Inspection on 30/05/07 for 5 Courtenay Avenue

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Courtenay Avenue 15/02/06

5 Courtenay Avenue 29/09/05

5 Courtenay Avenue 10/02/05

5 Courtenay Avenue 09/07/04

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 5 Courtenay Avenue 5 Courtenay Avenue Harrow Middlesex HA3 5JH Lead Inspector Julie Schofield Key Unannounced Inspection 30th May 2007 08:30 5 Courtenay Avenue DS0000017570.V339878.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 5 Courtenay Avenue DS0000017570.V339878.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. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Courtenay Avenue Address 5 Courtenay Avenue Harrow Middlesex HA3 5JH 020 8421 0466 020 8621 7244 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) T/A Idelo Limited Ms Diane Morleen Elizabeth Eastman Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: 5 Courtenay Avenue is registered to provide accommodation to 3 adults who have learning disabilities and at the time of the inspection there was 1 vacancy. The semi-detached house is in a residential area in Harrow and is close to another care home that the company operates. The home is close to transport links and local shops. Although it does not have its own off-street parking it is possible to park in adjacent streets, close to the home. There is one bedroom on the ground floor and two bedrooms upstairs. There are bathing and toilet facilities on both floors. The kitchen and the laundry are on the ground floor. There is also a lounge and a conservatory that is used as a dining room on the ground floor. Residents wishing to smoke are able to use a building in the garden. The garden is large and includes a patio area, decking and mature shrubs and trees. The office is situated on the first floor. Details of the fees charged for the service are available, on request, from the manager of the home. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of 2 visits to the home. The first visit, when the manager was off duty, was on a Wednesday in May 2007. It started at 8.30 am and finished at 12 noon. The Inspector would like to thank the member of staff on duty that assisted with the inspection. A partial site inspection took place, records were examined and the member of staff and each of the 2 residents spoke with the Inspector. The Inspector would like to thank them for their comments. The second visit took place the next day, when the manager was on duty. It started at 1.30 pm and finished at 3.25 pm. The site visit was completed, more records were examined and discussions with the manager, the proprietor and the member of staff took place. The Inspector would like to thank the manager for their assistance and would like to thank the manager, proprietor and the member of staff for their comments. What the service does well: What has improved since the last inspection? 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 6 Two statutory requirements were identified during the previous key inspection and both have now been met: A record of the administration of PRN is now kept on the back of the medication administration sheets. The radiator in the shower room is in working order. 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. 5 Courtenay Avenue DS0000017570.V339878.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 5 Courtenay Avenue DS0000017570.V339878.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): The home has not admitted any residents since the last key inspection in February 2006 so these standards have not been inspected. EVIDENCE: 5 Courtenay Avenue DS0000017570.V339878.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 Quality in this outcome area is good. Care plans identify the individual needs of the resident and address these and regular reviews of the placement confirm that the care home continues to be able to meet the individual needs of the resident. Having the opportunity to exercise choice in their daily lives contributes to the resident’s enjoyable and fulfilling life style. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both case files were examined. It was noted that information regarding the needs of the resident, the level of support and assistance required and progress being made was comprehensive. Each file contained a care plan that included an identification of personal, social and health care needs and goals had been set. A member of staff confirmed that the support and care given to 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 10 residents was “person centred” and explained that they met the individual needs of the resident and would be different from resident to resident. In addition each file contained a strengths and needs assessment. Information was in a format appropriate to the resident and one of the files contained a copy of “My Plan for My Life”. The resident had completed this, with the support of their key worker. The format included illustrations and helped the resident choose between different options. Residents had signed the documents in the care planning section of their files and added comments e.g. “I agree”. Documents had been recently drawn up. There was evidence that care plans and the suitability of the placement had been reviewed on a regular basis i.e. twice a year and that the relatives of the resident had been invited to attend. A copy of the minutes of the review meetings were on file. A resident said that reviews were held and that it was an opportunity to say what he wanted to happen. Residents gave examples of how they were involved in the decision making process. A resident showed me their room and said that due to decreasing mobility they had been offered a bedroom on the ground floor. The resident had decided whether they wished to move rooms and when they had decided that they would like to move room they chose what furniture they wanted and the layout of the room. A resident had made a choice about they wanted to receive medical intervention for a condition that they had. There was evidence on file that information had been given to the resident before a choice was made and this was clearly documented. One resident has control of their own financial affairs. The other resident has assistance with budgeting etc and records relating to the resident’s finances were examined. Both resident and member of staff sign the records when money is passed to the resident. A record is kept of purchases, with receipts, and there is a running total. Records were satisfactory. Care plans included risk assessments tailored to the individual needs of the resident. Assessments included risk factors such as falling over or a deterioration in the mental state of the resident. They also included risk management strategies. As part of the care plan the risk assessments were subject to a system of regular reviews. 5 Courtenay Avenue DS0000017570.V339878.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. Residents attending day care services are provided with an opportunity to develop their social skills. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. Residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet to maintain their wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident had a day care programme/ activity schedule and a copy of this was on their case file. It included activities taking place both inside and outside the home. On the day of the inspection one of the residents was staying at home for domestic duties (tidying their room) and relaxation. The 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 12 other resident was going out for lunch with their friend and then returning to the home later in the afternoon. Residents’ programmes include day centre attendance (3 days per week) and on one of these days 1 resident goes to college for computer sessions. Other sessions at day centre included reading and writing, painting and cooking. Residents confirmed that they used resources and facilities in the community. These included shops, cinema, pubs, restaurants etc. Staffing levels in the home enable one of the residents to have an escort when they go out, as this is the resident’s wish. A resident said that they have the use of a “9 seater air conditioned mini bus” when they go out although the other resident said that the situation of the home was convenient for bus routes. The manager said that the names of both residents are entered on the electoral roll. Residents have the opportunity to take part in an annual holiday and 1 resident told the Inspector about recent holidays abroad and pointed to photographs in the lounge that had been taken while they were away. The resident had been to Florida at the beginning of the year. The other resident had declined to go abroad recently although they had been away in the past. They described themselves as “not a holiday person” and said that they preferred to go on days’ outings instead. Residents confirmed that they were able to go out at the weekends and each had a list on their file of possible activities/outings for the year and they were ticked as each one was completed. The lists reflected the interests of the individual resident. The visits ticked on one list included outings to St Albans, Oxford, Whipsnade Zoo, Southend and Clacton. A resident confirmed that their friend had joined them in the home for lunch and dinner at the recent Bank Holiday and said that the members of staff always welcomed visitors to the home. A resident said that they are able to entertain visitors in their room or in the communal areas, as they please. Residents maintain regular contact with family members both personally and by telephone. One of the residents enjoys going to their day centre as they meet a relative there on one of the days that they attend. The other resident had travelled to south London, with a member of staff as an escort, to meet a relative. Daily routines in the home promote independence and respect the resident’s right to privacy, dignity and choice. Residents have keys to both their rooms and to the front door. Staff knock on the bedroom door if they wish to speak to a resident and wait to be invited in, before entering. Residents said that staff are always able to spend time talking with them, when the resident wants company. Residents enjoy different life styles and this is respected. There is a cabin in the garden where residents that wish to smoke may do so. It was noted that the meals for the day of the inspection were listed on the whiteboard, in the conservatory. Lunch consisted of Cornish pasty and 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 13 spaghetti and the evening meal consisted of gammon, boiled potatoes, cauliflower and carrots. Ice cream was to be served as the dessert. The residents said that they were satisfied with the meals served in the home. One resident said that they liked the variety. Residents’ files contained information about their likes and dislikes in respect of food. A copy of the weekly menu was also on display and it demonstrated a varied and wholesome diet. One of the residents enjoys helping to prepare a meal. A programme of healthy eating is encouraged in the home and residents help with menu planning. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. Residents receive assistance with personal care in a manner, which respects their privacy. Residents’ health care needs are met through access to health care services in the community. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained information in respect of the support needed by residents in maintaining good standards of personal hygiene. It was noted that residents were clean and tidy and smartly dressed. Assistance or prompting with personal care tasks was offered discreetly and residents are encouraged to be as independent as possible. Although times for getting up in the morning are influenced by day centre attendance routines are relaxed at the 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 15 weekend and the wishes of the resident to have a lie in at the weekend are recorded in their case file. Health records were up-to-date and in sufficient detail to demonstrate that residents had access to preventative care as well as direct intervention. Residents had flu jabs, blood tests and checks on their blood pressure readings. Both residents also had a well person check. A male resident had a prostate screening appointment. There were regular appointments with the dentist, optician, chiropodist and psychiatrist. Residents were supported to attend out patient clinics at hospitals e.g. a cardiac clinic. Medication is kept in a locked facility. Storage within the cabinet was orderly and safe. The home has changed to a monitored dosage system. The blister packs were examined and the opened blisters corresponded with the time of day and the day of the week that the inspection took place. Members of staff confirmed that they had received medication training in respect of the new system. (Training certificates were on staff files). A statutory requirement was identified during the previous key inspection that a record of the administration of PRN must be kept within the medication administration sheets. It was noted while examining medication records that the administration of PRN was recorded on the back of the administration record sheets. (Case files contained guidelines for the use of PRN that had been signed by the GP and which had been reviewed on a regular basis). The records of administration were up to date and complete. Both residents were satisfied that they received support from the staff team to take their medication, as prescribed. Neither resident wished to self-medicate or thought that they were ready to do this. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent. A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a copy of the complaints procedure and spare copies are kept in a rack in the conservatory. No complaints have been recorded since the last key inspection. Residents said that if they had any concerns or complaints they could speak to someone in the home. There are many opportunities for residents to do this. It was noted that on a daily basis there is time for members of staff to sit with residents and to talk. The senior managers are present in the home on a regular basis and available to talk with residents. Residents confirmed that their views were listened to and acted on. Residents meetings are held on a monthly basis and there is a suggestions and complaints meeting where residents are asked if there are any changes that they would like to see happen. The ethos in the home is that matters are discussed and resolved before they reach a stage where the matter is troubling the resident. The home is to be commended for all the opportunities that residents have to raise any matters of concern and for the way in which the home welcomes suggestions and comments. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 17 Members of staff confirmed that they have received training in adult protection procedures. (Training certificates are kept on staff files). The home has purchased a training video regarding prevention of abuse and clients with learning disabilities. This is to be used for in house training sessions. The manager said that no allegations or incidents of abuse have been recorded since the last key inspection. Residents confirmed that if they had any concerns or worries they could talk with someone in the home. Both residents confirmed that people working in the home “were kind” and they said that they wanted to continue to live in the home. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 18 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 Overall quality in this outcome area is good. Although some minor repairs are needed the overall high standard of maintenance and the décor in the home provides residents with a comfortable and pleasing environment. Good standards of hygiene are maintained in the home, promoting the health and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit took place. Both of the residents agreed to show the Inspector their rooms. It was noted that the home was well maintained and in a good state of repair. Furnishings and fittings were of a good standard and provided a comfortable and “homely” environment. The heating and ventilation in the home was appropriate for the time of year. The statutory requirement in respect of the radiator in the shower room needing to be repaired has been met. A problem with water seeping into the carpet 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 19 outside the shower room has been investigated and resolved. It was noted that there were gaps between some of the kitchen floor tiles and where a section of the work surface had been repaired it lacked a smooth surface and an impervious finish. Both residents expressed satisfaction with the accommodation and said that the home was in an ideal situation for bus routes and for access to local shops. They liked their rooms and said that there was sufficient storage space and a resident confirmed that the room included a lockable storage facility. The resident with mobility problems was pleased that he had moved from the first floor to a ground floor room. During the site visit it was noted that the home was clean and tidy and free from offensive odours. Standards of cleanliness were good and staff on duty confirmed that they had undertaken infection control training. (Training certificates were present on the staff files). Laundry facilities are situated in a covered building to the side of the kitchen area, although access does not have to be through the kitchen or any area where food is prepared or consumed. The washing machine and tumble drier are of a commercial quality and the washing machine includes a sluicing cycle. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. The home has exceeded the target for NVQ training for its members of staff and residents benefit from a service provided by an informed and skilled staff team. Recruitment practices protect the welfare and safety of residents. The training needs of members of staff are identified and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 4 support workers working in the home, one support worker has achieved an NVQ level 3 qualification and 1 support worker has achieved an NVQ level 4 qualification. One of the other two members of staff is in the process of enrolling on an NVQ level 3 training course and the manager said that the other member of staff has a nursing qualification, which is at least equivalent to NVQ level 2. Therefore the home has exceeded the target of at least 50 of carers achieving an NVQ level 2 or 3 qualification. The staff on duty during the inspection demonstrated the skills, knowledge and 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 21 understanding needed to respond to the needs of residents. Residents confirmed that the staff were “really nice and kind” and that they were “good and helpful”. There is always at least one person on duty in the home, when residents are present. The manager and the responsible individual cover vacant shifts, if required, so that agency staff are not used in the home. Staffing levels are sufficient to meet the needs of the residents. Residents confirmed that there was always someone there to help them. A member of staff said that there time to sit and talk with the residents and observations during the inspection confirmed this. An on call manager rota has been drawn up to support staff working in the evenings or at the weekend. Staff confirmed that regular staff meetings take place. Two staff files were examined. Both contained evidence of 2 satisfactory references, an enhanced CRB disclosure, proof of identity and right to reside and to work (if required). The training manager was on leave. However the registered manager confirmed that staff have all received training in safe working practice topics. There were no recent records of induction training to inspect as members of staff had worked in the home for between 2 to 7 years. Staff had recently undertaken medication and pova training and had received training in breakaway techniques. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is excellent. The manager demonstrates her competence and commitment to a quality service by continuing to develop her understanding, skills and knowledge through further training. Systems are in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 23 The manager is a qualified nurse and has achieved an NVQ level 4 in management qualification. She has extensive experience of residential care and has managed the home since it opened. The managing director is also extensively involved in the operations of the home. He has a social/residential background and has also achieved an NVQ level 4 in management qualification. Since the last inspection the manager and managing director have taken part in the training courses arranged for members of staff. These have included fire safety, medication, protection of vulnerable adults, first aid, food hygiene and breakaway techniques. A discussion took place regarding quality assurance systems. Both staff and residents said that their ideas and comments were requested. Feedback is given by residents on a day-to-day basis and staff members and managers sit down to talk with residents. Staff meetings and residents meetings take place on a regular monthly basis and the home is to be commended for also holding regular suggestions and complaints meetings where residents are asked if there is any way that the home can improve the service that it provides. Although they have tried to canvass the views of professional visitors to the home this has met with limited success. All the requirements and recommendations identified during the previous inspection have been actioned. Residents commented about the measures in place in the home to promote their health and safety. A resident said that the temperature of the hot water was controlled so that the water didn’t burn them, that they take part in a monthly fire drill that includes evacuating the building and that they attend fire safety training when the fire officer visits the home. Members of staff on duty confirmed that they had received training in safe working practices e.g. food handling, manual handling etc. There was evidence that the fire precautionary equipment and systems in the home were checked/serviced on a regular basis. The Landlords Gas Safety Record was dated September 06 and the certificate for the checking of the portable electrical appliances was dated April 07. A fire risk assessment had been carried out in November 06 and the last health and safety audit had taken place in March 07. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 24 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 4 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 4 33 3 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 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 4 X 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 25 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 01/10/07 2 YA24 16.2 The registered person must ensure that there are no gaps between the kitchen tiles trapping liquid, dirt or food debris so that hygienic conditions can be maintained in the kitchen. The registered person must 01/10/07 ensure that the work surface does not have ridges or uneven parts trapping dirt or food debris so that hygienic conditions can be maintained in the kitchen. 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 YA23 YA34 Good Practice Recommendations That training in respect of protection of vulnerable adults procedures is updated on a 2 yearly basis. That a system is developed for ensuring that documents that have expiry dates are identified so that a request for an updated document can be made to the member of staff. 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 26 5 Courtenay Avenue DS0000017570.V339878.R01.S.doc Version 5.2 Page 27 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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