Inspection on 14/06/07 for 23 Pierrepoint Road

This inspection was carried out on 14th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

23 Pierrepoint Road 21/02/06

23 Pierrepoint Road 15/08/05

23 Pierrepoint Road 15/02/05

23 Pierrepoint Road 02/08/04

23 Pierrepoint Road 02/02/04

23 Pierrepoint Road 18/07/03

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 23 Pierrepoint Road 23 Pierrepoint Road Acton London W3 9JJ Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 14 & 20th June 2007 11:30 th 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 23 Pierrepoint Road DS0000027748.V336359.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. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Pierrepoint Road Address 23 Pierrepoint Road Acton London W3 9JJ 0208 896 2581 0208 993 2280 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Ms Jennifer deBurgh Bradley Care Home 13 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The refurbished building to the rear of the property may be used to accommodate one service user. That service user must have been assessed as suitable to use the facility, which is intended for development of independent living skills. 21st February 2006 Date of last inspection Brief Description of the Service: 23 Pierrepoint Road is a care home registered for thirteen adults with a learning disability, who may be over the age of sixty-five. The home is owned and managed by Care Management Group Ltd, an organisation who became established in 1995. This establishment is a large detached house in central Acton. It is not purpose built, however the building has been adapted to meet residents needs. Service users bedrooms are situated on all floors. There are bathroom and toilet facilities on all floors. The home has a passenger lift to all floors. The home has a large dining area and a comfortable communal lounge. There is also a separate activities room and a well maintained rear garden. One of the homes main aims is to assist individuals to enhance and develop their independence skills where possible. The fees range from £600 to £900 per week. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 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 6 hours was spent on the inspection process. A tour of the home was carried out, and service user plans, medication records, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire and comment cards received from residents, visitors and healthcare professionals have also been used to inform this report. 5 people living at the home and 4 staff were spoken with as part of the inspection process. The Inspector made a second visit to the home in order to view the staff records and speak with the Deputy Manager. What the service does well: Assessment and planning for admissions to the home is thorough and the processes followed provide the resident with a well planned, measured admission to the home, thus minimising any concerns experienced by such a move. The service user plans are well constructed and comprehensive, providing staff with a clear picture of each resident and their needs and how these needs are to be met. The information is updated regularly to ensure it is up to date. All areas of individual risk are assessed and protocols put in place to minimise them. Activities are provided to meet the residents’ individual and collective interests and hobbies. The staff are very aware of the importance of maintaining contact with relatives and friends. Staff care for residents in a gentle and professional manner and there are very well good relationships between staff and residents. The meal provision is good, meeting the dietary needs and preferences of the residents. The healthcare needs of each individual are identified and met. The majority of residents can communicate verbally, and there are systems in place to effectively communicate with all residents, with the introduction of further visual communication aids being planned. The home has clear procedures in place for the management of complaints and adult protection, and staff are clear about these procedures. Procedures for infection control are in place and the home was clean and fresh throughout. The home is appropriately staffed to meet the needs of the residents, and the Registered Manager is very aware of their changing needs as part of the ageing process, and is staffing the home accordingly. Robust systems are in place for the recruitment of staff and these are followed. There is a good training provision for staff, to include induction training, NVQ in care training, and training in health & safety plus topics relevant to the needs of the residents. The home is being effectively managed and it was clear from comments from staff that the Registered Manager is approachable and leads her team well. There are good systems in place for quality assurance and there was evidence that audits and meetings take place and the home works hard to maintain a good service provision, valuing input from the residents, staff and visitors. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 23 Pierrepoint Road DS0000027748.V336359.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 23 Pierrepoint Road DS0000027748.V336359.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 & 4. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Thorough pre-admission assessment and planning is carried out in order to make the move to the home as easy as possible for each resident. EVIDENCE: The Inspector viewed pre-admission documentation for one resident. The CMG assessment team carry out a very thorough assessment that covers all aspects of the persons life and provides a clear picture of their needs. In addition copies of the Social Services and Occupational Therapy reports had been obtained. Pierrepoint Road had been identified as the most suitable home to meet the needs of the resident, to include maintaining links with family and the community. A transitional plan had also been put in place and mapped out arrangements on a day by day basis for the resident to familiarise themselves with the home, staff and other residents, whilst still having access to their own home. This was again very clear and the arrangements allowed for the resident to settle in gradually. The transition plan continued after the date of admission. The plan had allowed the resident to transfer at his or her own pace, and also had minimised the disruption caused to the resident by the move. 23 Pierrepoint Road DS0000027748.V336359.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. The service user plans are comprehensive and provide a clear picture of each resident and how their needs are to be met, thus giving staff the information they require to provide a good standard of care. All risks are individually assessed, thus minimising any risks to the resident. EVIDENCE: Two service user plans were viewed as part of the case tracking. These were very comprehensive, personalised and provided a clear picture of each resident, their needs and how these are being met. There is an individual action plan for each need and this again is thorough and is updated at least every 6 months. A monthly review document for the service user plan is also completed. Staff complete the daily record after each shift providing up to date information. At the time of inspection some of the documentation had been forwarded to head office for typing up, however there was appropriate information still available in the resident files. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 10 The residents are encouraged to make choices for themselves with regard to meals, dress, activities and also participate in making decisions about colour schemes for the home, both for their own rooms and also for the communal areas. Monthly residents meetings are held and at the recent meeting residents were consulted about their wishes for their annual holidays. Each resident has risk assessments in place for all areas of identified risk. These are comprehensive and kept under review. Staff sign to say that they have read and understood the individual risk assessments. 23 Pierrepoint Road DS0000027748.V336359.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. Outings and activities are arranged in line with individual interests, thus peoples wishes are planned for and respected. The home has an open visiting policy, thus encouraging residents to keep in contact with family and friends. Staff care for residents in a gentle, friendly and professional manner, respecting their privacy and dignity. The meal provision at the home is good, meeting the dietary needs and preferences of the residents. EVIDENCE: Activities are arranged for the residents and an individual activities plan is in each persons service user plan. Residents spoken with said that they enjoy the activities and outings and it was clear that peoples individual interests and wishes are respected. The home has a minibus for outings and one member of staff who is responsible for the activities and outings, and all staff get involved in activities. Two residents do supervised work, which they enjoy. The home identified some residents with an interest in gardening, and raised beds have 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 12 been constructed. Vegetables and flowers were growing in these, and the residents, supported by the staff, had also planted hanging baskets. Public transport and taxis are also used. Two residents attend church services every Sunday. The Deputy Manager explained that residents are given the choice to register to vote and are supported to do so either by attending the local polling station or by completing a postal vote. There is a payphone for residents to use and incoming calls can also be taken on the home phone. Each resident has a key worker and one-to-one time is scheduled for each resident and their key worker for activities such as shopping, meals out or going to a film. It was evident that there are good relationships between the residents and staff, with a very homely atmosphere. The home has an open visiting policy and visiting is encouraged. At the time of inspection staff were observed to make visitors welcome and comment cards received from visitors also reflected this. The Deputy Manager said that staff receive training in supporting residents with personal relationships and should such relationships develop then this would be treated in a sensitive and respectful manner. Staff were observed being gentle, friendly and professional with the residents, respecting their dignity. Staff knock on doors before entering bedrooms and respect peoples right to privacy. From the information in the service user plans it was clear that staff are able to identify when a resident might wish to spend time alone and this is respected. The home has an enclosed rear garden that residents have access to. The Inspector observed excellent interaction between staff and residents and it was evident that the staff know the residents well have a good understanding of each individual personality. The home has a 4 week menu and this is drawn up in consultation with the residents. Any changes to the menu are clearly recorded. Individual likes and dislikes are recorded and respected. At the time of inspection there were no residents requiring a special diet for cultural, religious or medical reasons. The main meal is in the evening, with a lighter meal at lunchtime. Residents are encouraged to eat a healthy diet. Lunch took place during the inspection and the residents were interacting well with each other and staff, making it a social occasion. Residents spoken with said that they enjoy the food at the home. Arrangements are made for meals out and take-away meals as well as meals at the home. The kitchen is due for refurbishment and the Registered Manager explained that arrangements for meal provision during this time had been put in place. 23 Pierrepoint Road DS0000027748.V336359.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. Staff are courteous to residents and support or assistance for any care needs is provided in a manner to respect the service users privacy and dignity. Residents’ healthcare needs are identified and met, thus striving to maintain each person in optimum health. Overall medications are being well managed at the home, with shortfalls identified easy to address, thus safeguarding the residents. EVIDENCE: The service user plans record the personal care needs of each resident. Residents are supported with their personal care and encouraged to do as much as they are able for themselves, with staff available to assist as necessary. Residents were well dressed and groomed to reflect individuality. Each resident has a ‘health action plan’ and this is in a user-friendly format, using pictures and words and is comprehensive, identifying all their healthcare needs. It also identifies each resident’s view of their own healthcare needs and how they want them to be met. From the records it was clear that staff are observant and report any concerns promptly, and medical conditions are being 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 14 well controlled. Separate documents are available to list the input from each healthcare professional. Each resident is registered with a GP and they are supported to attend any appointments. The Deputy Manager reported that input from the mental health team had recently stopped and the home was in the process of re-establishing this for one resident identified as still requiring this input. Each resident is weighed monthly and if any problems are identified they would be referred to the GP. Any phobias are listed so that staff are aware and action can be taken to minimise any problems. Communication was discussed with the Deputy Manager who reported that 2 of the residents are non-verbal and staff are able to communicate effectively with all the residents. CMG have communication skills training to include the use of Makaton sign language, and new staff are sent on this course. More visual aids are in the process of being put together in order to provide more picture aids for communication. The Inspector viewed the medication management in the home. The home uses the Boots monitored dosage system (MDS) and one member of staff has overall responsibility for the medication management. All staff receive medication training and this had recently been carried out in the home, with further training planned. A list of staff signatures and initials was available. Risk assessments and protocols for the management of medications were in place. Photographs and allergy information was available for each resident. The medication administration record charts (MAR) were viewed and 4 gaps in signing were identified. All receipts of medications had been recorded with the exception of one received mid-month. The importance of signing at the time for all medication receipts and administration was discussed. Two members of staff sign any hand written entries on the MAR. Temperature records of the office where the medications are stored and the locked cupboard used for storage are recorded daily and these were within safe limits. The readings were being carried out early in the morning and the Inspector recommended that they be done later in the day, to accurately reflect the warmer time of day. On the second day of inspection the Senior Support Worker in charge of the management of medications reported that the shortfalls identified on the first day had been addressed, all staff had been reminded about the importance of following the medication procedures correctly and that the temperatures were now being recorded at 2pm. Overall medications are being well managed at the home. 23 Pierrepoint Road DS0000027748.V336359.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear procedures for complaints and for adult protection are in place, thus safeguarding the residents. EVIDENCE: The home has a clear complaints procedure with timescales for completing any investigations. There is also a user-friendly version for the residents done in pictures and words. There had been no complaints since the last inspection. Monthly residents meetings take place, at which residents are encouraged to discuss any issues they have, plus each resident has a key worker with whom they meet regularly and can discuss any concerns. There was evidence in the service user plans viewed and also from observation during at the inspection that staff are very aware of each residents moods and recognise if someone is particularly quiet or unhappy, and any concerns are discussed so that the resident can express the problem. Comment cards received from representatives stated that they are confident that they could approach the Registered Manager or a member of staff with any issues. The home has an Adult Protection policy and also follows the Ealing Safeguarding Adults procedures. Staff had received POVA training and those spoken with were very clear that they would report any concerns of this nature. Three sets of personal monies were viewed. The records were up to date and all expenditure is recorded, with receipts being kept. The residents have individual bank accounts and statements were available on file. Clear procedures are followed for the management of resident monies. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 16 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. The home is being well maintained, thus providing residents a homely environment to live in, however a safety issue with the radiator provision could place residents at risk. The home is clean and infection control procedures are followed thus safeguarding residents, staff and visitors. EVIDENCE: The Inspector carried out a tour of the home. The bedrooms viewed were spacious and very personalised, providing a very individual, homely environment. Residents are involved in choosing the colour schemes for their own rooms. There is a dining room and a spacious sitting room, divided into 2 sections, one with TV, video and DVD players and one as a more quiet area, plus a separate activities area, all of which are being well maintained. There are two assisted baths that are easy for the residents to use with support from staff. Rails are available in all the corridors and grab rails are in place in the toilets. Individual items of equipment such as walking frames are available as required, to assist residents with their mobility needs. Ramps are in place at 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 17 the front and rear of the home, for ease of access. The radiators in the home are standard ones and at present there are no guards on them, and action must be taken to minimise the risk of burns to the residents. Plans to refurbish the kitchen had been delayed due to refurbishment input being required at other CMG homes. The kitchen was being kept clean and tidy. A written maintenance schedule of works completed has been forwarded to CSCI following the inspection. The maintaining of an ongoing redecoration and refurbishment plan with timescales for completion has been discussed. There is a separate laundry room and the washing machine has a sluice programme available. Hand washing facilities are available in areas where people may require to wash their hands. Protective clothing to include gloves and aprons are available in the home. The home has an infection control policy and no issues were identified. The home was clean and fresh throughout. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 18 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. The home was appropriately staffed to meet the needs of the residents. Robust systems for vetting and recruitment practices are in place and protect residents. The training provision is good, providing staff with the skills to meet the needs of residents. EVIDENCE: New staff undertake an induction programme in line with the Skills for Care common induction standards. Staff spoken with said that they do get good opportunities for training in topics relevant to the needs of the residents. There is an extensive list of training carried out in the past year, for all levels of staff. The Registered Manager reported that training in health & safety topics is being arranged for new staff, plus annual updates for all other staff. Currently one member of staff has an NVQ level 2 qualification in care, and it is evident that several members of staff with an NVQ qualification have been promoted to management positions within the company. The Registered Manager said that she has put forward 8 staff for NVQ level 2 in care training. From observations and speaking with staff it was clear that they are aware of individual residents needs and how to meet them. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 19 To meet the increasing needs of the residents that occur as part of the ageing process, the staffing is kept under review and increased according to resident need. The Deputy Manager reported that the plan is to have 4 staff on each day shift and this is already a regular occurrence. There has been a turn over of staff in recent months due mainly to the promotion of staff to management positions. Staff spoken with said that there is very good teamwork and this was endorsed by the Registered Manager who said that she has an excellent staff team work well together and between them have a good breadth of knowledge, experience and diversity. The Inspector viewed 2 sets of staff employment files. These contained all the information required under Schedule 2 of the Care Home Regulations 2001. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 20 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. The Registered Manager has the experience to manage the home and is completing the required qualification for this. Systems for quality assurance are in place, thus providing an ongoing process of practice review within the home. Overall systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager was on leave at the time of inspection but did ring and speak with the Inspector. The Registered Manager has NVQ level 4 in care and management and is completing the Registered Managers Award. She also attends training provided by CMG in topics relevant to her management role and the needs of the residents. Staff spoken with said that the home is well managed and everyone works well together as a team and this was very evident at the time of inspection. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 21 The company has a manual for quality assurance in place. Regulation 26 visits take place monthly and a comprehensive report is compiled, to include an action checklist to address any findings. Annual satisfaction questionnaires are completed for residents, relatives and care managers and the responses are collated. CMG must ensure CSCI receives a copy of the collated responses, and this has been agreed for future surveys. Staff meetings are held every 2 months and minutes taken. Residents meetings are held monthly in agreement with the residents and minutes are taken. These are good forums to discuss any issues or changes the residents might have, for example planning for their annual holidays was discussed at a recent meeting. Staff are receiving training in the completion of the new CSCI Annual Quality Assurance Assessment document that will be sent to all homes annually for completion. Boots attend the home to carry out medication audits and the Registered Manager ensures that documentation is kept up to date. The Inspector sampled maintenance and servicing records and these were up to date. A maintenance book is kept so that any repairs are recorded and these are actioned by the maintenance man for the CMG homes in the area. Cleaning and kitchen records viewed were also up to date. Staff undertake health & safety training to include moving & handling, fire safety, food hygiene, first aid and POVA. There is a training file with each member of staffs training recorded. Risk assessments are in place for safe working practices and individual ones for any risks identified for each resident. The fire risk assessment had been updated in April 2007. Fire drills take place every 3 months and there is a list of participants and any action required following the drill. An issue with the radiators was identified and a requirement is made under standard 24. Any accidents and incidents are recorded and Regulation 37 notifications sent to CSCI in line with the guidance. 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 22 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 4 3 X 4 4 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 3 3 X 3 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 3 X X 3 X 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 13(2) Requirement All receipts and administration of medications must be signed for at the time of receipt or administration in order to maintain accurate records. The radiators in areas accessible to residents must be reviewed and action taken to make them safe to minimise the risk of harm to residents. Timescale for action 20/06/07 2. YA24 13(4) 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 24 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 23 Pierrepoint Road DS0000027748.V336359.R01.S.doc Version 5.2 Page 25 - 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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