Inspection on 10/07/07 for 137a Tentelow Lane

This inspection was carried out on 10th July 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

137a Tentelow Lane 22/01/07

137a Tentelow Lane 05/12/05

137a Tentelow Lane 16/05/05

137a Tentelow Lane 16/12/04

137a Tentelow Lane 13/07/04

137a Tentelow Lane 09/09/03

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 08/07/2008.

CARE HOME ADULTS 18-65 137a Tentelow Lane Norwood Green Southall Middlesex UB2 4LW Lead Inspector Sarah Middleton Key Unannounced Inspection 10th July 2007 09:15 137a Tentelow Lane DS0000027763.V345242.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 137a Tentelow Lane DS0000027763.V345242.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. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 137a Tentelow Lane Address Norwood Green Southall Middlesex UB2 4LW 0208 893 6634 0208 893 6634 mettlelus@aol.com londonroad@tiscali.co.uk Milbury Care Services Ltd 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) Charles Nii Ashong Mettle Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Female 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 may be accommodated is: 4 22nd January 2007 Date of last inspection Brief Description of the Service: 137a Tentelow Lane is a home for four female residents with learning disabilities. One has a hearing and sensory impairment, in addition to a learning disability. The owner and care provider is Milbury Care Services. The home is a four bedroomed, semi-detached house, located on a busy road between Southall and Hounslow. There are local shops nearby and Southall, Ealing and Hounslow shopping centres can be accessed by car. There is a car and a larger people carrier for the house as there are no trains or bus routes close by. The adjoining house (137b) is for four male residents, whose Registered Manager is also the Registered Manager for 137a Tentelow Lane. 137a has four single bedrooms. One is on the ground floor and has its own shower. There is a shared toilet nearby. One first floor bedroom is en-suite, with its own bath. The two further bedrooms on the first floor share a bathroom and toilet. The office and sleeping in room for staff is located on the first floor. The lounge, dining room, kitchen and laundry room are located on the ground floor. There is a rear garden, which is mostly lawn with a patio area. There is parking at the front of the property for both houses. There is a joint staff team for 137a and 137b Tentelow lane, and staff work between the two houses. 137a is staffed twenty-four hours a day. Fees range from £1,165-50-£1,300.00 per resident, per week. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The term service user previously used has been replaced in this inspection report with the term resident and refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.15am-4.30pm. The Inspector viewed records, resident’s files and toured the home. Three residents and three members of staff were spoken with as part of the inspection process. One relative completed a postal survey. Overall feedback from the discussions and survey were positive. The Registered Manager was not present during the inspection. The two Deputy Manager’s assisted with the inspection. Equality and diversity issues are acknowledged by the home and where identified have been included into this report. The key Standards were inspected and nine of the ten previous requirements were met. Eight new requirements were made at this inspection visit. What the service does well: The home offers residents a variety of choices and activities to meet their individual preferences. The staff team are committed and knowledgeable regarding the residents’ needs. Feedback from the residents regarding the staff team was positive. Residents felt able to talk with staff, if they had any concerns or comments about the home. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents’ views need to be obtained and recorded when planning care plans. Risk assessments need to be completed on all potential risks. Menus need to consider providing residents with a balanced diet that is healthy and nutritious. Evidence must be available that regular medication checks take place. Consideration needs to be given to the environment, as several areas in the home need attention. The home needs to address the unpleasant odour in the home. To ensure residents health and safety is protected the testing for Legionella must be up to date. 137a Tentelow Lane DS0000027763.V345242.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. 137a Tentelow Lane DS0000027763.V345242.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 137a Tentelow Lane DS0000027763.V345242.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: The home has not had any new admissions into the home for several years. There are pre-admission assessments in place to assess a prospective resident. The Inspector viewed a blank pre-admission assessment and this contained information on relationships, health, personal and social needs. There was evidence that a prospective resident would be involved in their assessment and could sign the form when it was completed. The Inspector was satisfied that every step would be taken to fully assess a prospective resident before a decision would be made for them to move into the home. 137a Tentelow Lane DS0000027763.V345242.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and care plans reflect how these needs are to be met. Residents’ should be supported to contribute to their care plans. Residents are supported to make decisions about their lives. In order to safeguard residents, presenting and potential risks need to be assessed and recorded. EVIDENCE: The Inspector viewed samples of care plans. These had improved and were more comprehensive, detailing the resident’s personal, cultural and social care needs. The essential lifestyle plans were personal to the resident and recorded what was important to the resident and his or her preferred routines. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 11 Annual reviews are held with the resident, and where appropriate their family members. Reviews offer the opportunity to consider the resident’s aims and objectives and discuss any issues that might have arisen over the past months. Each resident has an assigned member of staff to support them and meet with them on a regular basis, these are known as keyworkers. The Inspector viewed samples of minutes from the keyworker meetings. The Inspector acknowledged that residents are involved in decisions about their day-to-day life, however there was a lack of evidence to suggest residents are asked about and involved in the development of their individual care plans. It is deemed good practice to actively involve residents in their care plans. A re-stated requirement was made for staff to consider how to involve residents when devising a care plan and the essential lifestyle plan. The Inspector viewed samples of daily records and these recorded the relevant information about each resident. Resident meetings occur on a weekly basis and minutes were seen of these meetings. These meetings are an opportunity for residents to speak about the home, consider the meals they want to eat, issues they might have and activities they might want to take part in. One resident spoken with said they worked as an advocate for people with learning disabilities and felt that it was important to be able to speak up and support others. Those staff asked, confirmed they make every attempt to encourage and support residents to do as much for themselves as they can. The Inspector observed staff assisting residents to take part in activities along with members of staff. The residents living at the home did not have independent advocates but did have contact with family or friends. The Inspector viewed risk assessments. Some were in place and outlined particular risks, including how to minimise the risks occurring. One resident can become stressed and anxious and certain behaviours can occur both in and out of the home. A risk assessment had not been completed for this resident and this was brought to the attention of the Deputy Manager. In addition, where residents might need assistance if there was a fire, or if a resident failed to respond safely to a fire, individual fire risk assessments must be completed. A requirement was made for risk assessments to be completed on any potential identified risk. 137a Tentelow Lane DS0000027763.V345242.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in appropriate and various activities that suit individual preferences. Residents are supported to maintain social relationships. Residents’ rights are respected and acknowledged by the home. In order for residents to maintain good health, the meal provision needs to incorporate varied and well -balanced meals. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 13 EVIDENCE: The Inspector spoke with the residents who were positive about the activities they took part in on a daily basis. One resident explained that she attended the local College and that she could now travel to College in the morning, independent of staff. Residents’ preferences are identified with help from staff. Activities are then planned accordingly. The local community is accessed through public transport, the home’s own transport or by walking. Often residents receive one to one support from a member of staff. One resident told the Inspector that she liked to go for walks and buy her own personal shopping with the help of staff. A reflexologist visits the home and provides a service to the residents. Day trips and holidays also take place. The home has developed a sensory room in the adjoining separate registered care home that is accessed for those residents who benefit and enjoy relaxing in this way. Residents are encouraged to make regular contact with their family or friends. This might be via the telephone or through visits. One resident spoke about seeing their family whenever they wanted to. As the residents are unable to read their own mail independently, some residents confirmed to the Inspector that staff read their personal mail to them. Members of staff were seen to interact positively with the residents throughout the inspection and not exclusively with each other. Residents confirmed they could spend time in their rooms or with others. One resident has their own mobile telephone and can use this to communicate with family and friends. The Inspector sat with the residents during lunchtime and those asked were happy with the meal provision in the home. One resident spoke of the cultural meals she has on a regular basis and stated that the home takes the time to ensure she has the meals that she prefers. The kitchen was viewed and overall was clean and tidy, (see Standard 24 regarding the flooring). Fridge and freezer temperatures had been taken and were within an appropriate range. The residents, with support from staff, choose the meals they would like to eat. The menus are planned with the residents from both this home and the adjoining separately registered care home. Thus each day a resident can choose the meal they want to eat. The Inspector noted that the menus did not provide sufficient fresh produce and daily healthy meals. Some foods were processed and high in fat. This was brought to the attention of the Deputy Manager, as some residents have particular health needs that need monitoring. A requirement was made for meals to be nutritious, varied and incorporate a balance of providing a choice of foods whilst promoting healthy eating. 137a Tentelow Lane DS0000027763.V345242.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in their preferred way. Health needs are identified and were being met. In order to safeguard residents, evidence of robust regular medication checks need to be in place. EVIDENCE: Residents need various levels of support when managing their personal care. Residents receive same gender personal care support, meaning that only female members of staff provide this support. This task is always carried out in private. Those residents asked confirmed they could go to bed and get up when they so choose. Residents are encouraged to wear the clothes they want to and accessorise their outfits as they so wish. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 15 The home uses a form to record medical health appointments. This enables staff to monitor and record relevant information about each resident’s health. Health needs are outlined on the care plans and residents have access to all health professionals, such as the GP, Dentist and Chiropody. Residents’ weights are checked to review any sudden changes and respond accordingly. The home had completed a health action plan for the one of the residents. This looks at the residents’ health in detail, such as their allergies, whether they are smokers and general women’s health. The Inspector discussed the need to involve the resident when completing these action plans. The medication systems were viewed and samples were counted. All medication was stored in a secure and locked cabinet. All those checked were correct and the Medication Administration Records had been correctly completed. The home did not have controlled drugs in the home and residents were unable to self-medicate. Currently there is no evidence in place to show that regular medication counts and checks are carried out. A requirement was made for this to be developed. A recommendation was made for the home to obtain information on the medication used in the home. This information would enable staff to be aware of the medication and its side effects. Members of staff receive training prior to administering medication and the Inspector viewed a medication competency form that staff work through with the Registered Manager. 137a Tentelow Lane DS0000027763.V345242.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. Residents feel their views are listened to and would be acted on, where necessary. Systems are in place to protect residents from abuse. EVIDENCE: The home has not received any complaints. Residents told the Inspector that they would be comfortable in talking with staff or the Registered Manager, if they had any concerns. The complaints policy was located in the dining room. The majority of the residents would not be able to read the complaints policy, however the Inspector was satisfied that residents, with the help of family, would be able to voice their concerns and complaints. Staff also confirmed that they felt sure the residents would speak out if they were unhappy. The home has not had any abuse allegations and training is provided for staff on adult abuse. The home has the Local Authority’s polices and procedures on adult abuse. The Inspector counted a sample of residents’ money. Those counted were correct at the time of the inspection. Residents are not able to manage their own finances and so the home keeps hold of their money and records any financial transactions that have taken place. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is not sufficiently maintained. Specialist equipment for individual residents’ is obtained as and when necessary. The home had not addressed the malodour on the first floor. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 18 EVIDENCE: The Inspector carried out a tour of the home. Various areas of the home require attention and this was pointed out to the Deputy Manager. • The laundry room had poor ventilation, with mould on the walls and ceiling. A requirement was made for this to be addressed. • The flooring in the kitchen had several holes in it. •The flooring in the small area leading from the main hall into the laundry room and living room had been poorly fitted and was lifting in places. •The flooring in the main bathroom and ground floor toilet needed replacing. A requirement was made for these areas to be addressed. • The seal around the bathroom sink and kitchen sink was mouldy and in need of replacing. A requirement was made for this area to also be addressed. The Inspector was aware that the Registered Manager had already informed the relevant professionals of the areas he felt needed attention, but there was no evidence to suggest the work would be carried. The home needs to be a pleasant environment for residents and the home in certain places was looking neglected. The majority of kitchen handles, bar one, had been put back onto the kitchen cupboard doors. The heating problems and the hot water temperatures had also been resolved. Environmental risk assessments had been completed and were viewed by the Inspector. The home had purchased and rented specialist information and equipment for one resident who has particular needs. The home was clean however on the first floor landing the Inspector noted an unpleasant smell. The Inspector was informed that the home had cleaned the carpet but it had not addressed the problem. The Inspector suggested the home considers more suitable flooring to be laid rather than carpet, as the smell is likely to be an ongoing issue. A requirement was made for this to be addressed. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team support the residents. Recruitment checks are carried out to a satisfactory level. Residents’ needs were being met through staff receiving appropriate levels of training. EVIDENCE: The home encourages and supports staff to study for an NVQ in care. The staff team is a mix of ages, gender and experience and reflects the diversity of the residents. The Inspector spoke with staff who were committed to meeting the needs of the residents. Staff are familiar with the triggers that can affect the residents and aim to support the residents through difficult moments in their lives. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 20 The Inspector noted that for one resident, staff recognise the need to spend one to one time with her, thus reducing the resident’s anxiety and stress levels. This way of supporting the resident has reduced the amount of medication used to calm the resident, who often just needs time with a member of staff to work through her feelings. There are staff vacancies at present but the home does not use external agency members of staff. Residents’ benefit from receiving support from a consistent staff team. Existing members of staff or regular bank staff, who are employed by the Registered Provider, cover the vacant staff hours. Staff confirmed they attend team meetings and bank staff are also encouraged to attend. These meetings are used to share information and to provide a forum for staff to learn and discuss particular topics. The home currently has no computer or access to the Internet. Therefore the Registered Manager types the documents away from the home. Staff told the Inspector that the home would benefit from having a computer so that relevant work could be carried out effectively and professionally. Accessing current information relevant for the home and staff team would be an advantage. This should be considered as both staff and consequently residents’ could benefit from having up to date technology available to them. Recently the Registered Manager had sent all of the staff employment details to the central Human Resources Department, which is not local to the home. The home had information on staff, such as photograph, Criminal Record Bureau checks, confirmation that references and health declaration had been obtained. The staff employment files are not currently available to be sent to the home during an inspection. A strong recommendation was made for these files to be made available during the inspection, so that the Inspector can verify the information obtained regarding members of staff. The Inspector viewed the induction programme new members of staff work through. The induction workbook covers a range of subjects such as, policies, principles of care and understanding the needs of the residents. During the induction period new staff also shadow and observe existing members of staff working with the residents. The expectation is then for new staff to study the Learning Disability Award Framework before commencing with an NVQ. The Inspector was informed that several training courses were to be provided through electronic learning, via a laptop. This new method of learning has yet to commence, but could mean that some mandatory courses are provided through this way. The Registered Manager is strongly recommended to monitor the quality and suitability of the training and ensure it is an effective way to provide information and skills to the staff team. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 21 The training programme provides staff with the opportunity to develop new skills and obtain information relevant to the work they are to perform. Mandatory subjects such as moving and handling, fire awareness and food hygiene were either up to date for staff or courses had been booked in the near future. Bank members of staff also attend the mandatory training courses. The Deputy Manager was in the process of devising individual staff training records. The Inspector discussed using the training records to record the in-house topics discussed during team meetings, as these are also an additional way of learning. Staff had received training in providing nail care services to the residents. The Inspector made a recommendation for staff to receive training and information on the Mental Capacity Act 2005, as this is relevant for the staff team and residents’. 137a Tentelow Lane DS0000027763.V345242.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well managed home. Resident views are taken into account and the home reflects on the care provided in the home. The health and safety of the residents is promoted and protected. The testing for Legionella needs to be up to date to fully safeguard the residents. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager has worked in the home for several years. He is studying for the Registered Managers Award and NVQ level 4 in care. Staff informed the Inspector that they could talk to the Registered Manager if they needed advice and guidance. The Inspector was informed that the home was due to give questionnaires to residents and family, so that their views on the home could be obtained. Monthly Regulation 26 visits are carried out and the reports are sent to the CSCI. The home had started to look at areas of the home, such as environment, staffing and residents so that shortfalls could be identified and improvements could be then be made. A strong recommendation was made for the home to devise a short report or summary following on from areas assessed and to make this available for residents and the CSCI. The Inspector viewed a sample of health and safety records. The Portable Appliance testing, Gas Safety Record and the fire equipment had all been tested and were up to date. Fire drills are held with different staff and take place at various times of the day. A fire risk assessment was in place and considered the hazards in the home. The fire officer had visited the home in April 2007 and no recommendations had been made. Water temperatures are taken in all areas of the home and the records viewed recorded appropriate and safe ranges of temperatures. The home regularly checks the water tanks and checks taps and showerheads for limescale. However the professional testing for Legionella had not taken place for a few years and a requirement was made for this to be addressed. Repairs are recorded in a maintenance book. This should record the work needing to be done, who was contacted to carry out the work and when the work is completed, so that there is a clear audit trail of works noted and carried out in the home. 137a Tentelow Lane DS0000027763.V345242.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 x 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 x 26 x 27 28 29 30 2 3 x 2 x x x 3 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000027763.V345242.R01.S.doc x Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 137a Tentelow Lane Score 3 3 2 x 3 x 3 x x 2 x 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 YA6 Regulation 15 Requirement Consultation with service users when devising and reviewing their care plans should be recorded onto the care plans. (Previous timescale 31/03/07 not met). In order to safeguard residents risk assessments must be completed on all potential risks. To ensure residents receive a well balanced diet, the meal provision must include healthy and nutritious options. To protect the residents’ safety, evidence must be available regarding the medication checks carried out. To ensure the home is pleasant to live in, the laundry room must have suitable ventilation to prevent mould and mildew developing. The seal around the bath and kitchen sink needs to be replaced. The flooring in the ground floor toilet, first floor bathroom and small ground floor hall area needs to be replaced. DS0000027763.V345242.R01.S.doc Timescale for action 30/09/07 2. 3. YA9 YA17 13(4)(b) (c) 16(2)(i) 31/08/07 01/08/07 4. YA20 13(2) 13/08/07 5. YA24 23(2)(p) 31/08/07 6. 7. YA24 YA24 23(2)(d) 23(2)(d) 30/09/07 30/09/07 137a Tentelow Lane Version 5.2 Page 26 8. YA30 16(2)(k) 9. YA42 To ensure the home is welcoming for the residents, the home must address the unpleasant odour on the first floor landing. 13(4)(a)(c) To ensure the health and safety of residents is protected the testing for Legionella must be up to date. 30/09/07 30/09/07 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. 2. 3. 4. 5. Refer to Standard YA20 YA34 YA35 YA35 YA39 Good Practice Recommendations It is recommended for the home to obtain information on the medication used in the home, including their side effects. It is strongly recommended that full staff employment files are made available during the inspection. It is strongly recommended for staff to receive information and training regarding the Mental Capacity Act 2005. It is strongly recommended for the Registered Manager to monitor the effectiveness and quality of the new electronic method of providing training and information to staff. It is strongly recommended for a summary or short report to be developed from the development plan. This should also incorporate a summary of the residents’ view on the home. 137a Tentelow Lane DS0000027763.V345242.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 137a Tentelow Lane DS0000027763.V345242.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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