Inspection on 10/02/06 for 4 College Road

This inspection was carried out on 10th February 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 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.

Other inspections for this house

4 College Road 23/08/07

4 College Road 19/06/06

4 College Road 04/11/05

4 College Road 22/07/05

4 College Road 31/01/05

4 College Road 05/04/04

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 4 College Road Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL Lead Inspector Julie Schofield Unannounced Inspection 10th February 2006 08:00 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 4 College Road Address Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL 020 8908 6894 020 8900 9633 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) Striving For Independence Group Homes Mrs Dorothy Pinnock Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation agreed for one named individual (MH) aged 65 years for the duration of his stay, subject to regular reviews. 4th November 2005 Date of last inspection Brief Description of the Service: This home is one of a group of 3 homes, in Brent and in Harrow, which are owned by the proprietors company (SFI - Striving for Independence). This care home provides a service for 3 adults with learning disabilities. At the time of the inspection there were no vacancies. The house is semi-detached and the property consists of two floors. The service users bedrooms are situated on the first floor, with bathing and toilet facilities on both floors. There is an open plan dining area and lounge and there is a lovely garden at the rear of the property. The proprietor is also the registered Care Manager. There is a close connection between the homes in the group and one resident from College Road attends the day centre, which is in the grounds of the other home in Wembley. Another resident works in this day centre on a part time basis. Residents from each of the homes are able to take part in joint activities arranged by the company that take place on a Wednesday and at weekends. College Road is a quiet residential turning close to Preston Hill and within reach of both bus and underground services. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started on a Friday morning in February 2006. Two Inspectors carried out the inspection in the home and this included discussions, an examination of records and a partial site inspection. It continued with an examination of records that were held at head office. The inspection started at College Road at 8.00am and finished at the company’s head office at 3.15pm. The Inspectors would like to thank the manager, carer and residents who took part in the inspection. What the service does well: What has improved since the last inspection? An inspection took place in November 2006 and a number of statutory requirements were identified. Compliance has been achieved in the following areas. Care is taken to ensure that money belonging to a resident is kept in 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 6 their named locked tin. The residents’ savings account books are available for inspection. There is a record in the home of the total number of hours worked per week by each member of staff (including hours worked in the company’s other care homes). There was evidence that the home has obtained or is obtaining the necessary documents to ensure that staff files are complete and contain a satisfactory enhanced CRB disclosure, 2 references, proof of ID and confirmation of right to work, if required. The carer on duty demonstrated her knowledge of policies and procedures and made links between a key policy and her care practice. 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. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No new residents have been admitted to the home for approximately 10 years. EVIDENCE: 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The needs of the resident are identified and addressed in the care plan. Regular reviews of the care plan and placement determine whether the care home continues to be able to meet the individual needs of the resident. Minutes of the review meeting convened by the placing authority had not been placed on a resident’s file. Minutes provide a point of reference for staff; enable the manager to monitor the achievements of the resident and to inform the resident of their progress in meeting goals and targets. Offering a resident choice encourages and supports the resident to develop their independent living skills. Staff support residents to take responsible risks so that residents can develop an independent lifestyle. The risk assessments for areas where the need for support is identified must be reviewed on a regular basis so that they reflect the current dependency level of the resident. EVIDENCE: Two case files were examined during the inspection. It was noted that each contained a comprehensive care plan and that these had been subject to 6 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 10 monthly reviews by the home. On one file the minutes of the meetings convened by the placing authority were absent. A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that care is taken to ensure that money belonging to a resident is kept in their named locked tin. During the inspection the tins belonging to the residents were seen and it was noted that the money inside the tin was the money belonging to that resident. This statutory requirement is now met. A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that savings account books are available for inspection. During the inspection the savings books of each of the 3 residents were seen. This statutory requirement is now met. It was noted and discussed with the manager that the full cost of holidays that the resident had taken part in had not always been deducted from the resident’s savings as there were insufficient funds. It is recommended that the choice of holiday venue is appropriate in terms of the money that the resident is able to save. A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that residents’ contributions towards their fees be collected so that the savings books contained only money belonging to the resident. This statutory requirement is now met. The manager said that the contributions would be collected by direct debit from April 2006 onwards. A discussion took place regarding the residents right to choose and to make decisions about their day-to- day life. Although one resident is able to make choices it is more difficult for the other 2 residents to always make their wishes known. The manager has made a referral to Brent Advocacy Services on their behalf. The resident who is able to confidently make choices gave examples of these to the Inspectors e.g. going out to do some clothes shopping before their holiday and deciding what to buy, what money to spend and what shops to visit. A statutory requirement was identified during an inspection that took place in July 2005. It stated that there is a record of the review of risk assessments included in the residents case file. It was noted that one case file included risk assessments dated 22.3.03. This statutory requirement remains unmet. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Residents have access to day centres and to employment and this provides them with opportunities to develop their social and independent living skills. Residents are able to use facilities in the community and to fulfil their civic duties. The residents’ quality of life is promoted by the provision of an annual holiday and by attending clubs and taking part in outings they have the opportunity to develop and maintain a stimulating and enjoyable lifestyle. The support of staff enables residents to maintain contact with their families so that residents can enjoy fulfilling relationships. Residents’ rights are respected and involvement in daily routines encourages residents to develop a sense of “home”. Residents have a varied and balanced diet, with dishes to satisfy cultural needs, which contributes towards their wellbeing. EVIDENCE: One of the residents said that they continue to attend college on 2 days per week and that they are taking courses in English, Maths and computer studies. They work part time on 3 days per week and have the assistance of a support worker at the Job Search Centre. The other 2 residents attend day centres Mondays to Fridays. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 12 The manager said that residents go out for a drink or for a meal to local pubs and restaurants and a resident named the pub, which was a favourite as “the food was good”. One of the residents goes to church on a weekly basis. Residents go out shopping or go out for a walk on a daily basis. If residents need transport when they go out they use a taxi, dial-a-ride or the company’s mini bus, which has 17 seats. Residents vote at elections. One of the residents told the Inspectors that he was going on a holiday to Florida, before the end of the month, which was being arranged by SFI. The manager said that the other residents were going on a holiday to Centre Parcs in April. A resident confirmed that he enjoyed annual holidays, arranged by the company. Residents have the opportunity to attend the Apple club and to go on outings arranged by the home/company. One of the residents has a family that they keep in contact with and they confirmed that they visit their family at the weekend of that family members come to visit them at College Road. The resident said that their family members are made welcome by the member of staff on duty and that the visit can take place in the privacy of their room, if they wish. It was observed during the inspection that daily routines were flexible in that residents were having breakfast at a time suitable for being ready to go to work or to the day centre. Residents had the use of the communal areas inside the home and the grounds and it was noted that residents went into the garden when they wished to smoke. Residents are able to choose to spend time in their rooms if they wish to be alone and this is respected. The member of staff on duty knocked on the bedroom door and called out when they were taking a resident a cup of tea in bed. It was observed that there was a good rapport between residents and the member of staff on duty and between residents and the manager. Residents are encouraged to take their plates into the kitchen when they have finished a meal, help to lay the table, make a cup of tea for themselves and for the other residents etc. During the inspection breakfast was prepared and served. The meal included fresh fruit. One resident is able to prepare his own breakfast. The menus were examined. There is a 4-week cycle. Each day there is a choice of main course and a choice of dessert on the menu. The menu also includes AfricanCaribbean foods to meet the cultural needs of one of the residents. One of the residents is diabetic and the member of staff said that he receives more vegetables and less starchy foods. Sugar free alternatives are given e.g. drinks. Before the preparation of the meal the member of staff is advised to check with the residents whether any changes to the menu are needed. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Residents receive assistance with or prompting with personal care in a manner, which respects their dignity. Residents are supported by staff to take their medication, at the times directed and in the doses prescribed by their GP, in order to promote their general health. Standard 19 was inspected during a previous inspection in July 2005. EVIDENCE: The assistance given to residents with personal care varies from prompting to direct support. When direct care is given, this in private. It was noted that residents were smartly dressed and one resident enjoys wearing a jacket each day and showed the Inspectors his suits. Before residents leave the home the carer discreetly checks that residents are appropriately dressed according to the weather. Residents also visit the hairdressers and have had a haircut recently. In the past residents have received help, as necessary, from speech therapists, occupational therapists etc. None of the residents self medicate. The storage of medication was inspected and was safe. Medication is delivered to the home in dosette boxes. These had been appropriately dispensed prior to the inspection and the records of the administration of medication to residents were up to date and complete. It was noted that when medication was given to the resident, a drink was also 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 14 offered. The medication policy was amended after the introduction of the weekly dosette box system. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The rights of residents are protected by a clear and simple complaints procedure. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: A clear complaints procedure is in place, which includes timescales for each stage of the process and refers complainants to other agencies e.g. the CSCI. Records are kept of complaints made. The manager said that no complaints have been recorded since the last inspection. She also said that matters are resolved at an early stage, before developing into a complaint. A resident said that if there was anything that they had concerns over they would speak to the manager. A protection of vulnerable adults policy is in place, which includes a whistle blowing procedure. The home has a copy of the local authority interagency guidelines in the event of abuse. Staff have received protection of vulnerable adults training. The manager said that no allegations or incidents of abuse have been recorded since the last inspection. Staff have also undertaken understanding aggression and challenging behaviour training courses arranged by a local authority. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 A comfortable and “homely” environment provides residents with an enjoyable place in which to live and a maintenance programme for the property keeps it safe and in a good state of repair. The clean and hygienic environment promotes the health and safety of residents. EVIDENCE: There is level access to the home and the property is well maintained. It is furnished and decorated in a “homely” manner. The premises are bright and airy and although it was a cold day the heating in the home made it feel warm and comfortable. The property is in keeping with its neighbours and provides residents with easy access to transport links and local facilities. There is a CCTV camera, which has been installed in the hallway and it covers the front door. It is not operational yet. There is also a clock with a swipe card system for staff to use when starting and finishing work. The parts of the home that were inspected were clean and tidy and free from any offensive odours. The home has an infection control policy and staff have received training on infection control procedures. Laundry facilities are situated in the kitchen. The home does not service incontinent laundry. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 NVQ training enhances the quality of care provided to residents and the home needs to ensure that staff undertake and complete this. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. The training programme for members of staff is developed to enable staff to meet the objectives contained in the Statement of Purpose and to respond to the individual and changing needs of residents. Individual supervision sessions enhance the overall support available to staff and are an opportunity to discuss working practices and to encourage personal development. In order to maintain their effectiveness the home must ensure that they take place on a regular basis. Staff appraisals identify the skills and abilities of the member of staff and where training is needed. In order to maintain their effectiveness the home must ensure that they take place on a regular basis. EVIDENCE: A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that 50 of carers achieve an NVQ level 2 qualification. The timescale for compliance has now been extended. The manager said that the deputy manager has completed an NVQ level 3 qualification and that the majority of the carers are currently undertaking an NVQ level 2 qualification. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 18 A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that the total number of hours worked per week by a member of staff is available in the home. Some members of staff working for the company work in more than one of the company’s care homes. During the inspection the manager showed the Inspectors a copy of the rota for each of the company’s care homes to demonstrate the total number of hours worked per week by each member of staff. This statutory requirement is now met. The rota was examined for week commencing 6th February 2006. There is one member of staff on duty at all times residents are in the home. At night the member of staff is asleep, but on call. A statutory requirement was identified during the previous inspection that took place in November 2005. It stated that staff files must contain an enhanced CRB disclosure, 2 satisfactory references, proof of ID and confirmation of the right to work, if required. There was evidence that the home has obtained or is in the process of obtaining these documents. The statutory requirement is now met. There is a company training plan and the home has an induction training programme for new staff, which is based on the TOPSS and Croner’s models. It is a 6-week programme. Some staff have attended a disability awareness course arranged by the local authority and the company has run an in-house equal opportunities course. Staff appraisals include an identification of training needs. The manager who carries out in-house training has completed a course in delivering training. The manager said that the supervision of the carers is a shared management responsibility. A manager from one of the other SFI homes supervises the deputy at College Road and the deputy supervises the carers. There was a certificate on the deputy manager’s personnel file confirming that he has undertaken training in supervision and appraisal skills. The individual supervision sessions are in addition to the day-to-day supervision and support given. However the personnel files of 3 staff working in the home did not provide evidence that individual supervision sessions are held at least every 2 months and the date of the last minutes were either 6/05 or 9/05. Team meetings take place on a monthly basis and staff are given a copy of the staff handbook, which includes details of the grievance and disciplinary procedure. Staff appraisals are carried out although 2 files contained appraisals that had been carried out in December 2004. . 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 19 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 The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Quality assurance systems, including both verbal and written feedback, need to be in place to gather feedback on the quality of the service provided and to assist in the development of the service. Policies and procedures are in place to promote and to protect the rights, welfare and safety of residents and staff are made aware of these. Standard 42 was inspected during a previous inspection in July 2005. EVIDENCE: The manager has completed her NVQ level 4 management training. She has managed the home for approximately 10 years. She has continued to undertake periodic training to update her skills and knowledge and said that since the last inspection she has attended seminars in respect of the provision of care. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 20 At present verbal feedback about the quality of care in the home is obtained from residents, either during meetings, or at their reviews or on a one to one basis. Verbal feedback is obtained from relatives when they visit the home or attend a social event arranged by SFI. Verbal feedback is obtained from staff during meetings, discussions with managers or in supervision. The home also receives verbal feedback from doctors, nurses, the hospital, the dentist, optician and staff in the day centre. There is a need for written feedback to be obtained and for this information to be used to plan the development of the service. It is recommended that a questionnaire could be supplemented by a question during the review meeting where the responses could be recorded in the minutes or that the questionnaires could be distributed at the end of the review meeting. A statutory requirement was identified during the inspection that took place in November 2005. It stated that staff be familiar with the content and detail of key policies and procedures in the home. The statutory requirement is now met. A discussion took place with the member of staff on duty and they were able to demonstrate knowledge of the medication policy and to relate this to working practices. The manager said that knowledge of policies and procedures forms part of the induction training and that these were also discussed at staff meetings. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 X 2 X 3 X X 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 22 YES 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 YA6 Regulation 15.2 Timescale for action That a copy of the minutes of the 01/07/06 placement review meetings convened by the placing authority is kept on the case file. That there is a record of the 01/05/06 review of risk assessments included in the residents case file. (Previous timescale of 01/12/05 has not been met). That 50 of staff achieve an NVQ level 2 or 3 qualification. 01/07/06 01/06/06 Requirement 2 YA9 13.4 3 4 YA32 YA36 18.1 18.2 5 6 YA36 YA39 That individual staff supervision sessions are recorded, carried out at least every 2 months and a copy of the minutes of the session are kept on the staff file. 12.5 That staff appraisals are carried out on an annual basis. 24.1&24.3 That written feedback regarding the quality of care provided in the home is obtained from relatives of the residents and from the placing authority etc. That this information is collated and used to help plan the development of the service. 01/06/06 01/07/06 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 23 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 Refer to Standard YA7 YA39 YA39 Good Practice Recommendations That the venue for an annual holiday takes into account the level of savings of the resident. That a question regarding the quality of care provided in the home is part of the review meeting and that the responses of those present is recorded in the minutes. That quality assurance questionnaires are distributed at the end of the review meeting. 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 24 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 4 College Road DS0000017436.V280571.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!