Inspection on 20/06/06 for Spring Grove Road, 233

This inspection was carried out on 20th June 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 4 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 01/12/05

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 Key Unannounced Inspection 20th June 2006 2:00 Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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.V293794.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 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, all male. 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. The current weekly fees range from £1476.23 to £1483.15. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 20th June 2006 from 2pm to 4.40pm. The Registered Manager was present. There were three members of staff on each of the early and late shifts. The inspection process took a total of four hours. One service user was at home at the commencement of the inspection and the two other service users arrived home after visits to the local Milbury Care Centre. All of the service users now enjoy a variety of outings and day services and two were due to go on holiday at the weekend following the inspection. Five of the staff were met and a tour of the home took place. A variety of records, which were found to be in good order, were examined. Three requirements were made at the last inspection. Two were met but one, on the contract/terms and conditions, is not fully met and this has been repeated. An additional three requirements have been made. What the service does well: What has improved since the last inspection? What they could do better: Work on the Contract/Statement of terms and conditions needs to be fully completed. Staff must be fully aware, particularly in the absence of the Registered Manager, that they must report any issues which may prove to the health and safety hazards for the service users. Both the excessive hot water and the non-closing fire door needed to be reported promptly to minimise risks. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 6 The bathroom is in need of refurbishment and an Action Plan is required to show when this work will be carried out. 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.V293794.R01.S.doc Version 5.1 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.V293794.R01.S.doc Version 5.1 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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Better documentation, to assist service users or their representatives to make a decision about living in the home, and about facilities and services, has been updated. This work has been long overdue and now includes an amended service agreement. No new service users have been admitted so the assessment procedures could not be fully assessed. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated to provide clearer information of the services provided. The current service users, because of communication difficulties, would be unlikely to be able to understand the Service Users Guide, even in a visual format. However, all have families who can make use the information on their behalf. No new service users have been admitted since the home was opened in 1995, so the assessment procedures cannot be assessed. However, reviews of the service users’ support needs take place regularly to ensure these are being met. Formal reviews were due to be held shortly and a date had been arranged. Procedures are in place should assessments be required in the future. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 9 The requirement for the Contract/Statement of terms and conditions to be completed, agreed and signed by the service users representatives has been long outstanding. These have finally been produced. None of the service users would be able to sign or understand the service agreements, but have families who are able to do so for them. These had not yet been fully completed, and the Registered Manager has undertaken to do this. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is in place to show how the support needs of the service users are to be met and how improvements can be made to their quality of life. Although the service users’ lack of verbal communication makes participation in decision-making difficult, the staff have made progress in helping them to become more independent and to choose what they would like to do, both in and out of the home. EVIDENCE: The care plans of the service users are due to be updated following the annual reviews in early July. The Registered Manager said that all aspects of the service users’ lives will be covered and the goals planned at that review will be detailed in the care plan. Although these have often been quite small aims, the work of the staff team to bring them to fruition has resulted in a better quality of life for the service users. The current care plans are reviewed regularly, at least three monthly, and risk assessments are in place where Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 11 required. All three of the service users now have a social worker from the local authority and their families, and professionals who provide support, are invited to their review meetings. The work carried out by the staff, in supporting the service users to improve their communication and independence, has resulted in the service users being much more active both in the home and the community. All three of the service users showed much more interaction with the staff team and a number of improvements were noted. One service user greeted the Inspector, leading the way to the kitchen to make tea. This is an activity never previously observed at the many inspections carried out. Another service user now has a small vocabulary of words. Staff spoke of the signs that the service users use to indicate that they would like to go out. Milbury’s behavioural therapist has been involved in supporting the staff to improve the communication of the service users. The eye contract with the service users is much improved. The Registered Manager and staff are to be commended for this work. Some symbols have been provided for staff to work with one of the service users. It is again recommended that this could be enhanced by the availability of a computer in the home, to enable staff to produce visual items which are individualised to the service users. Several albums of photographs are available to show the activities in which the service users take part, particularly when helping with small tasks around the home. No service users are able to go out unaccompanied and all need support in all areas of daily living. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users continue to enjoy a wider range of activities, particularly outside of the home. Relationships with families are maintained and encouraged. EVIDENCE: All three of the service users now attend the local Milbury day centre, which is within walking distance. One service user did not attend for many years but now goes for drives with the centre. He has made further progress by going inside the day centre, which he preferred not to do in the past and it is hoped that this will progress to staying there for longer periods. He is also able to indicate when he would like to go to the local shops or for a walk. One service user particularly likes to help around the house and helps with the shopping for the house. Another service user, who did not like to go out very far, has recently enjoyed trips further afield, including one to Macdonalds. A four day holiday was planned for two of the service users for the weekend Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 13 following this inspection. Another service user is due to go in the autumn, and for the second time, to Venice. Photographs were seen of the first visit, which looked to be very much enjoyed. Although one service user does have the radio and television on, often at the same time, the service users obtain limited enjoyment from entertainments within the home. The home has its own transport so use is made of this, as well as public transport and walks, to ensure that the service users can participate in activities out of the home. Each service user has a programme and one regularly attends bowling. There are regular visits to and from family members. Staff showed a good awareness of the service users’ improved communication skills and a good rapport between the service users and staff was observed. The menu seen was varied and is based on the foods that the service users enjoy and meals taken are recorded. The Registered Manager said that the menu is based on the diet recommended by the nutritionalist, who was consulted regarding a low cholesterol diet for one service user. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and medical needs of the service users are met with regular visits to medical professionals. The medication administration was found to be satisfactory. EVIDENCE: Support is required by all of the service users with their personal care. There is one bathroom for the use of the three service users. A health file is kept for each of the service users and details of all the visits made, and a schedule maintained to show clearly when the last visit to each of the services was made. Wherever possible, the service users are taken out of the home to access community services, rather than health staff coming to the home. The general wellbeing of the service users seems much improved and staff said that one service user now sleeps much better than in the past. Only two of the service users have medication. A 28-day blister pack system is used. Regular visits are made by the pharmacy, of which the reports were seen. The medication seen was in order and no PRN (“as and when” medication) or homely remedies are used. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All of the service users have advocates who would be able to complain on their behalf and the complaints procedure is displayed. Adult protection training has been held and the Registered Manager, who is a trainer, shows a good awareness of the procedures. EVIDENCE: No complaints have been made. While none of the service users would be able to make a verbal complaint, all have families who visit and would be able to advocate on their behalf. There have been no adult protection issues raised in the home. The Registered Manager is now an adult protection trainer and showed a good awareness of the procedures. No money is held on behalf of service users and the staff are not aware of the finances of each individual service user. The Registered Manager explained the procedure for managing the service users’ finances, which were new and had not been made clear at the last inspection. Any expenditure on behalf of the service users is paid from the home’s petty cash account and is reimbursed, by the London Borough of Hounslow, to Milbury’s head office. Larger sums, such as those for holidays, are requested through the Borough. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, tidy and pleasant environment is provided for the service users. Improvements continue to be made to the communal areas and bedrooms, although the bathroom is in need of refurbishment. EVIDENCE: All of the areas of the home were found to be well maintained by the staff. There is one domestic help employed, who is a service user from another home, who is provided with therapeutic earnings. The communal lounge and dining room are pleasantly furnished. Pictures and photographs are displayed, many of the service users’ activities and outings. Bedrooms have been nicely furnished and personalised, as much as possible, on behalf of the service users. All of the bedrooms were seen and found to be clean and tidy. The first floor bathroom, with toilet and bidet, is the only one available for the service users and also has to be shared by the member of staff who sleeps in. There is a separate toilet on the ground floor. There are no washbasins in the Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 17 rooms as the home was previously registered as a “small home” under previous legislation and did not require them. The provision of these should be considered. The bathroom is in need of refurbishment, and there is a broken tile which needs to be replaced. An Action Plan is required for this work. There is no shower over the bath and the choice of equipment would be beneficial. No special equipment is currently required as all of the men are mobile. The lounge/dining room and the small room between the kitchen and dining area are the only communal areas. The home is kept free from excessive furniture so that the men, who like to walk around these rooms, can do so with safety. Two of the men particularly like to look out of the lounge window, which overlooks a busy road. The small garden is now tidy and has seating for the service users and staff to use. The Registered Manager and staff carry out work on the gardens. Another barbecue was being planned, following a successful one last summer for families, staff and service users from other local homes. There is no laundry room, and an area outside of the bathroom houses the washing machine and dryer. The door to this area needed to be adjusted to ensure that it closes fully. The Registered Manager said that this was a recent problem and she reported this during the inspection for repair. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is now a full staff team, with no agency staff are used, which provides good consistency for the service users. All of the staff have undertaken the Learning Disability Framework Award induction procedures. EVIDENCE: The Registered Manager is continuing to manage both 231 and 233 Spring Grove Road, in addition to some supported living units. It has been previously required that the Registered Providers must demonstrate that she has sufficient time available for the management of the homes. The deputy manager has now returned, having been seconded to manage the supported living units, and the senior support worker has returned after nine months’ absence. This should ensure that there is more management support for the Registered Manager but it needs to be kept under review. The service users are supported with sufficient staff for one-to-one support throughout the day and evening shifts, with two staff in the home at night. All of the staff have been in post for some time and have undertaken the Learning Disability Framework Award induction programme as well as the Milbury induction. A completed induction record was seen for a newer member of staff. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 19 All of the records examined evidenced that the documentation in the home is up-to-date. The staff records were in order and supervision is being carried out on a regular basis. The Registered Manager has put into place a more comprehensive training schedule which shows that the staff training is up-to-date. Staff said that they have the opportunity to participate in training regularly. One staff member has National Vocational Qualifications Level 3 and is training to become an assessor. Three are undertaking National Vocational Qualifications, one at Level 2 and two at Level 3. Other staff are interested in taking the qualification as soon as the opportunity becomes available and have completed their Learning Disability Framework Award, which is required before they commence. However, the home has not met the target of having 50 of the staff team fully trained. The Registered Manager said that an audit of the home’s recruitment files had been undertaken by the company’s Human Resources officers. A small sample was seen on this inspection, which had been previously examined, as no new staff have been recruited. The Registered Manager said that the Human Resources department will now check the documentation before the staff are employed. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation in the home is good, with records up-to-date. However, staff need to be more aware of reporting health and safety issues, such as the excessively hot water and the fire doors needing repair. EVIDENCE: The Registered Manager is qualified to National Vocational Qualifications Level 4 and has the Registered Managers Award. She has been manager of the home for three years, during which time there have been many improvements to the management, environment and, in particular, the quality of life for the service users. There is a relaxed and pleasant atmosphere in the home, with a good rapport between staff and service users, even though little of this is verbal. Staff are encouraged to use their initiative. Regular Regulation 26 visits are made to the home on behalf of the Registered Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 21 Providers. Quality assurance reviews take place, although not presented in formats which would be easily understood or provide for an improvement and develop plan. The next report should be made available for service users, their representatives and Commission for Social Care Inspection in this format. Staff need to be more vigilant about reporting health and safety issues. As mentioned elsewhere in this report, a fire door would not shut tightly and needed repair. The records showed that the hot water in the bathroom was found to be recorded at over 50°C. It had been recorded in April as being over the safe limit of 43°C when there were problems with the boiler and repairs had to be made. The Registered Manager phoned the maintenance department during the inspection, who said that they would come the next day. The fire records were found to be in order with a schedule of fire drills and which staff had attended them being kept. The fire risk assessment had been reviewed. A visit by the London Fire and Emergency Planning Authority was carried out in March 2006 and, although no letter was received, the fire officer recorded in the records that the precautions were satisfactory. 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.V293794.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 X 4 X 5 2 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 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Version 5.1 Page 23 Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc 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 31/07/06 and conditions must be completed, agreed and signed by the service users representatives. (Previous timescale of 31/03/06 not fully met) It must be ensured that 15/07/06 designated fire doors close completely at all times and, when faults are found, staff must be made aware that prompt reporting is required for maintenance to be carried out. An Action Plan is required for the 31/08/06 refurbishment of the bathroom. Staff must be made aware that, 15/07/06 where hot water temperatures are recorded above the safety levels, action must be taken to have this reported promptly, so that action can be taken to remedy the fault. Requirement 2 YA24 23 (4) 3 4 YA27 YA42 23 (2) (b) 13 (4) Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 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 3 Refer to Standard YA12 YA27 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 provision of wash basins in the service users’ bedrooms is considered. That the information from the quality assurance reviews is compiled into an accessible report for the service users’ representatives and the Commission for Social Care Inspection. Spring Grove Road, 233 DS0000022907.V293794.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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.V293794.R01.S.doc Version 5.1 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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