Care Home: Colegrave Road, 77- 79

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What the care home does well Information is available to prospective residents about the service provision. People have the opportunity to visit and have trial stays at the home prior to moving in. People benefit from having detailed care plans which identify their needs and individual support plan. The service is particular person-centred at meeting peoples` cultural and diverse needs. People are supported to take appropriate risks to ensure they maintain their independence. Individuals are encouraged and supported to make choices about their lives that reflect their own preferences and to engage in their chosen social and community activities. Peoples` health care needs are met and medication administration practises are generally good. Staff are competent and sufficient in numbers and receive regular supervision and training. The recruitment process is robust to safeguard people who use the service. The manager is suitably trained and experienced. People benefit from living in a home which is generally well organised. Staff have access to policies and procedures to inform them about how to the deliver the service. Health and safety procedures are generally good to safeguard people in the home. People living in the home speak positively about the staff and service they receive, one person informed, "the home serves its purpose" and "on the whole, staff are supportive". What has improved since the last inspection? Most requirements made at the previous inspection have been met. Health and safety procedures have improved to ensure better safety of people living in the home. Medication administration has improved. Environmental issues identified at the last inspection have been attended to. Staff now receive regular supervision and the manager has commenced NVQ Level 4 studies. CARE HOME ADULTS 18-65 Colegrave Road, 77- 79 77-79 Colegrave Road Stratford London E15 1DZ Lead Inspector Nurcan Culleton Unannounced Inspection 12th May 2008 10:00 Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 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 Colegrave Road, 77- 79 DS0000058207.V363096.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 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. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colegrave Road, 77- 79 Address 77-79 Colegrave Road Stratford London E15 1DZ 0208 534 1101 0208 534 1153 dko@consensacare.com 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) Consensa Care Limited Dana Kotoulekova Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2007 Brief Description of the Service: 77 to 79 Colegrave Road provides residential support and accommodation to male and female service users with enduring mental health needs. The building is situated in a residential area in Stratford and is close to public transport and other local amenities. The home is owned and managed by Consensa Care Limited who provides a range of residential care services in Newham. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place on 12th May 2008. We met privately with the manager, two support workers and one person who uses the service, and also viewed resident’s personal files, staff personnel files and other documentation relating to the running of the home. We also took into account the homes’ Annual Quality Assurance Assessment (AQAA). What the service does well: What has improved since the last inspection? What they could do better: Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 6 People’s signed placement contracts do not have information in them which accurately reflecst their actual service provision and must be updated. Some areas of the home could improve in appearance to create a more homely living environment and some maintenance and repair issues are identified. The home still lacks a quality assurance system which is unique to the home to gage the views of people using the service. The home still lacks a business development plan incorporating these views. 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. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available to prospective residents about the service provision. People have the opportunity to visit and have trial stays at the home prior to moving in. People’s signed contracts do not accurately reflect their actual service provision and must be updated. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated, however staffing numbers are stated across Consensa Care and are not specific to the home. It is recommended that the Statement of Purpose and Service Users Guide’s are updated to reflect actual staff numbers at the home, including the staff ratio and cover. Pre-admission assessments and background information from placing authorities are available in individual files. One person spoken to stated he had visited and stayed overnight before moving into the home. The manager confirmed that this is normal practice. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 9 Records and documents seen throughout the inspection evidence that the home has the capacity to meet individual needs, as identified in their assessments and care plans. At the last inspection it was identified that weekly psychology sessions were included in the cost of the placement in peoples’ individual placement contracts. Also at the last inspection the manager informed that the home did not have such facilities and that any psychological input would need to be referred to the local Community Mental Health Team. A requirement was issued to ensure peoples’ contracts reflect their actual service provision and compliance was reviewed at this inspection. The contracts of three people were viewed and had not changed since the last inspection, still including the provision of a psychologist for each person within the home. Contracts also state that one to one sessions are provided weekly, when in fact they take place once monthly or more frequently, at the request of the individual. The contracts further state that the manager has an NVQ Level 4 qualification which is not correct as they have just commenced this study. The requirement to ensure contracts reflecting accurate service provision is restated and must be addressed within the timescale specified in this report. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6-10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People benefit from having detailed care plans which identify their diverse needs and specify their individual support. Updated care plans ensure that the service responds to peoples’ changing needs. People are supported to take appropriate risks to ensure they maintain their independence. EVIDENCE: We sampled the personal files of three people who currently use the service. Care plans comprehensively identify a range of individual health, personal and social needs and support identified in response to addressing those needs. Care plans are signed by the individuals to evidence their participation in the planning process. Care plans have been recently reviewed, meeting a previously made requirement. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 11 Needs are identified over eight broad areas, including medication, mental health needs, communication, finances and social and family networks. Individual plans shows that the home identifies people who have specific religious beliefs and are offered appropriate support for them to fulfil their spiritual needs. The plan for one Muslim person shows that they are supported to eat Halal food and to follow traditional procedures in their faith as regards washing, as reflected in the records related to this individual and in their selfcatering menus. Evidence was seen of regular 1:1 key working sessions in individual files, taking place every 1 to 2 months, though not weekly, as stated in the section above. These sessions are used to discuss issues such as activities of daily living, food choices and maintenance of good mental health. Comprehensive risk assessment tools were evidenced in files. They addressed a range of potential hazards, levels of risk and controls to manage risks, including non-compliance with medication, access to the community, smoking and diabetes. Interviews with the manager, staff and person living in the home demonstrate that staff give people information and support to make choices about their everyday lives. Minutes of residents’ meetings record peoples’ individual views and evidence that these views are respected and acted apon seen, including in minutes of staff meetings. People using the service receive varying levels of support to manage their finances. Details of the nature of the required support are found in individual plans. The home appropriately assists people to manage their money, keeping good records of financial transactions for peoples’ finances. Each person has a security-sealed bag containing his or her money held by the home for each transaction. Every time money is withdrawn from this bag the transaction date, amount and balance is recorded, signed by the person and a staff member and a new security tag fitted. Residents meetings now take place every two months, minutes of the last meeting on 17/04/08 were available. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11-17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals are encouraged and supported to make choices about their lives and diverse needs and to engage in their chosen social and community activities. People are encouraged to maintain valuable links with their family or friends. EVIDENCE: Individuals currently in the home come from diverse backgrounds. They are two females from a white and Bangladeshi background; Three males, one British, one Indian and one Afro-Caribbean male. There are presently two vacancies and one person admitted to hospital after a minor relapse in their mental state. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 13 Individuals using the service have mental health difficulties that can impact upon their motivation to participate in occupational and community activities. Staff encourage and support people to maintain activities outside the home wherever possible. Some individuals attend college courses, for example, one person learns basic literacy, numeracy and IT skills. One individual does volunteer work in a gardening scheme which they find theraputic. Activities at home are centred on activities of daily living, such as the cleaning rota or assistance in preparing meals, tidying bedrooms and doing laundry. Individual plans and records of visitors evidence that the home supports people to maintain contact with their families and friends. People who use the service can choose whom they see and when and can see visitors in their rooms in private during reasonably long hours in the day. During the course of we observed that staff were positive in the way they interacted with individuals in the home, respectfully talking to them and sharing meal times with them. The individual spoken to informed that he liked the staff and service provided in the home, stating, “if I need something to be done, they will help me” whilst at the same time, stating that the staff will respect and support him to maintain his independence. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18-20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to make decisions that reflect their personal preferences. Peoples’ health care needs are met and medication administration practises are generally good. EVIDENCE: Discussion with people living in the home, support staff and manager show that individuals have freedom of choice in their daily activities and that they are consulted for their views, for example, in their choice of colour scheme for their bedrooms, choice of meals, choice of college courses and daily activities. People have the freedom to decide on the extent to which they wish to participate in activities, though they are encouraged as part of their individual plans to achieve their identified goals and potential. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 15 Copies of correspondence relating to medical appointments and psychological assessments were found within individual files. Medical appointments are now recorded in a separate daily record form. The manager advised that there are currently no residents who are selfmedicating or taking prescribed controlled drugs. The medication policy has recently been reviewed and updated. The advised the Inspector that the home will shortly switch to a pharmacist-loaded medication dispensing system. The Inspector sampled the Medication Administration Record and noted that records were appropriately recorded. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are given information about how to complain. There are procedures for making complaints and safeguarding adults procedures are clear to protect people from abuse. EVIDENCE: The homes’ complaints policy includes information on how to make a complaint and the timescales within which the home aims to deal with these. The Inspector noted that the contact details for the Commission for Social Care Inspection found in the policy were out of date, though the contact details for the Commission had been updated in the Service Users Guide. The resident spoken to informed that they knew how to complain but had no complaints and found the staff to be very nice and helpful. We viewed the homes complaints log and noted that five complaints along with the date, investigation, findings and outcome had been appropriately recorded. The manager informed that all people are informed about the complaints’ procedure and one person had the telephone number of the CSCI. One person in the home confirmed that he had the complaints procedure on his bedroom wall. There had been one complaint since the last inspection which necessitated the managers’ liaison with the Newham Safeguarding Team and was appropriately Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 17 investigated using the homes’ policy and procedure. The support staff spoken to demonstrated a good understanding of adult protection issues and their responsibilities should they have any adult protection concerns. The homes’ adult protection policy includes definitions of the different types of abuse vulnerable adults may experience and gives guidance to staff. The policy and procedure also makes appropriate reference to local multi agency adult protection protocols. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in an environment that is safe and suitable for their needs, though some areas could improve in appearance to create a more homely living environment. EVIDENCE: The home is made up of two Victorian terraced houses that are joined together through a communal lounge. House number 77 accommodates three people with one ground floor bedroom and three first floor bedrooms that are accessed via stairs. There is also a first floor bathroom that contains a bathtub with mixer tap and shower curtain, a hand basin and WC. The paintwork of the ceiling in the bathroom is peeling, due to a leak from the roof. The manager informed that a builder and maintenance person visited last week to look at repairing it. The panel of the bath was observed to be chipped and worn and Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 19 needs to be replaced. This bathroom also appeared sterile due to its bare walls and could be more homely in its décor, as compared with the more pleasant bathroom at number 79. A communal kitchen is located on the ground floor to the rear of the property with access to the garden. A large lounge and dining room joins the two houses. There are comfortable sofas, a dining table and chairs and a TV. Despite pictures on the walls, the lounge still has potential to be a brighter and more homely environment. House 79 accommodates three female service users. One bedroom is on the ground floor with a further two bedrooms located on the first floor and accessed via stairs. A staff office and a bathroom with tub, mixer tap, shower curtain, hand basin and WC are also located on the first floor. On the ground floor to the rear of the property there is a smoking lounge, laundry facilities and access to the rear garden. The sofa in the smoking room is torn and unsightly and needs to be replaced. A washing machine and dryer are located in cupboards in the smoking room. Two bedrooms seen were personalised with pictures and mementos. The home was found to be generally clean and hygienic. The garden is being maintained by one of the people living in the home who has an interest in gardening. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are competent and sufficient in numbers to meet the needs of people in the home. People benefit from staff who are supported to carry out their duties through regular supervision and training. The recruitment process is robust to safeguard people who use the service. EVIDENCE: The rota shows that two staff are on duty on the early shift and late shifts and one staff member on the wake-in night shift. The home currently employs seven care staff. The manager works 9-5.30pm and is on call outside these times. Staff informed that there is a good atmosphere and communication among the team, including handovers at every shift where information is shared about each person in the home. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 21 Staff spoken to were knowledgeable about the people who use the service and have relevant previous experience in other residential homes Two staff have obtained NVQ level 2 qualifications, four staff are currently working towards NVQ level four qualifications and two of the staff are registered nurses. Consensa Care operates a centralised Human Resources Department that carries out pre employment checks. A summarised record sheet of these checks are held on site on ‘Schedule 2’ forms and were viewed at this inspection. They evidenced that two references, an enhanced Criminal Records Bureau (CRB) check and proofs of identity are obtained prior to staff starting work. However the medical clearance option was circled as “No” on all the record sheets. Head office clarified that this was due to the answers staff gave in their application forms to indicate that they were medically fit and did not need medical checks completed. However we informed that the way the record sheet is completed could be misconstrued as medical checks not being completed. It was recommended that the forms are completed with a “yes” to indicate that the organisation has sought to clarify peoples’ medical fitness. The manager advised that there is no formal process to involve residents in staff selection, however their views are sought when prospective staff visit the home prior to their employment and peoples’ views are sought at this time. It was recommended that these views are recorded. Staff are also subject to a three-month probationary period. Staff training records evidenced that a range of training had been provided since the last inspection including food hygiene, challenging behaviour, infection control, health and safety, adult protection, fire safety and medication. It is recommended that staff receive more substantial training in first aid. Three staff files examined showed that staff receive supervision. The manager informed that staff do not receive appraisal though the managers. It is recommended that all staff have annual appraisals. Records seen evidenced that staff follow a programme of induction, including in-house training. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is run by a manager who is suitably trained and experienced. People benefit from living in a home which is generally well organised. Staff have access to policies and procedures to inform them about how to the deliver the service. Health and safety procedures have improved to safeguard people in the home. The home still lacks a quality assurance system which is unique to the home to gage the views of people using the service and still lacks a business development plan incorporating these views. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 23 EVIDENCE: The current manager has been in post since July 2006 and successfully completed the registration process in February 2007. They have recently begun their NVQ Level 4 having completed their NVQ level 3. The manager has worked within Consensa Care for some years, with experience as a deputy manager within a different mental health residential care home. The care staff spoken to informed that the manager was open and responsive to any issues they raise and is supportive to their needs. Staff confirmed they receive regular training and supervision. Recently updated policies and procedures are available to all staff covering a range of suitable areas relevant to the needs of the service. Staff spoken to informed that they knew about the policies and procedures and able to state aspects of the protection of vulnerable adults policy and procedure which they were familiar with. Consensa care conducts a corporate quality assurance process for all its services, and that this includes surveying residents, staff, families of people who use the service and other professionals. However, there is no specific information available for this home and the results of these surveys are not made available to the home. This was identified at the last inspection and remains an important area for this service and organisation to develop. The service needs to ensure that the views of people linked with the home are incorporated into the ongoing business and development plan of the service, which itself is yet to be developed. We viewed a range of health and safety records including weekly fire alarm tests, water temperature testing, food temperature tests, and drills, which are carried out regularly. Portable appliance-testing, gas and electrical safety and insurance liability certificates are all available and in-date. Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 N/A 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 3 3 3 2 Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 25 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 & 14 Requirement Placement contracts should accurately reflect the service provision for each individual using the service. The previous timescale of 30/09/07 has not been met. Timescale for action 20/08/08 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 To assist people who may be choosing a service, the home must update its statement of purpose to accurately reflect the current situation within the home. 2. YA22 Update the contact details of the CSCI in the complaints policy and all other relevant policies and procedures requiring the contact details of the commission. Repair the paintwork on the ceiling of the bathroom in DS0000058207.V363096.R01.S.doc Version 5.2 Page 26 3. YA24 Colegrave Road, 77- 79 number 77. Replace the chipped and worn bath panel at number 77. Create a brighter and more homely environment in the bathroom at number 77. Create a brighter and more homely environment in the communal lounge. Replace the torn sofa in the smoking room. 4. 5. YA32 YA34 Provide staff with more suitable first aid training. The views of people in the home should be recruited when involved in the process of staff selection. Ensure the home has its own annual quality assurance process to obtain the views of people using the service and include these views in the development plans for the service. Ensure the home has a business development plan incorporating the views of people using the service. 6. YA39 7. YA43 Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Colegrave Road, 77- 79 DS0000058207.V363096.R01.S.doc Version 5.2 Page 28 - 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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