Inspection on 26/07/07 for 137b Tentelow Lane

This inspection was carried out on 26th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

137b Tentelow Lane 05/02/07

137b Tentelow Lane 06/02/06

137b Tentelow Lane 19/05/05

137b Tentelow Lane 28/01/05

137b Tentelow Lane 27/05/04

137b Tentelow Lane 03/02/04

137b Tentelow Lane 10/09/03

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 137b Tentelow Lane Norwood Green Southall Middlesex UB2 4LW Lead Inspector Sarah Middleton Key Unannounced Inspection 26th July 2007 09:05 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 137b Tentelow Lane DS0000027764.V346436.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. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 137b Tentelow Lane Address Norwood Green Southall Middlesex UB2 4LW 0208 893 6635 0208 893 6635 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 (4) registration, with number of places 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th February 2007 Brief Description of the Service: 137b Tentelow Lane is a home for four male residents with learning disabilities. The owner and 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 house car for both 137b and the adjoining care home, (137a). There are no bus or rail routes close by. The adjoining house is for four female residents. There is a joint staff team for 137a and 137b Tentelow Lane. 137b 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 lounge, dining room, kitchen and laundry room are located on the ground floor. The office is on the first floor. There is a rear garden, which is mostly lawn with a patio area. There are parking spaces for both homes to the front of the house. Fees range from £1,165.50-£1,300.00 per resident, per week. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previously used term service user has been replaced in this inspection report and the term resident is now used 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 9.05-4.10pm. The Inspector spoke with one resident and observed and met with the other residents. Three members of staff were spoken with as part of the inspection process. The Registered Manager had completed an Annual Quality Assurance Assessment, which provided the Inspector with information regarding the home. The Inspector viewed the maintenance records; residents’ care plans and toured the home. All of the National Minimum Key Standards were assessed. Three of the seven previous requirements had been met, one requirement remained within the required timescale and six new requirements were made at this inspection. The home is aware of equality and diversity issues and where identified have been included into this report. What the service does well: What has improved since the last inspection? Care plans had improved and clearly showed residents personal, social and health needs. Certain areas of the home had been decorated. The home had begun considering reviewing the care provided in the home. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 6 What they could do better: 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. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs would be 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 the assessment of their needs. 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. The Registered Manager confirmed that he would encourage and support any prospective resident to visit the home to meet with the staff and other residents. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 9 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. The essential lifestyle plan viewed was not up to date and this needs to be addressed. 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 recorded what was important to the resident and his or her preferred routines. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 10 However one essential lifestyle plan viewed had not been updated for almost eighteen months and included information regarding a resident that was no longer relevant. A requirement was made for information regarding the residents to be relevant and reviewed on a regular basis. 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. 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 want to take part in. One resident has full verbal communication, whilst the other residents communicate in different ways. Staff described how they always seek to understand and listen to all of the residents’ views. Those staff asked, confirmed they make every attempt to encourage and support residents to do as much for themselves independent of staff. The Inspector observed staff assisting residents to take part in activities. The residents living at the home did not have independent advocates but had have contact with various family members. The Inspector viewed risk assessments. Some were in place and outlined particular risks, including how to minimise the risks occurring. These risk assessments covered areas such as swimming, using the lawn mower and general risk assessments. 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 Registered Manager. In addition, where a resident refuses health treatment a risk assessment must be completed. Staff had noted the potential issues in the care plan viewed but this needs to be recorded clearly in the form of a risk assessment. A requirement was made for the shortfall to be addressed. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 11 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. Residents receive a well balanced diet that acknowledges preferences and cultural needs. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents are able to engage in various activities, both in and out of the home. One resident described how he likes to keep busy by going to the pub, bowling or visiting the cinema. Other residents also enjoy going to the cinema and where possible, staff ensure culturally relevant films are accessed, such as Asian films. One resident attends the local Mosque, with staff support, whilst another resident attends the local church every week. 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 and this could be either in the home or out in the community. A reflexologist visits the home and provides a therapeutic service to those residents interested. Day trips and holidays also take place. The home has developed a sensory room, with music and soft lighting 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 of waiting to hear from his family via the telephone, as they liked to receive regular calls. Staff support the residents to maintain social relationships by supporting them to visit family or encouraging family members to visit the home. Two residents are able to read their own mail independently. The other two residents have their personal mail read to them. Members of staff were seen to interact positively with the residents throughout the inspection and not exclusively with each other. The resident spoken with confirmed he could spend time in his room or with the other residents. 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, owned by the same Registered Provider. Recently the home had made improvements to the menus as it was recognised that some of the meals were high in fat and did not provide a varied and healthy diet for the residents. The resident spoken with said he liked the meals provided in the home and spoke of the meals he could make with some assistance from staff. One resident has specific cultural dietary requirements. The home respects these needs and seeks to ensure the differing preferences and needs are met. The Registered Manager acknowledged that considering additional ways to separately store utensils and some of the cooking equipment would be good practice and further meet cultural and religious preferences. Fridge and freezer temperatures had been taken and were within an appropriate range. Food that had been opened was wrapped and dated when opened. The Inspector viewed the kitchen and overall it was clean and tidy, (see Standard 24 regarding the kitchen cupboards). 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 13 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 personal care support in their preferred way. Health needs had been identified, recorded 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. Where possible, the residents receive same gender personal care support. When there are only female members of staff available the Inspector viewed a form that is used outlining the reasons why same gender care could not be provided. Personal care is always carried out in private and staff described how they encourage residents to do as much for themselves as they are able to. The resident spoken with confirmed he could go to bed and get up when he wanted to. Residents are encouraged to wear the clothes they want to and accessorise their outfits as they so wish. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 14 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 health needs. The home should consider how to involve the resident when completing these action plans. One resident has a fear of the dentist and spoke to the Inspector about his concerns. The Registered Manager confirmed that where residents might refuse health treatment various options are looked at to ensure this health need is not ignored. 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. The home had recently obtained information on the medication used in the home. This information would enable staff to be aware of the different types of medication and their different side effects. Members of staff receive training prior to administering medication and the Inspector was informed that on an annual basis a medication competency form is completed by each member of staff and verified by the Registered Manager. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 15 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’ 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. One resident told the Inspector that he would be comfortable in talking with staff or the Registered Manager, if he had any concerns. The complaints policy was located in the dining room. Two residents would be able to read the complaints policy. The Inspector was informed that residents are supported to voice their concerns, in resident meetings, or keyworker meetings, 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 Registered Manager informed the Inspector that he was a trainer on adult abuse. The home has the Local Authority’s polices and procedures on adult abuse. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 16 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. Residents’ money is counted on a daily basis but there was no detail regarding the financial checks that are carried out. This was brought to the attention of the Registered Manager who confirmed that he would ensure that on the expenditure records each daily check carried out would be recorded. 137b Tentelow Lane DS0000027764.V346436.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 & 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. Residents’ benefit from a home that is clean and free from offensive odours. EVIDENCE: The Inspector carried out a tour of the home. The lounge and hall had been decorated. However there were several areas of the home that needed attention. • The first floor bathroom flooring and the en-suite bathroom flooring on the first floor had not been replaced. This had been identified at two previous inspections. •The washbasin in the first floor main bathroom had not been replaced. This had been identified at the previous inspection. • The resident’s bedroom door on the first floor remained difficult to open or close. This had been identified at the previous inspection. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 18 • The resident’s en-suite bathroom had cracked tiles, the seal around the bath was mouldy and the whole room needs updating. • The kitchen had two cupboard doors that had come off from the units. These need to be put back onto the units. Requirements were made for each of the areas to be addressed. The resident, whose bathroom needs updating and replacing told the Inspector that he would like to have a new bathroom. The Registered Manager informed the Inspector that he had reported the maintenance areas needing to be addressed. Currently there are no dates for when or if the work will be completed. The Registered Manager must be mindful that the home needs to be pleasant and welcoming for the residents as areas are starting to look neglected. The home has a separate laundry room where residents carry out their laundry tasks with the support from staff. The staff team, with some input from residents, clean the home. Residents are expected and assisted to clean their own bedrooms. Overall the home was clean and free from odours at the time of the inspection. 137b Tentelow Lane DS0000027764.V346436.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 members 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. 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 20 One resident uses Makaton, which is using hands to make various signs, to communicate with staff. Staff were observed using Makaton as a way to communicate with the resident. The Inspector also used some basic signs to communicate with this resident. Staff told the Inspector that they had read literature and watched videos on how to use Makaton. Staff also went on to say they sought additional support and advice from staff who were more confident and competent in using this as a form of communication. The Registered Manager informed the Inspector that he would be meeting with the community speech and language therapist in the next few weeks to consider if the home needs to make improvements regarding how it promotes positive and appropriate communication. 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 regular staff team. Existing members of staff or 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. 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 employment information obtained. The Inspector viewed the induction programme that 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. 137b Tentelow Lane DS0000027764.V346436.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 staff also attend the mandatory training courses. The Deputy Manager had recently developed individual staff training records and the Inspector viewed the new training records. The Inspector discussed using the training records to record the in-house topics discussed during team meetings, as these forums are an additional way of recording learning. 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. 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’. 137b Tentelow Lane DS0000027764.V346436.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. 137b Tentelow Lane DS0000027764.V346436.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. The Registered Manager was present during the inspection and maintains a visible presence in the home. Staff spoken with commented positively on how he is approachable and supportive to the staff team. 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. The Inspector discussed with the Registered Manager the need to develop a short report or summary following on from areas assessed and to make this available for residents and the CSCI. This had been a previous requirement and remains within timescale. 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. Appropriate steps are taken to inform all residents of when there is a fire drill, for example providing a flashing light that goes off when the fire alarm has been set off. 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. 137b Tentelow Lane DS0000027764.V346436.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 x 28 x 29 x 30 3 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 Score 2 3 x 2 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 2 x x 2 x 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(b) Requirement Timescale for action 30/09/07 2. 3. YA9 YA20 4. YA24 5. YA24 6. YA24 To ensure residents’ routines and preferences are current, the essential lifestyle plans need to be up to date. 13(4)(b) In order to safeguard residents (c) risk assessments must be completed on all potential risks. 13(2) To protect the residents’ safety, evidence must be available regarding the medication checks carried out. 23(2)(b)(d) To provide residents with a suitable home to live in, the flooring for both bathrooms on the first floor must be replaced. Previous timescale 31/05/06 & 09/04/07 not met). 23(2)(b)(c) The washbasin in the first floor main bathroom must be replaced. (Previous timescale 31/05/07 not met). 23(2)(b)(c) To ensure the resident can easily open his bedroom door on the first floor, the door must be fixed. (Previous timescale 01/03/07 not met). 31/08/07 31/08/07 31/10/07 31/10/07 31/10/07 137b Tentelow Lane DS0000027764.V346436.R01.S.doc Version 5.2 Page 26 7. YA24 23(2)(b)(d) To provide the resident with a homely and pleasant place to live in the en-suite bathroom on the first floor needs fully updating. 23(2)(b) 31/12/07 8. YA24 9. YA39 24(2) To provide a pleasant home to 30/09/07 live in, the kitchen cupboard doors need to be fixed onto the kitchen cupboard units. A quality assurance 30/09/07 summary/report must be available for the CSCI and service users and or their representatives. This must briefly outline improvements the home has made and areas still to be addressed. (Not met but within previous timescale 30/09/07) To safeguard residents, the testing for Legionella must be up to date. 30/09/07 10. YA42 13(4)(a)(c) 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. Refer to Standard YA34 YA35 YA35 Good Practice Recommendations It is strongly recommended that 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. 137b Tentelow Lane DS0000027764.V346436.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 - 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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