Inspection on 06/07/05 for 17-19 Edgeware Road

This inspection was carried out on 6th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

17-19 Edgeware Road 21/07/06

17-19 Edgeware Road 11/01/06

17-19 Edgeware Road 17/01/05

17-19 Edgeware Road 06/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 17 - 19 Edgeware Road Staple Hill South Glos BS16 4LZ Lead Inspector Grace Agu Announced 6 & 7 July 2005 09:30 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. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 17-19 Edgeware Road Address Staple Hill South Glos BS16 4LZ 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) 0117 957 0404 0117 957 0404 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust Mr Alan Nuttall Care Home for Younger Adults 17 Category(ies) of LD Learning disability for 17 registration, with number LD(E) Learning dis - over 65 for 17 of places 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 17 persons aged 19 years and over requiring personal care. May accommodate one named person with a Physical Disability (PD). Will revert back to LD when named person leaves. Date of last inspection 17 January 2005 Unannounced Brief Description of the Service: The houses at 17-19 Edgware Road are properties run by Aspects & Milestones Trust, which is referred to in the report as The Trust. The houses at 17-19 Edgware Road were first registered as a nursing home for people with learning disabilities. However the registration changed in 1996 with the changing needs of service users to that of a Care Home. The houses are purpose built with off street parking. The Home is registered for seventeen people. The Edgware Road accommodation consists of seventeen single rooms split between the two houses. These are separately run. Each has it’s own staff group and is independent of the other with it’s own kitchen, dining /lounge and bathing facilities.There is a garden at the rear of the building that provides a small paved area for each house. Beyond this there is a larger, shared garden. The home is in a quiet cul-de-sac in a well-established residential area. The shopping area of Staple Hill is very close by with full public amenities. Staple Hill is on a main bus route to the city of Bristol. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over fifteen hours and was undertaken to view the care practice to ensure that it is in line with the legislation and that best practice is being followed at the home. It was also undertaken to review the requirements made at the last inspection and to ensure that they have been met. In addition to the above, the inspection was undertaken to follow up an allegation of abuse of a resident, which resulted in a Protection of Vulnerable Adults from Abuse strategy meeting. Generally, the home was found to be warm, well lit and tidy The residents met at the home were found to be relaxed, well cared for and were found interacting with staff in an informal way. This demonstrates that a good relationship exists between staff and residents. The manager and staff were noted using their professional skills to deal with challenging issues exhibited by some residents with complex needs. A tour of the building was undertaken and a number of records were viewed. Six residents and three staff members were spoken with at the inspection. What the service does well: The home is situated within the residential area of Staple Hill and the residents are supported by staff to live a chosen life style. One resident informed the inspector that she/he does anything she/he likes on Friday because it is her/his day off. The manager consults with existing residents before a new resident was allowed to stay at the home to ensure that residents are happy to share their home with her/him. Furthermore the new resident visited the home several times to make up his/her mind to stay. This shows a total commitment by the manager and the staff members to ensure that residents right and choice are upheld and that compatibility is assured. New residents are assessed holistically and are assured that the home is able to meet their needs. Individuals living at the home are encouraged and are supported to maintain links with family, friends and the community to ensure that they live as much a normal life as possible. One resident spoken with said ‘I help out with cooking and clean my room’. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: At the last inspection, an immediate requirement was made in relation to the return of unwanted medication to the pharmacy, although this requirement was met, it was noted at this inspection that the home is continuing with the same practice and another immediate requirement was made. The manager must address this concern to ensure that residents are protected from medication mishandling. In addition to the above, all medication given to the residents must be signed by the person dispensing them in order to protect the residents from the error of drug duplication and a resident on self medication would be better protected if a lockable space is provided for him/her. Residents would be protected from injury if the rusty radiator on the ground floor toilet is repaired or replaced. To improve residents’ safety and prevent infection, the fridge and freezer temperatures must be taken regularly and the residents would enjoy a cleaner and safer environment if the wallpaper in the shower room is replaced or redecorated. Residents would be better protected if staff receive COSHH training and if policies and procedures are regularly reviewed and updated. To ensure that residents are protected from harm and possible abuse, satisfactory references and Criminal Record Bureau disclosures must be obtained for all staff working at the home. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home provides information to prospective residents and their representatives and ensures that the admission process provides safeguards to meet the assessed needs of residents. EVIDENCE: The home has a statement of purpose and a Service Users Guide, which contained information, required by regulation. The service users guide is given to the prospective resident or their representative to enable them to make a choice of moving in to the home. Reviewing the newly admitted resident’s record showed that the manager attended a multidisciplinary meeting at the resident’s previous house to assess his/her suitability. The manager informed the inspector that the resident visited Edgware Road about a dozen times to meet the existing residents to ensure that both parties are happy to live together. On one of the visits the resident decided to choose a room. Discussions with some of the residents showed that the residents were consulted about the admission of the resident and that they were happy for the new resident to live at Edgware Road. The new resident has a Statement of Terms and Conditions of his/her stay in the care file. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 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 Individualised care plans are provided for the residents to reflect their assessed needs and residents are supported to participate in the running of the home. Required support with risk assessments are provided for the residents to live independent lives with the assurance that information about them will be kept confidential. EVIDENCE: Six care files were reviewed and each care file contained an individual plan of care on how the needs of the person were being met. Information noted on one of the care file includes an ‘Essential Life Plan’ which provided detailed information about the resident’s likes and dislikes, important things in his/her life and things people need to know about supporting the resident. The care plans are developed by the key workers with the residents’ involvement and all the residents needs and are regularly reviewed. One resident spoken with stated that her/his keyworker supports her/him to have a bath, clean the room, go shopping and go on holiday. Another care file had person centred planning information, which included risk assessment and how these risks are being managed by staff. Comprehensive details were noted on one of the care files on how the resident’s challenging behaviour is being managed. The manager stated that after several reviews of the resident’s care 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 11 plan is was decided in consultation with the resident to try a different day centre that now meets his/her needs. The resident when interviewed confirmed that he/she is happier with the arrangement to go to another day centre. He/she stated that he is satisfied with his/her overall care. Residents spoken with told the inspector that they are supported to participate in running of the home. One resident stated that she/he makes her/his own bed; goes out with ‘Jane’ for shopping and another resident said she/he helps out in the kitchen and does his/her own laundry. Residents were seen going in and out of the kitchen and making their breakfasts, some independently and others with staff support, others were noted accessing areas around the home without restriction. One service user’s care file showed evidence of risk assessment in relation to going out with friends. The resident when spoken with confirmed that she/he goes out with friends Monday to Friday to have a cup of tea or have a drink in the pub and that sometimes friends visit her at the home. She/he stated that ‘I come back on my own sometimes. Another resident with several episodes of staying out late and sometimes not returning to the home had a risk assessment in place and information on what measures that staff have to take if the resident fails to return to the home. The measures are supported with a missing persons policy. This clearly demonstrates that the home enables the residents to exercise their freedom of choice with well-managed, defined risk management strategies. The manager informed the inspector that another resident has been referred to Alcohol Assessment and Education Unit because of his/her increased challenging needs. Staff members spoken with demonstrated a clear understanding of the importance of keeping information about residents confidential. The bedrooms of residents attending day-centre or out of the home for any reason were noted to be locked. The home has a confidentiality policy. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 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) 11,12,13,14,15,16,17 Residents have opportunities for personal development and are supported to maintain links with the community, family and friends. Their individual rights are respected whilst providing healthy diets at chosen times. EVIDENCE: Based upon the needs of the residents the home ensures that resident engage in leisure activities outside and within the home. Review of the care records and discussion with the registered manager and staff showed that residents are encouraged to live an active life based on their choice. The care files contained evidence of residents’ weekly activities. Some residents attend day centres and some participate in activities with their keyworkers. One resident described her/his weekly activities and stated that Mondays she goes to the day centre. On Tuesdays and Wednesdays she goes to Chipping Sodbury. On Thursday she/he goes to Brandon Trust for a cleaning job and that Friday is her/his day off. The resident also stated that she/he goes home on weekends to see mum and dad. Another service user stated that he/she had been on holiday to Doniford Bay and is looking forward to another holiday this year. All the care files had daily events records completed by the key workers. During 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 13 discussion with the manager, the inspector was informed that other activities provided at the home-included games, puzzles, books, music and watching Television and DVDs. The manager also stated that the home has access to recreational and educational activities through Filton and Soundwell colleges and some residents are supported to participate in swimming at the leisure centre within the community. Trips are also organised to the zoo and seaside. Residents also attend concerts and cinemas depending on individual preferences. One of the day staff was noted interacting with residents and supporting them to participate in activities at the home. Residents interviewed told the inspector that they liked the food and that they are able to choose what they like. One resident stated that “staff ask me before they make my food”. The manager and staff confirmed that all residents are encouraged to make a choice at the beginning of the week when the menu is compiled however if on the day they don’t like what is on offer an alternative is provided. The home has two kitchens, which were found to be clean and tidy. The foods in both fridges were in date, however the stains on a panel the kitchen had not been removed, the manager stated that all efforts made by the cleaners to remove the stains failed and that the panel may have to be replaced. The freezer temperatures in the kitchen at no 17 had not been recorded from 29/5/05 to 2/6/05, the manager is to ensure that the temperatures are regularly recorded to prevent the risk of food poisoning to the residents. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 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) 18,19,20,21 Residents receive preferred personal support as required, their emotional and physical health needs are met, also respect is given to their wishes in the event of death, however medication practices at the home fails to protect the residents from potential harm. EVIDENCE: Care files reviewed showed evidence of the level of support that each individual resident need and this is dependent on their specific assessed need. One resident was noted being supported to have a bath, the resident stated that ‘staff help me to do things that I cannot do myself, staff respect my choice and will not force me if I don’t feel like it’. During a walk around the home, staff were noted knocking on the residents doors and waiting to be allowed in to assist the residents with personal care. One staff interviewed stated that she is a keyworker to two residents, she assists them with personal care, shopping has attended care plan reviews. The care files reviewed showed evidence of GP and Consultant medication reviews when necessary. The home accesses support from the Community Learning Difficulties Team for managing resident’s challenging behaviour. Other health professionals visiting the home include the chiropodist and occupational therapist. One comment card received from a health professional raised concerns in relation to disseminating information given to staff members at the home. The person felt that information is not always shared with all staff 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 15 members and that equipment supplied to residents on loan were often lost or damaged and not being used correctly. This was shared with the manager and he stated that he would meet with the health professional to discuss the issues raised. Staff members spoken with confirmed that the residents are supported to attend out-patient appointments; there was evidence on one residents care file of being supported to attend Sexual Health Clinic. One resident has regular blood tests to check for side effects from a special drug being administered to the resident. On reviewing medication at the home, the inspector noted that there are discrepancies in relation to storage and administration of medication. One resident on self–administration had a risk assessment dated 2002 that had not been updated, one resident’s medication dispensed between 30 June and 5 July 2005 were not recorded as given. Medication no longer required for all residents at the home had not been returned to the pharmacy. Two residents prescribed regular medication was being given as and when required but this has not been changed on the MARS (Medication Administration Record) or on the label from the pharmacy. An immediate requirement was made for the medication given to be signed and to ensure that all unwanted medications are returned to the pharmacy in order to protect residents from possible drug errors. The manager is also required to ensure that a lockable space is provided for a resident on self-administration. In addition to ensure that the temperature on the drug fridge is recorded to minimise risks to residents. Staff interviewed demonstrated knowledge of how to care for residents with terminal illness and the care files viewed had information in the event of death. The home has a death and dying policy. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 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 Residents are supported and encouraged to complain with the confidence that their views will be listened to and acted upon. Staff have received training and information on how to protect residents. Systems and procedures are in place on how to protect resident from harm and abuse. EVIDENCE: The complaints book showed evidence of three recorded complaints and how the complaints were successfully resolved. Each care file viewed had a complaint procedure in picture format, however it was agreed that the information about the Commission for Social Care Inspection be included in the procedure to enable the residents and representatives to complain to the Commission if they are not satisfied with services provided at the home. The home has a policy and procedure on the protection of Vulnerable Adults from Abuse. Staff spoken with demonstrated knowledge of how to report suspected abuse and where to access the information. Staff records showed that staff have attended training in relation to Abuse of residents. Resident monies were checked and were noted to be securely locked with appropriate records. One resident reported during a routine out–patient appointment that he/she had been abused. The Protection of Vulnerable Adults policy was invoked and was followed by a strategy meeting, which the Commission was invited to attend. The outcome of the meeting was that the home must update the measures already in place to ensure that the resident is adequately protected. The meeting was informed by the home that the risk assessment in relation to the person had been reviewed. Another alleged incident of abuse involving a bank staff member was reported to the Social Services Adult Protection Team. Aspects and Milestones (owners 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 17 of Edgware Road) were asked to investigate the incident internally and inform the Commission for Social Care Inspection of the outcome. The inspector was informed on the day of inspection that the matter had been resolved and that the bank support worker will not be working at the home again. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 The residents are provided with a good, clean, comfortable environment and with suitable specialist equipment where they feel safe to live. EVIDENCE: No changes had occurred in relation to the homes suitability for its stated purpose. The home was found to be clean tidy and free from unpleasant odours. During discussion with the manager it was agreed that some of the furniture in the communal areas in the houses needed to be replaced, the manager stated that it has been discussed with the management and that he is waiting for quotes before they are replaced. There are several corridors in the home and various equipment available for assisting residents’ mobility. Ten bedrooms were viewed on both houses and each bedroom is well furnished and decorated to each resident’s choice. One resident told the inspector that they liked their room. The bedrooms were noted to be homely and had appropriate electrical goods, which had portable appliance test stickers to show that they are safe to be used by the residents. The home has no shared rooms. The bathroom and toilets viewed had various facilities to meet the needs of the residents, however the shower room had the wallpaper peeling off. This was 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 19 discussed with the manager and it was agreed that the resident would enjoy a better environment if the wallpapers are replaced or the shower room redecorated. Generally the residents were found relaxed and enjoying the company of one another. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 The residents enjoy a good and warm relationship with competent staff however the home’s recruitment procedure fails to offer protection to the residents living in the home. EVIDENCE: Staff records viewed showed lack of evidence of documentation in relation to recruitment of staff at the home. Two staff members had no Criminal Records Bureau disclosures in their files four staff members have no references, the manager stated that all staff members have worked at the home for many years and that the references and CRB may be at the head office. The manager is required to provide evidence of the above documentation to the Commission for Social Care Inspection. Staff members spoken with demonstrated evidence that their roles and responsibilities in relation to meeting resident needs and that the home ensures that adequate staff are provided at all homes. On the day there were four staff in each house excluding the home manager. The home manager informed the inspector that three staff members have completed NVQ Assessors training. One staff has commenced a Learning Disability Degree, with modules in autism and challenging behaviour. Three staff attended ‘person centred planning’ and ‘key workers needs’ all staff home attended fire lectures and first aid update, 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 21 manual handling, protection of vulnerable adults from abuse and food hygiene. The home employs twenty-one care staff and eleven of the twenty-one have achieved NVQ2 in care. Discussions with staff and evidence from staff files showed that staff are regularly supervised to ensure that staff continue to show understanding, knowledge and experience of dealing with people with learning difficulties and are able to meet their needs on an ongoing basis. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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 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) 37,38,40,41,42,43 The home is managed by a competent leader who safeguards the rights and interests of residents and also protects them through the application of policies, procedures and good recording keeping. EVIDENCE: 17-19 Edgware Road is managed by an experienced and well-qualified home manager. Mr Nuttall informed the inspector during discussions that he had recently attended NVQ Assessors refresher course also an ‘Autism’ team day on 10/06/2005. Residents and staff spoken with stated that Allan is an understanding man who is approachable and listens. Staff stated that they feel motivated by the support provided to them by the manager in order to meet the resident’s needs. The manager showed the inspector during the discussion the audit tool that he intends to use to monitor the quality of service provided at Edgware Road. The manager stated that another document named ‘Quality of Life’ which is based 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 23 on O’Brien’s five accomplishments would also be used to monitor the quality of life at home. It was agreed that this would be reviewed at the next visit. The home has policies and procedures accessible to all staff to include Adult protection, Whistle Blowing, Recruitment, Missing Person and Health and Safety, however it was agreed that these policies need to be reviewed in line with the Legislation. Records kept at the home in relation to the Health and Safety of the resident were reviewed. The records and discussion with the staff members showed that staff have attended regular fire drills. Fire fighting equipment is regularly checked. Staff have received fire training at regular intervals. The liability insurance is in date. The maintenance book is up to date and the hoists are regularly serviced. Accidents are recorded and reviewed. The manager agreed that staff would benefit from Control of Substances Hazardous to Health (COSHH) training and documentation review to ensure that staff are aware of actions to be taken in the event of an emergency. Staff administering medication have received medication competency courses provided at the home by the manager. As a part of a group of homes owned by Aspects and Milestones the home is financially stable/viable. 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17 - 19 Edgeware Road Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x 3 3 D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. Standard 20 20 30 20 24 24 34 40 35 24 Regulation 13 13 23 13 23 13 19 18 13 13 Requirement Ensure that unwanted medications are returned to the pharmacy. Ensure that all given medications are signed for on the MARS. Ensure that fridge and freezer temperatures are recorded regularly. Provide a lockable space for a resident self- administering medication. Ensure that rusty radiator in the ground floor toilet is repaired or replaced. Ensure that the wallpaper in the shower room is replaced. Obtain satisfactory references and CRB for all staff. Ensure that policies and procedures are reviewed and updated. Ensure that staff undertake COSHH training. Remove the stains on the panel in the Kitchen at no 19. Timescale for action 14/7/05 7/7/05 7/7/05 14/07/05 7/8/05 7/8/05 7/8/05 7/8/05 7/8/05 7/8/05 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 26 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 Good Practice Recommendations 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 17 - 19 Edgeware Road D56 D05 S3375 Edgeware Road V228869 0670705 Stage 4.doc Version 1.30 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!