Inspection on 21/07/05 for Station Road 159

This inspection was carried out on 21st July 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station Road 159 21/08/07

Station Road 159 26/01/07

Station Road 159 16/01/06

Station Road 159 01/12/04

Station Road 159 19/05/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 159 & 159a Station Road Hendon London NW4 4NH Lead Inspector Margaret Flaws Unannounced 21 July 2005 @ 09.00am 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 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 Stationary 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. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 159 & 159a Station Road Address 159 & 159a Station Road, Hendon, London NW4 4NH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8203 5029 020 8203 5029 Norma Brier of Norwood Ravenswood Victoria Connelly-Hall PC Care Home only 14 Category(ies) of LD(E) Learning Disability over 65 (1) registration, with number LD Learning Disability (14) of places PD Physical Disability (1) MD Mental Disorder (14) 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 14 adults with a learning disability (LD) and/or a mental disorder (MD). 2. A specific service user who is currently resident in the home with a physical disability (PD) can reside in this home. This condition will need to be reviwed when s/he vacates the home. 3. A specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. Date of last inspection 1 December 2004 Brief Description of the Service: 159 and 159A Station Road are two self-contained buildings on one site that are currently registered as a single care home for fourteen adults who have a diagnosis of learning disability or mental disorder. One specified service user may also have a physical disability and another specified service user may also be over sixty-five years of age. The home is run by Norwood, a Jewish charity operating services for adults and children with learning disabilities. The two buildings opened in June 1997. 159 is a large detached property that has been adapted to accommodate five service users. The kitchen/diner, the lounge and managers office are situated on the ground floor. Four service user bedrooms and laundry are on the second floor and another bedroom on the third floor. 159A is a purpose built property located to the rear of the site. This building can accommodate up to nine people. There are currently eight service users accommodated. This allows one service user with specific identified needs to have additional personal space. There are six service user bedrooms on the first floor and three on the ground floor. There are toilet and bathroom facilities on both floors. There is a lounge, dining room, kitchen and laundry on the ground floor. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted approximately 8 hours. It was undertaken by Inspector Margaret Flaws, as part of the routine schedule of inspections for the home. The manager and 10 staff of 159a Station Road and four staff at 159 Station Road were seen on the first inspection day and the manager at 159 Station Road was available on the second day. There were two vacancies at 159a Station Road on the day of inspection and one at 159 Station Road. The inspector was able to speak to six service users, the managers of each house and a total of fifteen staff. No relatives were visiting during the inspection. A tour of the buildings and grounds, inspection of service user files, staff records, general home records and policies and procedures formed the basis of the inspection. Two new requirements were made and four restated from the last inspection. What the service does well: The home specialises in providing care to Jewish residents with learning disabilities. The quality of care at 159a and 159a Station Road is good. The environment in both houses is homely, comfortable and very well maintained and presented. Norwood’s commitment to supporting the service user’s lifestyles and goals was apparent from the range of activities (individual and group) undertaken, the degree of the service user’s participation in decisions affecting their lives and the sound processes of review in place. The staffing situation at 159 Station Road has improved since major issues were resolved earlier in the year with the dismissal of three staff. A new team staff has been recruited and were enthusiastic and competent in their work. They were observed to carry out their tasks in a caring and sensitive way. There were good relations between service users and staff and there was a friendly and welcoming atmosphere at the home. An adult protection issue has been dealt with appropriately. All service users spoken were positive about the quality of care they receive. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 standard(s) 2, 4, and 5 Service users’ needs are assessed before they move so that they can be confident that their needs will be met. However, each service user must have a copy of their terms and conditions on their files. EVIDENCE: There have been no new admissions at 159a Station Road but one long term service user has moved from 159a to 159 Station Road on request. This house has more independent service users and offers more appropriate accomodation for this service user. In discussing the move with the inspector, she said that her wishes to live more independantly had been fully considered and that her needs were fully assessed by her placing authority and Norwood’s placing coordinator. The service user felt that the process was well handled, the transition straighforward and she said she was very happy with her new living situation. This was confirmed by staff and both managers. There is considerable daily interaction between service users in both buildings and excellent continuity to support such a move. The previous requirement for all service users to have a copy of terms and conditions was partially met because only some service users have copies on their files. A requirement is made that copies are held on each service user’s file. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 standard(s) 6, 7 and 9 Service users’ personal, health and social care needs are assessed and regularly reviewed in consultation. Changes in care are well documented. Service users are fully involved in decision making in line with their abilities, and active in determining their own measure of independence. EVIDENCE: All care plans sampled contain detailed assessments, were comprehensively reviewed and updated regularly. Service users spoken to gave good descriptions of how their care is assessed and reviewed. They are assigned key workers who work closely with them on meeting their needs and reviewing their care. Key workers are assigned administrative time to update reviews – this is generally done on an afternoon shift at 159a Station Road, where an extra staff member has been added to the rota to help cover this time. However, some staff did say that, because of the service users’ high needs, it can be difficult to get this done in a timely fashion. In a 159a handover, staff described how they are working to meet the independence needs of a service user with deterioriating health and decreasing mobility.The process of reviewing his needs involves physiotherapy and 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 10 occupational therapy support to maintain his leg mobility, and additional training for staff in supporting him while walking without injury to either party. Their primary goal is to ensure that the service user’s independence is maintained for as long as possible. Observation by the inspector and interviews with service users clearly indicated that service users are highly involved in decisionmaking about their lives on a small and larger scale. Staff were observed constantly asking, explaining and discussing daily routines and planning activities with service users. Meal and activity planning at 159 Station Road is done entirely by service users on a weekly basis. One service user described her preference to have more regular visits to the hairdresser, especially when before visiting family, and staff confirmed that these preparations are supported appropriately. Service user meetings are held at least monthly and also on an impromtu basis. Service users have comprehensive individual risk assessments kept on their files. These are regularly reviewed in consultation with service users. Risk stretching activities are an integral part of the home’s programme. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 and 17 Service users live active lives according to their wishes and abilities, have ample opportunities for personal and social growth and leisure. They are supported to maintain links with family and community. Service users privacy and dignity is protected by staff. Service users are satisfied that their diet is culturally appropriate and healthy, and offers variety and choice. EVIDENCE: Some service users participate in educational and day centre activities. Like other activities, these are individually geared to each person’s needs. Care plans contain individual development plans and schedules. As the inspection was undertaken during the college holidays, these activities were not taking place but service users described regular classes they attended. Service users are involved in a range of individual and group activities. Activities on the inspection days included bowling, shopping for shabbat, day 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 12 centre, swimming, picnic in the park, sensory room visits, computer sessions, an art class and playing snooker at the local snooker hall. Many activities are individualised and there were sufficient staff rostered to insure one to one outings matched to service user’ wishes. Other group activities include regular singsongs and fitness classes. A number of service users went out for lunch and to the park. The communal areas were very welcoming and were well supplied with DVDs, games, books and magazines for individuals to pursue at their own leisure. Some service users have televisions in their own rooms. Hoilday planning was well advanced, with all residents of 159 planning a trip to Jersey in September and individual holidays arranged for residents of 159a. Staff accompany the service users on their holidays. Local, community based leisure and learning activities provided the framework of the service users’ days. Staff were observed taking service users out as described above. The service is part of the Norwood and Jewish communities and there are links between service users in different Norwood homes. Jewish celebrations are an integral part of the life of the home. Most service users spoken to had some degree of regular family contact. Some went to stay with their families for the weekends or had visits from family. The inspector observed many respectful interactions between staff and service users. Privacy was demonstrably protected in the way that staff knocked on doors and ensured that personal care was delivered in private. Service users at both houses often came and sat down in the office during the inspection and sometimes answered the phone. This was viewed by staff as part of the spectrum of normal day to day interactions. Staff moved quickly to reassure a service user whom they sensed becoming agitated. They demonstrated sound knowledge of service users’ behaviour patterns and minor mood shifts. Some service users participate, according to their abilities, in the day to day routines of the home. Two mealtimes were observed in the home and cooking staff interviewed. Menus are rotational, offered choice and were made from scratch using fresh ingredients. Both kitchens are kosher and Jewish meals are regularly offered. The cook at 159a shops daily for fresh fruit and vegetables and fresh fruit was in evidence. Picnics are made up for outings as required. Service users’ wishes about eating times and where they eat were observed to be respected and those who needed assistance with eating were helped. The cook at 159a demonstrated a sound knowledge of service users’ dietary needs and had a large repertoire of dishes matched to individuals. At 159 Station Road, service users meet on Sunday evening to plan their menus for the week and they do the food shopping with staff assistance. One service user takes responsibility for Shabbat shopping. The cooking is done by staff, with assistance from service users. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 13 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20 Personal care is provided in line with service users’ preferences. Health checks are routine. Medication policies and procedures are appropriate, reinforced by training and monitoring and adhered to by staff. EVIDENCE: Service user care plans set out the arrangement for providing personal care. Staff interviewed were able to demonstrate a good knowledge of service users and their needs, and how they provided personal care. Some service users require a high degree of personal care in 159a. Staff providing personal care are gender matched. Letters and appointment schedules in the care plans indicated that service users have good access to regular health care appointments and specialist check ups. On inspection days, two service users visited the dentist. An updated medication and procedure has been put into place. No service users self medicate. Staff were observed giving medication in an accurate, safe and respectful fashion. As a result of previous concerns about minor medication errors, all staff are required to have medication assessments and are observed in their practice. These are kept in the training section of staff files. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 15 The new medication policy and procedure contains a section on the administration of insulin and staff have received diabetes training. The procedure for administering insulin to a diabetic client at 159a has been written up by the manager but still needs to be checked and signed by the service user’s diabetic nurse. All staff have attended medication training and have regular refresher medication courses. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service user concerns are considered and effectively addressed by formal and informal processes. Policies are in place to ensure that risk to service users from abuse is minimised and most staff are trained in this area. Updated adult protection training needs to take place for those staff who have not received any recently. EVIDENCE: No complaints have been received by the home since last inspection. The inspector identifed that the home’s complaints policy and procedure is appropriate and accessible. The home’s Adult Protection Policy is comprehensive. It is required that they obtain a copy of Barnet Council’s Adult Protection Policy and Procedure and familiarise staff with it. Staff were able to describe the adult protection process correctly. While staff have had adult protection training, this must be updated for some staff who have not had recent training. All service users spoken to said they would be comfortable to complain if they had to. An adult protection investigation has been completed and service users’ safety protected. Norwood has tried to add the name of one dismissed staff member to the POVA list but this referral was refused because this person does not fit the criteria. Service user interests are also protected by Norwood’s lay advocate scheme. Two service users and the manager also attended a ‘say no to abuse’ workshop recently. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Service users live in a pleasant environment that is decorated and resourced to a good standard. Both houses are clean and hygienic and need only minor work to maintain this standard. EVIDENCE: Staff and service users took the inspector on a tour of each building. Communal areas and bedrooms are comfortably furnished, very pleasantly decorated and well supplied with recreational and personal items. Communal areas are of a high standard and well resourced. The hall and stair carpet in 159 has been cleaned but many stains did not come out and it will need replacing. The garden and greenhouse at 159 is well maintained by service users on a weekly basis. Both houses were very clean, tidy and well presented on the unnannounced inspection days. Infection control is maintained by safe working procedures, including a red bag system, and washing machines have sluice cycles. The carpet in one doubly incontinent service user’s room at 159a Station Road is due to be replaced and is subject to a requirement. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36 Service users benefit from a staff teams who are clear about their roles and responsbilities. The period of disruption at 159 Station Road appears to be over. Staff training is programmatic and broad in scope. The gaps are in adult protection training, which have been addressed under standard twenty three. Sound supervision policies and procedures and effective management grounds staff practice. EVIDENCE: 159a had two vacancies on the day of the inspection, both of which have been filled and new staff will start next month. Other shifts were covered on the day of inspection have been filled by a ‘cluster recruitment’ of staff from the Phillipines and Phillipino workers from Israel. At 159, there is one current vacancy for a ‘C’ grade staff member, which is covered internally with minimal use of agency staff. The service disruption caused by the suspension of five staff and the dismissal of three staff at 159 Station Road has been mitigated by the recruitment of a new staff team and the positive team culture instilled by the manager. Some staff have been recruited from other parts of the organisation. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 19 An examination of staff files and discussions with staff revealed that training, including an intense organisational induction, is well targeted and comprehensive. As part of Norwood’s core training programme, staff are trained in manual handling, record keeping and communication, fire safety, first aid, risk asssessment, understanding service user’s points of view, challenging behaviour, providing personal care, the Jewish way of life, autism, diabetes, adult protection, health and safety, food handling, epilepsy and adult protection. All staff receive regular supervision, covering appropriate areas, which is documented and signed off. Regular staff meetings are held and minuted. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 The registration of the houses as separate services is still in process but the homes are well run and the service users have not been disadvantaged. Service users are consulted in an empowering way. General health and safety practice is good but fire safety recording is poor and must improve. A magnetic door stop must be fitted between the dining room and the kitchen of 159a. The organisation has sound business planning cycles and practices which need to be reflected at service level. EVIDENCE: There is no registered manager for the service. Each house has a manager and separate registration applications for each manager are pending, along with the application for registration of both homes as separate services. The application for one registered manager has been returned by CSCI’s Central Registration team so that the applicant can apply for a CRB check first. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 21 The previous requirement is therefore partially met. Norwood’s organisational quality assurance working party, which included service users, has produced an action plan, has delegated responsiblities and set timeframes. Relatives are currently being surveyed for their views on the quality of care. A new cycle of working party meetings will review the health services provided and develop health assessment plans. The manager’s of each service have been participants in this process. Service user meetings are held monthly and are the main regular quality assurance tool currently in place. Fire records have not been kept up to date in both houses, although staff indicated that fire drills occur regularly and alarms are tested weekly. It is a requirement that all fire safety records be bought up to date and maintained up to date. It is also a requirement that the door between the lounge and dining room of 159a be fitted with a magnetic door stop . The home has requested a visit from the fire service but has not received a reply by the date of the inspection. Fire equipment is regularly checked and serviced on contract. Six monthly evacuations involving service users take place at 159a and at 159, there is an unplanned evacuation every three months and a planned evacuation every six months. Call bell systems have been serviced and are in good working order. Accidents and incidents are well recorded. On the day of the inspection at 159a, a service user accidentally shut his finger in the door. He was taken to hospital for emergency assessment, reports were completed when the inspector arrived and his care was discussed and planned at handover. All gas, electrical, water and insurance certifications were up to date and in order and legionella checks last took place in April 2005. The organisational business plan is complete but the service still needs to produce its own, which is required. 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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 3 1 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 159 & 159a Station Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 3 G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (1) (b) Requirement The registered person must ensure that service users have a written contract or statement of terms and conditions. Previous timescale of 1 March 2005 not met. The registered person must ensure that a written agreement is drawn up setting out the arrangements for staff to administer insulin to service users. Previous timescale of 1 March 2005 not met. The registered person must ensure that all staff receive updated adult protection training The registered person must ensure that the 159 hall and stair carpet is replaced. Previous timescale of 1 March 2005 not met. The registered person must ensure that the carpet in the room of the doubly incontinent persons room in 159a be replaced an appropriate floor covering The registered person must ensure that an application is made to the CSCI for each house to be registered as a separate Timescale for action 21 September 2005 2. YA20 13(2) 21 September 2005 3. 4. YA23 YA24 18 (1) 23 (2b) 1 October 2005 1 November 2005 1 November 2005 5. YA30 23 (2d) 6. YA37 10 (1) 21 September 2005 Page 24 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 7. YA43 25 (2) care home. The applications to include separate registration applications for each manager. Previous timescales of 15 August 2004 and 15 January 2005 not met. The registered person must ensure that a business plan is produced for the service 1 November 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 159 & 159a Station Road G59S10832 159 Station Road V231525 21.07.05 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!