020 8449 0142 www.Adepta.org.uk Adepta Miss Jacqueline Driscoll Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 6 adults who have a learning disability (LD) and who may also have a physical disability (PD). 8th December 2005 Date of last inspection Brief Description of the Service: 27 Sampson Avenue is a purpose built care home registered for six adults with learning and physical difficulties. The home was opened in 1993 and is run by Adepta, an organisation based in North Finchley, North London and specialising in operating care homes and supported living projects for people with learning disabilities. Metropolitan Housing Association own the building and Metropolitan Housing Association and Adepta maintain it jointly. The home is a two storey detached property with a kitchen, laundry room, lounge, dining room, office, three bedrooms, one bathroom and one shower room to the ground floor. There are three bedrooms, a staff sleep-in room and one shower room to the first floor. There is a lift with access to both floors. The home is situated on a relatively new housing estate in Barnet. Shops and local amenities are a short walk away. The fees for residents living in the home range from £1,211.54 to £1,463.59 per week depending on their individual needs. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 4 September 2006 at 9am and was completed at 4.45pm. The registered manager was very busy supporting residents and was available intermittently at the beginning of the inspection and constantly thereafter and was very helpful and accommodating. To gather evidence for this inspection, three residents were briefly spoken to, this was due to their communication difficulties. Four members of the staff team were spoken to individually in private in the main office. All of the residents’ files were viewed along with seven staff files, safety certificate and various documents. Staff were also indirectly observed interacting with residents and their colleagues. Evidence was also gathered from the preinspection questionnaire, five service users’ surveys, one, care manager/placement officer comment card, two relatives/visitors comment cards and one general practitioners comment card. A comprehensive internal and external tour of the home was conducted with the registered manager. What the service does well: What has improved since the last inspection? At the previous inspection, ten requirements were made. The staff have ensured that nine of the them were met. They have ensured that the home has a service users’ guide and residents’ representative have signed the tenancy agreements. Residents are participating more in the day-to-day running of the home. Staff are adhering to the medication procedures and they are endeavouring to ensure that residents’ wishes in the event of them dying is recorded. The home has a complaints format, which is made available for all. All staff are receiving protection of vulnerable adults training and an effective quality assurance system is in place and a portable appliances test and gas inspection have been carried out. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 6 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. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 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 Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 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): 1, 2 and 5 Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Comprehensive information is available for prospective residents to make an informed choice and assessments are carried out to ensure that the home can meet the residents’ individual needs. EVIDENCE: The service users’ guide was seen in accordance with a requirement at the previous inspection and was up to date and contained information on the aims and objectives of the service. It has been compiled in written and pictorial format to enable people to understand the content more easily. Each resident’s file contained a copy of the service users’ guide. All of the residents have lived in the home for many years and although their assessments have been archived, the organisation has policies and procedures on assessing potential residents to the home. The registered manager said, that she would, in conjunction with a social worker for the prospective resident, carry out the assessment. On looking through each resident’s file, they contained a comprehensive “assessment of support needs” document with information on all aspects of their social, domestic and physical and mental health care needs. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 9 The tenancy agreement for each resident was seen. They contained information on the fees, ownership and management of the home, good, utilities and conditions for living in the home. The staff and the resident or their representative have signed the agreements, which was a requirement at the previous inspection. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Comprehensive care plans ensure that the needs, choices and decisions of residents are acted upon and that they are supported to take appropriately managed risks. EVIDENCE: The care plans of all of the residents were seen and contained comprehensive information on all aspects of the care that the resident is receiving from the service. There was information on individual resident’s daily routines from when they get up in the morning to the time that they go to bed at night. There was also information on their completed and current goals. Some of the goals refer to acquisition of personal possessions, activities, health care and relationships. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 11 Some of the residents are able, with some support from staff, to make their own decisions. Although they all have some form of communication difficulties, the staff team have collated information on how the residents communicate such as through using facial expressions and hand gestures. Information in residents’ personal files show that a speech therapist has been supporting the residents. There was also information from a psychologist who has been supporting two residents and the staff team to understand the residents’ behaviour. One resident is also supported by an advocate, who, according to the registered manager, has a good understanding of the resident and attends meetings with the resident. Residents’ meetings occur regularly where residents have the opportunity, some with support from staff, to discuss and participate in any aspect of the service delivery in accordance with a requirement from the previous inspection. The statement of purpose and service users’ guide contains information on the aims of the service and what residents can expect, in an easy to understand format. In addition, residents have the opportunity to have their say about the quality of service through participating in the quality assurance monitoring. Feedback is given in the form of the home’s development plan. Each resident’s care plan contains information on assessed every day risks to them, compiled by staff in consultation with the resident or their representative. The home is using Adepta’s risk assessment format, which includes information on the risk and benefits to the resident, others and the organisation. The staff have been ensuring that the risk assessments are reviewed every month. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Staff are ensuring that residents are supported to access activities in the community and remain in contact with their family. The staff are also ensuring that residents are treated with dignity and that they receive healthy balanced diets of their choice. EVIDENCE: The registered manager stated that none of the residents work. She went on to say that the staff are very proactive in ensuring that residents are able to access activities in their area. Letters and certificates in residents’ personal files show that they have been accessing their local college and undertaking training courses such as: music therapy, sensory cooking and communication. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 13 Information in residents’ care plan and in their weekly activity plan show that they are being supported by staff to access the gym, college, visits to family and regular attend a day centre. Staff are also supporting residents with their interests. Staff spoken to said that residents go with them to do shopping and to eat out at restaurants. There was also information in one resident’s care plans about staff supporting her to attend church on Sundays, if she wishes to go. There was also information about one resident who enjoys attending football matches and watching his favourite football team play. The registered manager showed the tickets belonging to a resident, who will be going to see her favourite singer at a forthcoming concert. The registered manager said that all of the residents have some form of contact with their family, although some have minimum contact. She went on to say that none of the residents have as yet formed close relationships with other people outside of the home. One resident’s care plan contained information on visiting his family once a week, with staff support. Throughout the inspection the staff team were indirectly observed interacting with residents in a respectful and courteous manner at all times. Staff were observed knocking on residents’ bedroom door prior to entering. A resident was seen with a letter on her lad, waiting for a member of staff to support her to open it and read the contents to her. The registered manager stated that she has been supporting staff to understand and respect the daily routines of residents, especially with regards to residents’ privacy and dignity. The care plans of the residents contained information on the foods that they like and dislike. The menu was seen and contained a mixture of meals. In addition, the home has produced a booklet with photographs of a variety of popular meals such as spaghetti bolognese, jacket potatoes, salads, vegetables and fruits. A member of staff said that the booklet is used to support residents to chose what foods they enjoy and would like prepared. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Staff are ensuring that residents health care needs are being monitored. They are also ensuring that residents are supported in accordance with their wishes and that medication policies and procedures are adhered to. EVIDENCE: While touring the home with the registered manager, she was able to explain how she and the rest of the staff team support the residents with their personal care, ensuring that their dignity is respected at all times. Two members of staff were spoken to about supporting residents with their personal care and were able to explain how they support the residents. In residents personal file, was information on their daily routines and how they would like staff to support them. For instance, when they get up in the morning. One resident’s care plan states, “I don’t like to be rushed in the morning.” It went on to describe how she would like staff to support her throughout the day. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 15 Each resident has a “Record of Visits to a Medical Service”. Records show that they have been receiving advice and treatment from their GP, psychiatrist, occupational therapist, physiotherapist and speech therapist. A record is given of any advice and treatment and any follow-up arrangements. On the day of the inspection, a therapist visited the home for a reflexology session with some of the residents. The registered manager said that none of the residents administer their own medication. The Medication Administration Records (MAR) charts of all of the residents were viewed and staff have been completing them in accordance with Adepta’s policies and procedures. There were no gaps on the (MAR) charts, which was a requirement at the previous inspection. The medication is kept safely locked away in a metal cabinet in the office. At the pervious inspection, a requirement was made that residents’ wishes in the event of them becoming terminally ill and dying are recorded and signed by the resident, their family or representative. On looking through residents’ personal file the wishes of some of them were signed by their family and others had no information. The registered manager stated that since the previous inspection, the relatives have been written to and that they are awaiting a reply. The registered manager went on to say that in the mean time, the home has Adepta’s agreement with the local authority regarding funeral arrangements in the event of a resident dying, which has been added to residents’ personal file. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Residents or their representative are provided with sufficient information if they wish to make a complaint and staff are taking complaints and concerns seriously. Robust staff training in adult protection is ensuring that residents are protected from abuse. EVIDENCE: Residents have the information they need if they or their representative wishes to make a complaint. The service users’ guide and statement of purpose contains information about making a complaint. The home also has Adepta’s complaints policy and procedures and there is also a complaints book with forms to fill in the nature of any complaints made. The complaints format is more inclusive in that it can be used by anyone who wishes to make a complaint, in accordance with a requirement at the previous inspection. The last complaint recorded was on 11th January 2006. The home has the London Borough of Barnet’s Multi-Agency Protection Policy and Procedure and Adepta’s adult protection policies and procedures, which contains information on how to recognise signs of potential abuse and steps that the staff member should take. Within the homes training file was the certificate to show that all staff have been receiving adult abuse training, which was a requirement at the previous inspection. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The home is kept clean and tidy, although the lack of robust maintenance repairs lets down its overall appearance. EVIDENCE: While touring the home with the registered manager, a number of maintenance issues were identified. The paint on the walls in the laundry room was peeling off and a cupboard door was broken. There were also cracks around the frame of the back door. In the kitchen, the knob on the small oven was missing, which meant that the small oven could not be used and the freezer was not working, meaning that no foods could be stored in it. Some of the doors in the home were being propped open with wedges, even though some of them were fitted with ”dorguards”. When asked about this, the registered manager stated that the dorguards were not working properly. The London Fire and Emergency Planning Authority (LFEPA), who visited the home earlier on in the year, made a recommendation that magnetic door releases should be fitted to the doors. A requirement is made that the registered persons ensure that all doors are fitted with a device that automatically closes in the event of the fire alarm sounding. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 18 While touring the home, all areas were found to be clean and hygienic, there were no offensive odours. To the rear of the home is a laundry room with washing and drying facilities. The washing machine has a sluicing programme. The staff, along with the part-time cleaner, ensures that all areas of the home are kept clean and tidy. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Robust recruitment and training procedures are ensuring that residents are protected and that staff have the training and competences in sufficient numbers to meet the needs of the residents. EVIDENCE: Details in the home’s rota showed that there are usually three and a half staff on the early shift and on the late shift. The registered manager also provides support by working on shift providing support to residents. Throughout the day, staff were indirectly observed and were supporting the residents in all aspects of their care needs. Three members of staff were spoken to privately. They all said that as a team they get on well and are supportive of each other. The personal files of seven staff were viewed and all contained the required recruitment information such as: two references, a recent photograph, a Criminal Records Bureau (CRB) check. In addition, their was also other information to substantiate the authenticity of the member of staff such as: a birth certificate, passport or information, where required, from the Home Office regarding permission to work in the country. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 20 The two newest members of staff were spoken to and both said that they received comprehensive inductions when they first began working in the home. The training file for the staff was seen and it contained substantial certificates to show that staff have been receiving mandatory training in areas such as food hygiene, health and safety, moving and handling and protection of vulnerable adults. Staff are also undertaking their National Vocational Qualification (NVQ) at various levels. Staff spoken to were able to explain their roles and responsibilities and how their training has enhanced their understanding of the residents and their individual and collective needs. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. A competent manager is ensuring that quality assurance monitoring is carried out to measure the quality of service delivery to residents. Although, safety procedures are not being adequately monitored to ensure that people in the home are safe at all times. EVIDENCE: The registered manager said that she has managed residential services for various organisations for more than two years. Throughout the inspection, she demonstrated her knowledge and understanding of the needs of the residents and staff. Her personal file was seen and contained training certificates appropriate to the work that she does. She also said that she is undertaking her (NVQ) level 4. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 22 Adepta has a quality assurance manager, whose role is to co-ordinate reviews of the quality of service provided, through sending out questionnaires to residents, staff and other stakeholders. The information from the questionnaires received back are forwarded to operations managers and registered managers who will structure their development plan according to the views and comments from the questionnaires based on their overall findings. The home’s development plan for 2005 was viewed and contained information on how the organisation is intending for the service to develop for the year. The staff are ensuring that all health and safety checks are carried out regularly. Fire drills and tests have been occurring regularly and safety certificates such as gas, and the Portable Appliances Test (PAT) were carried out in accordance with a requirement from the previous inspection. The lift inspection and water test certificates were seen and were up to date and in order. However, the London Fire and Emergency Planning Authority (LFEPA) visited the home on 28th February and 1st March 2006 and made five recommendations, which the home has not met. A requirement regarding this has been made. Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 3 X 3 X X 2 x Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 (2) (b) (c) (4) (a) (c) (i) Requirement Timescale for action 29/12/06 2. YA42 23(4) (a) (c) (i) (v) The registered persons must ensure that the maintenance issues identified are rectified and that all doors are fitted with a device that automatically closes in the event of the fire alarm sounding. The registered persons must 27/10/06 ensure that the recommendations made by the (LFEPA), are complied with and an up to date certificate is obtained to show compliance. (Timescale of 27/01/06 not met). This requirement is revised and restated. 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 Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Sampson Avenue 27 DS0000010537.V310351.R01.S.doc Version 5.2 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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