Inspection on 29/09/05 for Walm Lane Nursing Home

This inspection was carried out on 29th September 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 but made no statutory requirements on the home.

Other inspections for this house

Walm Lane Nursing Home 17/06/08

Walm Lane Nursing Home 19/06/07

Walm Lane Nursing Home 28/06/06

Walm Lane Nursing Home 17/02/06

Walm Lane Nursing Home 09/03/05

Walm Lane Nursing Home 06/01/05

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Norbury Crescent (30)

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Henry Nihill House

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Wadham Avenue

Chatsworth Care - Dawson House

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Walm Lane Nursing Home 141 Walm Lane London NW2 3AU Lead Inspector Bernard Burrell Unannounced Inspection 29th September 2005 10:00 X10029.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 Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Walm Lane Nursing Home Address 141 Walm Lane London NW2 3AU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8450 8832 Ibexbrook Limited Amanoollah K Juhoor Care Home 21 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present alcohol dependence over 65 years of of places age (0), Past or present drug dependence (0), Past or present drug dependence over 65 years of age (0), Dementia (0), Dementia - over 65 years of age (0), Learning disability (0), Learning disability over 65 years of age (0), Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0), Sensory impairment (0), Sensory Impairment over 65 years of age (0), Terminally ill (0), Terminally ill over 65 years of age (0) Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 21 persons over the age of 18 in need of nursing care. Date of last inspection 9th March 2005 Brief Description of the Service: 141 Walm Lane is a nursing home that provides accommodation to 21 adults aged from 18 years. The primary care needs of the older adults are nursing and personal care and those of the younger adults are dementia, mental health and alcohol dependency. The home is a large detached building on three floors. At the time of this inspection, the home was undergoing major development and renovation, including the addition of a new laundry area, new smoking room with kitchenette facility and an office. There is also plan to convert the sluice/bathroom on the ground floor into a shower room. The home currently has 3 bathrooms to service the 21 residents and on the third floor there are 4 bedrooms, no bath and 1 small toilet. There is also a large garden at the back of the house and parking space in the front. The home is located close to Cricklewood Broadway and Willesden districts with good access to a variety of shops and public transport services Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in one day and the process was assisted with contributions from the manager, staff and residents at the home. Residents who spoke with the inspector gave and average level of satisfaction with their life experiences at the home. The staff who spoke with the inspector reported satisfaction about their work experience and the management support. The inspector’s finding indicated good effort is been made by the provider to improve the physical environment of the home, services and the facilities available to residents. This effort will need to be continued to help ensure the requirements of the National Minimum Standards (NMS) of the Care Standards Act 2000 are fully met in all areas. What the service does well: What has improved since the last inspection? What they could do better: The inspection findings indicated the following areas will need improvement to ensure service and facilities comply fully with the NMS of the Care Standards Act 2000. Effort should be made to summaries some of the information currently in the guide and where appropriate, pictorial references should be used to help communicate information, particularly for residents who have problems with poor memory, vision and concentration. The service must continue to work to ensure that when care needs assessment is carried out for each resident, the care planning is generated from such assessments, with indications of the expected outcomes. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 6 The service will need to ensure that the care plans and support programmes for residents with special health care needs such as diabetes, are fully understood by the care support and catering staff. The service will need to ensure that all case files are fully audited, better organised and records are up to date with clear and consistent audit trails. The service will need to ensure that the kitchen is kept clean and hygienic at all times. Storage of all foods must be done in line with regulatory requirements and health and safety guidelines. All staff working in or handling foods in the kitchen must hold current statutory required health, food and hygiene certificates of training and competence. All substance hazardous to health must be adequately and safely stored in line with the COSHH and health and safety guidelines. A full audit and review of all staffing files and records must be carried out to help ensure that all required employment documentations are on each file. These must include verification of satisfactory Criminal Records Bureau (CRB) checks and previous employment references. The service must ensure that all care staff who have not already done so, register to do the NVQ and other relevant training to help develop further, their skills and professionalism. The service users’/resident’s guide to the home needs reviewing and updating to include information in larger print that are suitable to the needs of most residents. 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. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. The information guide about the home and its services was comprehensive but written in a style and format that was not user friendly. It is unlikely most resident have read the guide or fully understood all the information recorded. EVIDENCE: The information guide to the home was comprehensive but written in a style and format that most residents would probably not read or find difficult to understand. The residents who spoke with the inspector stated they have not read the guide because it was too detail. The inspector discussed with the manager the need for the guide to be revised and written in a more userfriendly style with possible pictorial illustration to aid understanding for those residents with poor vision, concentration and limited reading ability. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 9 The inspector examined 8 case files of the 21 residents. Each file had an assessment carried out by the home manager and the referral agencies. The manager stated that pre-assessments are carried out for each new resident before any decision is made about offer of a place at the home. Fees are charged according to the level of care needs. The inspector noted that the assessment information for some residents was basic and there were cases where the care plans did not reflect the needs identified or how the level of care and support would be offered. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,10. Information about the health care needs and status of residents were recorded in individual care files, but in several cases it was difficult to make a judgement of how health care needs are been met. EVIDENCE: In several cases, the care needs assessments had only basic information about some residents. The care plans did not in most cases accurately reflected the needs identified. For example, one resident was assessed has having poor memory and impaired cognition. However, no information was recorded in the care plan about how this identified need would be met by the care support offered at the home. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 11 In addition, the diabetic condition of another resident was mentioned in the assessment, but no details of care support and treatment plan could be found. The care plans were also poorly organised and some daily recordings had wide gaps in dates and in several cases, no information recorded. There was evidence of link to community psychiatry and district nursing services on some case files. There was also evidence of medical and physiotherapy appointments, including care reviews carried out with social services in a few cases. The inspector spoke with some residents and the general view expressed was that some expected more therapeutic support from care staff at the home. The manager indicated that links is made with community mental health support services on behalf of those residents who need it. The inspector also discussed the need for all care support and nursing staff to have the necessary professional training and competence in areas such as mental health, alcohol related issues and cognitive impairment and behavioural difficulties. The pharmacy inspector from the Commission for Social Care Inspection (CSCI) carried out an inspection of the home’s medication administration on 18 October 2005. Several areas of shortfalls were identified. A report was sent to the registered provider with 9 shortfalls that fell below the NMS requirements and 4 good practice recommendations. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Most residents are able to exercise independent choices about their daily lives at the home. EVIDENCE: The inspector observed several residents coming and going from the home independently during the inspection process. However, these were mainly the younger adults under 65 years. The manager informed the inspector that some residents are supported by staff to access a range of services and facilities in the community. At least 4 of the residents receiving nursing care are totally dependent on the nursing and care support staff to assist them with daily living tasks. There Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 13 were no in-house activities taking place during this inspection. Two of the residents who spoke with the inspector stated they would like to see more activities made available to occupy their time when they are at the home. One resident stated he would like to see development of more structured programmes of rehabilitation to help manage lifestyles and prepare the younger adults for independent living. The manager informed the inspector that activities do take place such as day trips, music and dancing. The home has a mixed category of residents from various ethnic and racial backgrounds. The findings indicated continued effort should be made to help residents develop independent living skills, particularly those who are likely to move to independent community living. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 The home has a complaints policy and procedure in place but the provider must continue to ensure the procedure and process is fully understood by all residents. EVIDENCE: The home’s adult protection complaints and guidelines were in place. The findings indicated more effort should be made to help ensure all resident understand the procedure and encourage to do so if necessary. The manager informed the inspector that residents are encouraged to register their views and concerns at the house meetings or directly to staff or the management. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,26. Renovation and upgrading work is been carried out to some areas of the home. This is helping to improve the physical environment and provide additional communal and workspace. EVIDENCE: At the time of this inspection, building and upgrading work was been undertaken to add a separate room and kitchenette. The new addition will be used mainly by residents who are smokers. It is hoped this will minimise the current problem of heavy smoking that is done in the main communal lounge. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 16 It is also hoped the effect of passive smoking will be reduced to the nonsmokers at the home. The kitchen has been upgraded with addition of new facilities and equipmemt. However, better monitoring is needed to ensure the kitchen is maintained in a consistently clean and hygienic state. Food storage must be managed better, including cooked items. Substance hazardous to health, including chemicals used for cleaning and other household purposes, must be stored more securely. The broken fridge handle must be replaced as a matter of priority. A new laundry room is been built. The manager assured the inspector that a window and appropriate ventilation system would be installed in this room. The manager also assured the inspector that the back stairways (fire escape route) leading from the top floor to the garden would be made safe by the secure mesh net wiring. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. The procedure for the recruitment of staff does not offer protection to people living at the home. Not all staff have the necessary skills and competence to fully meet the needs of residents with complex mental health, cognitive impairment and alcohol related problems. EVIDENCE: The manager confirmed that the home employs 11 health care assistants, 8 registered nurses, 2 domestic workers, 2 cooks and 1 activities coordinator. The inspector examined eight staff files. The findings indicated that these were poorly organised and did not have sufficient evidence to verify that the home had undertaken all the necessary recruitment checks to ensure the protection of residents. Criminal Records Bureau verification checks were not available for several staff members and references were only available for some. The staff records for one kitchen staff had no evidence to verify an employment application was completed or food and hygiene training undertaken. The two certificates sent Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 18 to the CSIC by the provider in March 2006 were issued in 1998. Please refer to other statutory and professional practice guidelines relating food and hygiene. The inspector had discussions and interviews with some staff. There was general consensus they enjoyed working at the home and that the work with residents presented challenges that required various levels of experience, expertise, training and competence. The provider/manager should also ensure that staff are supported to undertake the required NVQ training. The manager stated that 7 full-time staff have been identified to undertake the training but no timescale was given. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 37,38. The manager has relevant professional training and experience and receives additional management support from the registered provider. The administrative systems and procedures also needed better organisation and management. EVIDENCE: Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 20 The manager has many years professional experience working in nursing and social care fields. He has been managing the home for over three years and has played key role in the development and improvements that have taken place in the last few years. The residents who spoke with the inspector commented favourable about the manager and his management approach. The general consensus from both residents and staff was that the manager is dedicated to improving the quality of care and services offered. Staff also reported they are offered good support and supervision. As indicated elsewhere in this report, action is needed from the manager and provider to ensure that the shortfalls identified, including staff recruitment practices and health and safety issues are addressed in the interest of resident’s safety, health and welfare. Action is also needed to ensure the administrative systems and procedures are managed better and in line with standard professional business practices in registered care homes. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 21 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 3 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 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 X 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 3 21 3 22 x 23 x 24 X 25 x 26 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X 37 2 38 3 Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 22 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 YA6 Regulation 14, 24. Requirement Timescale for action 30/01/06 2 YA9 13 (2) 3 YA30 16,13, 23. The registered provider must ensure that when assessments are carried out for new residents, the care plans must accurately reflect the care needs identified. These must be reviewed on a regular basis with the input of the residents. The registered provider must 01/12/05 ensure that the requirements and recommendations arising from the CSCI pharmacist inspection report on 18 October are carried out in full. The registered provider must 30/11/05 ensure that all areas of the home are kept clean and free from hazards at all times. This includes the stairs ways, kitchen and garden. The registered provider must ensure that substance hazardous to health are stored and handled in line with statutory and professional guidelines. The registered provider must ensure that all persons Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 23 5 YA37 working in the kitchen have current food and hygiene training certificate. Please also refer to the local borough environmental health guidelines. 9,10,12,13,17, The registered provider must 30/12/05 25. ensure that the home’s administrative and record keeping are better organised and kept up to date. 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 YA1 Good Practice Recommendations The registered provider must ensure that the service users’ guide to the home is reviewed and updated. It should also be written in communication language, style and format that meet the varied needs of residents. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. Walm Lane Nursing Home DS0000022945.V254775.R03.S.doc Version 5.0 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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