Inspection on 08/04/08 for 61 Somerset Road

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

61 Somerset Road 25/06/07

61 Somerset Road 12/06/06

61 Somerset Road 27/02/06

61 Somerset Road 11/07/05

61 Somerset Road 28/02/05

61 Somerset Road 22/09/04

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 61 Somerset Road Barnet Hertfordshire EN5 1RF Lead Inspector Tom McKervey Key Unannounced Inspection 8th & 16th April 2008 10:15 61 Somerset Road DS0000010530.V361374.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 61 Somerset Road DS0000010530.V361374.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. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 61 Somerset Road Address Barnet Hertfordshire EN5 1RF 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) 020 8364 8222 F/P 020 8364 8222 ckearns@adepta.org.uk www.pentahact.org.uk PentaHact Limited trading as Adepta Ms Rachel Gabriella Parker Ms Cheryl Adele Kearns Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Specific Service Users Two specific service users who are currently resident in the home and are over 65 years of age can reside in this home. This condition will need to be reviewed when one such service user vacates the home. 25th June 2007 Date of last inspection Brief Description of the Service: 61 Somerset Road is a care home for five adults of either gender, who have a learning disability. The home was opened in February 1991. The building is owned and maintained by Sanctuary Housing and is managed by PentaHact, which trades as Adepta. This is an organisation that manages several projects specialising in the provision of care for people who have special needs. The home is a detached two-storey building in a quiet residential area with shops and amenities close by. There is a gradient driveway leading up to the front door, and an area for off street parking to the front of the building. There is a large attractive garden at the rear of the premises. One bedroom is located on the ground floor, along with an adapted shower. There are four bedrooms upstairs. There is no lift available, so the home is not suitable for people who have problems with mobility. There is a shower and toilet on the ground floor and two bathrooms and toilet facilities on the first floor. On the first floor there is a bathroom/toilet and a sleep-in room for staff. There is a kitchen/diner, a large lounge and an activities room, a laundry room and an office located on the ground floor. The range of fees for people living in the home is from £1,110 to £1,145 per week, depending on the level of their disability. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This inspection was unannounced and was completed in seven hours over a two-day period. On my first visit, the manager was on leave and I returned on another day when she was back in order to meet her and discuss how the service was progressing. The inspection included visiting all areas of the home and meeting the people who live in the home and the staff. I also looked at residents’ and staffs’ records and other documents relating to the running of the service. Most of the people who live here are not able to converse but they can make their needs known in other ways that I was able to observe. Prior to the inspection, the manager sent valuable information to the Commission in a document called an Annual Quality Assurance Audit, (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. I have referred to the AQAA in appropriate sections in this report. What the service does well: What has improved since the last inspection? There has been significant improvements in the décor and maintenance of the home and team-building days have improved the morale and motivation of the staff team. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 6 The statement of purpose and service user guide, as well as individual care plans for people who use the service have been reviewed and are more service user friendly. There is a faster response from the landlords to requests for repairs and maintenance in the home. 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. 61 Somerset Road DS0000010530.V361374.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 61 Somerset Road DS0000010530.V361374.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): 1, 2 & 3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service and inspecting records. People who are considering using this service can feel confidant that an assessment of their needs will be carried out to make sure that the home will be suitable for them and they will be provided with good information about what they can expect from the service. EVIDENCE: There is a Statement of Purpose and a Service User Guide which accurately describe the service the home provides. The Service User Guide contains pictures to enable the people who live in the home to understand it. Five people are currently living in the home, one female and four males. There were no admissions to the home since the last inspection, and there are no vacancies at present. The case files that were examined, showed that each person had their needs assessed before they came to live in the home. The property is detached and on two floors. There is one bedroom on the ground floor, with an adapted shower facility to accommodate someone who has problems with mobility. Otherwise, as there is no lift, the home is only suitable for people who are fully mobile. The service is block-funded by the Primary Care Trust. All but one of the people who live in the home, have done so for a number of years. All the 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 9 residents have tenancy agreements that include details about what is covered by the rent they pay. There was evidence that a member of the Community Learning Disability Team carries out an annual review of each resident’s placement in the home to ensure that the home continues to be suitable to meet the person’s needs. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including looking at residents’ care plans and observing how staff and residents communicate with each other. The people who use the service can feel confident that the staff, are aware about what each person needs when they ask for support. This includes knowing what reasonable risks can be taken to ensure that people who live in the home can have as full a life as possible. EVIDENCE: I examined three care plans in detail. All the staff spent some time in training this year on care planning, as a result of which, the care plans are now personcentred and written in the first person. This is a good way to invplve the resident and important other people who are involved in their support; for example, relatives and advocates. Each person has a folder containing a very detailed history of their past, their likes and dislikes and their wishes for the future. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 11 Once a month, the resident’s key worker reviews their care plan with them to make sure that it is still relevant to meet their needs. Pictures are being introduced gradually to help the resident understand more easily, what is written about them. The support that is needed for personal care, activities of daily living, social and leisure activities, and the person’s cultural values and religious beliefs are all documented in each care plan. The case records of the people living in the home include individual risk assessments that tell staff and other people about anything that may harm the resident. This includes activities they do in the home or out in the community. Most of the people who use the service have difficulty with communicating verbally. However, the staff, with whom I had discussions, demonstrated a detailed knowledge of each person’s personality, needs and preferences and described how each individual resident makes their wishes known. By observing their interactions, I was satisfied that the residents and staff understood each other well and that the staff are aware of the individual methods that each person uses to express their thoughts and needs. I observed how residents who are non-verbal, expressed their wishes to staff on several occasions during the inspection; for example, gesturing, taking staff by the arm, pointing to indicate that they wanted a drink, or by putting on a coat to show they wished to go out. 61 Somerset Road DS0000010530.V361374.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. This judgement has been made using available evidence including observation and looking at case records. The people who live in the home are actively encouraged to maintain contact with family and friends and to partake in opportunities to develop and maintain religious, cultural and independent living skills as far as possible. Residents are able to choose what they like to eat from a well-balanced menu. EVIDENCE: On my first visit, one resident was at a day centre and two people were being supported by a staff member on a trip out in the home’s vehicle. Each person who lives in the home has an individual activity programme for the week, which includes day centres and attendance at colleges. Other activities include shopping trips, going to the pub and to various clubs. Daily records, including photographs, are kept as evidence of the social and leisure activities that each person participates in. I observed a resident clearing 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 13 up after lunch, and according to the daily records, some people also assist staff in daily chores for example; washing up, shopping and doing laundry. I was informed that all the people who live in the home had an individual holiday last year and plans were currently underway for this year’s holiday. In the AQAA, the manager gives examples of other leisure activities that she plans to introduce this year, for example; “Really spending fun time together engaging in communication and games/art sessions that people choose themselves”. The home is about to set up a relaxation room and they have purchased the appropriate equipment for this. They also plan to make a sensory garden. These new facilities will be of great benefit to the people who live in the home. Not all people have known relatives, but two residents have advocates and I saw evidence that the home has obtained advocates for the other residents on an “as needs” basis. They were also able to describe how respect for the residents is maintained Those people who wish to attend religious services are enabled to do so. Details of the social, leisure and culturally appropriate activities in which each person participates are written in their records. I noted that the people who live in the home were supported to visit friends in other homes and according to the AQAA, various social events are held in the home and visitors are encouraged to attend. There is an open visitors policy. The home has a key worker system and it is part of the key worker’s role to keep family members / advocates informed of the resident’s progress. Visitors can be seen in the communal areas or people’s own bedrooms if it is thought to be appropriate and safe to do so. I noted that staff knocked on residents’ bedroom doors before entering, and staff spoke to residents in an appropriate respectful manner. All the residents were clean, well dressed and appeared well cared for. I looked at the menus, which are rotated six-weekly. Although this seems a long timescale, I was told that the menus were flexible and residents could choose alternatives on the day. Pictures of meals are used to enable nonverbal people to choose their food. The menus showed a good variety of nutritious meals and I noticed that there was a good stock of food in the home and that fresh fruit was available. 61 Somerset Road DS0000010530.V361374.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has responded positively to residents’ wishes about how they want to be addressed. People who live in the home can be confident that the staff respect their privacy and dignity and are sensitive to their changing needs. Staff make sure that residents have regular appointments with local health care services and that their medication is administered safely. EVIDENCE: Each person who lives in the home has a care plan that provides details of how they like to be addressed and be supported by staff. In the past year, Adepta carried out a survey of all the people who live in their residential homes. One issue that people identified was that they disliked the term, “service users”, preferring to be called “people”. As a result, all the residents of Somerset Road are identified as “People we support – (Psw’s)”, in all records. The AQAA contains several references to the fact that the people who live in the home are becoming older and that, in this context, the staff must regularly give consideration to each individual’s changing health and other support needs. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 15 Care plans contain an assessment of peoples’ physical and mental health status. Each person is registered with a G.P, and all their appointments with healthcare professionals are recorded. All residents are seen regularly by the Community Learning Disability Team, including the consultant, who reviews their medication. Monthly checks are made of the residents’ weights, which is another means of monitoring someone’s health. I saw evidence in the files that people are referred to appropriate professionals if they are unwell and everyone had the flu vaccine last winter. The manager is developing “Health Action Plans” for each individual. This gives a comprehensive medical history and record of immunisation etc. This document will accompany the resident to any health appointments to provide appropriate information for the health professional. If anyone needs to take medicine then the staff help him or her to do this. None of the people who live in the home are able to do this by themselves and the staff have written down why this is so on each of the care plans. The staff make sure that people take their medicines so that they can stay well. I checked the medication and the records and I was satisfied that the procedures were being followed correctly and medication was safely stored. There is a record in each person’s file about their preferred end of life arrangements. 61 Somerset Road DS0000010530.V361374.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): Both these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who use the service can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The organisation recently carried out an audit of all of their homes, which included asking people who used the service and other stakeholders, about their views of the quality of the service they received. The result of this survey was positive and showed a high level of satisfaction. The home has revised their complaints form and it is now easier to understand and complete. No complaints have been made about the home in the past year but the staff successfully supported two residents in pursuing complaints to the landlord about maintenance issues. I recommended to the manager that she has a book for logging complaints so that it is easier to audit-trail complaints. At the time of this inspection, an investigation was taking place into a complaint by a resident who alleged they had been mistreated by a member of staff at the home. This investigation is still ongoing. I was satisfied that appropriate action was taken, as social services, the police and the Commission for Social Care Inspection were informed. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 17 All staff working at the home have either already been trained in adult protection procedures, or have been booked to do so in the near future. The staff I spoke to, showed a clear understanding of their responsibilities about this issue. 61 Somerset Road DS0000010530.V361374.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, 25, 26, 27, 28 & 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including looking at all areas of the home. Although there have been significant improvements to the property recently, further improvements are needed to provide a more homely environment for the people who live there. EVIDENCE: The home is owned and maintained by Sanctuary Housing Association. I visited all areas of the home, including residents’ bedrooms. I was informed that there is a handyperson who is responsible for minor repairs in the home. A book is used for recording any faults. The staff reported that the response times for maintenance requests are reasonable, but I advised that it would be good practice to also record the date when repairs are carried out as evidence of this. For a long time, it was planned to close this home and sell the property. This created a situation where there was a lack of investment in improving the fabric of the building. However, these plans have been dropped, and since 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 19 then, the standard of décor and maintenance throughout the property has greatly improved. The large garden was well maintained and looked attractive. According to the AQAA, the home is planning to install a sensory garden, which will be of great benefit to the people who live in the home. I was informed that each person’s bedroom is decorated to their own taste. Generally, bedrooms were in good order; however, there was an offensive odour in one bedroom, and in another bedroom, half the curtain was missing. I was concerned that this resident’s privacy and dignity were at risk. I was informed that the person who uses this room keeps pulling the curtain down. The staff told me that this resident would prefer wooden blinds instead of curtains and I am making a requirement that this be attended to as a matter of urgency. I noted that the surface of one of the baths upstairs was chipped and a new bath panel was needed. This bathroom is in need of complete refurbishment. In the kitchen, both light sockets were broken and the oven glass was dirty. Requirements are made to address these issues. The laundry room was well equipped and the communal areas had appropriate furniture and fittings. However, the communal areas appear sparse and lack a homely feel. This was acknowledged by the manager who intends to improve the décor. I was informed that a cleaner has just been recruited for the home. At the time of the inspection, this was being done by the care staff. With the exception of the deficits mentioned above, the home was otherwise clean and tidy. 61 Somerset Road DS0000010530.V361374.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 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including speaking to staff and examining their records. People who live in the home can be confident that their carers are well trained in how best to support them. The residents can also be confident that all staff are checked to make sure that they are not liable to harm them. EVIDENCE: There are two staff on duty during the daytime, plus the manager, and at night a member of staff sleeps in. A cleaner has just been recruited and will start working at the home soon. Staff to whom I spoke said that this level of staffing was appropriate to meet the needs of the current residents. 50 of the staff have attained a National Vocational Qualification at level 2 and other staff are currently on this course. Staff records showed that they had been trained on health and safety subjects that are mandatory for the safety and well being of the people who live in the home. Each member of staff has a training and development plan to ensure they keep updated about best practice. In addition, there is a system of staff supervision and annual appraisal in place. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 21 Since the last inspection, one new staff had started working at the home. After examining their records, I was satisfied that proper recruitment procedures were followed, including Criminal Records Bureau checks and references. I was made aware that the residents are involved in the process of recruitment of new staff. This is by potential recruits being observed by the manager and other staff while they undertake a particular task to support a resident. By observing how the candidate and resident react to each other, a judgement can be made about the suitability of the candidate. All the staff I spoke to, said they enjoyed their work and were committed to achieving the highest standard of care for the residents. 61 Somerset Road DS0000010530.V361374.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, 38, 39, 41 & 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who use the service can feel confident that they are living in a home that is run with their best interests at heart and that their views are sought. The service is well managed and staff are committed to provide a good quality of care. A better system is needed to account for residents’ money to protect their best interests and fire alarms must be tested weekly to safeguard the health and safety of residents and staff. EVIDENCE: The management of this home used to be job-shared by two people. One of the managers left and the current manager is now registered as solely in 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 23 charge. She has several years of experience of working in this home and at present, works four days a week. She has attained the RMA, (Registered Manager Award) at National Vocational Qualification level 4. In February this year, the manager and her staff spent valuable time away from the home on team-building and developing plans for improving the service. Several staff told me how much more motivated they felt after this exercise and that they worked much more as a team now. As mentioned earlier in this report, the home was involved in Adepta’s quality audit, which included people who use the service and other stakeholders, all of whom were invited to complete questionnaires. A copy of this audit and the resulting annual development plan were sent to the Commission for Social Care Inspection. A senior manager carries out monthly visits to the home and makes a report. These reports are kept electronically on computer and were made available for me to read at the inspection. Any issues resulting from these reports are identified and timescales are set for them to be addressed. I was impressed by the way the home manages the petty cash system with regular checks recorded by staff when money is withdrawn. However, while I was randomly examining one person’s records, I had some difficulty reconciling the records with the actual cash being held on behalf of this person. I found that the system for monitoring personal finances was confusing. The manager said that while she was on holiday, staff had changed the procedure and she would address this matter with the staff concerned. I was satisfied that the money was finally accounted for, but I am making a requirement for a clearer, more consistent system to be used so that all staff understand and adhere to. I saw records showing that health and safety checks had been carried out within the last year for gas and electrical appliances and the water system had been tested for Legionella. The home is generally good at making sure that the fire alarm and emergency lighting systems are tested every week, but the records showed that at the time of the inspection, this had not been done for three or four weeks. I asked for this to be done in my presence and was satisfied that the system was in working order. I have made a requirement about this important safety issue. There was evidence that fire drills had been carried out regularly. 61 Somerset Road DS0000010530.V361374.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 3 2 3 3 3 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 3 26 2 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 3 3 3 3 X 2 2 X 61 Somerset Road DS0000010530.V361374.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 13(4)(a) Requirement The broken electric switches in the dining room must be replaced to protect the health and safety of the residents. An appropriate device must installed in a specific resident’s bedroom window to protect their privacy. The upstairs bathroom must be refurbished for the comfort of the people who live in the home. A specific resident’s bedroom carpet must be thoroughly cleaned to remove the offensive odour. The glass cover on the oven must be cleaned to ensure residents’ health and safety. A simple, clear system must be implemented to ensure proper accounting for money held on behalf of residents. The fire alarm and emergency lighting system must be tested and recorded every week. Timescale for action 30/04/08 2. YA26 16(2)(c) 30/04/08 3. 4. YA27 YA30 23(2)(d) 16(2)(k) 30/06/08 25/04/08 5. 5. YA30 YA41 23(2)(d) 17(2) Sch 4.9 23(4)(c) 25/04/08 30/04/08 6. YA42 25/04/08 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 26 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 YA22 YA24 Good Practice Recommendations A system should be implemented, (for example using a book), for logging complaints so that it is easier to audittrail them. Dates of when maintenance repairs have been completed should be recorded as evidence of response times. 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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. Extracts may not be used or reproduced without the express permission of CSCI 61 Somerset Road DS0000010530.V361374.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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