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Inspection on 29/11/05 for Warwick Road, 17

Also see our care home review for Warwick Road, 17 for more information

This inspection was carried out on 29th November 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A comfortable and relaxed home is provided for the service users, as a base from which they enjoy their daily activities and leisure pursuits. Staff support them to carry out many of the activities. This entails good organisation, particularly with the small staff team currently employed and eight service users resident in the home. The service users are encouraged and supported by the staff to have a positive attitude and are assisted to work towards resolving their concerns.

What has improved since the last inspection?

Improvements have been made in the record keeping and documentation, with an emphasis on providing a better focus on the individual service users. Use is being made of visual aids, such as photographs and internet materials, to record the interests and lives of the service users to assist with their care planning. The majority of the outstanding requirements have been addressed.

What the care home could do better:

From being fully staffed at the last inspection, the home now has vacancies. This will impact on the quality of the service which can be offered, in spite of the best efforts of the staff team to provide cover and maintain consistent support to the service users. The Registered Providers need to ensure that every effort is made to recruit and retain a full staff team again.The admission and assessment procedures still need to be revised to take into account the requirements of Regulations 14 and 15 of the Care Homes Regulations 2001. The previous timescales for this have not been met by the Registered Providers. Although work has been carried out in the kitchen and new flooring and worktops have been provided, the kitchen units need to be replaced. An Action Plan is required to show when this work will be completed. Two of the bedrooms have had, on occasions, insufficient heating and additional heaters have had to be provided. This is not satisfactory and the central heating in the home needs to be repaired to ensure that all of the rooms are heated adequately. If it cannot be repaired to provide consistent heating, then the replacement of the system must be considered. Although a survey of service users` views have been undertaken, a regular review of the quality of care, which include these views and those of their representatives, must be undertaken and submitted to the Commission for Social Care Inspection and made available to the service users. As only a random sample of water is tested, the Registered Providers must clarify that the tests for Legionella are sufficient to maximise safety in the home.

CARE HOME ADULTS 18-65 Warwick Road, 17 Ealing London W5 3XH Lead Inspector Ms Jane Collisson Unannounced Inspection 29th November 2005 11.50 Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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 Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Warwick Road, 17 Address Ealing London W5 3XH 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) 0208 840 3109 Ealing Consortium Limited Ms Paulette Mohammadi Care Home 8 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users, can continue to be accommodated under the categories of Mental Disorder (1) and Physical Disabilities (1) as agreed with the Commission for Social Care Inspection on the 19th November 2004, whilst the home can meet the needs of all service users. The home must advise the CSCI when a service user no longer resides at the home. 13th June 2005 Date of last inspection Brief Description of the Service: The home is registered for eight service users with learning disabilities, including those over 65. There are currently five female and three male service users. The home is situated in a quiet residential area of central Ealing and is within walking distance of Ealing Broadway’s shops, facilities and public transport links. Notting Hill Housing Trust owns the premises. Ealing Consortium Ltd, a voluntary organisation, provides the care. The house is semi-detached, and has three floors, with two mezzanine floors. There is no lift and service users require good mobility to access all but the ground floor. The home has eight single bedrooms and the bedroom on the ground floor is en suite with its own shower. There are three additional bathrooms. The ground floor is wheelchair accessible and has a lounge, a kitchen with a dining area, and a laundry room. There is a small lounge on the top floor which is used as the smoking area. The sleeping-in room is on the first floor and the top floor has an office with staff toilet and shower. There is a large rear garden, with seating, which has ramped access from the kitchen. A parking area is available at the end of the garden which has now been made more secure. The staff team consists of the Registered Manager, one senior support worker and six support workers. There are usually two staff on duty on each shift, and one member of staff sleeps in at night. There are no waking night staff. A variety of day facilities are accessed by the service users, including college courses in Ealing and Acton. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 29th November 2005 commencing at 11.50am. As the Registered Manager was not present, a further visit was made on the 16th December to meet with her. An additional visit was made on the 5th January 2006 to see the completed ground floor shower room and check further records. The inspection took a total of eight hours. Five of the staff were met in the course of the inspection and all eight of the service users. For an assessment of all of the key standards, this report should be read in conjunction with the unannounced inspection report of 13th June 2005. There were seven requirements at the inspection in June 2005 and, of these, six have been met. One is restated and a further five have been made. What the service does well: What has improved since the last inspection? What they could do better: From being fully staffed at the last inspection, the home now has vacancies. This will impact on the quality of the service which can be offered, in spite of the best efforts of the staff team to provide cover and maintain consistent support to the service users. The Registered Providers need to ensure that every effort is made to recruit and retain a full staff team again. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 6 The admission and assessment procedures still need to be revised to take into account the requirements of Regulations 14 and 15 of the Care Homes Regulations 2001. The previous timescales for this have not been met by the Registered Providers. Although work has been carried out in the kitchen and new flooring and worktops have been provided, the kitchen units need to be replaced. An Action Plan is required to show when this work will be completed. Two of the bedrooms have had, on occasions, insufficient heating and additional heaters have had to be provided. This is not satisfactory and the central heating in the home needs to be repaired to ensure that all of the rooms are heated adequately. If it cannot be repaired to provide consistent heating, then the replacement of the system must be considered. Although a survey of service users’ views have been undertaken, a regular review of the quality of care, which include these views and those of their representatives, must be undertaken and submitted to the Commission for Social Care Inspection and made available to the service users. As only a random sample of water is tested, the Registered Providers must clarify that the tests for Legionella are sufficient to maximise safety in the home. 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. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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 Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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, 3, 4 Progress has been slow in addressing the changing needs of the service users. This has been outside of the control of the home’s staff who have taken the action required to facilitate the changes necessary. EVIDENCE: The aims and objectives of the home are detailed in the Statement of Purpose. Because the home has limited facilities for people with poor mobility, and does not have waking night staff, service users are required to have a reasonable amount of independence. The current staffing levels do not allow for service users with more than moderate dependency to be admitted. Facilities are in place on the ground floor for the service user who has a wheelchair and a new shower room was being fitted during the inspection. However, the provision of this facility has been unnecessarily lengthy and has not supported staff to provide a good quality of support to the service user. No new service users have been admitted to the home since the last inspection, so the standards could not be fully assessed. The admissions policy and procedure are still in the process of being reviewed. This needs to be in accordance with the Care Home Regulations 2001, particularly Regulations 14 and 15, and should reflect the National Minimum Standards so that prospective service users are fully aware of how their needs and aspirations can be met. This has not been met at two previous inspections and needs to be completed Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 9 by the Registered Providers. The needs of one service user, who was admitted to the home as an emergency four years ago, cannot continue to be met by the home and alternative accommodation is being sought. The Registered Manager has made every effort to ensure that this move would be facilitated as smoothly as possible but, to date, this has not been achieved and needs further input from Social Services for this to happen. The staff have been seen to provide as much support as possible during a difficult period but this situation needs to be resolved for both the service user concerned and the other service users in the home. Another service user, in different circumstances, wishes to move to alternative accommodation in another part of the country and is being supported to do so. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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, 8, 9 Service users are encouraged to make decisions about their activities and all aspects of their daily lives. Staff were seen to support the service users to make the choices. EVIDENCE: Work has been carried out in providing a file for each service user which reflects their interests and the activities they undertake. These files provide an insight into the hobbies and activities enjoyed by the service users. Service users have the opportunity to make decisions about most aspects of their lives. All are able to make their wishes known regarding the level of activities they want to undertake, which vary considerably. One service user was seen to be gently encouraged to participate in activities well within her capabilities. Firmer action has had to be taken with a service user whose bedroom had not maintained to a good standard of cleanliness as this was affecting other service users. Staff were observed to respond to the different needs of the service users appropriately. One service user uses sign language as the main form of communication and staff show a good awareness of ensuring that she is included in the decision-making. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 11 Those service users who are able to do so are encouraged to retain their independence and examples of this were observed during the inspection. One service user was being encouraged to continue to access public transport, with another service user, so that this skill would not be lost and the service user would remain confident about doing so. Staff showed awareness of the importance of building confidence and not allowing service users to become too dependent on staff. One staff member is a moving and handling key trainer and was instrumental in providing appropriate risk assessments and methods to minimise manual handling for staff due to the absence of the specialised bathing facility. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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): 11, 12, 13, 16 Most of the service users enjoy a variety of day services, including day centres and college courses. Staff try to ensure that the service users maintain and expand their activities, and encourage a positive attitude to any difficulties and problems which arise. EVIDENCE: The service users are encouraged to participate fully in the running of the home, which can include helping with cooking and shopping. They are also encouraged to keep their personal spaces clean and tidy. The daily records indicate how much the service users are involved in helping around the home and in expanding their interests. Service users enjoy a variety of day activities which include day centres and colleges. Two service users assist at an older peoples’ luncheon club. During the course of the inspection, one service user was offered part-time work in a supermarket and was being supported by staff to try and ensure that this will be a positive experience. Service users have recently enjoyed visits to the theatre, to a pantomime and to a horse show arranged by staff. A Christmas Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 13 meal had been held at a local pub. Service users indicated that they enjoyed the activities, particularly the horse show. The home is situated in a pleasant residential area of Ealing, within walking distance of Ealing Broadway shops and services. Service users are able to travel by public transport to enjoy local facilities, some independently. One service user goes regularly to church. Service users are encouraged to remain in contact with their families and advocates and one service user spoke about regular contact with a parent. Good relationships between the service users were observed with appropriate friendships giving service users the opportunity enjoy each other’s company. The service users are offered every opportunity to exercise their rights, through their daily routines and individual choices. This may include the preference to remain in their own rooms. Regular meetings of the service users take place and they are asked for and give their views on life in the home and on the house rules. One service user has had to be reminded of the responsibilities of living in a communal home and the Registered Manager has had to take appropriate action regarding the service user’s future in the home. There was evidence of the measures taken by the home to try and improve the situation for all concerned but the rights of the other service users have had to be taken into account. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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 Service users’ health and medical needs are accessed with staff support and through the appropriate community services. Staff are also seen to give good and appropriate support with emotional and behavioural needs as they have arisen. EVIDENCE: Service users are assisted with their personal care appropriately and those who require only prompting are encouraged to maintain a good standard of hygiene and personal grooming. The improvement of the bathing facilities for one service user should assist considerably in the safety for both the service user and staff. One service user has given cause for concern for some months. This has been with both behavioural and emotional needs, and staff were seen to be dealing with this appropriately, trying to maintain the self-esteem of the service user and minimising the effect on other service users. Concerns with the service user’s refusal to eat properly within the home were being documented and emotional support has been offered where required. This situation needs to be resolved as soon as possible by Social Services. The staff assist service users, where required, to attend General Practitioners and other appointments, which are accessed through the community services. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 15 One service user was observed to be unwell during the inspection visits and was seen to be supported through this episode of ill health. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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): 22, 23 Although there have been no formal complaints recorded, service users are encouraged to express their concerns. Further efforts are being made to provide more user-friendly materials for the service users to understand the complaints procedures. EVIDENCE: There have been no recorded complaints by service user or their representatives. One complaint had been made to the Housing Association, by the home, regarding the time taken to carry out the work on the en suite bathroom as this was having a detrimental effect on the service user concerned. The home has an up-to-date complaints procedure and there is a visual format for service users. In one of the care plans seen, it was noted that staff had gone through the complaints procedure with the service user to ensure that they had a good understanding of the process. Further efforts are being made by Ealing Consortium to produce visual information for service users to gain better access to this information. here have been no adult protection issues in the home. The whistle blowing procedures are displayed to remind staff about the process. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30 There is a comfortable and homely environment, which has been improved over the last year. Although there is limited space for eight, this does not seem to present a problem but needs to be kept under review should new service users be admitted or the needs of the current service users change. EVIDENCE: To complete the refurbishment of the main lounge, new curtains have been provided since the last inspection. The space, although not very large, provides sufficient seating for all of the service users, including space for the service user who uses a wheelchair. It would be quite crowded if all of the service users decided to use it at the same time. However, the kitchen, which has a large table, is an area which is popular with some service users, who gather to talk to staff and each other. Bedrooms are also used for watching television and relaxing. There is additional communal space on the second floor, which would also be for service users who smoke, but staff said that this is not a popular facility. This would benefit from old electrical equipment being removed. New worktops and ovens have been provided in the kitchen. It is planned that the kitchen units will be replaced in due course and an Action Plan needs to be provided to show the timescale for this work to be carried out. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 18 Since the last inspection, security has been improved by the addition of locks to the back garden gate and the gates to the car parking area. However, the lock on the latter was broken and was to be repaired. The London Fire and Emergency Planning Authority officer visited the home in September 2005. The review of the fire risk assessment needed to be completed and there was insufficient emergency lighting. The Registered Manager said that this work has now been ordered, although it had not been completed within the LFEPA deadline and the Registered Providers should ensure that the timescales are met. The other requirements had been completed. The fire records checked were satisfactory. Eight fire drills had been held in 2005. However, it was noted that one newer staff member had only attended one and it is recommended that, because only one staff member is available during the night, sleeping-in, staff are involved more frequently, particularly when new to the service. Two of the bedrooms of the service users were seen on this inspection. Both were pleasantly decorated and personalised. There has been problems with the central heating in two of the bedrooms, with the heating being intermittently low. This has been reported and some work has been carried out but the problem still remains. Additional heaters have been supplied to those affected but the action needs to be taken to ensure that the system works without these being required. This system will need to be replaced if repairs are not successful. The only en suite bathroom was being refurbished at the commencement of this inspection and completed, apart from redecoration, by the end. This has provided a much better facility but has taken a long time to come to fruition. Service users encouraged to assist with maintaining a clean and well ordered home and, apart from the concerns with one service user’s room, mentioned elsewhere in this report, all those areas seen were clean and tidy. There was a vacancy for a domestic worker at this inspection. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 The recruitment of a full, functioning staff team is again a requirement for the home to ensure that there is continuity for the service users and the staff team have the opportunity to develop their roles. EVIDENCE: All of the staff, including the Registered Manager, are involved in providing support to the service users on a practical level. This includes accompanying them to day services, medical appointments and leisure activities. All members of the care staff, and the Registered Manager, participate in sleeping-in duties at night. The staffing situation had been found to have improved at the last inspection, with a full staff team in place. However, since then a number of staff have left the home, one for promotion. At the time of this inspection there were 2.5 staff vacancies, although one new member of staff was due to commence early in 2006. The Registered Manager was undertaking further recruitment interviews during the inspection. The lack of staffing has meant that staff, including the Registered Manager, have had to provide additional cover for vacancies, sickness and other leave. Every effort needs to be made by the Registered Providers to ensure that the vacant posts are filled as quickly as possible. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 20 One newer member of staff has completed part of the Learning Disability Framework Award induction and has completed a number of the basic courses in fire awareness, first aid and health and safety. The staff meet on a regular basis and the minutes of the meetings showed that these are used for a variety of purposes, including ensuring that staff understand the procedures in the home. Those discussed included the fire and sickness procedures. The time is also taken to discuss the progress of the service users and to ensure that their reviews and appointments are maintained. Staff also receive regular supervision. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 21 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, 42 Although the home continues to be well managed, and the service users benefit from this, the problem of retaining a permanent staff team does not assist the Registered Manager to fully develop the service and puts some strain on the remaining staff team. EVIDENCE: The home has a friendly atmosphere, with staff and service users interacting very well. A very good rapport exists between the Registered Manager and the service users and she provides good leadership for the staff team. Staff are encouraged to build on their strengths. One staff member commented on the supportive nature of the team. A staff member who is particularly good at recording systems has been given the opportunity make improvements. Problems that have arisen in the home, including the serious concerns with one of the service users, the delay in providing suitable bathing facilities, staff absences and the lack of a permanent staff team, have impacted on the progress that should have been made. The current team have worked hard to ensure that there has been a minimal impact on the service users, but there Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 22 needs to be recognition that this cannot be sustained indefinitely and the staff problems must be addressed. A number of the daily logs for the service users were examined. These provide an ongoing record of their activities and appointments. The Registered Manager was advised to ensure that all of the staff sign their entries in case any queries should arise. Regular monthly visits are made to the home on behalf of the Registered Provider, under Regulation 26, and these are supplied to the Commission for Social Care Inspection. A survey of the service users was carried out in 2005, by staff from another home, and the results of the survey were provided to the Commission for Social Care Inspection. However, a full review of the quality of care, which involves quality monitoring, has not been made available by the home and this must be completed, to meet Regulation 24 of the Care Home Regulations 2001. The Registered Manager was making enquiries during the inspection to ascertain if the Legionella testing was sufficient as only a random test of the water has been carried out. The Registered Providers need to clarify that the tests are sufficient to maximise safety. A small amount of food was found to be out-of-date during the first visit to the home and staff need to ensure that perishable food is labelled when opened and checked regularly. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 2 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 X 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Warwick Road, 17 Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 2 X DS0000027719.V265387.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA4 Regulation 14 & 15 Requirement The admission and assessment procedures must be revised to take into account the requirements of Regulations 14 and 15 of the Care Homes Regulations 2001. (Previous timescale of 31/8/05 not met). An Action Plan is required to show the timescale for the work on the kitchen units. The central heating in the home must be repaired to ensure that all of the rooms are heated adequately, without recourse to additional heating. If it cannot be repaired to provide consistent heating, then the replacement of the system must be undertaken. Every effort needs to be made by the Registered Providers to ensure that the vacant staff posts are filled as quickly as possible. A regular review of the quality of care, which include the views of the service users and their representatives, must be undertaken and submitted to the Commission for Social Care Inspection and made available to DS0000027719.V265387.R01.S.doc Timescale for action 28/02/06 2 3 YA24 YA25 23 (2) (c) 23 (2) (p) 31/03/06 31/01/06 4 YA33 18 (1) (a) 31/03/06 5 YA39 24 (1) & (2) 31/03/06 Warwick Road, 17 Version 5.0 Page 25 the service users. 6 YA42 13 (4) (a) & (c) The Registered Providers must clarify that the tests for Legionella are sufficient to maximise safety. 28/02/06 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 YA24 Good Practice Recommendations It is recommended that, because only one staff member is available during the night, sleeping-in, staff are involved more frequently in fire drills, particularly when new to the service. Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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 Warwick Road, 17 DS0000027719.V265387.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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