Inspection on 18/10/06 for 385 Torbay Road

This inspection was carried out on 18th October 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

385 Torbay Road 08/05/07

385 Torbay Road 10/01/06

385 Torbay Road 16/08/05

385 Torbay Road 17/02/05

385 Torbay Road 05/08/04

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 18-65 385 Torbay Road 385 Torbay Road Harrow Middlesex HA2 9QB Lead Inspector Judith Brindle Key Unannounced Inspection 18th October 2006 08:10 385 Torbay Road DS0000017564.V306386.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 385 Torbay Road DS0000017564.V306386.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. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 385 Torbay Road Address 385 Torbay Road Harrow Middlesex HA2 9QB 020 8933 2625 01895 638 974 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) Ms Santa Bapoo Ms Santa Bapoo Care Home 4 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation agreed for one named individual VP aged 65 years for the duration of her stay. 10th January 2006 Date of last inspection Brief Description of the Service: 385 Torbay Road is a care home providing personal care and accommodation for up to 4 adults with a learning disability. The owner and registered manager is Ms Santa Bapoo. The home opened in 1996. It is located in a quiet residential street in North Harrow. The care home is within a few minutes walk from a variety of shops, restaurants, library, banks and other amenities. Public bus and train facilities are accessible close to the home. The home is a semi-detached house, which is in keeping with other houses in the locality. There is parking for 2-3 cars at the front of the house. All the homes bedrooms are single without en-suite facilities. There is one bedroom located on the ground floor. The home has an enclosed accessible maintained garden at the rear of the property. Documentation/information about the care home is accessible to residents and visitors. Information in regard to fees can be obtained by contacting the registered manager/provider. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 8.25 hours during a day in October 2006. A Gujarati speaking interpreter was present for part of the inspection. There were no vacancies at the time of the inspection. The inspector was pleased to meet and talk (with support from the interpreter) with all the residents. The inspector also spoke with staff. Staff were very helpful during the inspection, and supplied all documentation and information asked for by the inspector. Several care staff were present during the inspection as there was staff training taking place in the care home during the unannounced inspection. The registered manager/provider was present for most of the inspection. The inspection focussed on spending time talking with residents and observing their interaction with staff and with other residents. Assessment as to whether requirements from the previous inspection had been met also took place. A resident kindly showed the inspector around her home. Documentation inspected included, all the resident’s care plans, complaints and accident/incident records, the staff rota, and medication records. 25 National Minimum Standards (including key Standards) for adults were inspected. What the service does well: The care home has a very welcoming atmosphere. Staff and residents make visitors feel very welcome. The care home has ‘homely’ features, and is very clean. The environment of the care home is generally well maintained. Residents are fully involved in the care home and participate in completing household duties including cooking and housework. Residents are supported and encouraged to be as independent as they are able. Staff have a good knowledge and understanding of resident’s needs, and were observed to be very sensitive and respectful to residents during the unannounced inspection. Residents spoke highly of staff and described them as helpful and caring. Residents confirmed that they were happy living in the care home. 385 Torbay Road DS0000017564.V306386.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. 385 Torbay Road DS0000017564.V306386.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 385 Torbay Road DS0000017564.V306386.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): Standard 1 and 2 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. Arrangements are in place to ensure that prospective resident’s needs are assessed, but all assessment information needs to be accessible. EVIDENCE: Records confirmed that there was information about the care home available for residents and visitors. The service user guide documentation should be dated. The registered manager/provider informed the inspector following the inspection that she had reviewed the statement of purpose. The previous inspection report was accessible in the home. Since the last inspection there has been a new admission to the care home. This resident’s care plan was inspected. There was some evidence of recorded assessment information from the purchasing authority, but no evidence of the initial assessment completed by the registered manager. The manager reported that this had been completed, and that she would endeavour to locate it. The registered manager contacted the Commission for Social Care Inspection following the inspection and confirmed that she was in the process of locating this information. There was some information included in a recorded profile of the resident, which had been completed by staff, but this was not 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 9 comprehensive, particularly in regard to the resident’s varied and possibly complex needs. There needs to be evidence of an initial assessment of the needs of all prospective residents. 385 Torbay Road DS0000017564.V306386.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): Standard 6,7 and 9 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all residents have a plan of care, with recorded personal goals, but some development in care plan records is needed. Residents are supported and encouraged to make decisions. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: All the residents had an individual plan of care. Three care plans were inspected. The care plans inspected included assessment information, which included a profile of the resident, which was clear, and included evidence of the resident’s involvement and their preferences such as clothes and dietary ‘likes’ were recorded. Personal information is also recorded, and staff guidance to meet assessed needs including resident’s behaviour needs was recorded. There was recorded evidence of resident’s goals and objectives. All care plans had been regularly reviewed. A staff member had signed these reviews. There needs to be evidence of residents involvement (if practicable) in their care plan and it’s development, and review. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 11 One resident’s plan of care inspected needs to be further developed to ensure that all the resident’s up do date assessed needs and goals are evident and includes clear staff guidance to manage behaviour from resident’s that might challenge the service, and that there is this information is easily accessible to staff. A resident confirmed that she had a key worker, who can communicate with her in her first language and has knowledge and understanding of her cultural needs. Resident’s daily progress records were fully recorded and included positive and comprehensive information about each person living in the home. Residents spoke of the varied choices that they make. These include shopping for clothes, toiletries and choosing preferred activities. Staff spoke of supporting residents to make decisions about their lives. This was evident during the inspection. A resident kindly made the inspector a cup of coffee during the inspection. Residents are supported in the management of their finances. Appropriate records of incoming and outgoing payments, and receipts are maintained. Two staff generally sign a record when items are bought. The care plans inspected recorded evidence of risk assessment in resident’s care plans. These risk assessments included, accessing public transport, cooking, swimming, and risk of ‘wandering’. These had bee regularly reviewed, and developed. The home has a missing persons policy/procedure. 385 Torbay Road DS0000017564.V306386.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): Standard 12,13,15, 16 and 17 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents have the opportunity to take part in a variety of activities including those promoting personal development, and being community based. Arrangements are in place to enable residents to maintain contact with family/significant others, as they wish. Resident’s rights are respected and responsibilities recognised in their daily lives. Meals are varied and wholesome. EVIDENCE: Residents spoke of the variety of activities that they chose and enjoyed. These included ‘in house’ and community based activities, such as needlepoint, knitting, cooking, listening to music, watching television, and shopping trips. A resident confirmed that Asian films were regularly shown in the care home, and that visits to the cinema often took place. An Asian radio channel was 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 13 playing music during part of the inspection. A resident said that she enjoyed the music. Several residents attend day resource centres (including an Asian cultural day centre) during weekdays. A resident spoke of attending clubs were she could meet friends, and that she enjoyed the computer sessions that she participated in at a day resource centre. Records confirmed that staff accessed a variety of community facilities and amenities. The home has access to a minibus. Residents spoke about the religious festivals including Diwali and Eid that they were planning to celebrate within the home and/or with families. Records and residents confirmed that they had the opportunity to attend places of worship, as well as being enabled and supported to practice their religion within the care home. A resident spoke of the enjoyment that she had in doing a regular voluntary job in a charity shop. It was evident from talking to the resident and staff that the resident had received support and encouragement from staff to enable her to do the job. Residents access local public transport, independently or with staff support. Residents, records and staff confirmed that the home values and seeks to reflect the racial and cultural needs of each resident. The care home has a visitors’ policy/procedure. Records confirmed that visiting times were flexible. The care home has a visitor’s recording book. Residents spoke of the contact that they had with family, friends and significant others. This contact included visits by relatives, going out with their visitors and telephone contact. Visitors are able to see residents in their own room m or in the communal areas including a ‘quiet’ room. Staff were observed to respect residents privacy during the inspection. Staff interacted in a positive manner with residents, and not exclusively with each other. Residents were observed to have unrestricted access to the care home, and to choose when to and when not to join in an activity The home has a smoking and alcohol policy. . One resident spoke of wanting to have a key to her bedroom. This was discussed with the registered manager, and should be actioned unless this was assessed high risk. Residents spoke of choosing meals on a weekly basis, and of participating in the process of food preparation. Food eaten is recorded. Resident’s specialist dietary needs are met by the care home. The residents confirmed that meals provided meet their cultural needs, and preferences. A variety of dried, fresh and frozen foods were stored. Fresh fruit was accessible during the inspection. All the residents informed the inspector that they enjoyed the meals provided. 385 Torbay Road DS0000017564.V306386.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): Standard 18, 19 and 20 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s personal and healthcare needs are met. There needs to be development in regard to a healthcare assessment. Medication is stored and administered safely, but there needs to be development in regards to some medication administration guidance. EVIDENCE: The care plans inspected recorded residents preferred routines, and their personal care needs. A resident spoke of the flexible times for going to bed and getting up. A resident made the choice not to attend a day resource centre during the inspection and this decision was respected by staff. Records confirmed that residents have their health needs monitored by having access to care and treatment from a variety of healthcare professionals. These include GP appointments, optician, dentist, chiropody and psychiatric care. Residents as needed access additional specialist support and advice. A resident spoke of having recently received a flu vaccination. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 15 Records confirmed that residents weight was closely monitored, and that residents receive hospital appointments as required. Staff guidance was recorded in regard to a resident’s specialist health needs. The home has a medication policy. This should be dated. The medication storage and administration systems were inspected. There needs to be recorded guidance in regard to PRN (medication to be given as required) medication, and that there is evidence of GP agreement in this administration guidance. This was discussed with the registered manager. There were no gaps in the medication administration records. Records are maintained of medication received from, and returned to the pharmacist. Staff spoke of having received medication training, records confirmed this. Resident’s medication needs were recorded in their plan of care. 385 Torbay Road DS0000017564.V306386.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): Standard 22 and 23 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place for ensuring that complaints are taken seriously and handled objectively. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints procedure. This includes required information, such as timescale for responding to complaints. There have been no recorded complaints since 2004. Records confirmed that appropriate action had been taken to investigate and resolve complaints. It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. A resident spoke of speaking to staff or family if she had a complaint or ‘concern’. The care home has appropriate policies and procedures in regard to responding to any suspicion or allegation of abuse. There is an accessible recorded whistle blowing and a counter bullying policy. There was recorded evidence that staff had received Protection of Vulnerable Adults training. Staff who spoke to the inspector were aware of reporting and recording procedures in regard to an allegation of abuse. The home should obtain a copy of the up to date Local Authority guidance in regard to safeguarding adults. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 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): Standard 24,26 and 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely and comfortable. The premises are suitable for the care home’s stated purpose. Residents bedrooms are individually personalised, meet their individual needs. The care home is very clean, and odour free. EVIDENCE: The home is a semi- detached house located in a quiet residential street in Rayners Lane, North Harrow. The home is in keeping with the other houses in the area. The home is close to a variety of amenities that include shops, restaurants, cafes and banks. Local transport facilities that include train and bus services are within a few minutes walk from the home. A resident kindly showed the inspector around her home. The home is furnished in a homely manner, with quality furniture and fittings, and was clean, airy and free from offensive odours at the time of the inspection. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 18 The garden is generally maintained, but the grass should be cut. A resident spoke of having enjoyed the garden facility in the summer. There was evidence of garden furniture. The two previous inspection requirements in regard to maintenance issues were judged as having been met. A resident kindly showed the inspector her bedroom. It included several personal items and the resident spoke of being very happy with her room. Laundry facilities are located away from food storage and food preparation areas. The home has a policy in regard to infection control. There was information displayed in the care home, which recorded appropriate procedures to minimise risk of infection. Records confirmed that a staff member had received infection control training. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 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): Standard 32,34,35 and 36 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities. Arrangements are in place to ensure that residents are supported and protected by the care home’s recruitment policy and procedures. Arrangements are in place to ensure that staff receives regular supervision. EVIDENCE: Staff who spoke to the inspector was knowledgeable and understanding of residents needs. Residents spoke positively about staff. Records and staff confirmed that staff have the skills and experience necessary for the tasks they are expected to do. Staff have knowledge and understanding of the cultural needs of the residents, and the majority of staff can speak Gujarati. Staff were heard speaking with residents in Gujarati. Records confirmed that staff are informed on a daily basis about each residents activities and plans for the day, and of the staff role and duties in ensuring that these needs are met. Staff record when they have completed a duty. Staff spoke of receiving regular staff supervision. Staff supervision records were available for inspection. Records confirmed that regular staff meetings 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 20 take place regularly, and have the opportunity to participate fully in these meetings, including in the production of the agenda. A sample of records inspected confirmed that two members of care staff had received an appraisal this year. The registered manager informed the inspector that two staff have completed NVQ level 3 in care, and that three other staff members were planning to complete NVQ level 2 in care. Another staff member is in the process of completing NVQ level 4 in management. Three staff personnel files were inspected. These incorporated required information and documentation and included an enhanced Criminal Record Bureau check. Care staff job descriptions were available for inspection. A staff member reported that she had received an induction training programme. Records confirmed that staff had received induction training. The registered manager reported that staff completed Foundation Induction training with a certified trainer. A ‘staff and development plan’, and a record of a completed staff appraisal were available for inspection. Records and staff confirmed that staff receive appropriate training. This includes ‘in house’ training using videos and questionnaires, and training from external training organisations. Recorded training included, health and safety training, moving and handling, fire training, basic first aid training, Control of Substances Hazardous to Health training. The registered manager spoke of ‘mental health’ training having been planned for staff. On the day of the inspection, all staff were receiving training in ‘breakaway techniques’ from an external training organisation. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 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): Standard 37,39 and 42 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The management approach of the care home creates an open, positive and inclusive atmosphere. The registered manager is qualified, competent and experienced to run the care home. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home, but this should continue to be further developed. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. Some lock mechanisms and incident recording procedures within the care home need review. EVIDENCE: 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 22 The registered manager/provider has worked with adults with learning disabilities for several years. She is also a trained nurse, and has completed a NVQ level 4 in management course. She managed the home for many years. The manager confirmed that she regularly up dates her knowledge and skills. The manager’s job description was available for inspection. The care home has significant information and documentation in regard to quality assurance monitoring systems. These recorded general monitoring systems of the service provided. This record should be dated and fully completed. A document that included review of systems, including policies/procedures, health and safety, physical resources, policies and procedures, residents needs, and staff training was available for inspection. A business plan dated 2006/7 was available for inspection. The registered manager reported that questionnaires in regard to views of the service had been supplied to a variety of stakeholders, and feedback from these was being audited. The manager confirmed that questionnaires for obtaining feedback from residents were being developed. This should be actioned. Residents have the opportunity to participate in regular resident meetings. Records of these meetings confirmed that issues including health, the menu, complaints and privacy were discussed. Certificates of worthiness in regard to servicing of electrical and gas safety systems in the care home were up to date. The home has an accident reporting procedure. Records are generally maintained of accidents/incidents, and of action taken in response to them. An incident recorded in a Care Manager report of an incident (5/4/06) in which a resident challenged the service was not documented in the care home’s accident/incident records. There needs to be evidence that all incidents are clearly documented appropriately by staff. It is recommended that there are documented systems in place to ensure that staff and/or residents are supported and if receive guidance following incidents, particularly in regard to behaviour from residents that might challenge the service. Routine maintenance checks of the fire systems and fire drills are recorded. The care home has a recorded fire risk assessment. The locks on the bathroom/toilet doors need to be assessed, and replaced if needed to ensure that in an emergency staff can access these areas to assist a resident if they are in difficulty. The certificate of employers liability insurance was up to date and displayed. 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 2 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 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 2 X 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 12,13,14 Requirement Timescale for action 01/02/07 2 YA6 14, 15 3 YA20 12,13(2) 17 4 YA42 12,13(4) 23 There needs to be evidence of an initial assessment of the needs of all prospective residents. 01/03/07 • A resident’s plan of care needs to be further developed to ensure that all the resident’s recorded assessed needs and goals are evident and that this information is accessible to staff. • There needs to be evidence of residents involvement (if practicable) in their care plan and it’s development, and review. There needs to be recorded 01/02/07 guidance in regard to PRN (medication to be given as required) medication, and that there is evidence of GP agreement in this administration guidance. The locks on the bathroom/toilet 01/02/07 doors need to be assessed, and replaced if needed to ensure that in an emergency staff can access these areas DS0000017564.V306386.R01.S.doc Version 5.2 385 Torbay Road Page 25 5 YA42 12,13 (4), 17,18 There needs to be evidence that all incidents are clearly documented appropriately by staff. 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA1 YA16 YA22 YA23 YA24 YA39 Good Practice Recommendations The service user guide documentation should be dated. A resident should have a key to her bedroom unless this is assessed as being of high risk. It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. The home should obtain a copy of the up to date Local Authority guidance in regard to safeguarding adults. The grass in the rear garden should be cut. • The quality assurance record should be dated and fully completed. • Questionnaires in regard to feedback about the service should be supplied to residents. It is recommended that there are documented systems in place to ensure that staff and/or residents are supported and if receive guidance following incidents, particularly in regard to behaviour from residents that might challenge the service. 7 YA42 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 26 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 385 Torbay Road DS0000017564.V306386.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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