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Care Home: The Mulberries

  • 68 Bath Road Hounslow Middlesex TW3 3EQ
  • Tel: 02085776487
  • Fax:

The Mulberries is a purpose built home which provides a service to seven people with profound learning and physical disabilities. Adepta are the Registered Providers but the building is owned by the Notting Hill Housing Trust. The service is situated on the ground floor of a two-storey building in Hounslow. There are seven single bedrooms, a large lounge/dining area, kitchen, utility room, two bath/shower rooms, and staff sleep-in room with en suite bathroom facilities. The garden and patio are at the rear of the building and accessible to wheelchair users. Hounslow Central underground station, various bus routes and the local shopping centre are located within walking distance.

  • Latitude: 51.467998504639
    Longitude: -0.37200000882149
  • Manager: Mary Bridget Kearney
  • UK
  • Total Capacity: 7
  • Type: Care home only
  • Provider: Dimensions (ADP) Limited
  • Ownership: Charity
  • Care Home ID: 16271
Residents Needs:
Learning disability

Latest Inspection

This is the latest available inspection report for this service, carried out on 26th September 2008. 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

For extracts, read the latest CQC inspection for The Mulberries.

What the care home does well The home provides a service to people with different cultural and religious needs and is reflected in a diverse staff group. The needs of people who use the service are comprehensively assessed prior to admission. Risk assessments associated with activities identified within care plans are clearly and appropriately detailed. The physical and emotional needs of residents are being met satisfactorily and their dignity is respected. Varied and nutritional cooked meals are provided. Residents are being protected from abuse and neglect. Their safety and welfare are promoted, and their dignity is being respected. Several members of the staff team care have been employed at the home for many years and residents have benefited from continuity of care. Appropriate staff training and refreshers are being delivered. Care support workers were observed being competent and attentive in meeting the needs of residents, and related with them in a friendly and caring manner. An Expert by Experience reported: `The staff are experienced and have worked in the home for many years`. Overall, the home was clean and hygienic. The environment was bright, airy, calm and homely. What has improved since the last inspection? Requirements made at the last inspection had been complied with. Specifically, quality assurance has been undertaken. Care support workers have received training on the Protection of Vulnerable Adults. The complaints procedure has been updated. What the care home could do better: Seven requirements were identified at this inspection. These related to the Service user`s guide, Care plans, bottled medicines, issues regarding the environment, staffing levels and recruitment files. The service user`s guide must be at all times accessible. Care plans must be reviewed on a regular basis. Dates of opening bottled medication must be entered on labels and signed. Stained floor coverings must be cleaned or replaced and doors on kitchen cupboards must be repaired or replaced. The ratios of care staff to residents during peak periods and on weekends must be appropriate for ensuring that the needs of people who use the service are being met. Staff files must contain copies of all required recruitment documents. CARE HOME ADULTS 18-65 The Mulberries 68 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Ms Jean Bovell Key Unannounced Inspection 26 September 2008 10:00 th The Mulberries DS0000069517.V364607.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 The Mulberries DS0000069517.V364607.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. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mulberries Address 68 Bath Road Hounslow Middlesex TW3 3EQ 020 8577 6487 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) www.pentahact.org.uk PentaHact Limited trading as Adepta Mary Bridget Kearney Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 7 30th May 2007 Date of last inspection Brief Description of the Service: The Mulberries is a purpose built home which provides a service to seven people with profound learning and physical disabilities. Adepta are the Registered Providers but the building is owned by the Notting Hill Housing Trust. The service is situated on the ground floor of a two-storey building in Hounslow. There are seven single bedrooms, a large lounge/dining area, kitchen, utility room, two bath/shower rooms, and staff sleep-in room with en suite bathroom facilities. The garden and patio are at the rear of the building and accessible to wheelchair users. Hounslow Central underground station, various bus routes and the local shopping centre are located within walking distance. The Mulberries DS0000069517.V364607.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 two stars. This means the people who use the service experience good quality outcomes. This unannounced inspection was carried out between 10:00am and 4:00pm on 26th September 2008. The Acting Manager, three care support workers and one resident were at the home. We were informed that six residents were at the day centre. An Expert by Experience and his Supporter were also present and contributed to this inspection by reporting on specific areas. During the course of the inspection: records, documents, policies and procedures maintained at the home were viewed. A tour of the premises was undertaken, observations were made and discussions were held with three care support workers. A completed annual quality assurance assessment document (AQAA) was considered. Requirements made at the last inspection and all key Standards were examined. The Acting Manager was co-operative and provided appropriate assistance throughout the inspection. The positive and negative findings of an Expert of Experience are incorporated into the Inspection Report. What the service does well: The home provides a service to people with different cultural and religious needs and is reflected in a diverse staff group. The needs of people who use the service are comprehensively assessed prior to admission. Risk assessments associated with activities identified within care plans are clearly and appropriately detailed. The physical and emotional needs of residents are being met satisfactorily and their dignity is respected. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 6 Varied and nutritional cooked meals are provided. Residents are being protected from abuse and neglect. Their safety and welfare are promoted, and their dignity is being respected. Several members of the staff team care have been employed at the home for many years and residents have benefited from continuity of care. Appropriate staff training and refreshers are being delivered. Care support workers were observed being competent and attentive in meeting the needs of residents, and related with them in a friendly and caring manner. An Expert by Experience reported: ‘The staff are experienced and have worked in the home for many years’. Overall, the home was clean and hygienic. The environment was bright, airy, calm and homely. What has improved since the last inspection? What they could do better: Seven requirements were identified at this inspection. These related to the Service user’s guide, Care plans, bottled medicines, issues regarding the environment, staffing levels and recruitment files. The service user’s guide must be at all times accessible. Care plans must be reviewed on a regular basis. Dates of opening bottled medication must be entered on labels and signed. Stained floor coverings must be cleaned or replaced and doors on kitchen cupboards must be repaired or replaced. The ratios of care staff to residents during peak periods and on weekends must be appropriate for ensuring that the needs of people who use the service are being met. Staff files must contain copies of all required recruitment documents. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 7 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. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 8 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 The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 9 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 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user’s guide was not available. The needs of prospective residents are assessed comprehensively prior to admission. EVIDENCE: The service user’s guide was not accessible for viewing at the time of the inspection. The personal files of four residents were viewed at random. Each file contained a written assessment and background/family history submitted by the placing authority at the point of referral. It was evidenced also that a subsequent needs led assessment had been carried out by home. Relatives, previous carers, healthcare professionals and social workers were involved in the process of determining the capacity of the service to meet separate identified needs of prospective residents. The Mulberries DS0000069517.V364607.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, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are appropriately carried out but are not being regularly reviewed. Risk assessments are satisfactory. Attention is paid to people’s specific likes and dislikes, wishes and/or feelings and acted upon. EVIDENCE: Care plans relating to four residents were viewed at random and reflected that their changing personal, healthcare and social needs were assessed, and that action plans and goals were put in place. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 11 Risk assessments associated with issues/activities identified within care plans such as moving and handling, behaviours, epilepsy and seizures were undertaken. All care plans and risk assessments viewed were clearly and appropriately detailed. However, care plans were not being regularly reviewed. People who use the service are non-verbal and have profound learning and physical difficulties. We were informed by care support workers that people were offered alternatives if they refused to eat meals provided and were encouraged to choose what they wore each day from options provided. Individual choices and interests were also reflected in residents’ bedrooms. Care support workers were observed being able to interpret and act upon specific body language which indicated that a resident wished to participate in an activity within the local community. The Mulberries DS0000069517.V364607.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The religious needs of people are being met and they are supported during separate activities in the community. Contact with relatives is encouraged and facilitated. Residents are able to be present while housekeeping tasks are being undertaken. Varied and nutritional cooked meals are provided. EVIDENCE: The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 13 Separate religious needs were identified within care plans and indicated that residents were supported while attending Church services on a Sunday. This was confirmed by the Acting Manager. Records were also reflective of people attending the day centre, being taken for walks, shopping and visiting the cinema and parks. It was not evidenced that annual holidays had been arranged. At the time of the inspection, six residents attended the day centre and an individual was supported in two separate activities within the local community. An Expert by Experience reported: ‘Residents get out in the community. The home does not have a care or van’ but ‘the dial-a-ride service is used to take residents to the day centre. For outings they use local wheelchair taxis.’ ‘The residents have not been on holiday this year and none is planned.’ An open visiting policy was in place. We were informed by care support workers that residents received regular visits from relatives and were taken out by them. An Expert by Experience reported: ‘Family and friends are free to visit the residents when they can.’ Despite their lack of capacity, support workers confirmed that residents were able to be present when housekeeping tasks such as laundry and tidying bedrooms were being undertaken. Meals are prepared by care support staff and varied and wholesome options were reflected on menus. An Expert by Experience found that: ‘Residents have meal choices according to their dietary needs.’ Residents were observed being patiently and appropriately fed with drinks and liquidized meals at the time of the inspection. The Mulberries DS0000069517.V364607.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, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Separate personal and healthcare needs are being met as required. Medication policies and procedures are satisfactory. EVIDENCE: The separate personal and health care needs of residents were identified within care plans and reflected that the people who used the service were highly dependent on care staff for meeting their overall needs. Support workers confirmed that the dignity of residents was at all times respected and that they were encouraged to choose what they wore each day from options provided. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 15 A resident appeared clean, attractively dressed, with matching accessories, make up and hairstyle at the time of the inspection. It was reported by an Expert by Experience that: ‘The residents’ dignity is respected in the home’. Specifically, staff was careful not to ‘talk over’ residents while being interviewed. Records were indicative of people receiving access to healthcare professionals as required and included GPs, Physiotherapists, Dentists and Chiropodists. Regular health checks were arranged and residents were accompanied to medical appointments. Although medication was safely stored, dates of opening bottled medicines were not recorded on labels and/or signed. Records were maintained of medicines received and those returned to the pharmacist. Medication Administration sheets were accurately documented and signed. People who use the service lack capacity to self-administer medication. There was documented evidence that training on medication had been delivered to all care staff. Policies and procedures on medication were in place. The Mulberries DS0000069517.V364607.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and concise. People who use the service are protected from abuse and neglect. EVIDENCE: The complaints procedure was clearly and appropriately detailed. The complaints book was viewed and reflected that recorded complaints had been satisfactorily investigated and resolved. The Acting Manager reported that residents received state benefits and that personal allowances were held in safekeeping at the home. Separate financial records were inspected at random and no discrepancies were identified in relation to income and outgoing expenditure. Incidents and accidents were appropriately recorded. Regulation 37 forms were completed and submitted to the CSCI as required. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 17 The records indicated that staff training on Safeguarding Adults had been delivered on 16th September 2008 and care staff spoken with confirmed knowledge of Whistle Blowing. Policies and procedures on ‘Protection of Vulnerable Persons from Abuse’ were in place. The Mulberries DS0000069517.V364607.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, 25, 26, 27, 29 and 30. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home is safe and comfortable. Bedrooms are personalised, bathroom facilities are appropriate for meeting the personal needs of residents and specialist equipment are in place. Overall, the home is clean, hygienic and adequately maintained. But attention must be paid to a loose wire in the hallway, kitchen cupboards and floor coverings. EVIDENCE: The home is spacious, comfortably furnished and suitable for wheelchair users and shared and/or individual activity. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 19 Hallways were carpeted and in reasonable decorative order. However, there was a large stain on an area of carpet which led into the kitchen. An electrical wire hung loosely from a small radio/cassette player which was placed on a shelf in the hallway. Although the kitchen contained the required equipment and fittings, several cupboards were without doors or doors could not be shut as they hung loosely on hinges. There was also a large burnt area on floor coverings in the kitchen. There were no issues in relation to the laundry. The garden and patio were adequately maintained and accessible to wheelchair users. An Expert by Experience reported that the home ‘has a small neat garden which is wheelchair accessible for residents but the ‘lawned bit of the garden is not accessible by wheelchair as it is elevated.’ All bedrooms were suitably furnished, fitted and personalised. An Expert by Experience reported ‘bedrooms are large and have wide doors to allow wheelchairs’. The number of bathroom facilities is appropriate for meeting the personal needs of residents. Specialist equipment for maximising residents’ independence was in place and included adjustable baths, hoists, wheelchairs and sensory equipment. An Expert by Experience observed: ‘bathrooms are fitted with tracking for bathing and hoisting residents in and out of the bath. Overall the home was clean and hygienic. The environment was safe, calm and homely. The Mulberries DS0000069517.V364607.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): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ratios of care staff to residents during peak periods and/or weekends may not be appropriate for meeting the specific needs of people who use the service. Care support workers have received appropriate training for meeting the needs of people who use the service. Staff files do not contain all the required recruitment documents. Staff meetings are being held and support workers receive regular supervision. EVIDENCE: The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 21 The Acting Manager confirmed that there were staff shortages at the home and that new care staff were being recruited. There were eight permanent support workers at the time of the inspection. The rota was reflective of three care support workers being on duty during waking hours and one sleeping and waking staff cover at night. There was documented evidence that regular training and refreshers appropriate for meeting the needs of residents were delivered to care staff. One permanent support worker had achieved NVQ level 2 in health and social care. Five staff recruitment files were viewed at random but none contained copies of all the information required under Schedule 2 of the Care Homes Regulations 2001. Three care support workers spoken with expressed concerns regarding staffing levels during peak morning periods. This was due to various tasks that must be undertaken in relation to the high dependency needs of residents which included personal care/toileting, medication, preparing breakfast and feeding, prior to being transported to the day centre. As a consequence, care delivery may be rushed or delayed. And inadequate staffing levels on weekends resulted in people not being supported in separate activities within the community. An Expert by Experience reported: ‘There are only 3 members of staff on duty in the morning. I felt that this was not enough and that the residents may not be getting proper attention and care in the mornings as staff have to attend to residents personal care and breakfast before going out to day services.’ There was recorded evidence that care staff received regular supervision and staff meetings were being held. This was confirmed by care support workers that were spoken with. An Expert by Experience reported ‘staff have regular meetings.’ Care support workers were observed being competent and attentive in meeting the needs of residents and communicated with them in a friendly manner. The Mulberries DS0000069517.V364607.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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Acting Manager is suitably qualified and experienced. Quality assurance has been satisfactorily undertaken. The health, safety and welfare of residents are being protected. EVIDENCE: The Acting Manager was appointed in January 2008 and is appropriately qualified and experienced. The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 23 An annual quality assurance assessment has been completed satisfactorily and returned to the CSCI at the required time. Fire safety records and portable appliances checks were up to date. The Acting Manager confirmed that the gas boiler had been serviced. Environmental risk assessments were in place. The records indicated that staff training had been delivered on Moving and Handling, Fire Safety, Food Hygiene and Infection Control. The Mulberries DS0000069517.V364607.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 2 2 3 3 X 4 X 5 X 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 25 No 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 YA1 Regulation 5(1)(2) 6(a) 15(2)(b) Requirement The Registered Person must ensure that the service user’s guide is at all times available for viewing. The Registered Person must make sure that the care plans are regularly reviewed to ensure that the changing needs of people are being met. The Registered Person must ensure that dates of opening bottled medication are recorded on labels and signed to avoid risks to the health and safety of residents. The Registered Person must ensure that doors on kitchen cupboards are repaired or replaced. The Registered Person must ensure that carpets in the hallway are cleaned and floor coverings in the kitchen are replaced. The Registered Person must make sure that ratios of staff to residents are appropriate for ensuring that people’s needs are being met. Timescale for action 30/11/08 2. YA6 15/11/08 3. YA20 13(4)(c) 10/11/08 4. YA24 23(2)(c) 31/12/08 5. YA24 23(2)(d) 30/11/08 6. YA33 18(1)(a) 15/11/08 The Mulberries DS0000069517.V364607.R01.S.doc Version 5.2 Page 26 7. YA34 19(1)(a)(b) The Registered Person must ensure that copies of all information required under Schedule 2 of the Care Homes Regulations 2001 are within staff recruitment files and available for viewing. 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Mulberries DS0000069517.V364607.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 The Mulberries DS0000069517.V364607.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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The Mulberries 30/05/07

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