Inspection on 07/06/05 for 63 Kingsley Road

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

63 Kingsley Road 10/10/07

63 Kingsley Road 04/10/06

63 Kingsley Road 16/11/05

63 Kingsley Road 11/01/05

63 Kingsley Road 13/09/04

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 Clover Residents 63 Kingsley Road South Harrow Middlesex HA2 8LE Lead Inspector Judith Brindle Unannounced 7 June 2005 16.15pm 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 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 Stationary 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. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 63 Kingsley Road Address 63 Kingsley Road South Harrow Middlesex HA2 8LE 020 8422 4277 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Clover Residents Miss Jasmin Johnson Care Home 3 Category(ies) of LD 3 registration, with number of places Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/5/05 Brief Description of the Service: 63 Kingsley Road is a care home registered to provide personal care and accommodation for three adults with a learning disability. The home is owned by Clover Residents (Organisation). The house is a semi-detached property, located in South Harrow, close to a variety of amenities, which include shops, restaurants,and banks. Local public transport facilities include train and bus services. There is a large accessible park located very near the care home. The premises is in keeping with other houses in the residential area. All the service user bedrooms are single and are located on the first floor. The communal areas of the care home are on the ground floor. There is an accessible maintained enclosed garden. There is restricted residents parking on the street at the front of the house. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place from 16.15 to 19.15pm during a day in June 2005. The registered manager and a care staff member were on duty. The proprietor was present for part of the inspection. There was one vacancy. The inspector was pleased to greet and speak to both residents, and the staff on duty. Verbal feedback/comments was accessible from one of the two residents due to the communication needs of the other resident. A resident kindly accompanied the inspector on a tour of the premises, and was very helpful in describing the service provided. Care records and staff personnel records were among the records inspected. The registered manager supplied the Commission for Social Care Inspection with further requested documentation following the inspection. The inspector supplied the residents each with a leaflet with information about the role of the CSCI, and contact details. Commission for Social Care Inspection comment cards were also supplied to the registered person to give to relatives and significant others for their comments to the CSCI in regard to the service provided. All the requirements from the previous inspection had been met. What the service does well: What has improved since the last inspection? The care and support provided to residents has remained consistent in regards to quality. Policies and procedures are in the process of being reviewed. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 standard(s) 1,2 and 5 Arrangements are in place to ensure that there is information about the service, which can be accessed by residents and others. Residents have their needs assessed prior to admission to the care home, and following admission, to ensure that staff have understanding of how to meet their individual needs. Residents have a written contract of statement of terms and conditions with the provider of the service. EVIDENCE: The home has accessible documentation, and information about the service provided. This includes a statement of purpose, and a service user guide (service users’ handbook), which includes required information. There has not been an admission to the care home for sometime. The registered manager, and the proprietor reported that they are in the process of assessing a prospective service user for the vacancy. A copy of the needs assessment form was supplied to the Commission for Social Care Inspection following the unannounced inspection. This contains comprehensive information in regard to identification, and assessment of prospective resident’s needs, and of staff guidance to meet any assessed needs. The registered manager reported that the assessment process includes visits to the care home by prospective residents. The two care plans were inspected. These included information and Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 9 documentation in regard to assessment of individual health, social and welfare needs. The care plans inspected included a statement of terms and conditions between the resident and provider in regard to the service provided. The recorded statement of terms and conditions includes documentation in regard to the fees. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7, 9 and 10 Arrangements are in place to ensure that residents’ individual needs are identified, recorded, and reviewed. There is staff guidance in place to meet residents’ assessed needs. Residents are supported to take risks as part of encouraging an independent as possible lifestyle. There needs to be some further development in recorded risk assessments Residents’ privacy and dignity is respected by staff. EVIDENCE: The home has a care plan, and personal care policy. Both the residents have a recorded plan of care. These care plans were inspected, and included up to date information in regard to residents’ personal care needs and their health and welfare needs. Both care plans recorded evidence of having been reviewed recently. Records confirmed that a care plan review meeting held in September 2004 had included the purchasing authority reviewing officer, the resident, and the registered manager. This care plan had been reviewed in May 2005. The care home has a risk management policy. The care plans inspected recorded evidence of risk assessment. Risk assessment included residents’ participation in everyday living skills, such as use of the vacuum cleaner, and Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 11 other health and safety risk assessments. A risk assessment in regard to a service user shopping was supplied to the Commission following the inspection. This should be further developed to include more recorded information in regard to the risks of carrying shopping that could be ‘heavy’. A service user who kindly spoke to the inspector was very aware of a variety of risks in regard to health and safety. The registered manager, and records informed the inspector that a resident went swimming regularly. The manager reported that the swimming generally takes place with the day resource service, and that they have swimming risk assessment in place, but that the resident also goes swimming on occasions with staff from the home. There needs to be a recorded swimming risk assessment in place that is accessible by staff within the care home for any resident who goes swimming. The care home has a confidentiality policy. Records were kept accurate, up to date and secure. The staff who spoke to the inspector were aware of the importance of confidentiality and of respecting residents privacy. A resident was observed to be aware of this issue during the tour of the premises. He knew not to enter another resident’s bedroom without their permission. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,14,15 16 and 17 Arrangements are in place to ensure that residents have the opportunity to participate in a variety of leisure activities, which include accessing community based facilities. Residents are supported in maintaining and developing contact with family and friends. Meals provided for residents are varied and wholesome. EVIDENCE: Records, staff, a resident, and observation confirmed that residents have the opportunity to participate in a variety of preferred leisure activities. Resident’s needs in regard to day care, life skills; family and friends, were recorded in their individual plan of care. A resident spoke of the various clubs that he attended and enjoyed. During the weekdays the residents attend different day resource services. A resident spoke of the activities that he participated in at the day services, and of the friends that he had there. Other activities included shopping, listening to music, watching ‘soaps’ on television, football, visiting family, going to the cinema, restaurants, funfairs, and college. A resident spoke of a part time paid job that he was doing, and of enjoying it. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 13 He also spoke of the television programmes that he regularly watched and enjoyed. The other resident was observed participating in an ‘in house’ activity following her return from the day services. Preferred activities were identified and recorded in residents care plans, and were reviewed regularly. Records, staff, and a resident confirmed that contact with family and friends was supported and encouraged (with the residents full involvement and agreement) by staff. Records and a resident confirmed that residents spent time with their relatives, often spending days out with them and/or visiting them at their homes. The registered manager reported that a resident (with staff support) visits her mother every two weeks. A resident spoke of the positive aspect of the location of the care home in regard to the easy access of community facilities. A resident and staff spoke of looking forward to a planned summer holiday. The home has an accessible payphone. House rules are recorded in the service user handbook. Staff and residents interacted with each other in a respectful and positive manner. Residents were observed to access communal areas freely. A resident kindly described some various household chores that he participated in. Both residents participated in helping to clear their plates following supper. The registered manager confirmed that a resident had his own key, and that residents are given support by staff in regards to reading, and understanding their mail. The home has a smoking policy. A resident spoke of enjoying the meals provided, another resident indicated from signs and gestures that she enjoyed the meal provided during the unannounced inspection. Residents on a day-to-day basis generally choose meals. Meals are recorded and were judged as wholesome, and nutritious. Residents were offered choice during the meal and it was unhurried. Staff and a resident confirmed that food is bought locally. Fresh fruit was accessible. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Arrangements are in place to assess and meet the personal care and health needs of residents. Residents’ choice and their preferences are supported and encouraged. Medication is stored and administered safely. EVIDENCE: Both the residents each have an individual plan of care. This includes assessment of resident’s personal care needs, and their health needs. There is recorded staff guidance to meet those needs. Records confirmed that residents’ health is monitored. They have support in accessing dental, optician, and chiropody services. Both residents are registered with a GP. Specialist healthcare services are accessed with staff support as needed by the residents. The residents each have a key worker. A resident spoke positively of their key worker. Records, staff, and a resident confirmed that support to residents from family, and friends is evident. Residents have a routine during the week of attending their resource centres, so need to get up fairly early, but a resident confirmed that at weekends there is flexibility and choice in when they get up. A resident spoke of having choice in regard to going to bed. The home has a medication policy. Medication was stored securely during the inspection. Medication administration record sheets were fully recorded. A resident went out with a staff member to obtain his medication prescription Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 15 from the GP surgery during the inspection. The home has an accessible copy of medication guidelines from the Royal Pharmaceutical Society. Records confirmed that two staff members had received some ‘in house’ medication training. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Arrangements are in place for handling complaints objectively. There is awareness among the residents of how to complain and confidence that a complaint would be listened too. Arrangements are in place in regard to responding to any suspicion of abuse. There needs some development in these procedures to ensure that there clear appropriate ‘in house’ staff guidance in regard to the protection of vulnerable adults procedures. EVIDENCE: The home has a complaints policy/procedure. This procedure is displayed, and is recorded in the statement of purpose, and the service user guide documentation. The registered manager reported that the complaints procedure had been recently updated. A resident who kindly spoke to the inspector was aware that he would be supported if he wished to make a complaint. The complaints book recording book was not accessible during the unannounced inspection. A previous inspection confirmed that the format for recording complaints had been updated to ensure this procedure is followed appropriately. The complaints recording book needs to be available for inspection. The home has the Local Authority Protection of Vulnerable Adults policy, and an ‘in house’ adult protection policy. The in ‘in house’ policy needs to record a clear procedure of informing the appropriate Local Authority (and generally the police) prior to any investigation taking place in the event that there is suspicion or allegation of abuse. The care home also has policies and procedures in regard to counter bullying, whistle blowing, anti harassment, gift policy, and ‘managing violent situations’. The registered manager and records confirmed that staff had received abuse awareness training. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24,26 28, and 30 Arrangements are in place to ensure that the care home is well maintained. Resident’s bedrooms are individually personalised. Arrangements are in place to ensure that there is sufficient communal space to meet the residents’ individual needs. The residents are provided with clean and comfortable surroundings. EVIDENCE: The home is in keeping with the other houses in the vicinity. It is located within a few minutes walk from a variety of local amenities and facilities, which include shops and restaurants. Public bus and train transport facilities are very accessible from the home. A resident spoke of regularly ‘catching a bus’. A resident kindly showed the inspector around the home and garden. The home is maintained, with furnishings are of quality. It is clean, light and airy. The laundry is located separately from food storage, and food preparation areas. The washing machine has the facility to wash laundry at high temperatures. The home has a risk assessment in regard to infection control. Hand washing facilities are prominently sited, and are easily accessible by staff and others. Residents’ rooms are individually personalised, with personal items such as photographs, and pictures. A resident spoke of choosing items for his Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 18 bedroom. A resident had his own television in his room. The garden was maintained. A resident spoke of spending time in the garden. Communal facilities consist of a kitchen, utility room, sitting room, dining room and garden. Residents accessed these facilities freely during the unannounced inspection. The dining room area, which is fairly small, is also used as an ‘office’ facility for storing records, storing medication, and for staff to record information. At a previous inspection the inspector was informed that a loft extension to relocate the office and ‘sleep in’ areas had been considered by the registered person. This should be actioned (if it meets the appropriate planning and building requirements) so the dining room would then be a more accessible communal facility for residents. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33, 34 and35 Arrangements are in place to ensure that staff understand their job role and responsibilities, and understand residents’ care, and support needs. Arrangements are in place to ensure that the number, and skill mix of staff on duty enable resident’s assessed needs to be met. The recruitment procedures include required safeguards to offer protection to people living within the home. Staff receive appropriate training to be able to meet residents’ assessed needs including changing needs. EVIDENCE: Staff job descriptions, and a copy of the staff General Social Care Code of practice were accessible. Two staff personnel records confirmed that staff had received a statement of terms and conditions of employment. A staff member kindly spoke to the inspector of her role and responsibilities. The care staff and registered manager both knew the residents well, and had knowledge and understanding of their varied needs. The care home has an equal opportunities policy. The staff rota was inspected. It recorded the two staff on duty at the time of the inspection. These staff knew the residents well. There are one to two staff on duty when the residents are at home. There are two staff on duty prior to the residents leaving for their day services. The home during the week is not staffed during the hours when residents are attending day services. A staff member completes a ‘sleep in’ duty at night. Staff work also work in another Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 20 of the providers’ care homes, which is located in Harrow. The inspector was informed that this ensures that the is not a need for agency staff, and that when staff from the other care home work at 63 Kingsley Avenue they know the residents well, and have a good understanding of their needs. A resident spoke of the staff as being ‘nice’ and caring, and of having a key worker. Residents approached staff with ease during the inspection. Two staff personnel files were inspected. These contained required information, but one file did not have documentation in regard to a Criminal Records Bureau check. This information was supplied to the Commission for Social Care Inspection following the unannounced inspection. Records, and staff confirmed that staff had received appropriate staff training for the provision of care, and support to residents. A staff training plan was available for inspection. This training included manual handling training, medication training, food and hygiene training, and risk assessment training. The registered manager reported that ‘in house’ training using training videos took place regularly. This training included ‘effective communication’ and ‘challenging behaviour’. Staff and the registered manager confirmed that some staff were working towards achieving NVQ level 2 in care qualifications. Records and a staff member confirmed that staff receive an induction programme. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41 and 42 There is leadership, direction and guidance for staff to ensure that service users receive consistent quality care. The management approach of the care home creates an open, positive and inclusive atmosphere. Records are maintained and kept securely, to ensure that up to date information in regard to meeting residents’ needs is accessible by staff and that confidentiality is respected. The health and safety of service users is an issue identified by the service and promoted. EVIDENCE: The registered manager informed the inspector that she had completed the NVQ level 4 management qualification. She reported that this NVQ course had been beneficial in regard to developing her knowledge and skills. The registered manager spoke of her role in the participation in the review of policies and procedures. She undertakes periodic training, and has had several years experience of working with adults with a learning disability. Records, Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 22 and the registered manager confirmed that she generally works during the weekdays. Staff, a resident and observation confirmed that the manager was approachable, and that the processes of managing, and running the home are open and transparent. Records, and staff confirmed that there was a clear sense of direction from the manager and proprietor. The registered manager works hard to meet inspection requirements, and staff who spoke with the inspector were judged to be motivated. Staff spoke of receiving regular staff supervision. Generally records, which were requested by the inspector, were available for inspection. The registered manager reported that some records were in the process of being reviewed, and these were located at the other care home of the provider. Some policies and procedures had not been reviewed since 2003. The registered manager reported that she was in the process of reviewing policies with the provider. It is recommended that when records are removed from the care home for review that a copy is left in the care home. Records were kept securely. A format of accident/incident recording documentation that is in accordance with the Data Protection Act 1998 was supplied to the Commission for Social Care Inspection following the unannounced inspection. Required fire safety checks were recorded. Records confirmed that staff had received fire training. The home has a fire risk assessment. Health and safety risk assessments were available for inspection. Food and hygiene safety guidelines were displayed. The home has a food and hygiene policy. Fridge and freezer temperatures were recorded. A resident who spoke to the inspector had an awareness of health and safety issues. An up to date certificate of employers liability insurance was displayed. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clover Residents Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 x G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 24 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 9 Regulation Reg 12, 13(4) Requirement There needs to be a swimming risk assessment in place that is accessible by staff within the care home for any resident who goes swimming. The complaints recording book needs to be available for inspection. The in ‘in house’ abuse policy needs to record a clear procedure of informing the appropriate Local Authority (and generally the police) prior to any investigation taking place in the event that there is suspicion or allegation of abuse. Timescale for action 1/8/05 2. 3. 22 23 Reg 17(3)22 reg 12 13 (6) 1/8/05 1/9/05 4. 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. Refer to Standard 9 Good Practice Recommendations The shopping risk assessment should be further developed to include more information in regard to the risks of carrying shopping that could be ‘heavy’. Risk assessments should be further developed. G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 25 Clover Residents 2. 3. 24 41 The registered person should consider plans for an office area that is located away from the dining area. It is recommended that when records are removed from the care home for review that a copy is left in the care home. Policies/procedures should be reviewed at annually. Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clover Residents G62-G11 S17575 63 Kingsley Rd v217525 7.6.05 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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