Inspection on 30/05/06 for 27a Old Kenton Lane

This inspection was carried out on 30th May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27a Old Kenton Lane 19/01/10

27a Old Kenton Lane 24/09/09

27a Old Kenton Lane 07/11/08

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

CARE HOME ADULTS 18-65 27a Old Kenton Lane 27a Old Kenton Lane Kingsbury London NW9 9ND Lead Inspector Clive Heidrich Key Unannounced Inspection 30th May 2006 08:00 27a Old Kenton Lane DS0000062900.V296876.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 27a Old Kenton Lane DS0000062900.V296876.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. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27a Old Kenton Lane Address 27a Old Kenton Lane Kingsbury London NW9 9ND 020 8959 3965 020 8201 0213 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) Integrated Care Services Limited Mr Godwin Percy Bamunuwatte Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection None Brief Description of the Service: 27a Old Kenton Lane is a newly registered home. The registered manager is Mr Percy Bamunuwatte. Mr Bamunuwatte and his wife jointly run the Integrated Care Services company. They provide a similar service at one other local home. The home is located in a residential area of Kingsbury. The property is detached. There is one bedroom, a bathroom, a toilet, a lounge/diner, an office, and kitchen on the ground floor. Three more bedrooms, and a bathroom/WC can be found on the first floor. The home has a self-contained back garden of medium size. There is parking space for two cars in the home’s own drive and free kerbside parking on a road around the home. There are a few shops in walking distance. More shopping facilities are in Wembley or Harrow, which can be reached through public transport. The home is registered for four residents and is currently occupied by three residents. Fees for the home start from £850 a week. The service user guide is available on request. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across one day in late May. The site visit lasted just over six hours. This was the first inspection of the service provided at this home following its registration during the autumn of 2005. There is a continuity of service provision from one of the organisation’s previouslyregistered homes, at 345 Church Lane, and hence inspection requirements from that home’s last report were checked on for compliance at this inspection. All of the key standards were additionally inspected. The inspection process involved meeting with all service users to discuss the services provided in the home. Communication between service users and the inspector was however limited, with little more than ‘yes/no’ responses generally understood. All service users had gone out to their respective day services by 9am. The inspector also discussed aspects of the service with the three staff who were working during the visit, with the manager who was present and available across most of the visit, and with the managers wife who is the other owner of the organisation along with the manager. Additionally, care practices were observed, records were read, and aspects of the environment were checked on. A few months prior to the inspection, the manager was requested to send out comment cards to involved people, and to complete an inspection questionnaire. Consequently comment card information from two relatives, all three service users with staff support, and one health & social care professional has been included in this report. Feedback was almost entirely positive. The manager completed the inspection questionnaire shortly after the site visit. The inspector thanks all involved in the home for the patience and helpfulness before, during, and after the inspection. What the service does well: Written comment cards confirmed that everyone is satisfied with the overall care provided. Service users receive excellent support to develop their individual skills, and good support to access the community at all times. The new home has a comfortable, clean and homely environment that meets service users’ living needs. The staff team has an excellent record of achieving relevant NVQs. Staff receive good support from management for their work. 27a Old Kenton Lane DS0000062900.V296876.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. 27a Old Kenton Lane DS0000062900.V296876.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 27a Old Kenton Lane DS0000062900.V296876.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is suitable information available to prospective service users and their representatives in respect of the home’s services. Pre-admission assessment processes consider whether the home can suitably meet the prospective service user’s needs. EVIDENCE: The three service users living in this home moved in during late 2005 from another home provided by the organisation. Feedback, from management and records, found that all service users had been consulted about the move, along with their relatives and social workers. Records showed that service users have settled into this home reasonably, and there were no concerns evident, from observations and records, during the visit. The service provided in this home differs only in the physical environment. The Statement of Purpose and Service User Guide have been reviewed since the service in this home began. They refer jointly to the organisation’s two homes. They were seen to be compliant with National Minimum Standards. The guide contains some pictorial cues to assist service users to understand its contents. The inspector found these documents in service users’ files. The manager noted that the guides have been distributed to service users and their representatives. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 9 Management stated that they have had enquiries about the vacant room downstairs, but that the proposed people have not been appropriate to this home, either in terms of high dependency or through them not fitting in with the established service users. This is appropriate consideration. It was confirmed verbally that the home has an admissions process and that a member of management meets prospective service users to assess their needs before offering a placement. The admissions policy was judged as suitable at previous inspections. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Strengths include an established care planning and reviewing system, and suitable risk assessments, which all reflect service users’ individual needs and abilities. Service users are provided with appropriate support to make decisions about their lives. Improvements are only needed with ensuring that that care planning system captures all current and recently changed needs. EVIDENCE: The care files of two service users were checked through and then discussed with management. Each file has a care plan that explains the needs of the service user and how these should be met, and also a review document about progress across from the previous formal review meeting to the current review meeting. The latter document includes short and long-term goals. These all provide good overall pictures of the service users care needs, including about how staff are to provide support, but they lack update since the last review meeting. This could lead to inappropriate or outdated support. This was discussed with the manager, who agreed to ensure that brief updates about changed needs would be appended to the care plan. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 11 Key aspects of the care plans have been made more accessible to service users, through the use of pictorial cues, since the last inspection. Activity descriptions were for instance seen. Feedback from relatives, via comment cards, showed that they are consulted with about decisions in respect of their relative. Records showed appropriate consultation with service users and their relatives about care planning. The home has a keyworker system in place that helps to facilitate this. There were also risk assessments on care files. These generally covered all of the key hazards that each service user might present, and about how to minimise these hazards. They were generally up-to-date. One issue, as discussed with the manager, is referred to further under standard 23. The organisation looks after the money of two service users. Checks of the records for one service user were found to be well-organised and detailed. They showed all expenditures and tracked how this related to bank balances. Receipts were in place. The manager said that monthly audits are sent to the respective social workers. A relative looks after the money of the third service user. Service users are supported to handle small amounts of money relative to their abilities, according to records and feedback. The service emphasises service users’ skills development in this respect, which is encouraging. There was evidence, from feedback and records, that service users are supported to make decisions about their lives. For instance, the inspector observed that service users have freedom of the home, but that staff provided support such as for personal care where this was detailed within care plans as necessary. It was explained that meal choices are established partially through service users going shopping to make choices on the food bought, which shows efforts to facilitate effective communication. There was also little unnecessary direction by staff towards service users observed. Direction was respectful and pitched at the level of need and understanding of the service user. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive excellent support to develop their skills, and good support to access the community at all times. The provision of food is suitable. EVIDENCE: There was good evidence, from feedback and records, of service users being supported to develop skills within the home and in the community, for such things as cleaning, communicating clearly, and handling money. Individual abilities are considered within this context. Service users have established weekday routines. One service user attends a day service, whilst the other two service users are provided with considerable and varied community support through the organisation. Activity plans in this respect were seen. They include a significant focus on swimming. Feedback and records also found that service users attend evening clubs, are provided with some degree of community support at the weekend, and in some cases have regular visits to family. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 13 There was a party at the home the previous evening to celebrate the birthday of one service user. The service user reported enjoying it. Friends and family attended, and a barbeque was reported to have been newly purchased for the event. Comment cards from relatives confirmed that they are welcomed into the home, that they are given privacy with their relative, and that they are kept informed of important matters. Records and feedback confirmed appropriate family involvement in service users’ lives. Standard leisure facilities, such as music and television, are provided in the home. The manager reported that satellite TV has been purchased and is awaiting wiring-up. Records showed that service users are supported to develop leisure options at home. Some service users attended a ten-day holiday at a camp in Blackpool last year. The manager confirmed that holiday plans are being considered for this year. Comment cards from service users, filled in with staff support, indicated that service users all like the activities provided by the service. There was a good amount of food available in the home. Fresh fruit was on display, and service users were seen to easily acquire drinks. The records of food eaten showed that a nutritious menu is provided based around meat and vegetables. Minor food restrictions are recorded about, to support service users to balance their diets between processed and healthy foods. This follows dietician input. Comment cards from service users, filled in with staff support, indicated that service users all like the food provided in the home. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are well supported to consult with health professionals where needed. Personal care is appropriately provided. Medication systems are generally reasonable. One storage issue must be addressed, to help ensure appropriate hygiene. EVIDENCE: There were no concerns with any of the service users appearances from the start of the inspection. They were all dressed in individual and well-fitting clothing, with reasonable hair and nail care apparent. Staff feedback and records showed that good attention to personal hygiene is provided on an individual basis. Feedback and records established that service users are provided with good support to access suitable health-professional advice. There was good work in trying to enable dentist support despite some service users reluctance. Changes in diet and medication, following consultation with health professionals, were recorded and fed-back as being beneficial to individual service users. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 15 Some of the health records were difficult to find within the service users’ files. It is recommended that a summary sheet, for attendance and outcomes of consultation with a health professional, be set up for each service user. None of the service users self-medicate. Staff support service users to take prescribed medications. A weekly monitored-dosage system is supplied from a local pharmacist in support of this. Checks of administration records tallied with the medications in secure storage. The medication cupboard was found to be very sticky on its lowest shelf. This was from a bottle of lactulose liquid that was being stored on its side. It was too big to be stored upright. This has hygiene consequences. The manager must ensure that medications are suitably stored, and change the size of the medication cupboard if appropriate. The medication policy was seen to be easily accessible to staff. There was no stockpiling of medications. Allergies were being recorded about. The manager noted that staff attended medication training both through their NVQs and via the local community nurse team. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Both of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a suitable complaints process and adult protection procedure. Challenging behaviour from service users is responded to respectfully. However, shortfalls in respect of guidance and of recording all incidents must be improved on. EVIDENCE: The home has a suitable complaints policy. Alterations required from the previous inspection have been addressed. There were no entries in the complaints book. Comment cards, from relatives, a social worker, and service users with staff support, found people generally aware of complaints procedures and of no complaints having been made. Service users’ comment cards found that all service users feel safe in the home. The home was seen to have suitable policies on the protection of service users from abuse. A recent memo to staff by the manager clarified the expectations with regard to whistleblowing suspected abuse, which is good practice. The manager reported that staff have attended abuse-prevention training. Some service users show some degree of challenging and aggressive behaviours. Guidance to staff on how to address these appropriately was found in applicable service users’ care plans and risk assessments. These have an emphasis on calm responses, and on distraction and occupation. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 17 Checks of records found inconsistencies in recording about one service user who occasionally scratches others. Incidents were not always recorded about in the applicable service users’ daily records, nor in the incident book that is being used to monitor the behaviour on the psychiatrist’s advice. Additionally, there was no risk assessment and guidance in respect of how staff are to address this particular behaviour. This can lead to inconsistency of staff approach, greater risk to service users, and can misrepresent the behaviour to the psychiatrist. The manager must address this. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 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, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The premises is a comfortable, clean and homely environment that meets service users’ living needs. A couple of minor environmental considerations need addressing. EVIDENCE: The home is situated in a quiet residential road close by to central Kingsbury. Its external appearance is in keeping with other homes along the road. All bedrooms are single occupancy. They were seen to have suitable furnishings. All have window restrictors, and suitable door locks. They all meet space standards. Three are upstairs, with the currently vacant room downstairs. The communal areas of the home are well-decorated and with suitable furnishings, especially plentiful seating. The areas comprise a lounge, a dining area, and a kitchen, all of which are interconnected. There is also an office downstairs. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 19 There are suitable toilet and bathing facilities available both up and downstairs. The home has suitable domestic laundering equipment. The home was clean and free of offensive odour from the start of the inspection visit. The home has a small, enclosed garden that has garden furniture and a barbeque. The home is not designed to meet the needs of wheelchair users. Reports from the fire authority and the local environmental health department raise no concerns about their standards in respect of this home. Improvements have been recently made to fire safety in the home in response to a previous fire authority report. There were a few minor improvements needed to the décor, due to health and safety considerations: • A leak from the guttering down the side of the house has produced a puddle on the path. • There are a few cracked and indented kitchen floor tiles. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 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 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff team has an excellent record of achieving relevant NVQs. Other training is also provided. Staffing levels are suitable. Staff receive appropriate support. Improvements are only needed in making suitable documentation of training and supervision. EVIDENCE: Staff were seen to treat service users respectfully and knowledgably during the inspection. Staff also demonstrated understanding of the service users’ needs during discussions with the inspector. The social worker’s written comments additionally reflected this. Service users’ comment cards, with staff assistance, all noted that staff treat them well. Records and feedback showed that most staff have achieved the NVQ level 2 in care qualification. Staff meeting records indicated that two remaining staff will be enabled to start the course in September. Additionally, a number of staff are working towards the NVQ level 3. The organisation clearly puts great emphasis on these qualifications. The staff team’s achievements in this respect merit standard 32 to be judged as excellent. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 21 The rosters for the previous two weeks show that there are always two staff working when service users are at home. There are three staff at times across the weekend, in support of community activities. This meets service users’ needs. Relatives’ comment cards also noted that there is always sufficient staffing on duty. The registered people (the manager and his wife) work additionally in the home at weekends. Agency staff are not used, and the staff pool is not excessive. The manager reported that most staff have been working with the organisation for at least two years, which is useful consistency. The recruitment file of a newer staff member was checked through. Two written references, and a Criminal Record Bureau check, were in place. The manager reported that all staff have suitable such checks in place. Records and feedback indicate that staff have received mandatory training such as food hygiene and emergency first aid. However, individual training records and plans, and a general training plan, were out-of-date, the latter for instance dating from the previous home. The manager must ensure that they are updated, to help ensure that refresher training for individual staff is kept up-to-date. The manager noted that his wife has attended training in the induction standards expected from the national training body. This will be implemented before any new staff start working in the home. Records and feedback found that all staff receive three-monthly development reviews. The manager explained that they also receive one-to-one sessions inbetween. These should additionally be recorded about, to evidence key points from the discussions. There are also monthly staff meetings in which service users’ needs are clearly discussed. Staff reported receiving good support from management. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has an experienced manager, reasonable standards of health and safety, and consults with people to help run the service in service users’ best interests. Improvements are needed to formalise the consultation and make a development plan from the process, and to ensure that pages are not ripped out of formal records. EVIDENCE: The home’s manager, who is also one of the organisation’s owners, has over seven years’ experience of managing care homes for people with learning disabilities. He has completed the Registered Managers’ Award, an appropriate qualification for his position. He came across as competent in his role, and is significantly involved in service users’ care. Records showed that the organisation have audited the views of some family members about how it operates. There was also a business plan in place, and 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 23 recent staff meeting minutes were devoted entirely to addressing standard 39, the quality assurance standard. The manager must ensure from this, that an annual development plan, which includes the views of all stakeholders (service users, family members, staff etc.) is produced. It must then be made available to all involved in its development, and to the CSCI. The general standard of record-keeping was reasonable. The manager must ensure that paper is no longer ripped out of bound books, so as to ensure that an open and transparent culture is upheld. Pages were found to have been ripped out of the communication book and one service user’s daily records, albeit from the back end of these bound books. Professional safety checks were found to be up-to-date for the gas systems, the electrical wiring, and the fire system and equipment. The fire risk assessment was also up-to-date. It was produced by a fire professional who also provided refresher training to staff. The manager stated that internal fire checks are undertaken regularly. General risk assessments, to minimise hazards to people using the home, were in place for such things as window locks and fire drills. Other records showed that health and safety considerations are regularly discussed within the staff team. The only health and safety issue for improvement would be to ensure that food in the fridge is kept labelled when opened, to help people to know when it will have expired. 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 3 X 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2) Requirement The manager must ensure that brief updates about changed needs are appended to applicable service users’ care plans when any service user’s needs change significantly. The manager must ensure that medications are suitably stored, changing the size of the medication cupboard if necessary. The manager must ensure that, for the service user who occasionally scratches others: • A risk assessment, with staff guidance on handling the situation, is in place; and • Incidents of this nature are consistently recorded about within relevant documents. The manager must ensure that the following issues are addressed: • The leak from the guttering down the side of the house which has produced a puddle on the path; and • The few cracked and indented kitchen floor tiles. The manager must ensure that DS0000062900.V296876.R01.S.doc Timescale for action 01/08/06 2 YA20 13(2) 01/08/06 3 YA23 13(4), 15(2), 17(1)(a) 01/07/06 4 YA24 23(2)(b) 01/09/06 5 YA35 17(2) 01/09/06 Page 26 27a Old Kenton Lane Version 5.2 sched 4 part 6 6 YA39 21, 24 7 YA41 17 individual staff training records, and the general training plan, are kept up-to-date. The manager must ensure that an annual development plan, which includes the views of all stakeholders (service users, family members, staff etc.), is produced. It must then be made available to all involved in its development, and to the CSCI. The manager must ensure that paper is no longer ripped out of bound books, so as to ensure that an open and transparent culture is upheld. 01/10/06 01/07/06 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 YA19 Good Practice Recommendations It is recommended that a summary sheet, for attendance and outcomes of consultation with any health professionals, be set up for each service user within their care files. The one-to-one sessions held between individual staff and the manager should be recorded about, to evidence key points from the discussions. Food in the fridge should be kept labelled when opened, to help people to know when it will have expired. 2 3 YA36 YA42 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 27a Old Kenton Lane DS0000062900.V296876.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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