Inspection on 14/12/05 for 79 Harrow View

This inspection was carried out on 14th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

79 Harrow View 21/10/08

79 Harrow View 04/01/07

79 Harrow View 18/05/05

79 Harrow View 06/01/05

79 Harrow View 29/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 79 Harrow View 79 Harrow View Harrow Middlesex HA1 4TA Lead Inspector Judith Brindle Unannounced Inspection 14th December 2005 08:50 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 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 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 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. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 79 Harrow View Address 79 Harrow View Harrow Middlesex HA1 4TA 020 8863 0981 020 8861 0735 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) Harrow Consortium for Special Needs Mr Allan Claudius Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Temporary variation for named service user GG aged 65 years for the duration of his stay. Temporary variation for named service user DA aged 65 years for the duration of his stay. 18th May 2005 Date of last inspection Brief Description of the Service: 79 Harrow View is a care home providing care, support and accommodation for 9 adults who have mental health needs. Harrow Consortium for Special Needs is the proprietor of the care home. The Family Welfare Association is the care agent and employs the staff. Paddington Churches Housing Association owns the property. The registered care home was opened in 1995. The home is located in a busy residential road close to central Harrow. It is a large semi-detached house and consists of three floors. The home is within a few minutes walk from a variety of amenities, which include shops, banks, restaurants, parks and leisure services. There are also accessible train and bus public transport facilities of close to the care home. The service users rooms are single, and are located on each floor. Communal space includes two sitting rooms, and a kitchen/dining area. The home has a garden, which is enclosed, well maintained, and accessible to residents. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 4.5 hours during the day in December 2005. The focus of the inspection was to spend a significant part of the inspection with residents to obtain their views of the service provided, and to assess as to whether previous inspection requirements had been met. The inspector was pleased to meet all the residents during the inspection. Two residents kindly showed the inspector their rooms, and one resident accompanied the inspector on a partial tour of the care home. The staff on duty were very helpful, and were able to provide all the documentation and information asked for by the inspector. The documentation inspected included residents’ care plans, some policies and procedures and health and safety documentation. The registered manager has recently left his position as manager of 79 Harrow View and a new manager is now in post. The manager is in the process of applying for registration with the Commission for Social Care Inspection, and was present for part of the unannounced inspection. Commission for Social Care Inspection feedback/comment cards were given to residents, and other feedback forms given to staff to be distributed to health and social care professionals, relatives, and significant others. Two residents kindly completed their comment cards during the inspection. Comment cards received confirmed that that the residents were very satisfied with the service provided. All the requirements from the previous inspection apart from two had been met. 16 National Minimum Standards were inspected, and these were all met or almost met. What the service does well: The care home has a very welcoming atmosphere, and has continued to provide a service of quality. . Residents are supported by staff to be as independent as they are able too. Residents are empowered, and the care home is very much ‘their’ home. A resident reported that the home was ‘like the Harrow View family’. All the residents who kindly spoke with the inspector were very positive about the service provided. There were many examples observed during the inspection of residents making choices. Staff are motivated, competent, and have a good knowledge, and understanding of residents varied needs, and are keen to provide a quality service. The residents have a pet cat, which residents spoke fondly of. Within a week following feedback from the inspection the manager responded to the issues which were identified and raised by the inspector during the inspection, and informed the Commission for Social Care Inspection of how and 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 6 when these requirements and recommendations had been met and/or would be met. What has improved since the last inspection? 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. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 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 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Arrangements are in place to ensure that residents have their needs assessed prior to admission to the care home, which ensures that the service is appropriate for meeting their individual needs. EVIDENCE: The home has an admission policy, and a procedure for referral. There have been no residents admitted to the care home for several years. The admission procedure includes a recorded process of referral and assessment, with residents’ involvement. The inspector was informed during the previous inspection that the purchasing authority and provider would complete assessment of prospective residents’ needs, with involvement from the resident. The three care plans inspected recorded evidence of comprehensive assessment of residents’ varied needs, which are regularly reviewed. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7(partially inspected) and 9 Arrangements are in place to ensure that each resident has a plan of care and support, which reflects their identified needs. Residents are empowered and supported to make decisions about their lives. Residents are supported to take risks. These should be further developed and reviewed to ensure that residents are supported to be as independent as possible, and that any risk is identified. EVIDENCE: All the residents have a care plan. Three care plans were inspected. These included evidence that health, social and welfare needs were identified and that staff guidance was in place to meet assessed needs, and specialist requirements. The care plans inspected recorded evidence of having been regularly reviewed, with the individual resident’s participation. Staff, residents, and records confirmed that the residents have a key worker, who meets with them regularly, and supports them in meeting goals. Residents, and staff who kindly spoke with the inspector had a good understanding of the key worker role. Residents were positive about their key worker. Residents confirmed that they were supported and enabled to make choices about their lives. This was clearly demonstrated during the inspection. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 10 Residents were observed to have keys to their own room. Limitations in regard to choice are recorded within a risk assessment format, and this includes consultation with the individual resident. Records confirmed that action is taken to minimise identified risks and hazards. Records, and staff confirmed that there was recorded staff guidance in regard to a residents’ behaviour, which could be a fire risk. But this needs review as there needs to be clarity as to whether the resident can or cannot smoke in their room. The risk to the environment, and in regard to the safety of other residents, and staff must be clearly documented. This needs to include recorded staff guidance in monitoring the risk and residents’ actions in regard to smoking within the care home (including their bedrooms). Advice needs to be sought from the Local Authority fire service if needed. The issue of smoking within the care home and in bedrooms was discussed with staff and the manager. The inspector was informed by the manager following the inspection that this issue had been discussed with his the housing manager and that she would be writing to residents in regard to the smoking policy. There was some recorded evidence of general risk assessments in regard to individual residents. It is recommended that general and individual risk assessment be further developed within the care home. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,14 Arrangements are in place to ensure that residents have the opportunity to take part in a variety of activities, including leisure pursuits, educational, and employment opportunities. EVIDENCE: Residents who kindly spoke to the inspector reported that they participated in many varied, chosen activities. These included involvement in educational and employment opportunities. All the residents participated in some activity of choice during the inspection. Everyday living skills, which include resident participation in household duties, were clearly demonstrated during the inspection. A resident kindly informed the inspector of the various household duties that residents participated in within the care home. A resident is employed part time to complete some domestic duties in the home. Residents informed the inspector of a recent West End show that they had been to, and had enjoyed. They spoke of a planned staff and residents meal out in celebration of the festive season. Another resident spoke enthusiastically of a staff member who was teaching him Italian and how to cook Italian dishes. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 12 Residents spoke of the contact that they had with family and friends. Some of this contact takes place regularly. Residents have access to a telephone. A resident spoke of attending local clubs where she met friends. Residents spoke of enjoying a summer holiday this year. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 and 20 Arrangements are in place to ensure that residents’ health and welfare needs are met. Medication is administered safely. Some areas of storage of medication need review. EVIDENCE: Records confirmed that monitoring of residents healthcare needs take place. Staff and residents confirmed that residents are supported, and facilitated to take control and be fully involved in their own health care. A resident demonstrated this during the inspection in organising a dental appointment for a check up. Records, and residents informed the inspector that residents accessed GP, optician, chiropody services and hospital appointments. Services to meet specialist healthcare needs are accessed by residents. Records confirmed that monitoring of residents healthcare needs take place. Medication is stored securely. Currently residents do not self medicate due to the recent medication administration system that has been introduced. The issue of self medication was discussed with the manager. He reported that there were plans to ensure that each resident would receive assessment (with the residents involvement) in regard to administrating their own medication. This is recommended. Medication administration records that were inspected were up to date and fully recorded. A staff member was observed to 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 14 administer medication safely during the inspection. A staff member who spoke with the inspector had a good understanding of the safety aspects of medication administration. Records confirmed that a staff member had received medication training. Three bottles of liquid medication were observed to be not stored securely in a resident’s room; one of these bottles was dated 2004. A staff member reported that action would be taken to remove this bottle during the inspection. Medication needs to be stored securely at all times and out of date medication must be discarded. Residents need to receive assessment prior to self medication. The manager informed the inspector that action had been taken by the resident and their key worker to ensure that the medication is stored securely within the care home’s medication cupboard. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. They were assessed during the previous inspection, and there were no requirements. EVIDENCE: 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24, 26 and 30 The home’s premises are suitable for its stated purpose, and for meeting resident’s assessed needs. Resident’s bedrooms are personalised and decorated to the resident’s individual choice. Arrangements are in place to ensure that the care home is clean and hygienic. EVIDENCE: The home’s location is close to central Harrow. Residents spoke of regularly accessing the amenities and facilities of Harrow. A resident reported that he planned to go out shopping in Harrow with a staff member during the afternoon of the unannounced inspection. The house is in keeping with other houses in the area. A resident kindly showed the inspector around the care home. She informed the inspector of areas of the care home that had been recently decorated. Some maintenance requirements had been recently carried out. A resident was having her bedroom window repaired during the inspection. Staff informed the inspector that a basin surround in a resident’s room was awaiting repair. This was a previous requirement and needs to be actioned by the registered person. Staff spoke of delays in attending to maintenance issues within the care home. It is recommended that the systems in place for 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 17 ensuring that maintenance and repairs are carried out, be reviewed. Furnishings and fittings within the care home were judged to be of quality. Two residents kindly showed the inspector their bedrooms. They reported that they were very happy with the rooms and were pleased with the recent decoration and maintenance that had been carried out. They both said that they had chosen the colour schemes of their rooms. Both bedrooms were individually personalised. The care home is clean, warm and airy. Laundering facilities are located away from food storage and food preparation areas. Protective clothing is accessible to staff. A resident spoke of her participation in the laundering of her clothes. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32 and 34 Residents are supported by competent, skilled staff. Arrangements are in place to ensure that resident’s are protected by the home’s recruitment policy and practices. EVIDENCE: Residents spoke of staff being supportive, and of having understanding of their needs. Residents were observed to approach staff frequently during the inspection, and staff were observed to be on each occasion positive, and respectful towards the residents. Records and staff confirmed that staff were experienced, skilled and competent in regard to carrying out their role and responsibilities. Copies of certificates confirmed that staff had completed varied and appropriate training in regard to meeting the needs of residents. A staff member reported that she had recently completed a NVQ level3 in care course. Three staff personnel records were inspected. These contained required documentation. Two staff files of staff that had been employed for several years in the care home did not include evidence that the staff had received a satisfactory Criminal Record Bureau check. There needs to be evidence that all staff have received a satisfactory Criminal Record Bureau check. Following the inspection the manager informed the Commission for Social Care Inspection that he had contacted the Family Welfare Association human resource 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 19 department, and that staff were looking into accessing the CRB documentation. It is recommended that the staff personnel files be reviewed to ensure that all the required documentation and information is easily accessible. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 Resident’s benefit from a well managed care home. Arrangements are in place to ensure that there are systems in place to monitor the quality of the service. EVIDENCE: The registered manager has recently left the position of manager of 79 Harrow View to take up another management post within the Organisation. The present manager has been in post for several weeks, and kindly informed the inspector of his experience. He reported that he had completed a management and development course, and was a qualified NVQ assessor. He said that he had sixteen years experience of working in social care, and seven of those years were spent working with adults with mental health needs. He gave examples of how he has continued to update his skills, and informed the inspector of his management experience The manager spoke of plans to complete an NVQ level 4 training course. This should be actioned to meet the National Minimum Standards. The manager informed the inspector that he 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 21 was in the process of registering with the Commission for Social Care Inspection. There was recorded evidence that some policies had been reviewed. Records, staff and service users confirmed that service user individual service users plans are regularly reviewed. Service monitoring visits by the representative of the proprietor take place monthly and copies of this documentation are regularly supplied to the Commission for Social Care Inspection. There was recorded evidence of a recent review of the Family Welfare Association (which is the care agent and employs the staff), which had involved service users, within the FWA organisation and had recorded objectives. During a previous inspection staff informed the inspector that the home remains part of a quality assurance scheme and annually service users from the care home, and ‘others’ have the opportunity to complete satisfaction questionnaires in regard to the service. The registered person shall supply to the Commission a report in regard to an annual development plan of 79 Harrow View. This was discussed with the manager, who reported that he would access this documentation. Records confirmed that staff had received health and safety training, food and hygiene training, and manual handling training. A staff member informed the inspector that the water systems within the care home had recently been assessed in regards to risk of Legionella. The ‘smoking’ room was very ‘smoky’ despite the extractor fan in the room being turned on. The manager and care staff informed the inspector that there has been an examination of ways to ensure that residents and staff are of minimal risk from smoke inhalation from residents smoking in the present smoking room. There should be an action plan in place to meet this need and the registered person should inform the Commission of Social Care Inspection, and other appropriate organisations of plans, particularly if they concern environmental changes. The manager informed the Commission that this issue continues to be under consultation, and that the CSCI would be kept informed of its progress. Doors of the office and the door near to the office were propped open. The registered person needs to ensure that doors are kept closed unless there is an appropriate safety mechanism in place that allows the door to be left open during the day at minimal risk to residents. This was discussed with the manager, and following the inspection he informed the Commission for Social Care Inspection that appropriate safe mechanisms would be put in place to ensure that some doors could be left open during the day safely. The registered person needs to ensure that this is actioned. Some doors within the care home were not closing as required. The inspector was informed following the inspection that all but one door has been appropriately adjusted to ensure proper closure, and that there were plans to have this door repaired. This needs to be actioned by the registered person. Until then an appropriate risk assessment needs to be in place. Some cleaning agents were observed to be not kept securely i.e. in an upstairs toilet room, and in the laundry. These items need to be kept securely unless 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 22 there is a recorded risk assessment that confirms that it is of low risk to have them not locked away. Required fire safety checks were recorded. The employer’s liability insurance certificate was displayed. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 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 X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 79 Harrow View Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000017538.V269505.R01.S.doc Version 5.0 Page 24 YES 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 YA9 Regulation 12, 13(4) • Requirement Timescale for action 01/02/06 2 YA20 13 (2)(4) 3 YA24 23(2) 4 YA34 13(4)(6) A residents’ risk assessment needs review as there needs to be clarity as to whether the resident can or cannot smoke in their room. • The risk to the environment and the safety of other residents and staff must be clearly documented. This needs to include recorded staff guidance in monitoring the risk and residents’ actions in regard to smoking within the care home (including their bedrooms). • Medication needs to be 01/02/06 stored securely at all times. • Out of date medication must be discarded. • Residents need to receive assessment prior to self medication. The basin surround in one 01/03/06 service users room needs maintenance. Previous timescale 01/09/05 not met. There needs to be evidence that 01/03/06 DS0000017538.V269505.R01.S.doc Version 5.0 79 Harrow View Page 25 5 YA39 24 6 YA42 23(4) 7 YA42 12,13(4) 23 8 YA42 12, 13 (4) 23 all staff have received a satisfactory Criminal Record Bureau check. The registered person shall supply to the Commission a report in regard to an annual development plan of 79 Harrow View. The registered person needs to ensure that doors are kept closed unless there is an appropriate safety mechanism (agreed by the fire service) in place that allows the door to be left open during the day at minimal risk to residents. Previous timescale 01/08/05 not met. Cleaning agents (COSHH) need to be kept securely unless there is a recorded risk assessment that confirms that it is of low risk to have them not locked away. • The door within the care home that is not presently closing safely needs to be repaired. • Until then an appropriate risk assessment needs to be in place. 01/04/06 01/02/06 01/01/06 01/02/06 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. 3 Refer to Standard YA9 YA20 YA24 Good Practice Recommendations It is recommended that general and individual risk assessment be further developed within the care home. It is recommended that each resident receive an individual assessment in regard to administrating his or her own medication. It is recommended that the systems in place for ensuring that maintenance and repairs are carried out, be reviewed. DS0000017538.V269505.R01.S.doc Version 5.0 Page 26 79 Harrow View 4 5 6 YA34 YA37 YA42 It is recommended that the staff personnel files be reviewed to ensure that all the documentation and information is easily accessible. The manager should complete an NVQ level 4 training course. There should be an action plan in place to meet the needs of non-smokers within the care home, and the registered person should inform the Commission of Social Care Inspection and other appropriate organisations of plans, particularly if they concern environmental changes. 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Harrow Area office Fourth 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 79 Harrow View DS0000017538.V269505.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!