Inspection on 01/12/05 for Spring Grove Road, 233

This inspection was carried out on 1st December 2005.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Grove Road, 233 23/07/07

Spring Grove Road, 233 20/06/06

Spring Grove Road, 233 11/07/05

Spring Grove Road, 233 06/12/04

Spring Grove Road, 233 10/05/04

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 Spring Grove Road, 233 Isleworth Middlesex TW7 4AF Lead Inspector Ms Jane Collisson Unannounced Inspection 1st December 2005 11.20a Spring Grove Road, 233 DS0000022907.V268234.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 Spring Grove Road, 233 DS0000022907.V268234.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. Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spring Grove Road, 233 Address Isleworth Middlesex TW7 4AF 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) 0208 568 0263 londonroad@tiscali.co.uk Milbury Care Services Limited Teresa Franze Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: 233 Spring Grove Road is a detached house situated on a busy road in Isleworth, near to the London Road and the A4. There are local shops and public transport links within walking distance. Hounslow Town Centre and Brentford are within easy reach. The home is registered for three service users with learning disabilities. The owners and care providers are Milbury Care Services. The current service users have lived in the home since it opened in 1995 and all have profound learning disabilities, with non-verbal communication. All three men have good mobility. The home has three bedrooms, one on the ground floor and two on the first floor. There is a bathroom and toilet on the first floor and a separate toilet on the ground floor. The communal space consists of a lounge/dining room, kitchen and an area between the two rooms which currently houses the fridge/freezer. There is a small office on the first floor and the sleeping-in room is in the loft, accessed by a staircase. The washing machine and dryer are housed in an alcove next to the bathroom. There is a small garden to the rear with a lawn, shrubs and seating. The management team consists of the Registered Manager and Deputy Manager, who also manage 231 Spring Grove Road, a neighbouring home for two service users. The designated staff team for 233 Spring Grove Road are a Senior Support Worker and nine day and night Support Workers. There are three staff on each day shift, with one waking and one sleeping-in staff during the night. The team supports the service users with personal care and practical tasks, leisure and social activities. Local day services are accessed for the service users and a house car is available. Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 1st December 2005 at 11.22am. The Registered Manager was on leave and an additional visit was made on the 14th December to meet with her. A third visit took place on 30th December to examine records not available previously. The inspection took a total of five hours. At the first visit to the home, all three service users were present and three staff were on duty. One of the service users was due to attend the local Milbury day centre in the afternoon. On the second visit, all of the service users were out initially, two at a college Christmas party and one for a drive with the day centre staff. The service users continue to enjoy a range of activities and all had been on holiday since the last inspection. For an assessment of all of the key standards, this report should be read in conjunction with the unannounced inspection report of July 2005. There were four requirements at the inspection in July and three of these have been met. One is restated and a further two have been made. What the service does well: What has improved since the last inspection? What they could do better: It has been a long outstanding requirement that the Contract/Statement of terms and conditions must be completed so that services users and their representatives are fully aware of the service and facilities provided by the Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 6 home and any costs involved for the service users. It is understood that this is near completion and will be provided in the spring of 2006. Whilst the service users’ finances are managed by the London Borough of Hounslow’s customer finances department, it needs to be clarified how the personal allowances are managed by Milbury’s head office. The home’s Registered Manager is responsible for the recruitment of staff and maintenance of the records and some information was incomplete in the records examined. In order to ensure that the documentation is satisfactorily and complete, the Registered Providers need to provide the training, support and monitoring to ensure that staff employment records are compiled and maintained in accordance with the Care Home Regulations 2001 and other relevant legislation. 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. Spring Grove Road, 233 DS0000022907.V268234.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 Spring Grove Road, 233 DS0000022907.V268234.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): 2, 5 No new service users have been admitted, so the procedures could not be assessed. The provision, by the Registered Providers, of the current terms and conditions for the service users and their representatives has been long overdue and needs to be provided within the timescales now given. EVIDENCE: There have been no new service users admitted since the home was opened in 1995, so this standard could not be fully assessed. However, the policies and procedures are in place for service users to be admitted in accordance with the National Minimum Standards and Care Home Regulations 2001. The requirement for the Contract/Statement of terms and conditions to be completed, agreed and signed by the service users representatives has not yet been carried out. The Registered Manager was unsure of the current status of the terms and conditions, which were in the progress of being agreed at the last inspection, as this is within the remit of the Registered Providers. The Commission for Social Care Inspection have been informed that these are in production, along with a more user-friendly Service Users Guide and Statement of Purpose, and should be in place by the spring of 2006. It is essential that service user and their representatives are aware of the responsibilities for payments, and the services and facilities offered by the home. The Registered Providers must ensure that these are provided as soon as possible, as this is a long-outstanding requirement. Spring Grove Road, 233 DS0000022907.V268234.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): 6, 7, 8, 9 The service users’ disabilities and lack of verbal communication make full participation in decision-making difficult. However, progress has been made in involving them in the life of the home and professional help has been sought to encourage better communication. EVIDENCE: The Registered Manager has put into place new care plans that explain concisely the care that the service users need in each area of their support. Formal reviews are now taking place once a year with Social Services, to which relatives are invited. The Registered Manager will need to ensure that the new care plans are reviewed every six months, at least, to meet the National Minimum Standards. Service users are supported to participate in decision making. Although they have very little verbal communication, all of the service users are able to make their views known and one has made progress with his speech. The Registered Manager had arranged for speech therapists to attend and visual communication aids are being put into place to assist two of the service users to made decisions. This work would be greatly enhanced by the availability of Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 10 a computer in the home and it is again recommended that the Registered Providers provide this equipment. Service users are encouraged to participate in the running of the home. Because of their disabilities, there are limited ways in which this can be achieved but the service users are seen to be completing small tasks around the home, such as taking the cups to the kitchen, and clearing the table. One service user, who has not previously been involved, is now helping to take out the refuse and has become more assertive, making more eye contact than previously seen. It is noticeable that the service users seem very happy to participate and all appeared more comfortable and relaxed. None of the service users are able to go out unaccompanied and need support in all areas of daily living. Risk assessments are in place for all activities that the service users undertake. These include bathing and staff accompanying service users outside of the home. There are also risk assessments in place for the environment. These seen had been reviewed in March 2005. The Registered Manager said that she intends to review all risk assessments on a three monthly basis in future. Spring Grove Road, 233 DS0000022907.V268234.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): 11, 12, 13, 15, 16 The activities available to the service users have improved, with all of the service users now enjoying a wider choice, particularly outside of the home. EVIDENCE: Two of the service users enjoy going to activities out of the home, which include college courses and visits to the Milbury Day Centre, which is within walking distance. The third service user now goes out of the home on a regular basis and, although he still does not enjoy organised activities, goes for a weekly drive with the day centre staff. He will, however, indicate that he wishes to go to the local shop to buy a magazine and sweets and he now does at least daily. He is also walking to the day centre, which he had previously declined for many years. A picture board has been provided for him to be able to indicate the activities he wishes to undertake. Although staff now have access to a computer at the Milbury day centre, the availability of the equipment in the home would enable the staff to build on the communication tools available and tailor them to the needs of the service users, who are starting to respond to this visual stimulation. This is again recommended. The home is situated near to the busy London Road, where there are transport links to the Hounslow and Brentford shopping centres. A parade of local shops Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 12 is nearby. The home has its own transport and the service users enjoy drives. All of the service users have benefited from a holiday this year, one in Italy. Photographs are in evidence around the home of the holidays and activities enjoyed. Two of the service users had been out to the end-of-year party at the college, which included a visit to the bowling alley. All of the service users have regular contact with their family members and those who are able visit the home on a regular basis. All would be able to advocate on behalf of the service users. The Registered Manager said that the families have expressed their satisfaction with the care provided, particularly during the recent illness of one service user, and written evidence of this was seen. Service users’ rights are recognised by the staff taking notice of, and acting upon, their non-verbal communication and the choices they make. None of the service users are able to go out independently but they have freedom to move around the home and, in the summer, have been able to use the garden which has been much improved. The standard of the meals was not assessed on this inspection but the National Minimum Standards for the provision of food have been met at all previous inspections. Spring Grove Road, 233 DS0000022907.V268234.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): 18, 19, 20 The service users have their needs met by appropriate referrals to health care professionals and are fully supported through the processes by the staff. EVIDENCE: All of the service users require support with the personal care needs and details are included in their care plans of how these tasks are performed. One service user had a recent hospital admission and was supported by the staff throughout his stay. A complimentary letter from the service user’s family was seen. Service users are supported appropriately with their medication, as none would be able to self-medicate. Only two of the service users have medication at present and the Boots Monitored Dosage System is used. The medication cupboard was found to be kept in a satisfactory condition. The medication administration files contains photographs of the service users and all of the Medication Administration Sheets were in good order. The Registered Manager confirmed that there had been no medication errors. Regular visits are made from the pharmacy supplying the medication and on last one had been made in November 2005. Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaints policy and procedures are in place although none of the service users would be able to voice their concerns because of their disabilities. EVIDENCE: None of the service users would be able to make a complaint but all have family members who would be able to do so on their behalf. No complaints have been made. There have been no adult protection issues raised in the home. All but the newest members of staff have received Protection of Vulnerable Adults training and they will be attending the next available training. The London Borough of Hounslow manages the finances of all three service users. Regular payments are made monthly, for each service user, to the Milbury’s head office by the Borough. The Registered Manager explained that money is spent from the home’s weekly budget for the personal items that each service user requires. Receipts and records are kept individually on behalf of each service user for all expenditure made, a sample of which was seen. Payments for holidays and other large items are paid, from the London Borough of Hounslow, to the Milbury head office account. This is a comparatively new procedure and it was not clear how the accounts would be reconciled, as information on individual expenditure is not passed, by the home, to the Milbury head office to offset against the money received from the London Borough of Hounslow. The Registered Manager said that she would contact the Milbury finance department to make clear the status of the accounts and to ascertain if the service users have individual accounts held by Milbury so that deficits or Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 15 surpluses can be identified. Once the system is clarified, information must be held in the service users’ care plans regarding the financial procedures in place. Spring Grove Road, 233 DS0000022907.V268234.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): 24, 25, 27, 28, 30 Improvements continue to be made to the communal areas and private spaces of the individual service users to make a more comfortable and pleasant environment. EVIDENCE: It was a requirement at the previous inspection that the Registered Providers must ensure that all areas of the home are maintained on a regular basis, with a programme of ongoing refurbishment. A system for repairs that ensured the works are carried out within reasonable timescales was also needed. The Registered Manager said that a new system is in place for responding to requests to repairs and that this was working much better than in the past. The communal lounge and dining room have been improved over the last two years, with new furniture and carpets. Pictures and photographs of activities undertaken by the service users are displayed. The service users’ bedrooms have been pleasantly and comfortably furnished. A staff member has carried out some of the redecoration in the service users’ bedrooms as this was not included in the redecoration programme. All of the bedrooms were seen and were clean and tidy. Whilst the disabilities of the service users mean that they cannot always fully participate in personalising Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 17 their rooms, the staff have tried to ensure that the rooms suit the service users by providing a calmer environment. The home has one bathroom for the use of the three service users and the sleeping-in staff. There is one separate toilet on the ground floor. All of the service users are able to use the current facilities without any special equipment. Although the small room between the kitchen and the dining room does not have a specific use, apart from housing the fridge/freezer, the Registered Manager said that it provides valuable space for two of the service users who like to spend their time in the home walking around and observing. The home was found to be clean and hygienic on this unannounced inspection. A service user from another Milbury home is employed, in a therapeutic capacity, to assist with some of the cleaning of the home and is supervised by the care staff. Spring Grove Road, 233 DS0000022907.V268234.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): 31, 32, 34, 35 Staff now have the opportunity to undertake a more thorough induction, with staff training being given a high priority. EVIDENCE: It was a requirement at the last inspection that the Registered Providers must demonstrate that the Registered Manager has sufficient time available for the management of the home. In addition to the management of 231 and 233 Spring Grove Road, she manages some supported living services. She confirmed that she has a deputy manager in post to manage the supported living schemes and is carrying out the management work in time which is additional to that allocated for the management of the registered homes. Although two of the staff have been working in the home for many years, the majority of the staff team have been employed in the last two years. More training is being made available and a record was in place of the training undertaken. Staff were appreciative of the opportunity to undertake the training courses. The Registered Manager was recommended at the last inspection to add the dates of the training to the schedule, as several staff will now be requiring updated training. Work on this commenced had before the end of this inspection. A sample of staff records was examined. There were two pieces of information which were not available for inspection and the Registered Manager was asked Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 19 to provide these. At the last visit to the home, these were examined and found to be in order. The Registered Managers currently undertake their own recruitment but are not trained to do so. The Registered Providers must provide the training, support and monitoring to ensure that staff employment records are compiled and maintained in accordance with the Care Home Regulations 2001 and other relevant legislation. Two new staff had undertaken first aid, health and safety and food hygiene training shortly before the commencement of this inspection. New documentation has been put in place by Milbury which will provide a comprehensive record book of the induction of new staff. However, these were not yet complete so a full assessment could not be made. Five staff have completed the Learning Disability Framework Award induction and foundation training and one had almost finished the course. The Registered Manager said that the staff will be commencing their National Vocational Qualifications. At present only two staff, including the Manager, have these qualifications but this is partly due to there being a new staff team who have had to complete LDAF before commencing NVQ training. The Registered Providers need to ensure that the staff team are working towards their qualifications without undue delay. Regular staff meetings take place and the Registered Manager aims to carry out supervision with the staff on a monthly basis. Schedules of the recent sessions were seen and evidenced the regularity of supervision. Spring Grove Road, 233 DS0000022907.V268234.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): 37, 38, 39, 41, 42, 43 Progress continues to be made in improving the organisation of the home and the majority of the records were in place and easy to access. However staff need to be assessed to be competent at carrying out the health and safety checks in the home before being given this responsibility. EVIDENCE: Improvements have been made by the current Registered Manager and her staff to the general management of the home which has resulted in a better quality of life for the service users. The staff indicated their satisfaction with the management of the home and good leadership has been observed. The Registered Manager tries to encourage staff to undertake training and take on areas of responsibility in order to develop their skills. The staff team were found to be friendly and helpful and the home has a good atmosphere. Because of the disabilities and non-verbal communication of the service users, they would not be able to express their views directly about the quality of care in the home. However, all have relatives who visit and would be able to advocate of their behalf. The Operations Manager has made detailed, regular Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 21 visits to the home under Regulation 26 of the Care Home Regulations 2001 and these have been submitted, along with copies of the financial budgets, to the Commission for Social Care Inspection on a regular monthly basis. Quality assurance reviews have been held and statistical information provided to the Commission for Social Care Inspection regarding these. However, the information has not been provided in a format which would be readily accessible to the service users’ families who act on their behalf. It was discussed with the Registered Manager and recommended that a report should be compiled from the information, which would detail the development of the service, and in a format which would be accessible to service users’ representatives. This also needs to be submitted to the Commission for Social Care Inspection. At the last inspection, the Registered Manager was required to ensure there was sufficient monitoring of the maintenance records for accuracy and that staff are fully aware of their responsibilities and obligations regarding health and safety. An error was found on the first visit regarding the way in which the fire alarms were being tested. This was discussed with the member of staff on duty, who had been given responsibility for the testing while the Registered Manager was on holiday, and the correct method was explained. The Registered Manager said that she reinforced this when she returned from holiday and the correct system in now in place. Fire drills have been held on a monthly basis and there is a record of individual instruction being given to each staff member regarding the fire precautions. There had been a 50 service of alarms and emergency lighting in February 2005 and a further visit in September 2005. London Fire and Emergency Planning Authority last visited in July 2003. The Landlord’s Gas safety check was carried out in September 2005 and small electrical appliance testing was carried out in January 2005. Spring Grove Road, 233 DS0000022907.V268234.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 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Spring Grove Road, 233 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 2 3 3 DS0000022907.V268234.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5 (1) b Timescale for action The Contract/Statement of terms 31/03/06 and conditions must be completed, agreed and signed by the service users representatives. (Previous timescale of 31/08/05 not met) Information on the service users’ 28/02/06 financial accounts must be clarified to ascertain if individual accounts are held and how they are reconciled. This information must be available for available for inspection. The Registered Providers must 31/03/06 provide the training, support and monitoring to ensure that staff employment records are compiled and maintained in accordance with the Care Home Regulations 2001, Schedule (6) and other relevant legislation. Requirement 2. YA23 20 (1) 3. YA34 17 (2) Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 24 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. Refer to Standard YA7YA12 YA39 Good Practice Recommendations That the provision of equipment, such as computers, be explored to provide the non-verbal service users with additional activities and stimulation. That the information from the quality assurance review is compiled into an accessible report for the service users’ representatives and the Commission for Social Care Inspection. Spring Grove Road, 233 DS0000022907.V268234.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Spring Grove Road, 233 DS0000022907.V268234.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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