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Inspection on 28/08/07 for Station Road (1)

Also see our care home review for Station Road (1) for more information

This inspection was carried out on 28th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Annual Quality Assurance Assessment (AQAA) states: "We have weekly House meetings where the people we support have the opportunity to discuss the things that they like, dislike, the food they want to eat, days out, holidays etc. We have a motivated, committed and skilled staff team." Most of the people who live in the home have lived there for many years, and some have been there since the home first opened. For them it is truly their home, and the staff assist them to make choices about their daily lives. The staff have a good relationship with the residents, and provide a good quality of personal care for those who need it. MacIntyre has a robust system of quality assurance that takes the views of the residents into account.

What has improved since the last inspection?

The Annual Quality Assurance Assessment (AQAA) states: "It is fair to say that Station Road has gone through a transition period over the last 12 months. However in the latter part of the last 12 months improvements have been made in a number of areas which include: More daily activities. Service users involved in the recruitment process. The building has been redecorated, and the people we support have been heavily involved in the process." A new manager has been appointed since the last inspection. He has extensive experience of management and senior management of care homes and supported living for people with learning disabilities. In the short time that he has been in post he has taken forward improvements in the home, such as recruiting new staff, organising additional training, and updating the care plans. Training courses have been organised for specific needs, including end of life care, mental health in later life and dementia. A trainer from Sense is providing training and information about sensory impairment. The staff who we spoke to said that the care plans provide them with good information on each person`s needs, so that they are able to provide a good quality of care in the way that each person wishes. The care plans have good information on specific needs, such as sensory impairment and behaviour management. One person has been assessed for and provided with a new wheelchair that suits their individual needs. Another person has had an assessment by the sensory impairment rehabilitation officer, who provided advice on making the environment more suitable for them. The number of support staff has increased since the last inspection. There are now three support staff in the home during the day. The staff that we spoke to said that they are now able to provide one to one activities and outings for the people in the home. They are much happier now, and feel very positive about working in the home. Training courses have been organised for specific needs, including end of life care, mental health in later life and dementia. The dining room and first floor landing have been redecorated. The bedroom of the person who is blind has been redecorated in light colours that provide some differentiation so that they can find their way around more easily. The garden has been redesigned, and there is now a patio area and summer house that are accessible for wheelchairs.

What the care home could do better:

The Annual Quality Assurance Assessment (AQAA) states: "We have found that during the last 12 months the issues that made it hard for us to improve as much as we would have liked are support worker vacancies, there has not been a full time Head of Service for over six months, and inadequate staffing levels due to changing needs. We have tried to reduce these barriers by a continuous recruitment campaign, and requesting reassessments from sponsoring authorities." The manager recognises that further recruitment is needed to increase the number of permanent staff, and this is in process. The sponsoring authorities have not yet responded to the request for reassessments. This means that the additional staff that are already in place are not funded by the fees received from the sponsoring authorities. The people who live in the home are aged between 71 and 80. Most of the people who live in the home have lived there for many years, and they are becoming physically frailer. The lift in the home has been out of action twice in the last six months, and some people have not been able to go upstairs to their bedrooms. On one occasion one person slept in the lounge for four days, and on another two people stayed at another home for one night. Some of the recommendations made by the sensory impairment rehabilitation officer havenot been implemented. These issues need to be addressed so that the home is safe and accessible for everyone who lives there.

CARE HOMES FOR OLDER PEOPLE Station Road (1) 1 Station Road Wheathampstead Hertfordshire AL4 8BU Lead Inspector Claire Farrier Unannounced Inspection 28th August 2007 12:00 X10015.doc Version 1.40 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 Station Road (1) DS0000019556.V349941.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 Older People. 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. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station Road (1) Address 1 Station Road Wheathampstead Hertfordshire AL4 8BU 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) 01582 833 957 01582 833 969 Macintyre Care Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th February 2007 Brief Description of the Service: 1 Station Road is a care home providing personal care and accommodation for six people with a learning disability, who may also be aged over 65. It is owned by MacIntyre Care, which is a voluntary organisation. Station Road is a two storey, Victorian house, standing in large grounds in the village of Wheathampstead, close to local shops and amenities. The accommodation comprises six single bedrooms, one of which is ensuite, dining room, lounge, large kitchen, utility room, two bathrooms plus a shower room. The first floor is served by a passenger lift. The home has a riverside garden with seating area and has car parking to the rear. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective residents. The current charges are £1034.81 per week, and each person pays a personal contribution of £98.60 towards this. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent one afternoon at 1 Station Road, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We met and talked to all the people who live in the home. We also talked to some of the staff, and to the home’s manager. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CSCI before the inspection, and his assessment of what the service does in each area. Evidence from the AQAA has been included in this report. What the service does well: What has improved since the last inspection? The Annual Quality Assurance Assessment (AQAA) states: “It is fair to say that Station Road has gone through a transition period over the last 12 months. However in the latter part of the last 12 months improvements have been made in a number of areas which include: More daily activities. Service users involved in the recruitment process. The building has been redecorated, and the people we support have been heavily involved in the process.” A new manager has been appointed since the last inspection. He has extensive experience of management and senior management of care homes and supported living for people with learning disabilities. In the short time that he has been in post he has taken forward improvements in the home, such as recruiting new staff, organising additional training, and updating the care plans. Training courses have been organised for specific needs, including Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 6 end of life care, mental health in later life and dementia. A trainer from Sense is providing training and information about sensory impairment. The staff who we spoke to said that the care plans provide them with good information on each person’s needs, so that they are able to provide a good quality of care in the way that each person wishes. The care plans have good information on specific needs, such as sensory impairment and behaviour management. One person has been assessed for and provided with a new wheelchair that suits their individual needs. Another person has had an assessment by the sensory impairment rehabilitation officer, who provided advice on making the environment more suitable for them. The number of support staff has increased since the last inspection. There are now three support staff in the home during the day. The staff that we spoke to said that they are now able to provide one to one activities and outings for the people in the home. They are much happier now, and feel very positive about working in the home. Training courses have been organised for specific needs, including end of life care, mental health in later life and dementia. The dining room and first floor landing have been redecorated. The bedroom of the person who is blind has been redecorated in light colours that provide some differentiation so that they can find their way around more easily. The garden has been redesigned, and there is now a patio area and summer house that are accessible for wheelchairs. What they could do better: The Annual Quality Assurance Assessment (AQAA) states: “We have found that during the last 12 months the issues that made it hard for us to improve as much as we would have liked are support worker vacancies, there has not been a full time Head of Service for over six months, and inadequate staffing levels due to changing needs. We have tried to reduce these barriers by a continuous recruitment campaign, and requesting reassessments from sponsoring authorities.” The manager recognises that further recruitment is needed to increase the number of permanent staff, and this is in process. The sponsoring authorities have not yet responded to the request for reassessments. This means that the additional staff that are already in place are not funded by the fees received from the sponsoring authorities. The people who live in the home are aged between 71 and 80. Most of the people who live in the home have lived there for many years, and they are becoming physically frailer. The lift in the home has been out of action twice in the last six months, and some people have not been able to go upstairs to their bedrooms. On one occasion one person slept in the lounge for four days, and on another two people stayed at another home for one night. Some of the recommendations made by the sensory impairment rehabilitation officer have Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 7 not been implemented. These issues need to be addressed so that the home is safe and accessible for everyone who lives there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on residents’ needs and access to appropriate services to enable their needs to be met. EVIDENCE: No one has moved into the home since the last inspection. In the last report we said that an assessment was carried out before the person moved in, and there has been a continuous process of assessment, so that the staff could get to know the person’s needs. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 10 There are more staff in the home during the day, and the staff that we spoke to said that they now have time to support each person appropriately. The care plans have good information on each person’s individual needs, and training has been put in place so that the staff have a greater understanding of the needs associated with increasing age, such as the possibilities of dementia, depression and decreasing mobility. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans provide clear information on the residents’ care needs, which enable the staff to provide a good quality of care. The home has good procedures for administering and recording medication safely. EVIDENCE: The care plans are written in a person centred format, which shows that people are involved in making decisions about their care and their lives in the home. The care plans that were seen contain good details of each person’s personal care and health care needs. Since the last inspection a new format has been introduced, which provides clearly written details of each person’s needs and the procedures for supporting them. The process of transferring all the care plans to the new format has not been completed. One new care plan was seen. This is written in a person centred way and contains good information to assist the staff to support the person appropriately. The person is partially sighted, and the information on supporting them includes, “The two Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 12 main areas that you need to think about when supporting me are light and contrast.” And, “The people supporting me need to remember that I did once have sight.” It was reported that different methods are being considered so that each person can have access to their care plan, including the use of photographs for one, and the use of the computer for another. This should be developed and progressed. Well written risk assessments have been completed that relate to the care plans, to ensure that the people who live in the home can do the activities that they wish to. The risk assessments are kept in a separate file, and the care plan makes reference to them where appropriate. The staff who we spoke to said that the care plans provide them with good information on each person’s needs, so that they are able to provide a good quality of care in the way that each person wishes. One care plan that we saw has good information on understanding the person’s behaviour. This person’s recent Whole Life Review states that an improvement is: “The staff understanding on how to respond to X and the increased awareness of X’s commutative needs. This appears to have impacted on X, who does appear to be more happy and relaxed. If X does become distressed the people supporting X place more of an emphasis on trying to understand X, solve the problem, and less on the impact of the behaviour displayed.” Referrals have been made where appropriate for professional assessments, such as psychiatrist and occupational therapist. One person has a new wheelchair designed for their needs. The home has satisfactory procedures for the administration and recording of medication. A weekly audit is carried out to make sure that the medication has been administered properly. The temperature in the medication cupboard is recorded twice a day, to make sure that it does not rise above the manufacturer’s recommended temperature for any medication. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported to live full and active lifestyles. EVIDENCE: Following the last inspection the number of staff in the home has increased, and everyone is now supported to take part in their choice of activities in the home and in the community. The home has a good relationship with the local community in Wheathamstead, especially with the local Church. Most of the residents attend a day centre for two or three days a week, and one goes to a local club once a week. Two people have had a holiday, and are now planning their next one. The other people in the home have chosen not to go on holiday, but to have day trips. These include trips to the zoo, the seaside and a boat trip. One person goes to the hairdresser every week, and has beauty treatments and manicures. One person talked about a recent visit from their brother, and showed us photographs of the visit. The people who live in the home choose the weekly menus with the staff, and may also do the weekly shop with a member of the staff. Lunch took place Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 14 during this inspection. The staff had lunch with the people in the home, and it was a very sociable occasion. The staff supported people who needed assistance or encouragement. After the meal one person cleared the table and swept the dining room floor. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are confident that their concerns are listened to, and that they are safeguarded from the risks of abuse. EVIDENCE: There has been no change in the procedures for safeguarding people from abuse. At the last inspection we found that the home has a satisfactory complaints procedure in place. The people who live in the home are encouraged to make their concerns and complaints known. The record of complaints shows that people have made complaints about the care of their clothes and about the quality of food. There have been no complaints since the last inspection. The home has adequate policies concerning safeguarding adults (adult protection) and whistle blowing. All staff have had training in the prevention of abuse, and the staff spoken with were aware of the procedures for reporting any allegations of abuse. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a safe and comfortable environment for the people who live there. EVIDENCE: 1 Station Road is a two storey Victorian house, standing in large grounds in the village of Wheathampstead. It is furnished and decorated in a domestic styles that produces a homely, comfortable environment and that allows the residents to relax and feel very much at home. Each person has their own room, arranged and decorated to reflect their particular interests and tastes. The lounge, dining room and kitchen are domestic in style and are comfortably furnished and well equipped. Since the last inspection the dining room and first floor landing have been redecorated. The bathrooms are due to be completely refurbished, with baths and a shower that are suitable for the Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 17 changing needs of the people in the home. The garden has been redesigned, and there is now a patio area and summer house that are accessible for wheelchairs. There is an ongoing programme for redecorating the bedrooms, and most have been completed since the last inspection. The bedroom of the person who is blind has been redecorated in light colours that provide some differentiation so that they can find their way around more easily. The sensory impairment rehabilitation officer carried out an assessment, and recommended some changes in lighting in the communal areas and visual strips on the stairs. These improvements have not yet been carried out. Within the last six months, people have been unable to access their rooms on the first floor on two occasions. On the day following the last inspection the lift broke down, and was out of use for four days. One person had to sleep in the lounge on the ground floor as they were unable to use the stairs. Since then, it has been reported that the lift was again out of order due to a power cut, and two people had to stay at another home for the night. The home appeared to be clean and generally well maintained, and the staff follow appropriate procedures to maintain hygiene and prevent the risk of infection. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A stable staff team who have the experience and training to understand and meet the residents needs support the people who live in the home. EVIDENCE: The number of support staff has increased since the last inspection. There are now three support staff in the home during the day. The staff that we spoke to on this occasion said that they are now able to provide one to one activities and outings for the people in the home. They are much happier now, and feel very positive about working in the home. The home has a stable staff team. Two new permanent members of staff have been appointed since the last inspection, and more are currently being recruited. MacIntyre provides a good training programme that covers all the mandatory health and safety training. The induction training for new staff is designed for their work with people with learning disabilities. All the support workers either have a NVQ qualification or are waiting to start. All staff are expected to train for a qualification, and the company gives them a pay increase when they complete the qualification. Training courses have been organised for specific needs, including end of life care, mental health in later life and dementia. A Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 19 trainer from Sense is providing training and information about sensory impairment. Staff records are kept at MacIntyre headquarters. The procedures for recruitment of staff ensure that suitable people are employed to safeguard the people who live in the home. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The views of the residents and other involved people are actively sought in order to ensure that a good quality of care is provided. EVIDENCE: A new manager has been appointed since the last inspection. He has extensive experience of management and senior management of care homes and supported living for people with learning disabilities, and he has completed the Registered Managers Award. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 21 Macintyre has a robust system for quality assurance, including an annual audit of the service and regular monitoring visits to the home. These visits include consultation with the people who live in the home, and any issues that are raised are addressed by an action plan. The quality assurance process includes an annual development plan for the service. The last development plan recommended that everyone should have a person centred care plan, and this had been acted on. The arrangements for management of residents’ money were inspected during the last inspection and appeared to be accurate. Money is stored safely and adequate records are maintained in order to protect service users from financial abuse. The home maintains appropriate records for the health and safety of the residents and staff in the home, and staff follow the home’s policies and procedures. All the staff have training in moving and handling, fire safety, food hygiene and infection control as part of their induction. Regular fire drills take place in the home, but there is no evidence that every member of staff takes part in a fire drill. Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP22 Regulation 13(4) Requirement All areas of the home must be accessible for the people who live in the home. In particular, people must be able to reach their bedrooms on the first floor. The improvements recommended by the sensory impairment rehabilitation officer must be put in place. The names of staff taking part in fire drills must be recorded to ensure that every member of staff takes part in at least one fire drill a year. Timescale for action 30/11/07 2. OP38 23(4)(e) 30/11/07 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 Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Station Road (1) DS0000019556.V349941.R01.S.doc Version 5.2 Page 25 - 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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