Inspection on 13/06/05 for Warwick Road, 17

This inspection was carried out on 13th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Warwick Road, 17 16/08/07

Warwick Road, 17 11/05/06

Warwick Road, 17 29/11/05

Warwick Road, 17 25/10/04

Warwick Road, 17 04/08/04

Warwick Road, 17 06/01/04

Warwick Road, 17 04/06/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Warwick Rd 17 Warwick Road Ealing London W5 3XH Lead Inspector Jane Collisson Unannounced 13 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Warwick Road Address 17 Warwick Road, Ealing, London, W5 3XH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 840 3109 Ealing Consortium Ltd. Ms Paulette Mohammadi Care Home 8 Category(ies) of Learning Disability and Learning Disability - Over registration, with number 65 of places Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two named service users continue to be accommodated in the home under the categories of Mental Disorder (1) and Physical Disabilities (1) as agreed with the Commission for Social Care Inspection. That the two service users remain living in the home for as long as their needs can be met. Date of last inspection 25/10/05 Brief Description of the Service: The home is registered for eight service users with learning disabilities, including those over 65. There are currently five female and three male service users. The home is situated in a quiet residential area of central Ealing and is within walking distance of Ealing Broadway’s shops, facilities and public transport links. Notting Hill Housing Trust owns the premises. Ealing Consortium Ltd, a voluntary organisation, provides the care. The house is semi-detached, and has three floors, with two mezzanine floors. There is no lift. The home has eight single bedrooms and the bedroom on the ground floor is en suite. The ground floor is wheelchair accessible and has a lounge, a kitchen with a dining area, and a laundry room. There is a small lounge on the top floor which is used as the smoking area. The sleeping-in room is on the first floor and the top floor has an office with staff toilet and shower. There is a large rear garden, with seating, which has ramped access from the kitchen. A parking area is available at the end of the garden. The staff team consists of the Registered Manager, one senior support worker and six support workers. A variety of day facilities, including college courses, are accessed by the service users in Ealing and Acton. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced on 13th June 2005 at 10.05. A further visit was made on 6th July at 1.35pm to conclude the inspection, which took a total of nine hours. The Registered Manager was present on both occasions. All of the eight service users were met during the two visits. The majority of the permanent staff team were present, a staff meeting was attended and records were examined. What the service does well: What has improved since the last inspection? What they could do better: The admission and assessment procedures need to be revised to take into account the Care Homes Regulations 2001 and demonstrate that the process is completed for new service users to enable a good transition when moving to the home. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 6 The home has not updated all of the risk assessments for the service users and these need to be reviewed on a regular basis and kept up-to-date to assist with minimising risks. Not all of the repairs in the home have been carried out within a reasonable time or to a good standard. The Registered Providers need to ensure that repairs and refurbishments are carried within reasonable timeframes, particularly where there are health and safety issues. The worktops in the kitchen are damaged and an Action Plan is required for their replacement. There are areas of carpet on the stair treads which are becoming loose and need to be repaired. Although Ealing Consortium is in the process of asking the service users for their views, a review of the quality of care has not been carried out, as required under Regulation 24. This was an outstanding requirement from the last two inspections. The frequency of fire training and fire drills need to be in accordance with the London Fire and Emergency Planning Authority’s guidance to ensure that service users and staff are protected as fully as possible. 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. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 The information to enable new service users and the representatives to make a choice about living in the home has been revised, providing a much more informative, and easier to read, document. No new service users have been admitted so the procedures could not be assessed. EVIDENCE: A new Statement of Purpose was required at the last inspection to clarify the services available in the home and in a format which could be easily understood. This has now been produced to include the information that the home has limited facilities for people with physical disabilities. The home’s stated aim is “helping people to working towards greater independence” and explains that the service is for people who require limited support at night as there are no waking night staff. The Service Users Guide is available in a pictorial format. As required, information has been included on emergency placements. The home has previously taken service users at very short notice. While it has been demonstrated that their needs have been met, it has now been agreed that one of the service users needs accommodation and support, in a smaller home, with service users of a more similar age. This was being actively pursued during this inspection. The care needs of two service users with mobility concerns have been kept under review. It has been agreed that a more suitable bathroom facility is to be installed for one of the service users who uses a wheelchair. The Occupational Therapist has been involved in Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 9 ensuring that the facility provided will be suitable, although changes were about to be make to the plans on the second visit to the home. No new service users have been admitted since the last inspection. The admission and assessment procedure have not been included in the updated policies and procedures, which are now in place, and is due to be revised this year. A requirement for this work completed by the end of 2004 was not met. This policy needs to be revised to take account of Regulations 14 and 15 of the Care Homes Regulations 2001. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 All of the service users are able to make decisions about their daily lives and staff encourage them to do so in a considered and enabling manner. They are able to be involved in the running of the home and supported to remain independent. EVIDENCE: The service users each have care plans and those examined showed that reviews of these take place. The compilation of a file for each service user is underway, with photographs and other visual information, regarding their interests and activities. Notes are recorded twice a day. The daily logs also include information such as the personal care provided, domestic tasks, visitors and activities undertaken to demonstrate that care plans are being followed. Service users are able to make to make their wishes known to the staff and consultation takes place about the support and activities in which they wish to participate. It was clear from the discussions held in the team meeting that staff are aware that several of the service users need to be encouraged to take part in new activities and that the process needs to be carefully thought through to ensure that they get the best from these. One service user was Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 11 pleased to report that he is assisting with the gardening at an older people’s club. A service users’ meeting was to be held during the evening of the second visit. A manager from another home was due to attend to obtain the views of the service users for an Ealing Consortium survey. Managers are carrying out this consultation, in homes other than their own, to obtain more objective views. During the regular meetings, service users are involved in planning the weekly menus, each choosing their favourite meals. During the inspection, one service user was able to express her opinion, very assertively, that she did not like being called a “client” and that she prefers that people are referred to by their personal names. Risk assessments are in place for the service users but the Registered Manager agreed that some are required to be updated. The risk assessments need to be reviewed on a regular basis and kept up-to-date. The office on the second floor, where service users’ information is stored, is kept locked when not in use. Staff information is held securely by the Registered Manager. One service user showed an awareness that information held in some of the files is about her. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 17 Service users have the opportunity to take part in a variety of activities, both for leisure and education, and to access the community. Good relationships are maintained in the home between service users and with the staff team. EVIDENCE: The staff were seen to be encouraging service users to participate in activities that they enjoy and which help them remain independent. The Registered Manager has introduced calendars for each of the service users, with their planned activities, so staff and service users can ensure that these are carried out. The domestic activities in the house include the service users wherever possible. Staff discussed, in their meeting, how they can best provide activities that service users enjoy whilst still supporting and developing their skills. At the last inspection, not all of the service users had been taking part in day activities. Since then, efforts have been made to find activities the service users may enjoy and everyone now has at least one day a week at a structured service. These include courses in IT, catering and music. A variety Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 13 of day services are accessed including a college, work centre and a club for older people, where two service users are able to assist. As service users are out more, this enables staff to provide more individual support for the service users. Three service users had been accompanied to holiday in Majorca just before the inspection and the photographs demonstrated how much this has been enjoyed. Another service user was on an activity holiday during the second visit. Holidays were being planned for the remaining service users in accordance with their wishes. Leisure activities undertaken include swimming, visits to the cinema and shopping. One service user goes regularly to church and all of the service users access various community services, some independently. There are positive relationships between the service users. This was observed, particularly in the kitchen/ dining area where service users like to spend their time, and are seen to interact well with staff and each other. While a number of service users are independent and able to go out unaccompanied, two service users are wheelchairs users. The staffing levels are such that there are generally two staff on each shift. The Registered Manager covers shifts to provide additional support if service users wish to go out and, with the additional day service provision, there is the opportunity take service users out during the day. Individual or group outings are also provided by Ealing Consortium’s “Door to Door” which has staff and transport. All of the service users are involved in planning the menu and it contained a good variety of meals. On one of the visits to the home, some service users were seen to assist staff to cook the meal. A meal of sausages, Yorkshire puddings, potatoes and peas were being served. Service users are able to have alternatives and meals are recorded. A special gluten-free diet is provided for one service user. The service users eat together in the evenings, at the large dining table, and a pleasant and social mealtime was observed to be commencing. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Service users are supported with their health needs and appointments by the staff team. The medication administration was found to be in good order with new staff competency tests being introduced. EVIDENCE: Staff are fully involved in providing support to the service users with their health and emotional needs. During this inspection, one member of staff attended a hospital appointment with a service user and another was checking on the result of tests. The occupational therapist and physiotherapist have been involved with providing advice and service users are encouraged to carry out the exercises prescribed. Emotional support was also seen to be offered where appropriate. The wellbeing of the individual service users was discussed at the staff meeting. Staff showed a good awareness of each individual service users’ needs. A check was made on the medication and it was found to be in order. Running totals are now kept of the PRN medications and, in the sample checked, all were correct. These are counted at night, by the member of staff who sleepsin, to minimise the risk of errors. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 15 A new medication procedure is in place and a medication competency test has been devised for the staff. They were in the process of completing these for the Manager. This is good practice and it is recommended that the tests are periodically retaken. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The policies for staff to understand the complaints and adult protection procedures are now in place. Service users are given the opportunity to express their views. EVIDENCE: One complaint from an outside source, which had been investigated satisfactorily, was the only complaint made since the last inspection. The complaint concerned the answering of the front door, and the home is installing a more suitable door bell. A temporary system has been put into place in the meantime. A new complaints policy and procedure has been produced. There have been no adult protections issues reported. The Registered Manager has had Protection of Vulnerable Adults training and said that she has discussed this with the staff in a team meeting. It is planned that all staff will have training and this is now included in the induction training. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 30 The standard of the environment in the home is satisfactory, with good use made of the communal space, which is quite limited when all eight service users are at home. Not all repairs and refurbishment have been carried out within reasonable timescales and this is an area which needs improvement. EVIDENCE: The carpet in the hallway was damaged when the doors were widened. This has not been replaced, but is not a safety hazard. There are some areas on the stair treads where the carpet is becoming loose and these need to be repaired. New floor covering was laid in the kitchen/dining area after an Immediate Requirement was issued at the last inspection. Areas of the kitchen were potentially dangerous where the floor covering was damaged and this should have been replaced much sooner. The Registered Providers need to ensure that the landlords carry out their responsibilities for repairs and replacement, particularly when hazards are identified. The main lounge has had new sofas, which provides sufficient seating for all of the service users to sit in comfort. The Registered Manager said that new curtains are to be purchased and other items to make the room more homely. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 18 Although the space available is used to the best advantage, and the kitchen/dining area a favourite space for service users and staff to sit and talk, the amount of communal space available in the home for eight service users is quite limited. The small lounge on the top floor, which can be used as a quiet area, is not accessible to all service users and is also used as the smoking area. Although there has been no agreement to have the kitchen units being replaced, the work is required and there are damaged work surfaces which will need replacement. An Action Plan is required for the replacement of the worktops. The service users’ bedrooms were not seen on this inspection. The Registered Manager confirmed that the repair on one bedroom window, required at the last inspection, has been completed and a restrictor has been fitted. To solve the problem of bathroom floor becoming wet when service users have showers, the Registered Manager said that the baths are due to be fitted with shower screens. The en suite bathroom is due to be refurbished, to better suit the needs of the service user who has mobility difficulties. It is planned that this will be a “wet room” and the work should commence by September. An Occupational Therapist has been involved in planning this but, during the inspection, she asked for changes to be made to the plans. Staff were hopeful that this would not delay the proposed timescale as this work has been outstanding for a long time. To assist with hygiene and infection control, the bathrooms now have paper towel dispensers installed. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 A full staff team has now been recruited and the newest member of staff was on her induction during this inspection. The Registered Manager provides good leadership and motivation to the staff team. EVIDENCE: The full staff team has recently been completed, following a successful recruitment drive by Ealing Consortium and with staff transferred from other homes. The newest member of staff had just completed her Ealing Consortium induction. She was very enthusiastic about this and is now completing her Learning Disability Award Framework workbooks. The staff team consists of the Registered Manager, a Senior Support Worker, five full-time and one parttime Support Workers. This provides for a minimum of two staff on each shift. The Registered Manager said that there are sufficient staff to cover for annual leave and training but she generally covers for sickness leave as there is no agency provision for this. The provision of sufficient time for management tasks needs to be kept under review. The staff team have varied and complementary skills and experience. There is now a gender balance to reflect the service user group. Staff meetings take place on a regular basis and one of these was observed on the second day of the inspection. Staff were found to be very well aware of the service users’ Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 20 needs and wishes. Staff are also encouraged to use their initiative and to bring new ideas to support the service users and widen their interests. A number of staff files were sampled, including those of the new staff, and were found to be in order, with references and other information as required by Schedules 2 and 4 of the Care Homes Regulations 2001. However, the information on Criminal Records Bureau disclosures in not kept in the home except for the disclosure number. A number of staff require updated training of the core courses, such as moving and handling, food hygiene, fire safety and first aid. Evidence was seen that Ealing Consortium has been asked to place staff on the next courses for these. These courses need to be undertaken within a reasonable timescale. Both the Registered Manager and the Senior Support Worker provide supervision to the staff. Examples of supervision sessions were seen and sessions were also taking place during this inspection. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 The Registered Manager promotes a good quality of care and support for the service users. The staff team have been seen to be supportive of each other and work well as a team. EVIDENCE: The Registered Manager has managed for five years and has ten years’ experience of working with people with learning disabilities. She has the Registered Managers Award and is an NVQ Assessor. She will be taking her NVQ Level 4 in Care in due course. The home has an open and positive ethos. The friendly staff team interact well, and with good humour, with service users and each other. The manager of another Ealing Consortium home is currently undertaking questionnaires with the service users to gain their views. This is a reciprocal arrangement between the managers of the homes. Ealing Consortium management staff, including other home managers, make Regulation 26 Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 22 monthly visits and these are submitted to the Commission for Social Care Inspection on a regular basis as required. When the questionnaires, and other quality assurance information is completed, it will need to be summarised and a report made available to service users and the Commission for Social Care Inspection. Previous timescales for this Regulation have not been met. Many of the Ealing Consortium policies and procedures required reviewing to being them into line with current legislation, including the Care Homes Regulations 2001. Prior to the first visit to the home, new files of policies and procedures had been delivered. Not all have been updated but review dates have been included for those which have not. The records in the home are generally easy to access and were found to be in reasonable order. The Ealing Consortium fire procedures show that fire training, by an external trainer, is provided every three years. The Registered Manager needs to ensure that regular refresher training is provided to the staff, in additional to the basic fire drills which are undertaken. Although the records demonstrated that most staff have taken part in drills, it is advised that staff have the number of fire drills recommended for night staff, which is at least four a year. The Registered Manager said that service users are involved in the fire drills and staff try to explain the importance of these. The majority of the radiators in the home have been replaced by low temperature surface radiators. This installation has, unfortunately, damaged a number of areas of wallpaper which the Registered Manager has plans to repair. There have been concerns about the security of the home and there have been two recent incidents, one involving the theft of the lawn mower, and one involving a service user seeing a person in the parking area of the garden. The back gates are now to have a security system. Although this should improve security, a solution also needs to be found to the access to the fire exit in the laundry where it has been on the advice of the London Fire and Emergency Planning Authority that the door is opened during the day. It is recommended that the London Fire and Emergency Planning Authority are asked again for their advice to try and find a solution to the security concern. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 2 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Warwick Rd Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 x v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 24 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 YA4 Regulation 14 & 15 Requirement The admission and assessment procedures, must be revised to take into account the requirements of Regulations 14 and 15 of the Care Homes Regulations 2001. (Previous timescale of 31/12/04 not met). Risk assessments must be reviewed on a regular basis and be kept up-to-date. The Registered Providers must ensure that repairs and replacements are carried out within reasonable timescales, particularly where hazards are identified. An Action Plan is required for the replacement of the worktops in the kitchen. A quality assurance and monitoring system must be in place and a review of quality of care, in accordance with Regulation 24, must be carried out. (The previous timescale of 31/1/05 has not been met). The carpet on the stair treads must be repaired. Sufficient fire training and fire drills must take place to ensure that all of the staff are trained, Timescale for action 31/08/05 2. 3. YA9 YA24 13(4a-c) 13(4c) 23(2b) 31/08/05 31/07/05 4. 5. YA24 YA39 23(2b&c) 24 31/08/05 30/09/05 6. 7. YA24 YA42 13(4c) 23(2b) 23(4d&e) 31/07/05 31/08/05 Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 25 on a regular basis, and in line with the London Fire and Emergency Planning Authoritys guidance. 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 YA42 Good Practice Recommendations It is recommended that the London Fire and Emergency Planning Authority are asked again for their advice concerning the laundry door to try and find a solution to the security concern. Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Warwick Rd v228672 g61 s27719 warwick rd v228672 13.06.05 stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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