Inspection on 23/08/07 for 4 College Road

This inspection was carried out on 23rd August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 College Road 19/06/06

4 College Road 10/02/06

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 Key Unannounced Inspection 23rd August 2007 09:05 4 College Road DS0000017436.V337863.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 4 College Road DS0000017436.V337863.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. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 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.V337863.R01.S.doc Version 5.2 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. 19th June 2006 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, kitchen and office (including sleeping in facility) situated on the ground floor. Patio doors lead from the dining area to the 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 the company also runs a day care facility in Wembley. College Road is a quiet residential turning close to Preston Hill and within reach of both bus and underground rail services and local shops. Enquiries regarding fees charged for placements should be made to the manager of the home. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? During the random inspection that was carried out on the 6th December 2006 compliance with the statutory requirements identified during the key inspection in June 2006 was checked. All the requirements had been met. It was noted that the garden at the front of the house that was being redeveloped in December had been completed. It has been planted with shrubs, a small tree and bedding plants and provided an attractive feature. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 4 College Road DS0000017436.V337863.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 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use this service experience good outcomes in this area. A comprehensive assessment of need prior to the admission of the resident assures the resident that the home is able to their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an admission procedure, although no new resident has been admitted to the home since the last inspection. The policy is that if a referral is made a representative of the company will carry out a comprehensive assessment of the needs of the prospective resident. This information would be in addition to the information provided by the funding authority, which would include a copy of their needs assessment for the prospective resident. In addition to the combined information, a programme of pre-admission visits to the home, by the resident, would be carried out so that the home is able to determine whether a service can be provided that would meet the individual needs of the resident. The content of these visits would be recorded. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People who use this service experience good outcomes in this area. Personal planning programmes have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. Each file contained a personal planning programme (ppp) that had been drawn up in November 2006, October 2006 and April 2007. The ppp identified needs in respect of education, leisure, health, behaviour and community presence. There was space to record the 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 10 comments of the resident and their relative or advocate. It included an action plan with short term, medium term and long term goals. It is recommended that the home develop a ppp in a format that is suitable for the needs of the residents. A six month review had taken place for the ppp’s drawn up in 2006 in May 2007 and April 2207. Two of the residents had a review of the placement with the funding authority within the last 12 months and a copy of the minutes was on file. The third resident had a meeting with the reviewing officer in May 2007 and the possibility of semi-independent living was discussed. Case files also contained a copy of recent positive behaviour assessment, which included an identification of triggers for unacceptable behaviour and prevention strategies etc. They also contained an individual care plan. One of the residents leads quite an independent lifestyle and he confirmed that he worked part time and went out on his own. The other 2 residents are able to make decisions but may have difficulties in making their wishes known. The manager said that residents have their own way of saying yes or no and that the staff team are able to understand these and to support residents. She said that only staff that are familiar with the residents are asked to cover a shift in the home. The manager has made referrals to Brent Advocacy Service on behalf of the residents. The manager is the appointee for each of the 3 residents and one resident uses his bankcard independently. Records are kept of the daily transactions for the other 2 residents. Record books were up to date with details of expenditure, receipts and the balance remaining. A discussion took place with the member of staff 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. She said that residents decide whether to take part in activities and will say “no” if they chose not to. At the weekend residents may want to do different things i.e. one resident may wish to go out while one resident prefers to stay at home. Where possible the resident wishing to go out may be able to join in an outing organised at another of the SFI’s care homes, provided there are sufficient staff on duty in the other care home, or the manager may take the resident out on an individual basis. The resident who has part time employment confirmed that he leads an independent life and comes and goes as he pleases. He is supported with managing his finances although he goes to the bank and withdraws an amount of his choice. Previously the manager has made a referral to Brent Advocacy Services on behalf of the residents. Copies of risk assessments were included in the case file and these included topics such as absconding, cooking, mobility, road safety, sexual awareness, shaving, bathing and the danger of coming into contact with sharp objects. Risk management forms were dated 2007 and identified the hazard, the likelihood, the severity of the hazard, the risk score, the risk provoking factors 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 11 and the action to be taken to reduce the risk. They were subject to an annual review. 4 College Road DS0000017436.V337863.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 People who use this service experience good outcomes in this area. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 13 Each resident has a programme of activities. One resident goes to a day centre in Harrow, although on a Wednesday they join residents from the Pettsgrove day centre and take part in the weekly outing. The second resident attends Pettsgrove day centre on a daily basis. The third resident said that they had left college but were still continuing with their part time employment. The manager said that residents have literacy and numeracy sessions at the day centre and also cooking, music and pottery sessions. A resident said that they felt good; they had been to the day centre and had enjoyed having a cigarette and a chat. Residents use facilities and resources in the community including shops, pubs, parks, leisure centres, the library, church and cinemas. The home has its own transport (a 17 seater minibus) and during the inspection the deputy manager of the home arrived to take the two residents to their individual day centres. The names of all residents are entered on the electoral roll and they vote, if they wish. One of the residents went on holiday to Florida in 2006 and he said that he is hoping to go there again this year. The manager said that they are hoping to book a holiday in the UK for the other 2 residents, although to a different location from last year. A barbecue took place on the Saturday and a time for returning to the home was agreed with the residents. A resident said that it had been “good”. He said that it had been his birthday recently and that he had been to the pub for a meal and drinks. He said that he went for a walk on Saturday and that he had been to the park and had an ice cream on one of the Wednesday outings. The manager said that other outings had been to Brighton, Battersea Park and to the zoo. Residents also went to clubs. One of the residents has a family that they keep in contact with and they visit their family on a regular basis or their family members come to visit them at College Road. The resident previously confirmed 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. Residents are able to decide if they want to spend time in their room or whether they want to socialise with other residents in the lounge. The home has a no-smoking policy within the house and if residents wish to smoke they must go into the garden. It was noted during the inspection that this was respected. One of the residents chose the ingredients for a packed lunch and helped to prepare this. Residents take part in the daily routines in the home and they put their dirty washing in their laundry basket and load these into the washing machine. It was noted that one of the residents helps to set the table for the evening meal and that residents took their plates into the kitchen after finishing a meal. Two of the residents that are able to make a cup of tea will make a cup for themselves and for others. Residents have a key to their bedroom, if they wish. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 14 During the first visit residents were having breakfast. Although porridge was on the menu a resident had requested a cooked breakfast and this was served. The home has a menu cycle and week 3 was on display. The menu was varied and included choice. An African-Caribbean resident confirmed that AfricanCaribbean foods were prepared for him and mentioned fried chicken and rice and peas. The member of staff on duty confirmed that alternatives were served if a resident wished and that the cultural needs of residents were respected. She explained how the menus were adapted for a diabetic resident. The packed lunch prepared for a resident consisted of a cheese sandwich, low fat yoghurt and piece of fruit. During the evening visit the member of staff was preparing either cottage pie or chicken with potatoes, cabbage and carrots. Records are kept of what each resident consumes on a daily basis and these were available for inspection. Staff have received food hygiene training. Another resident said that the food was good and pointed to the member of staff and said that she was a good cook. Residents are able to help themselves from a large bowl of fruit on the dining room table. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use this service experience good outcomes in this area. Residents receive assistance with or prompting with personal care in a manner, which respects their dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was noted during the inspection that all residents were clean and tidy and were smartly dressed. One of the residents likes to wear a jacket or a suit and after dry cleaning these are kept in a wardrobe in the office and the resident chooses which to wear next. He likes to lay clothes out in the evening for wearing the following morning. Prompting and encouragement or direct assistance is provided to residents for their personal care needs although the level of support varies. A resident signalled that he had a shower and a hair wash in the morning and pointed to the member of staff to say that she had 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 16 helped him. Independence is encouraged and the member of staff said that if she did the first button on one of the resident’s shirts the resident would do the rest. Routines are more flexible in the home at weekends and a resident said that they liked having a lie in at the weekend. There was evidence on the case files of access to health care services in the community including regular appointments with the dentist, podiatrist, chiropodist, optician and the GP. Residents had the opportunity to have a flu jab, if they wished. There was also access to routine screening e.g. blood tests. Residents were escorted to out patient appointments at the hospital. The storage of medication was safe and secure. None of the residents are selfmedicating and each resident has an individual dosette box, filled by the pharmacist. The empty compartments corresponded with the day of the week and the time of day that the boxes were examined. The member of staff discussed a recent reduction in the dosage prescribed for a medication taken by one of the residents and of the need to monitor the resident for any changes in behaviour. The record book for the administration of medication included a copy of the medication policy and this had been reviewed on the 1st July 2007. All the record sheets had been initialled and were up to date and complete. Staff administering medication have received training. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use this service experience good outcomes in this area. 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. This judgement has been made using available evidence including a visit to this service. 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. One of the residents is unable to speak and the manager was previously asked how the resident signified their concern or distress. The manager said that if the resident was not happy about something the resident would not have eye contact. The member of staff on duty was also familiar with the ways that the resident communicated concern or distress. 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, for each placing authority, in the event of abuse. There was evidence that staff have received training in protection of vulnerable adults procedures. The manager said that no allegations or incidents of abuse have 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 18 been recorded since the last inspection. Previously staff have also undertaken understanding aggression and challenging behaviour training courses arranged by a local authority. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People who use this service experience good outcomes in this area. Residents enjoy a comfortable and homely environment with pleasant communal facilities although the carpet on the stairs and landing is in need of replacement. Single bedrooms assure the residents of privacy. Residents live in a home where standards of cleanliness are good and where bathing and toilet facilities are appropriately placed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit was carried out. It was noted that the property was in a good state of repair and decorated and furnished in a “homely” manner. The stair and landing carpet is showing signs of wear and needs replacing. During the inspection visits residents spent time relaxing in the lounge areas. Residents have their own single bedroom and there are bathing and toilet facilities on both the first and ground floors. One of the 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 20 residents said that he likes his room upstairs and that it is “big”. The building was bright and airy and ventilation was appropriate for the time of year. Local shops and amenities, including transport routes, are within walking distance and a resident said that it is in a convenient location. The outside of the home is in keeping with its neighbours and the redesigned front garden provides an attractive façade. The current layout of the home, with residents’ bedrooms on the first floor, would make the home unsuitable for wheelchair users. At the moment all 3 residents are fully mobile but it is recommended that the home prepare a plan taking into account future needs of residents in the event of deterioration in their mobility. During the site inspection it was noted that all parts of the home are clean and tidy and free from offensive odours. Staff undertake training in respect of infection control procedures. As this is a care home for 3 residents the laundry facilities are accommodated in the kitchen. The manager confirmed that the home does not service incontinent laundry. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 People who use this service experience good outcomes in this area. NVQ training enhances the quality of care provided to residents and the home has now met the target of 50 of its carers having achieved an NVQ level 2 or 3 qualification. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents. Residents benefit from support given by carers that are skilled and trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion took place with the manager regarding the percentage of staff working in the care home that have achieved an NVQ level 2 or 3 qualification. A description of the qualifications obtained by each of the members of staff listed on the rota was given and the home demonstrated that it continued to meet the target of a minimum of 50 of carers achieving an NVQ level 2 or 3 qualification. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 22 Although residents leave the home during the day to go to their day centres, or to go out or to go to work there is always at least one member of staff on duty when residents are present in the home, day and night. This is sufficient for the current needs of the existing residents. At the weekend the manager may take one of the residents out so that other residents are able to take part in other activities, according to their choice. The mangers hours were recorded on the rota and consisted of 9 am to 5 pm Wednesday, Thursday and Friday. Some of these hours are worked at the head office at Pettsgrove Ave, where 1 of the residents attends the day centre and another resident helps out at the day centre. However the recorded hours total 24 for the week and this is below the minimum expectation of 35 hours per week. It was noted that there was a good rapport between the member of staff on duty and the residents and between the residents and the manager. The residents benefit from continuity of care from people working in the home that they know well, some for many years. Staff are able to communicate with residents and they demonstrated that they were able to understand and to respond to the needs of a resident that is unable to communicate verbally. The member of staff on duty said that she has undertaken Makaton training. She confirmed that regular staff meetings take place. Three staff files were examined. It was noted that each contained an application form, 2 satisfactory references, proof of identity (passport details), an enhanced CRB disclosure, a pova first check for the 2 most recently recruited members of staff and proof of right to work or to reside (where necessary). There was evidence that induction training is provided to new members of staff during their first 6 weeks of employment. Staff files contain a record of training courses attended and where possible the attendance certificates. There was evidence of training in safe working practice topics, medication, protection of vulnerable adults procedures and understanding challenging behaviour. In house training is also given during staff meetings that take place on a regular basis. A copy of the training plan for the whole of the company’s staff team was provided and a copy of the training plan for 2007, with costings. The plan linked training to business objectives. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use this service experience good outcomes in this area. Continuing to undertake further training enables the manager to develop her knowledge, skills and understanding and to provide a service that is responsive to the needs of residents. Information is being gained through the quality assurance systems to shape the future development of the service and ensure that the changing needs of residents are met. Training for staff in safe working practice topics promotes the health and safety of residents, staff and visitors to the home. Certificates for the checking/servicing of equipment and systems in the home need to be available if the home is to demonstrate that they continue to be safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 24 The manager has completed her NVQ level 4 management training. She has managed the home for over 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 a seminar in respect of adults with learning disabilities and the prevention of abuse. 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 or during discussions with managers. The home also receives verbal feedback from doctors, nurses, the hospital, the dentist, optician and staff in the day centre. The company has now developed a satisfaction questionnaire for relatives, professionals in contact with residents, placing authorities and one for residents, which is user friendly. The manager said that these have been distributed and it is planned to use the information obtained in a development plan. The staff questionnaire has already been distributed and the completed questionnaires were available. It was noted that the areas of training and supervision scored highly. The policies and procedures file has been recently revised and updated and was available for reference. There was evidence that staff have received training in safe working practice topics. There were valid certificates for the servicing/testing of the fire alarms & emergency lighting and the electrical installation. The appointment for carrying out the Landlord’s Gas Safety check had to be changed and the new one is set for September. The certificate for the testing of the portable electrical appliances was not available. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 16(2) Requirement Timescale for action 01/04/08 2 YA33 3 YA42 The registered person must ensure that the carpet on the stairs and landing is replaced so that good standards are maintained for the fixtures and fittings in the home. 17(2)S4(6) The registered manager must ensure that a minimum of 35 hours per week are recorded for her on the rota to demonstrate that staff and residents have the opportunity to benefit from her guidance, support and supervision. 13(4) The registered must ensure that the certificates for the checking/servicing of the systems and equipment in use in the home are valid and available to demonstrate safety in the home. 01/10/07 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 27 No. 1 2 3 Refer to Standard YA6 YA24 YA42 Good Practice Recommendations That the home develops a personal planning programme in a format that is suitable for the needs of the residents. That the home prepares a plan, which takes into account future needs of residents in the event of deterioration in their mobility. That the home forwards a copy of the Landlord’s Gas Safety Record and the certificate for the testing of the portable electrical appliances to the Commission for Social Care Inspection. 4 College Road DS0000017436.V337863.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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