Inspection on 10/01/06 for 19-21 Haymill Close.

This inspection was carried out on 10th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19-21 Haymill Close. 10/11/06

19-21 Haymill Close. 31/08/05

19-21 Haymill Close. 12/08/04

19-21 Haymill Close. 28/01/04

19-21 Haymill Close. 25/09/03

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 19-21 Haymill Close 19-21 Haymill Close Greenford Middlesex UB6 8HL Lead Inspector Sarah Middleton Unannounced Inspection 10th January 2006 10:25 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 19-21 Haymill Close Address 19-21 Haymill Close Greenford Middlesex UB6 8HL 0208 566 7060 0208 810 9531 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) Ealing Consortium Limited Mr Stuart McQueen Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include MD and LD with Physical Disabilities up to 9 in total 31st August 2005 Date of last inspection Brief Description of the Service: 19/21 Haymill Close is a home for nine adults with learning disabilities. The home is two houses joined in the middle by a small office. There is a separate staff team who work in either number 19 or 21. The whole service is managed by one Registered Manager and one Senior in number 19 and one in number 21, other staff members are support workers. The service offers twenty four hour care and support for the service users. The bedrooms are single and there is a large communal garden to the rear of the property, with parking to the front of the service. The home is situated from a main road on a residential estate. The main road has public transport which from there is a short distance from the main town of Ealing Broadway. There is an tube and railway service from this town. The service is managed by Ealing Consortium and the building is owned by a housing association. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of four hours was spent on the inspection process. The Inspector carried out a tour of the home and inspected service users plans, maintenance records and staff files. One service user and two members of staff were spoken with as part of the inspection process. There were no visitors present during the inspection. It must be noted that it is sometimes difficult to ascertain the views of service users with learning and communication difficulties. The Registered Manager was present during the inspection and assisted with the process of the inspection. The Pharmacy Inspector carried out a separate inspection regarding the medication systems in the home, following previous concerns by the Inspector, on the 20/12/05. They found the medication systems had improved and set two requirements following their inspection. The Inspector would like to thank the staff and service user who contributed to this inspection. What the service does well: What has improved since the last inspection? The home met all of the previous requirements made at the last inspection. This demonstrates that the home had worked hard to make improvements and raise the standards of the home. Food that had been opened or prepared was clearly being dated to ensure out of date food was not being offered to service users. The medication systems showed signs of improvement with the home being more aware of the need to monitor medication storage, administration and 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 6 recording medication that had been administered. Liquid medicines had dates of opening written on them and stock was being checked to ensure out of date stock was not being used. The home had organised training for all staff on the protection of vulnerable adults. Servicing records had contained the appropriate documentation to demonstrate that the home has ensured that relevant appliances and equipment was being checked when legally required. 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. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Service users are assessed prior to admission to ensure the home can meet their needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. Service users receive details of their tenancy along with details of the service to ensure they or their representatives have information about what they can expect from the home. EVIDENCE: Pre-admission documentation was viewed on the most recent admission, which was over a year ago. This gave an indication as to the service users needs. A member of staff assesses the prospective service user and then refers them to the most appropriate service. The Registered Manager stated they would then meet and further assess the prospective service user to ensure the home can meet their individual needs. The Registered Manager confirmed that a prospective service user would have the opportunity to visit the home, stay for a meal and have over night stays, all prior to moving into the home. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 9 Tenancy agreements from the housing association were located in service users individual files and service user agreements were also viewed. It is difficult to assess how much information service users would understand regarding tenancy agreements. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 & 9 The health and personal care needs of service users had been identified and were being met. This informed staff of service users routines, preferences and abilities. Service users were supported and promoted to make decisions, where appropriate, in their lives. Staff were aware of service users rights to make informed choices. Risk assessments were in place and aimed to promote independence, whilst balancing the potential risks present for service users every day life. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users’ identified health, personal and social needs would be met. Aims and objectives were set out for the forthcoming months and details of how these could be achieved were noted for all staff to be aware of when supporting the service user. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 11 A sample of daily records were seen and overall these outlined the care the service users had received and any other relevant information regarding what the service user had done that particular day. Assessments for moving and handling were in place. Monthly summaries had been completed to ensure staff monitor service users needs and note any significant changes. Care plans are reviewed six monthly and all relevant professionals, relatives and where possible the service user, contribute to this review. Staff spoken with stated they encourage service users to make decisions about their every day lives. Staff were aware of service users preferences and routines and these are recorded in service users care plans. It is documented on care plans if service users cannot manage their own personal finances. Samples of risk assessments were viewed and had recently been reviewed. These contained details of potential risks to each service user, both in the home and when out in the community. The risk assessments outlined details of a particular risk and noted the ways to then minimise risks to the service user or others. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 the following standard(s): 12, 14, 15, 16 & 17 Social and leisure activities are in place in order to offer a stimulating and varied life for service users. Visiting is encouraged for service users to maintain contact with family and friends. Service users rights are respected and staff aim to promote choices and preferences in service users daily lives. Meal provision offers service users a healthy and varied diet, which also meets individual needs. All meals, where service users are with staff, must be recorded in order to monitor service users overall diet and to ensure service users are eating nutritious meals. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 13 EVIDENCE: Social activities are available and service users engage in various activities and outings that aim to meet their individual preferences and abilities. The service users are not able to seek employment and so spend their time attending day centres, the local activity resource centre, where they might receive aromatherapy massages or attend drama therapy sessions. Often there is the opportunity for service users to have one to one time with a member of staff. During the inspection service users were seen to be going out with staff and appeared active throughout much of the day. Often staff will go for a walk with service users or access public transport to reach a destination. Although one service user spoken with stated they did not like using public transport and preferred to be in a car when travelling to places. Service users have the opportunity to go on holidays. Sometimes this is on a one to one basis, for others it is the opportunity to spend time away from the home with another service user and members of staff. One staff member spoken with said the home was aiming for service users to receive two holidays a year, with one of these being a short break. In addition group day trips are often planned, usually in the summer months. Leisure time is seen as important as it is a way for service users to engage in meaningful activities that might encourage them to relax and/or support them to pursue hobbies or interests. Where service users have relatives the staff encourage contact and assist service users to visit family members if this is amore suitable arrangement. Staff spoken with stated they might send postcards, on behalf of service users, to relatives when they are on holiday to maintain a relationship between service user and family members. Daily routines aim to promote independence and encourage staff to recognise service users rights. Staff were seen to interact regularly with service users throughout the inspection and responded to service users when they were being called. Service users have unlimited access to the home and one service users sat with the Inspector for much of the day. Service users were seen to be with staff, when they were in the office. This room is not a locked and service users are able to walk through it to reach the other side of the home. Often service users eat out at lunchtime; therefore meals for the home were not viewed at the time of the inspection. Menus were seen and the Registered Manager explained that for one side of the home, two members of staff plan the weekly menus, incorporating all the service users preferences and dietary requirements. Some service users need soft food, whilst others need food that is high in fats, as they need to put on some weight. Pictures are used for those service users who respond to pictorial forms of communication. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 14 Fresh food was seen in the fridges and staff aim to prepare meals with fresh ingredients. Fridge and freezer temperatures had been recorded on a regular basis and were within an appropriate range. Food that had been opened had dates of opening written on them. The kitchens were clean and tidy at the time of the inspection. One service user said they were sometimes happy with the food, whilst other times they were not. Daily records, where meals are recorded, did not always contain details of what individual service users had eaten. This was particularly noticeable when service users had eaten a meal out in the community. It is a requirement that all meals, other then those where staff are not present, such as day centres, are recorded. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 18, 19 & 20 Service users receive personal care in a way that respects their privacy, dignity and preferred routine. Service users health needs are addressed through seeing relevant health professionals and by staff monitoring the general health of service users and recording this in their individual care plans. Medication systems were in place, were being followed and aimed to safeguard service users health and safety. EVIDENCE: Staff confirmed that all service users require support with personal care and that this is offered in private in either service users bedrooms or bathrooms. One service user spoken with stated staff encourage them to do things for themselves. They said they were prompted to wash themselves and were left with a bell they used when they needed staff to assist them. Personal care guidelines were present in the service users files viewed and outlined where individual service users needed personal care assistance. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 16 Health appointments were documented and detailed the treatment or action to be taken following an appointment. Service users have the opportunity to see Dentists and Opticians and any other relevant health professional in order to meet their health needs. The Registered Manager informed the Inspector that every three months health professionals from the community team, such as Psychiatrists and Community Psychiatric Nurses, visited the home and meet with staff to discuss any particular health problems that service users may have and/or to refer service users for specialist support. Service users are weighed on a regular basis that enables staff to monitor any weight loss or gain. Those service users with Epilepsy have seizure charts so that seizures can be monitored and discussed with the appropriate health professional. Samples of the medication administration records were tracked. Those seen had been correctly completed. Liquid medicines had dates of opening written on them and there were no medicines out of date. Guidelines were in place for the use of aromatherapy oils. The Pharmacy Inspector had made a requirement that a specific eye drop must be stored in a locked container in the fridge. This requirement has been met. Discussions took place with the Registered Manager regarding offering staff ongoing training and assessment on administering medication. There is a new system that has been introduced to assess the competency of staff and to assess their knowledge of medication. The Registered Manager acknowledged the need for medication training and assessment to be offered on an ongoing basis. Overall medication errors have decreased and staff are more confident in administering medication. The home has designated members of staff who complete a checklist with the aim to monitor and minimise any medication errors. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 22 & 23 The home has a complaints procedure and the service user spoken with was confident that a member of staff would listen and act on their complaint. Systems are in place for the protection of vulnerable adults. EVIDENCE: The home has a complaints procedure, which is freely available. Although for some service users it could be difficult in assessing their ability in making a formal complaint. There is one outstanding complaint that has been independently investigated and the Registered Manager is waiting for the outcome. The complaint has been clearly recorded with the action that has been taken so far. There have been no undue number of complaints and the CSCI has not directly received any complaints. The service user spoken with was aware of whom to complain to if they were unhappy about something. Staff are due to receive training on the protection of vulnerable adults, (POVA) in the next two months. There are internal verified POVA trainers who will offer ongoing refresher training to those members of staff who require it. Staff spoken with were aware of how to respond in the event of a POVA incident. There have been no POVA investigations or allegations. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 the following standard(s): 24, 26, 27 & 30 The environmental standard of the home is of a good standard. The home is bright, clean and free from malodours. Maintenance plans are in place to ensure service users live in a welcoming and inviting home. Service users can personalise their bedrooms and these rooms are sufficient in size to offer the space service users might need when they want to be alone. There are sufficient and suitable bathrooms and toilets to meet the needs of the service users. EVIDENCE: A tour of the home was carried out and a sample of rooms were viewed. These were being satisfactorily maintained. The home was bright, airy and free from offensive odours. The Registered Manager showed the Inspector a maintenance plan for areas needing redecorating or refurbishment. Future plans are to replace sofas and the washing machines. This plan demonstrates that the home reviews each year items that will need replacing and areas that will need updating, in order to offer a modern and inviting home for the service users and visitors. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 19 One service user showed the Inspector their bedroom. This was spacious and offered the service user a room for their personal items to be kept in and a private area where only they and staff access. There were suitable furniture and furnishings in the bedroom to meet the needs of the service user. A sample of bathrooms and toilets were seen. These were clean and tidy at the time of the inspection. These are sufficient in numbers and in appropriate locations to meet the needs of the service users. Laundry facilities are located in a separate room with the majority of laundry tasks carried out by staff. It is recommended that infection control procedures are located in the laundry room to remind staff of the guidelines to prevent the spread of infection. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 A competent staff team supports service users. Staff study NVQ courses and receive mandatory and additional training in order to meet the individual and specialist needs of the service users. Overall the staff team work well together and consistently in order to offer the care the service users need. There are recruitment systems in place, however there was a shortfall with regards to obtaining a fully employment history of a recently appointed employee. Recruitment procedures must be robust to protect the safety of the service users. Staff receive regular supervision in order to reflect on their practice and to improve areas of their work practice for the benefit of the service users. EVIDENCE: Staff have the opportunity to study NVQ level 2 or 3. Those staff members who joined the team in the last twelve months have been completing their induction programme and the Learning Disability Award Framework. Staff spoken with were enthusiastic and motivated to meet the needs of the service users. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 21 Staff demonstrated they were aware of individual needs and felt confident that although some of the service users were non-verbal, they were still able to ascertain when a service user was unhappy or did not want to take part in an activity. Staff spoken with confirmed that regular team meetings are held, both for the two separates houses and as a whole staff team. Staff also stated that overall there were sufficient numbers of staff working on each shift to meet the needs of the service users. One staff member stated that communication could be better between staff and that some staff help each other out more than others. Currently the home has no staff posts that are vacant. When staff are sick or on holiday, the Registered Manager stated the hours are covered by either permanent staff working additional hours or regular relief/agency staff. The staff employment files viewed contained applicants completed application forms, Criminal Record Bureau check disclosure numbers, medical declaration and references. On one staff file, regarding a fairly new employee, there was limited employment history with no explanation of gaps in employment. This is vital information as it can give an indication as to the exact work the applicant has done and could be important should there be any discrepancies in the work of the member of staff. This issue was discussed with the Registered Manager who acknowledged the importance of obtaining all required documentation. This is a requirement. Samples of individual staff training files were viewed. These outlined the mandatory courses, such as, food hygiene, first aid and health and safety topics covered and additional training, on subjects such as epilepsy and keyworking. Staff spoken with were happy with the training offered and felt it was of a high standard. Staff spoken with confirmed they receive regular supervision and that these one to one sessions were useful as it gave them the opportunity to consult with another member of staff, if they had issues or concerns. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 The home is well managed and the Registered Manager has an open and approachable style of management. The quality assurance systems in place seek to monitor areas of the home and identify ways to improve the care and support offered to service users. Where possible, service users views have been sought and considered when reviewing the running of the home. Servicing records were up to date and protected service users health and safety. However, fire drills/practices had not been carried out on a regular basis. This shortfall could pose a risk to the service users, staff and visitors in the event of a fire. This must be addressed immediately to ensure those living, working and visiting the home are safe. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Registered Manager has been in post for some time and has obtained an NVQ level 4 in management and is currently studying the NVQ level 4 in care. They are also an NVQ assessor. Staff spoken with stated the Registered Manager maintains a visible presence in the home and will work in the home when needed. Furthermore staff stated the Registered Manager is flexible and approachable and that they were confident that they could go to him if they had any concerns or queries. Various systems are in place to monitor the quality of care offered in the home. Monthly Regulation 26 visits are carried out which look at various aspects of the home, such as the environment, care plans and medication. The Registered Manager also completes a monthly report regarding different areas of the home and notes where there are issues and notes action that is needed to be taken to rectify identified problems. The Registered Manager also described that regular updates and alterations are made internally. This is usually when problems have been identified and need addressing. Additionally, a few months ago, a service user satisfaction survey was carried out to ascertain service users views of the home. The Registered Manager did acknowledge that it was difficult to obtain views from some of the service users and that methods in obtaining service users opinions were being reviewed by the Registered Provider and relevant members of staff. Servicing records were viewed at random. The Gas Safety and Portable Appliance Testing was up to date. Written confirmation was seen regarding the testing for Legionella, which would be carried out two days following the inspection. Water temperatures are taken on a regular basis of all areas where service users have access. These were within an appropriate range. Fire call points are tested regularly, however fire drills/practices had not occurred on a regular basis for both service users and staff. Discussions took place with the Registered Manager with regards to the importance of fire drills and that they must take place at various times and with different members of staff to ensure all staff know how to respond effectively in the event of a fire. A requirement was made that the home has regular fire drills and clearly records the date, time and who was present during the fire practice. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 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 3 5 3 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 3 25 x 26 3 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 2 x 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation Schedule 4 Schedule 4 Requirement Timescale for action 11/01/06 2. YA34 3. YA42 23(4) Meals eaten by service users must be recorded. This includes meals eaten out with staff in the community. Details of an applicant’s 31/01/06 employment history, with explanations of gaps in employment must be obtained when recruiting for staff. Fire drills/practices must be 11/01/06 carried out at regular intervals, & various times of the day/night & with various members of staff. These drills/practices must be clearly recorded for the home. 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 YA30 Good Practice Recommendations The policy and procedure regarding infection control should be visible in the laundry room. 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 19-21 Haymill Close DS0000027739.V274231.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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