Inspection on 08/12/06 for 4a Ash Street

This inspection was carried out on 8th December 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4a Ash Street 14/10/08

4a Ash Street 15/11/07

4a Ash Street 06/06/07

4a Ash Street 06/12/05

4a Ash Street 26/07/05

4a Ash Street 29/11/04

4a Ash Street 29/06/04

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Dovedale Court

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

CARE HOME ADULTS 18-65 Ash Street (4a) 4a Ash Street Ash Nr Aldershot Hampshire GU12 6LT Lead Inspector Suzanne Magnier Key Unannounced Inspection 8th December 2006 13:00 Ash Street (4a) DS0000013508.V305136.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 Ash Street (4a) DS0000013508.V305136.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. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Street (4a) Address 4a Ash Street Ash Nr Aldershot Hampshire GU12 6LT 01252 350582 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) www.new-support.org.uk New Support Options Limited Miss Clare Twomey Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service users may have both learning and physical disabilities The age/age range of the persons to be accommodated will be: 40 65 Years of age, with one service user over the age of 65 years. 6th December 2005 Date of last inspection Brief Description of the Service: 4a Ash Street is a modern bungalow situated just off the main road on the outskirts of Ash Village. Windsor Housing Association owns the premises and the service is provided and managed by a not-for-profit organisation, New Support Options Ltd. Accommodation and personal care is provided for up to five residents who have both physical and learning disabilities. Each resident has a single room and there is also a kitchen, dining room, living room, sensory room and laundry. There is parking available at the end of the drive next to the home. The current weekly fees are £1,320-23-£1,331.31 Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours and was conducted in part with a visiting New Support Options Area Manager and staff on duty. The inspector met with all the supported people and members of staff covering two shifts. For the purpose of the report the staff told the inspector that that the people who live in the home are referred to as supported people. Comments from cards received by the Commission for Social Care Inspection (CSCI) regarding the operation of the home have been included in the report. The home currently supports four people who have very complex needs and do not use formal speech to communicate. The environment can be noisy with people communicating in their own way, which could be viewed as testing, and who need specific understanding of their individual needs. Due to the complexity of the of the lifestyles and needs for the people supported the inspector observed staff interaction with the people being supported noting communication through tone, eye contact, support interactions and other body language. The inspector wishes to thank the supported people and for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection? The home has made improvements in further developing the supported peoples person centred plans, which has promoted the individuals participation in meaningful activities. Improved information regarding the supported person or their representatives wishes regarding their final affairs have been more fully developed. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 6 Three new staff have been recruited offering a stable and consistent approach to the needs of the supported people. 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. Ash Street (4a) DS0000013508.V305136.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 Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Supported people have sufficient information, are given the opportunity to visit the home in order to make an informed choice if they would like to live in the home. EVIDENCE: The homes Statement of Purpose was seen by the inspector and has been updated since the previous inspection. The home is supporting four individuals and has one vacancy. The home has a pre assessment procedure and policy, which makes sure that prospective supported peoples needs are assessed prior to moving into the home. One staff member told the inspector that people would visit the home prior to moving in so they can see what it is like and if they would be happy and could get on with the other people in the home. Ash Street (4a) DS0000013508.V305136.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The person centred plans and risk assessments were current, well documented and recorded to ensure the supported persons wellbeing and health needs were evidenced as being met. Improvements must be made regarding the storage of individual’s information in order to promote dignity, respect and privacy. EVIDENCE: The inspector sampled two supported peoples person centred care plans. The plans and risk assessments included a variety of documents to illustrate the support needs for the individuals. These consisted of communication skills, likes and dislikes, personal care guidelines including safe bathing guidelines, use of the hoist, continence management, use of bed rails, support with dressing, guidelines to ensure dignity and respect. The plans and risk assessments also included the individual’s preferences and safety regarding eating and drinking, dietary needs and additional precautions against choking. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 10 The inspector noted that all care plan folders contained a number and staff have signed to evidence that they have read the care plan. The care plans sampled reflected the current care being provided to the person. It was noted that individual supported people’s epilepsy charts were selo taped onto the front of the medication cabinet in the homes office. The inspector questioned this practice with the area manager and staff. One staff member advised that they need not be displayed as the handover form asks the question if all events have been recorded appropriately in the supported persons care plan. It is required that each individual’s personal information is removed from the front of the medication cabinet in order to promote the individuals right to privacy, dignity and confidentiality. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 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): 12,13,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promotes and maintains supported peoples involvement in their community, and be involved in the running of the home and improving daily living skills. The menus and choice of food provided were of a good standard. EVIDENCE: All the supported people have complex needs and use a variety of aids including adapted wheelchairs and specialised seating. The inspector was advised that the home had improved in supporting people to take part in a variety of activities which includes going to the local newsagents to get the paper or magazines, listening to music, making sweets, hand massages, singing, attendance at a drama group, listening to the football on the radio, going out for day trips and enjoying the garden. The inspector noted that guidelines were in place within the supported persons care plans for support with physiotherapy passive movements, use of the Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 12 hydrotherapy pool and guidelines, moving and handling assessments, comfortable and safe seating guidelines, use of the homes transport and use of the individual’s wheelchair. The staff use objects of reference to assist the supported individual to understand their daily routines. One person’s goal set out in their person centred plan was to listen to a newspaper tape. Others goals included continued community outings and hydrotherapy; use of the light box and use of bean bag. The kitchen of the home is an open plan style, which enables the supported person to be in safe proximity whilst the staff members prepare the meals. This proximity affords the person to be involved in the sensory experience of the mealtime and the active engagement in the home. The service have pictorial menus for the supported people to use. A menu was displayed on a board in the dining area and also on the fridge door. The inspector arrived just after lunch and noted that there was sufficient staff to support the people at lunchtime. Staff cooked the evening meal. Crockery and equipment for people at meals times was available and suitable to meet the person’s needs. The inspector noted that all food in the fridges was stored in compliance with food safety guidelines. The atmosphere in the home was calm and friendly. The supported people were supported after lunch to sit in their bedroom or the lounge and have a change of position from their wheelchairs and listen to music or have a snooze. The afternoon staff supported the people up and had an afternoon snack of a cup of tea of fruit juice. One member of staff read to all the supported people in the afternoon. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 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): 18,19,20,21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that supported people attend health care appointments. The homes medication procedures are robust to ensure the safety and wellbeing of the supported people and staff. Improvements have been made to seek the views of supported people and their representatives regarding their final affairs. EVIDENCE: The inspector observed that the staff spoke respectfully and offered privacy and dignity to the supported people. It was observed that staff knocked on people’s doors before entering their bedroom and one staff member advised the supported people that an inspector would be looking at their notes. The staff explained that all supported people require maximum support from staff regarding their personal care needs. The care plans sampled by the inspector evidenced a full health history of the supported people. Clear records evidenced attendance at appointments for health care checks. Records indicated that all supported people were registered with a General Practitioner. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 14 The inspector sampled daily records, which evidenced a clear and consistent way of supporting individuals, and included a night log for the waking night staff, which was also well documented. Comments received from health care professionals included ‘the residents are impeccably cared for by very caring, professional staff.’ ‘An excellent home.’ ‘This house (manager and staff) can be trusted to contact me when there are problems or a need to update movements and procedures. All staff know the residents well and I’m never told ‘Oh you’ll have to wait till X comes back from annual leave or whatever’. The inspector noted that documents within the supported persons person centred plans contained improved information regarding the supported person or their representative’s wishes regarding their final affairs. The inspector observed two staff undertaking the medication following the lunchtime. The staff supported the person in their wheelchair to the office and explained that they were due their medication. The medication was administered safely and in a dignified manner. The medication administration chart was completed following the administration. Staff were observed to be vigilant in checking that the supported person had taken their medication. The home has included a written brief description of how the person prefers to take their medication for example with milk or squash. One staff member advised that there had been occasional difficulty with the prescriptions from the health centre and staff are very vigilant to check all prescriptions are accurate. The inspector sampled the MARS sheets and the stock medication, which had been recorded accurately. The home have developed a document which details the medication and significant details of the supported person should the person be admitted to hospital in order that the hospital staff have an understanding of the persons needs with regard to medication and life events. No supported people currently within the home self medicate. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to demonstrate that complaints will be acted upon and a Safeguarding Adults (Adult Protection) policy and procedure in order that supported people are adequately protected by the same policy and procedure. EVIDENCE: The home has a complaints procedure, which clearly documents the process that a complainant should take if they need to make a complaint. There has been one complaint, which was promptly acted upon and satisfactorily concluded. There have been no safeguarding adult referrals. The inspector sampled that the home has the Surrey Multi Agency Procedures dated 2005. The homes induction incorporates the safeguarding adults training and what constitutes abuse. The inspector sampled the homes whistle blowing policy. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 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): 24,25,26,27,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a homely and comfortable environment. Supported peoples bedrooms and bathrooms promote individuality and independence. Specialist equipment is available and maintained. Improvements have been required regarding the maintenance of cleanliness, control of infection and repairs in the home. EVIDENCE: The home offers a comfortable, spacious environment and includes the use of the homes sensory room. Improvements from the previous inspection include the redecoration of the lounge and a new carpet and the purchase of more visual items such as mirrors and lava lamps. Peoples bedrooms were well decorated, personalised and contained personal affects, framed pictures, photos, leisure items, clocks, adequate furniture and profiling beds. One carpet in a supported persons bedroom had a frayed seam where two pieces of carpet were joined and could potentially be a trip hazard and must be replaced or repaired. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 17 During the tour of the premises the inspector noted that the office carpet, and main corridor carpet were heavily soiled and in need of replacement in order to ensure safety and hygiene in the home. The bathrooms and toilets in the home were fitted with specialised baths, and overhead hoists. The inspector discussed at length the practice of leaving the large bathing mats on the bathroom floor when the staff are sterilising the bath. The staff explained the difficulty of storing the mats when cleaning the bath, as the mats must not be bent as the material cracks and as a result the floor was the only place they could be placed. Water damage to a ledge in the bathroom where the mats rest was noted and also at the back of the bath. A requirement has been made that these areas are redecorated and alternative measures are put in place regarding the storage of the mats when the bath is being sterilised in order to prevent infection, toxic conditions and the spread of infection ion the care home. The use of signs in the bathroom regarding the use of the bath and how to clean the bath were noted. In addition signs regarding water temperatures were in place. It has been recommended that the use of signs be reviewed in order to reflect a more homely atmosphere in the bathrooms. The inspector noted that in the small bathroom a significant number of tiles were loose and bowed. This was noted as a significant potential hazard and a requirement has been made that the tiles are refitted promptly in order to ensure the safety of all persons using the bathroom. The staff at the home during the inspection told the inspector that they had not had the time to undertake the general cleaning and hovering in the home at 13.00. The area manager explained that the cleaning was done over a 24hour period, which also included night staff. Several areas in the home were sampled as not clean for example the ledge under one persons bed and a ledge behind a fire door were very dusty, hovering in the home, including peoples bedrooms had not been attended and water on the floor in a bathroom from a morning bath had not been mopped up causing a potential slip hazard. Following the inspection the inspector spoke with the manager who explained that the focus of staff would be to support the people in the home. Whilst this is acknowledged it is required that the current day to day housekeeping arrangements in the home be reviewed in order that all parts of the home have maintained satisfactory standards of hygiene to ensure the safety and welfare of the supported people and staff. During the tour of the premises that inspector observed that several areas in the home for example door frames and the window ledge in the laundry were in need of decoration and a requirement has been made that all areas of the home are reasonably decorated. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 18 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): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust system for the induction, training development and recruitment of staff. EVIDENCE: The inspector sampled the staff files on the 1st September 2006 at the New Support Options local area office in Aldershot. The home has recruited three new staff members. New Support Options undertake the initial advertising of the vacancy and two senior managers undertake the short-listing process, which includes the registered manager. New Support Options have recruitment and selection policy, which incorporates equal opportunities and the inspector, sampled three staff files all of which complied with the current legislation regarding information and documentation in respect of persons working in the care home. All staff have job descriptions and employment contracts in order that they are clear about their roles and responsibilities. The inspector was advised that staff applicants are invited to visit the care home in order that both parties can meet and the supported people have an opportunity to express their views about the prospective member of staff. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 19 The inspector sampled the finance records for one person supported and noted that the procedure was robust and all transactions accounted for and measures in place to safely secure peoples finance. The staffing levels in the home appeared adequate to meet the current needs of the supported people. All but one comment card stated that there ‘were not always sufficient staff on duty.’ Staff training records were in place. The training records did not give a clear indication of the attendance of staff and following the site visit the inspector contacted the registered manager to seek clarification. Information received following the inspection detailed that all staff had received statutory training and where there were some voids staff had been booked to attend the training. The inspector was advised that New Support Options would be implementing a database in order that staff training records could be more accessible. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 20 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): 37,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home is robust and the supported people benefit from a well run home. The health, safety and welfare of supported people must be improved. EVIDENCE: All supported people were at home when the inspector arrived and three staff members and a visiting area manager were on duty. During the inspection the staff demonstrated competency and were well organised in the absence of the registered manager. Following the inspection the inspector spoke with the registered manager to give feedback from the inspection. During the feedback it has been recommended that the manager review the current storage of some records in the office which are stored on high shelves and contain documents which were no longer current for the needs of the supported people or the service generally for example health and Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 21 safety records dated back to 2004. The review would promote easier accessibility to staff and other health care professionals who have right of access to the documentation. Records of fire practices, fire drills, maintenance of equipment and individual supported people guidelines in the event of fire in their home were current and well organised. Records detailing water temperature checks, fridge and freezer checks, temperatures of food before serving and the maintenance of the vehicle were also sampled. One staff member on duty advised the inspector that they were the designated person to oversee the health and safety records and they were in the process of fully updating the file which the inspector noted contained current electrical checks, gas certificate, bath servicing reports, hoists servicing records, the homes health and safety policy, clinical waste policy and sensory suite checks. During the tour of the premises the inspector noted that the fire doors to a bathroom and the laundry was evidenced as not closing properly. An immediate requirement was made that the fire doors, which were not closing properly, must receive attention. The door to the office did not have a magnetic holding device as did other doors in the home and was wedged open on several occasions to enable easy access. It is required that the home consult with the fire authority to ensure that adequate arrangements are in place for containing fires and if necessary an magnetic holding device must be fixed to the office door. The laundry area in the home was viewed as hazardous as it was noted that mops and buckets were stored by the fire exit causing a potential obstruction to the fire exit and a fully loaded free standing clothes rack was blocking access to a fire extinguisher. It has been required that a review of the storage of these articles takes place in order to ensure the safe evacuation, in the event of fire, by the supported people and staff in the home. The paint was noted as peeling on the windowsill in the laundry and a requirement has been made that this is redecorated. The management of soiled linen in the laundry needs to be reviewed as the inspector observed potential cross infection in the laundry control for example clean laundry being placed with soiled laundry and no lid on a waste bin. It has been required that the home review the current management of laundry in order to make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the care home. It is required that the broken concrete on the pathway outside the bathroom door leading to the garden needs to be repaired as this could potentially be a trip hazard. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 22 Several Velux windows in the home were not working and the inspector has made a requirement that the home must ensure that there is adequate ventilation is provided for the supported people in all parts of the home, which is used by them. The inspector noted that some large containers of disinfectant had not been stored in compliance with the Control of Substances Hazardous to health (COSHH) guidance and were stored in an unlocked cupboard. A member of staff advised the inspector that none of the supported people would be able to access the chemicals and it has been recommended that a documented risk assessment be completed in order to assess the hazard and subsequent risk of not storing the chemicals under the COSHH guidelines. Ash Street (4a) DS0000013508.V305136.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 3 3 3 4 3 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 3 26 3 27 3 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 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 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X X X 2 X Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA10 Regulation 12.(4)(a) Requirement The Registered Person must ensure that each individual’s personal information is removed from the front of the medication cabinet in order to promote the individuals right to privacy, dignity and confidentiality. The registered person must ensure that the heavily soiled carpets in the main hallway and office and one persons bedroom are repaired or replaced in order to ensure safety and hygiene in the home. The registered person must ensure that the water damage to a ledge in the bathroom and at the back of the bath are redecorated. The registered person must ensure that alternative measures are put in place regarding the storage of the mats when the bath is being sterilised in order to prevent infection, toxic conditions and the spread of infection ion the care home. The registered person must ensure that the loose tiles in the small bathroom are refitted DS0000013508.V305136.R01.S.doc Timescale for action 18/12/06 2 YA24 13.(3)(4) (a-c) 08/03/07 3 YA24 23.(2)(d) 08/03/07 4 YA30 13.(3) 08/02/07 5 YA24 13.(4)(a) (c) 08/01/07 Ash Street (4a) Version 5.2 Page 25 6 YA30 16.(2)(j) 7 YA24 23.(2)(d) 8 YA42 23.(4) (a)(i) 9 YA42 23.(4)(a) (c)(i) 10 YA42 23.(4)(b) (c)(iii) 11 YA42 13.(3) promptly in order to ensure the safety of all persons using the bathroom. The registered person must ensure that the current day to day housekeeping arrangements in the home is reviewed in order that all parts of the home have maintained satisfactory standards of hygiene to ensure the safety and welfare of the supported people and staff. The registered person must ensure that all areas of the home for example doorframes and the window ledge in the laundry are reasonably decorated. The registered person must take adequate precautions against the risk of fire, including the provision of suitable fire equipment and for containing and extinguishing fire. The fire doors, which are not closing properly, must receive attention. The registered person must consult with the fire authority to ensure that adequate arrangements are in place, regarding the office door, for containing fires and if necessary a magnetic holding device must be fixed to the office door. The registered person must review the current storage arrangements of the mops and buckets which were stored by the fire exit causing a potential obstruction to the fire exit and a fully loaded free standing clothes rack was blocking access to a fire extinguisher. A review of the storage of these articles must take place in order to ensure the safe evacuation, in the event of fire, by the supported people and staff in the home. The registered person must DS0000013508.V305136.R01.S.doc 31/12/06 08/02/07 08/12/06 08/01/07 08/01/07 31/12/06 Page 26 Ash Street (4a) Version 5.2 12 YA42 23.(2)(p) 13 YA42 23.(2)(b) review the current management of laundry for example clean laundry being placed with soiled laundry and no lid on a waste bin in order to make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the care home. The registered person must 08/03/07 ensure that adequate ventilation is provided for the supported people in all parts of the home and the Velux windows in the home, which are not working are repaired. The registered person must 08/02/07 ensure that the broken concrete on the pathway outside the bathroom door leading to the garden is repaired, as this could potentially be a trip hazard. 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 Refer to Standard YA30 YA24 Good Practice Recommendations A documented risk assessment is completed in order to assess the hazard and subsequent risk of not storing some the chemicals under the COSHH guidelines. The use of signs is reviewed in order to reflect a more homely atmosphere in the bathrooms. Ash Street (4a) DS0000013508.V305136.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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