Inspection on 04/01/07 for 79 Harrow View

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 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 14/12/05

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 HCSN 79 Harrow View 79 Harrow View Harrow Middlesex HA1 4TA Lead Inspector Richard Adkin Key Unannounced Inspection 4th January 2007 10:00 HCSN 79 Harrow View DS0000017538.V325290.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 HCSN 79 Harrow View DS0000017538.V325290.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. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service HCSN 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 Sean Robert Mathew Brown 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) HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 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. 14th December 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 1988. 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. There is a block contract in place for the residents who originate from Harrow; except for one external placement. Residents pay rent per week between £62.35 - £94.55, which goes directly to Harrow Consortium. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place midweek on two separate days during the day in early January 2007. The focus of the inspection was to assess the care home’s performance against the key national minimum standards and to see how the previous requirements and recommendations had been addressed. A tour was made of the premises and the Inspector met with residents, care staff and the Manager. Records and polices and procedures were looked at during the course of the inspection. The Inspector would like to thank all residents and staff for being made most welcome. What the service does well: What has improved since the last inspection? What they could do better: The recording of incidents needs to be tightened up and be outcome driven. Several repairs need to be undertaken in the care home. There is a problem with a continual flow of hot water being pumped up to the top floor of the house. There is an underlying issue of maintenance being carried out within reasonable timescales. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 6 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. HCSN 79 Harrow View DS0000017538.V325290.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 HCSN 79 Harrow View DS0000017538.V325290.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential admissions to the home only take place if the service is confident staff have the skills to meet the assessed needs of the prospective resident. It is a flexible inclusive process. EVIDENCE: There have been no new residents in the care home for at least seven years. However, one resident is in the process of having a trial stay at a placement locally that will more appropriately meet the resident’s complex needs. The home has a ‘Referral and Admission’ policy, which was reviewed in March 2006 by the Manager. The Inspector was informed by the Manager of the process of referrals for any vacancies that may arise at the care home. There is a discussion of vacancies at a ‘Spare Panel’ where multi-disciplinary agencies attend to look at potential matching of a resident’s individual needs with what the care home can offer. Harrow consortium for Special Needs are represented at this Admissions Panel. A number of trial stays take place. There is flexibility built in to ensure that the potential resident and the residents in the home are comfortable. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 9 The home’s admission policy is a clear policy. Inherent in the policy is addressing the potential residents’ aspirations, assessing their needs and the importance of review at the end of the assessment stay and having a link assessment worker allocated to the person having a trial stay. Reviews are a central part of the care planning process at the care home. The Inspector looked at the Service User Guide (reviewed July 2006), which confirmed the care home’s commitment to promoting each resident’s potential and the values of the service. HCSN 79 Harrow View DS0000017538.V325290.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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promoting independence of residents is balanced by minimising risk. Residents are given support and are empowered to make informed choices. EVIDENCE: At the time of the previous unannounced inspection a risk assessment for one resident needed to be reviewed to provide clarity as to whether the resident could or could not smoke in their room. It was required that the risk to the environment and the safety of other residents and staff must be clearly documented. This needed to include recorded staff guidance in monitoring the risk and resident’s actions in regard to smoking within the care home (including bedrooms). The resident posing a significant risk around smoking has now moved on to a placement that addresses his needs and risks more appropriately. All residents have a fire risk assessment. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 11 One resident described the staff as being most supporting and that they were ‘very nice kind people’ to work with. It was recommended previously that general and individual risk assessments be further developed within the care home. This has taken place and links to the care plans more strongly, how risks etc. affect day-to-day living. Records and discussion with staff and residents confirmed that steps and actions are taken to minimise risks. Risk assessments and fire risk assessments looked at by the Inspector were up to date. The risk assessments are comprehensive and include medical, physical, mobility, and social etc. elements. Staff at the care home prepare substantial reports prior to CPA reviews, covering medication, mental health, physical health, activities outside of the house, relationships, family contact and finances. Specialist requirements are addressed. Residents spoken to by the Inspector confirmed that they were given support and empowered to make choices about their lives. Residents’ independence is meaningfully promoted. Each resident has a room key and staff are respectful about going to a resident’s room. HCSN 79 Harrow View DS0000017538.V325290.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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encourages residents to take control of their life and is actively involved in the running of the home. Family and friends feel welcome and know they can visit the home at any time. Food and mealtimes are a positive experience for residents The care home promotes independence and choice. Food is creative and nutritious. EVIDENCE: The range of activities that residents take part in is wide and varied. There are a range of work and day care activities that residents attend and a range of activities that residents take part in. Every day living skills including HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 13 involvement in household duties were observed and discussed with residents and staff. At the time of the inspection it was observed that some good quality home cooked food was available for residents. Positive comments were received from residents about the food available. There was a bowl of fruit available and a cold purified water dispenser. The evening meal is the main meal and each resident takes in it turn to cook. Consideration and discussion takes place about balanced and nutritional diets. The benefits to diet and good mental health and good memory are discussed in community meetings. A cookery class takes place fortnightly to introduce dishes. Two members of staff take a lead in this area. Menus are drawn up with residents. There is a weekly shopping rota where residents contribute. Most residents draw up their own personal shopping list and shop for fresh ingredients for the meal that they are cooking. Residents spoke to all felt that contact was supported with family and friends and visitors were made most welcome. There was a strong sense of support that residents gave each other and also as a group, taking part in activities locally like the cinema or meals out. Everyone spoke positively about the house cat and the importance of having a pet in the home. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Residents have right of access to meeting their health, emotional and social needs. Medication procedures and practice have been progressed. EVIDENCE: At the last unannounced inspection medication needed to be stored securely at all times; out of date medication needed to be discarded. An assessment was needed also for any resident prior to self-medicating taking place. It was also recommended that each resident receive an individual assessment in regard to administrating his or her own medication. It was a goal in the service development plan for the home to achieve self-medicating for residents. No one is currently self-medicating; however, this is now being taken forward via individual CPA’s. The process is structured and gradual. There is a goal to achieve 30 of the residents to be self-medicating by April 2007. The Manager updated a review of progress in self-medicating in November 2006. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 15 Discussion had taken place with Boots the previous month about the plans for self-medicating. Medication is stored in a locked cabinet in the office, which is locked if no member of staff is present. There is no medication stored in the fridge. The Pharmacist from Boots visits twice a year to check the medication cupboard contents. There were no issues arising; out of date medication had been discarded. Records looked at confirmed that the healthcare needs of residents are addressed. Residents access a range of healthcare appointments and specialist healthcare appointments. Residents were satisfied with the respectful supportive nature of care that they received from staff. The residents are actively involved in all aspects of their care. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the service and feel safe and feel that their views are taken into account. The training of staff in the area of protection is up to date. EVIDENCE: Four members of staff attended at the end of last year, the Introduction to Adult Protection Basic Awareness (on 14/12/06). The Manager also attended the Investigating and Interviewing for Protection of Vulnerable Adults course and will shortly attend a further POVA course with the Deputy Manager. The Inspector looked at the complaints book, but there had been no complaints for several years. Evidence was seen in the care home’s community agenda and minutes (August 2006) of discussion about complaints taking place and being encouraged. FWA complaints leaflets are displayed along with CSCI’s information in the communal area. Five incidents were recorded as having taken place since the last inspection. Notification to CSCI has occurred when appropriate. Review, outpatient appointments, staff discussion and so on pick up incidents. The recording of incidents needs to capture the conclusions or outcomes of the incident and the HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 17 recording needs to be more process driven. Evidence was seen however, of incidents being fully considered and followed through by staff at the care home and professional colleagues. Away days happen yearly with residents and community meetings happen fortnightly. Residents’ views were seen to be taken on board and acted upon reasonably. Residents spoken to felt safe and supported by the Manager and staff at the care home. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, tidy, comfortable and welcoming. EVIDENCE: The care home feels homely. The dining area and living room are comfortable and pleasant. Residents spoken to like the home where they live and their bedrooms. One resident kindly showed the Inspector her bedroom. It was recommended previously that the systems were in place for ensuring that maintenance and repairs are carried out/reviewed. The care home staff refer maintenance concerns and issues to Harrow Consortium who assess whether they can undertake the work, then the consortium refer on to Paddington Churches Housing. The next stage to take place is that there is a discussion about paying for the repair. On occasion there has been dispute about resolving payment that has led to delays in work being completed. An HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 19 example of this concerned a requirement that arose at a previous inspection concerning the repair of a sink in one of the resident’s rooms was still cracked after almost a year. There remains an issue about the repairs and maintenance being progressed at the care home. The Manager and staff regularly send e-mails to support a trail concerning requests for repairs etc., but the strong recommendation remains that there needs to be a system in place that ensures maintenance and repairs are promptly completed. A quiet room has been created on the ground floor. This is well decorated and furnished and a peaceful spot. A major refurbishment is about to be undertaken in the office area. A cleaner comes into the care home three times a week; one resident is also employed to undertake cleaning tasks in the care home. Cleaning was being undertaken on the occasion of both the days that the Inspector visited. The home was clean and hygienic throughout during the course of the inspection. HCSN 79 Harrow View DS0000017538.V325290.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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are skilled in their role and residents have confidence in the staff that care for them. Staff receive appropriate training. Recruitment practice has improved. Staff are supervised and supported in their role. EVIDENCE: Evidence was needed that all staff have received a satisfactory Criminal Record Bureau check. It was also recommended that the staff personnel files be reviewed to ensure that all the documentation and information is easily accessible and further work is needed in this area. FWA hold central records of all CRB checks and pass the CRB number and any recorded offences to the Manager. All agency staff employed have to show their CRB before commencing and a copy is kept of the original in a secure book to which only the Manager has access. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 21 The Manager has reviewed the files. The Inspector looked at the files of two staff members and further streamlining is needed of the files. The Manager keeps supervision records separately to personnel records. The Manager currently supervises six staff members, including the Deputy. At the moment there is one vacancy at the care home. FWA hold the original personnel records at head office but the Manager keeps a copy. Staff spoken to were positive about the supervision they received every 3-4 weeks. Newer members of staff have supervision more regularly. No induction records were available for two staff members who have worked at the care home for several years. Since coming into post a year ago, the Manager had introduced an Induction Programme (Skills for Care – Common Induction Standards Social Care Adults). This was looked at for one member of staff and the process was linked to supervision. The Inspector sat in on the staff handover meeting that took place at lunchtime, looking at progress of residents. The Manager was in the process of introducing appraisal for staff members. The policy was looked at by the Inspector and the appraisal of a staff member that had taken place recently. The Inspector looked at the training folder for staff members. There is a summary of training undertaken by all staff. For instance the staff group had attended recovering model training. The staff training records were not fully up to date in terms of records of certificates awarded and this needs addressing. Good feedback was received from residents and observed by the Inspector concerning the skills of staff. The process of a resident having a trial stay at another care home with the view to moving on was taking place at the time of the inspection when a farewell do was taking place. Preparation for the move with the resident and other residents was noted to be undertaken in a sensitive and skilled manner. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a strong ethos of being open and transparent in all areas of running the home. The Manager and staff are resident focussed. Fire procedures are up to date. Processes are in place to increase the quality of life for residents. EVIDENCE: A number of requirements and recommendations arose at the last unannounced inspection concerning the conduct and management of the care home. The registered person needed to supply the Commission for Social Care Inspection with a report in regard to an annual development for 79 Harrow View. This is now in place and identifies key objectives for the care home, which are reviewed and acted upon. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 23 The Manager should be completing an NVQ Level 4 training course. The Manager has commenced the Registered Managers Award. A number of steps needed to be taken to address the health, safety and welfare of residents. The registered person needed 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. Magnet door closures are in place that close when the fire alarm goes off. Cleaning agents (COSHH) needed 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. These items are kept in the locked office. A door within the care home that was not presently closing needed to be repaired. Until this essential repair had taken place an appropriate risk assessment needed to be in place. All these areas around doors and fire protection have been addressed. Finally, it was recommended that 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 for Social Care Inspection and other appropriate organisations of plans, particularly if they concern environmental changes. The latter item has been successfully addressed. Details were shown to the Inspector of the planned smoking shelter in the garden to be completed. There has been positive reaction by residents for this move. The intention is to have a possible patio heater. The creation of a quiet non smoking room has been a positive spin off of exploring the development of a smoke free environment. The Inspector looked at two fire files. The one that contains checks is kept in a fireproof box. Fire alarm checks are taking place regularly. Evidence was recorded of regular discussions with residents around fire matters, fire quizzes take place regularly with prizes, and residents take part in checking fire equipment. The Manager and the staff team are committed to continually improving the service. HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x HCSN 79 Harrow View DS0000017538.V325290.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA23 YA24 Regulation 13(4)(c) 23(2) Requirement The recording of incidents must include outcomes and be more process driven. The basin surround in one service users room needs maintenance. (Previous timescales of 01/09/05 01/03/06 not met.) The hot water does not flow in two hand basins in the upstairs bathroom, and one resident’s room. Timescale for action 01/05/07 01/05/07 3. YA42 23(2) 01/05/07 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 YA24 YA34 Good Practice Recommendations It remains recommended that systems in place for ensuring that maintenance and repairs are carried out be further reviewed. It remains recommended that the staff personnel files be reviewed to ensure that all the documentation and DS0000017538.V325290.R01.S.doc Version 5.2 Page 26 HCSN 79 Harrow View information is easily accessible. 3. YA34 Staff training records should be kept fully up to date. HCSN 79 Harrow View DS0000017538.V325290.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. 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