Inspection on 31/10/06 for 8 Courtenay Avenue

This inspection was carried out on 31st October 2006.

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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Courtenay Avenue 29/11/05

8 Courtenay Avenue 10/10/05

8 Courtenay Avenue 16/11/04

8 Courtenay Avenue 22/07/04

8 Courtenay Avenue 25/02/04

Similar services:

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

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

CARE HOME ADULTS 18-65 8 Courtenay Avenue T/A Idelo Limited 8 Courtenay Avenue Harrow Middlesex HA3 5JJ Lead Inspector Ms Sue Barker Key Unannounced Inspection 31st October 2006 09:30 8 Courtenay Avenue DS0000035899.V306383.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 8 Courtenay Avenue DS0000035899.V306383.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. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 Courtenay Avenue Address T/A Idelo Limited 8 Courtenay Avenue Harrow Middlesex HA3 5JJ 020 8428 2338 020 8420 1861 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) T/A Idelo Limited Ms Minna Roach Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: 8 Courtney Ave is a registered care home providing personal care and accommodation for a maximum of 3 adults aged 18-65 who have learning disabilities. The registered providers are Mr Winston Mayers and Ms Diane Eastman trading as Idelo Ltd. The registered manager is Ms Minna Roach. The Registered Provider also owns another registered care home in Courtenay Avenue. The home is located on a main road that leads into central Harrow. It is close to a bus stop that allows service users access to Harrow’s shops, pubs and other community and leisure amenities. The care home is a two storey dwelling with all bedrooms located on the first floor. The building is well set back from the road. All of the bedrooms are single and none have en-suite facilities. The home has gardens to the rear that are well maintained and accessible through the rear conservatory and side extension. The weekly placement fee for the service is determined by the needs of the potential resident and is available from the company’s Business Manager. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were two service users living in the care home at the time of the unannounced inspection. The unannounced inspection commenced at 9.30pm and finished at 6.05pm. The Inspector was pleased to meet and speak with both residents, the member of staff on duty and Ms Roach. The inspection also included viewing the communal areas of the home and one resident kindly showed the Inspector their bedroom. The Inspector also viewed a sample of the statutory records maintained by the care home. Residents spoke extensively about their likes and dislikes, weekly routines, family contacts, holidays and attendance at day placements. Residents let the Inspector know what they do at their day placements. Residents also commented positively about their accommodation and the care/support available to them in 8 Courtenay Avenue. The member of staff was preparing the resident’s evening meals in the kitchen. Each resident had a different meal that was served at approximately 5.30pm. Residents commented that they had “liked” their meals. One resident had a vegetarian meal and the other had meat. Residents kindly advised the Inspector that they “liked” living in 8 Courtenay Avenue. Residents and staff made the Inspector most welcome and facilitated the unannounced inspection process fully. The unannounced inspection covered all key inspection National Minimum Standards. What the service does well: 8 Courtenay Avenue offers small and homely community based accommodation for to up to 3 residents. Residents living in 8 Courtenay Avenue have individual care plans that offer extensive guidance and advice on how to work with them in a consistent manner. Care plans cover aspects relating to residents’ needs in terms of their equality and diversity. Residents living in 8 Courtenay Avenue were observed to be offered ordinary living choices by staff during the unannounced inspection. The home has completed written assessments of those risks identified in respect of individual residents living in 8 Courtenay Avenue. Residents are supported by staff to participate in a range of activities/pursuits both within the care home and the wider community. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 6 Inspection confirmed that residents living in 8 Courtenay Avenue enjoy a range of family and personal contacts. Daily routines within 8 Courtenay Avenue presented as being in place to accommodate resident’s individual lifestyles. Residents are supported/assisted by staff to choose and eat a range of meals within the care home. Residents’ personal care and support needs are met by staff in the care home and this aspect forms part of their care plans. Staff support residents to access preventative healthcare support and services within the community. Residents have access to information about how to complain in 8 Courtenay Avenue. Residents are protected through the care home’s Protection of Vulnerable Adults from Abuse procedures. Residents’ live in a homely and comfortable building. Residents’ environment within the care home is largely clean and hygienic. Residents present as being supported by a knowledgeable and caring staff group in 8 Courtenay Avenue. Residents are supported and protected by the care home’s recruitment procedures. These have not been implemented since the last unannounced inspection, as there has been no staff recruitment. Residents are supported by a staff team that individually undertakes an induction when they start work in the care home. Subsequent required training is made available to staff What has improved since the last inspection? What they could do better: Work need to be done on developing care plans in areas regarding the use of physical restraint. Residents’ medication is largely stored and administered safely within the care home, though attention must be paid to ensuring a clear audit trail of items administered to residents from the blister pack. Within the building attention needs to be paid to those areas identified within the requirements below. Attention needs to be paid to the cleanliness of one area of the building identified below. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 7 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. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 8 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 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ referred for placements in 8 Courtenay Avenue will participate in an assessment of their needs, this will include their visiting the care home. EVIDENCE: The resident group remains the same since the last unannounced inspection, with no new residents having been admitted. The Inspector viewed a policy for the care home in respect of admission. This indicated that potential residents would be visited in their home situations, as part of their assessment, and the admission of that person would be based upon the assessment. Care plans were in place for all residents living in 8 Courtenay Avenue. 8 Courtenay Avenue DS0000035899.V306383.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents living in 8 Courtenay Avenue have individual care plans that offer extensive guidance and advice on how to work with them in a consistent manner. Care plans cover aspects relating to residents’ needs in terms of their equality and diversity. Work need to be done on developing care plans in areas regarding the use of physical restraint. Residents living in 8 Courtenay Avenue were observed by the Inspector to be offered ordinary living choices by staff during the unannounced inspection. The home has completed written assessments of those risks identified in respect of individual residents living in 8 Courtenay Avenue. EVIDENCE: Care plans were in place for both residents. Each contained individual ‘strengths & Needs’ assessments for the resident. The care plans covered aspects relating to residents’ individual needs in terms of mobility, hygiene, eating, religious and spiritual needs, relationships and environment. Daily routines are identified for each resident, with their likes and dislikes in terms of food. Care plan summaries are available within the daily report books. Care plans included some clear and detailed guidance for staff in terms of the 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 11 resident’s personal hygiene needs. The care plans viewed clearly identified the individual equalities and diversity needs of residents namely regarding their clothing, religious worship and food preferences. Residents have identified key workers. Reviews are held every 6 months and there was evidence of the input of residents into their care plans and reviews. The Inspector discussed the need to have clearly agreed guidance for working with residents who may challenge the service physically. The Inspector gathered from the documentation that staff had undertaken breakaway technique training in order to work with residents who may challenge in this way, though there was no indication of any multidisciplinary approach to developing safe methods of working with the residents. This is required. Staff maintain daily notes of residents’ welfare and well-being. Care plans included evidence of consultation with resident’s families. The Inspector discussed the adoption of a person centred approach to care planning within 8 Courtenay Avenue. This is being considered. The Inspector observed staff communicating choices to residents verbally. This was regarding where they wished to be in the building or whether they wanted to eat. Residents kindly let the Inspector know what they liked doing. Residents confirmed that they were “OK” in 8 Courtenay Avenue. The Inspector viewed individual risk assessment documentation within one resident’s care plan file. This related to risks identified both within the care home and in the community. There was evidence of risk assessments being reviewed. Risk assessments included an indication of the numbers of staff needed to safely work with individual residents. Risk assessments are individualised for each resident. Risk assessments have been developed in respect of the use of physical restraint. 8 Courtenay Avenue DS0000035899.V306383.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 at least once during a 12 month period. 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 the service. Residents are supported by staff to participate in a range of activities/pursuits both within the care home and the wider community. Inspection confirmed that residents living in 8 Courtenay Avenue enjoy a range of family and personal contacts. Daily routines within 8 Courtenay Avenue presented as being in place to accommodate resident’s individual lifestyles. Residents are supported/assisted by staff to choose and eat a range of meals within the care home. EVIDENCE: Residents kindly let the Inspector know about the range of day placements/college that they attend, including what they particularly enjoy doing. Residents also spoke about how they spend their evenings and weekends. Residents spoke about how they had recently celebrated Diwali. Residents had recently had a holiday. There were discussions about where they wished to go on holiday in 2007. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 13 Residents spoke about activities that they enjoy within the community. The Registered Provider has a vehicle in order to assist residents to go out within the community. Within the staff rota it was noted that there are times when there are 2 members of staff on duty. Resident’s family and significant contacts were clearly documented within their personal files. Inspection of the visitor’s book indicated that there were a range of visitors to 8 Courtenay Avenue. Residents kindly spoke to the Inspector about their family contacts and when they had seen their families The Inspector observed that residents were addressed by their first names. In addition staff knocked on residents’ bedroom doors before entering. One resident was observed unlocking their bedroom door. Residents’ individual ‘self help skills’ are considered as part of the care home’s care planning processes. Staff informed the Inspector that residents’ daily routines are determined by their planned activities and pursuits for the day. Residents ate their dinner in the care home. Residents let the Inspector know that they take turns to cook with dinner with staff. Residents also assisted with other aspects of the meal such as laying the table. Residents kindly let the Inspector know that they “liked” what they eat in 8 Courtenay Avenue. They also let the Inspector know that they decide what they want to eat and this goes on the menu. On the day of the unannounced inspection residents had aubergine curry, lentils and rice for their dinner. One resident ate this meal with a breaded turkey burger. A chocolate mousse followed this. The Inspector viewed the resident’s menus that contained a range of individual options for each resident and also includes fruit. Residents ate their dinner in the dining room. Staff maintain a record of the food that residents eat. Staff maintain a record of residents’ weights on a monthly basis. 8 Courtenay Avenue DS0000035899.V306383.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ personal care and support needs are met by staff in the care home and this aspect forms part of their care plans. Staff support residents to access preventative healthcare support and services within the community. Residents’ medication is largely stored and administered safely within the care home, though attention must be paid to ensuring a clear audit trail of items administered to residents from their blister packs. EVIDENCE: Residents have care plans in respect of their ‘hygiene’. One resident spoke to the Inspector of their own personal care routine and preferences. Residents also spoke of their preferences in terms of getting up and going to bed. During the week this is determined by the time that they have to attend day placements. The Inspector viewed contact details for residents’ GP’s within the care home’s documentation. There was also recorded information about residents’ preventative health care checks and medical appointments are noted and planned for. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 15 The Inspector viewed the medication storage facilities in the care home. Medication is stored in locked cupboards. The contracted pharmacist supplies resident’s medication to the care home in blister pack form. Staff hold medication on residents’ behalf and no residents self-medicated at the time of the unannounced inspection. A record is maintained of medication administered to residents by staff. This was fully signed to the day of the unannounced inspection. There were written instructions for staff on the circumstances in which medication is to be administered to residents on a PRN basis. The Inspector noted that medication is not always dispensed from the blister packs on the date stated if supplies of previously held medication is being used up first or the item was stopped and restarted at some point. It must be ensured that there is a clear written account of medication received into the home within the blister pack (including when it is taken by the resident) and if it is returned to the pharmacist. 8 Courtenay Avenue DS0000035899.V306383.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 at least once during a 12 month period. 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 the service. Residents have access to information about how to complain. Residents are protected through the care home’s Protection of Vulnerable Adults from Abuse procedures. EVIDENCE: The ‘Complaints Procedure’ is displayed pictorially for residents in the care home. This indicates that complaints will be responded to within 28 days. There is information about how to contact the local office of the NCSC. This should be amended to include the correct regulatory authority for the care home. A record is maintained of any complaints received by the care home. There had been no entries since the last unannounced inspection. Residents indicated that they would talk to staff in the event of anything not being right. The Inspector viewed the Protection of ‘Vulnerable Adults from Abuse procedure’ for 8 Courtenay Avenue. This included definitions of abuse and process for dealing with any allegations. Additionally the Inspector advised Ms Roach to obtain a copy of Harrow Council’s Protection of Vulnerable Adults from Abuse Procedure. Ms Roach was aware of the need to report any allegations of abuse. Records indicated that staff had undertaken training in Protection of Vulnerable Adults from Abuse as is required. Staff hold monies on behalf of residents within a lockable facility. The Inspector observed staff recording transactions involving residents’ monies 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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 the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ live in a homely and comfortable building though attention needs to be paid to those areas identified within the requirements below. Residents’ environment within the care home is largely clean and hygienic, though attention needs to be paid to one area identified during the unannounced inspection. EVIDENCE: The unannounced inspection included a tour of the communal areas of the building and one resident kindly showed the Inspector their bedroom. The building presented as comfortable with homely touches. It was found to be warm, bright and clean. The home was free of offensive odours. Furnishing and fitments presented as of good quality. Ms Roach advised the Inspector that she was planning to arrange for the care home to be redecorated in the near future. Requirements noted are listed below. Residents spoke positively to the Inspector about their accommodation in 8 Courtenay Avenue. It was described as “OK”. The home is close to community transport, leisure and shopping facilities in Harrow. There is a bus stop a short distance away. The house is in keeping 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 18 with others in the immediate vicinity. Residents were observed accessing different areas of the building. There is a small garden to the rear of the building that contained some seating for residents. The premises were noted to be clean during the unannounced inspection and staff were observed undertaking cleaning tasks. The care home has a laundry that is located in a side extension in an area of the home that does not require washing to be transported through areas where food is stored, prepared, served and eaten. The laundry contains a domestic washing machine and dryer, with some shelving/storage facilities. The washing machine washes to 95ºC. The Inspector observed supplies of protective clothing for staff to use. Residents participate in the cleaning of the care home. Arrangements for this are clearly displayed. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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 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): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents present as being supported by a knowledgeable and caring staff group in 8 Courtenay Avenue. Residents are supported and protected by the care home’s recruitment procedures. Residents are supported by a staff team that undertakes an induction when they start work in the care home. Subsequent required training is made available to staff. EVIDENCE: The Inspector observed staff communicating with residents verbally. The Inspector observed the residents communicating what they wanted and staff replied. Residents presented as confident in their verbal approaches to staff. During the unannounced inspection, staff presented as knowledgeable regarding residents and their individual needs and preferences. Staff kindly spoke to the Inspector about resident’s needs and preferences in terms of their religion and cultural heritage. Ms Roach advised the Inspector that 1 member of staff had completed their NVQ Level 3 in care. Two other members of staff are undertaking an NVQ Level 2 in care. It is planned that 50 of care staff employed in 8 Courtenay Avenue will achieve a minimum of an NVQ Level 2 in care as is required. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 20 There is a small staff team employed in 8 Courtenay Avenue. The staff rota contained the names of 4 care staff in addition to Ms Roach. There were no staff vacancies at the time of the unannounced inspection and no new staff had been recruited since the last unannounced inspection. Hence the Inspector did not view any staff records during the unannounced inspection. Ms Roach advised the Inspector that she was evaluating the training needs of the staff team. The Inspector viewed the staff training records for 8 Courtenay Avenue. New staff undertakes a period of induction that accords with LDAF accredited training. A range of training is available to the staff team including moving and handling, medication, health and safety, medication, physical intervention and breakaway techniques, POV A, emergency first aid, food hygiene and Protection of Vulnerable Adults. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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 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): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a care home that has a registered manager, whose focus is resident development and well-being. Stakeholders have been consulted about their views on the quality of care available in 8 Courtenay Avenue and this work is underway. Residents’ health, safety and welfare are largely promoted and protected within the care home, with 2 requirements arising. EVIDENCE: Ms Roach has been the Registered Manager for 8 Courtenay Avenue since the home was registered in 2002. Ms Roach spoke to the Inspector of her management aims for 8 Courtenay Avenue. This involved accommodating a third resident in the care home and consideration of residents’ long-term goals, day care options and development of their independence skills. Ms Roach spoke of her plans to redecorate areas of the building. The care home presented as well run during the unannounced inspection. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 22 The Inspector viewed the quality assurance work for 8 Courtenay Avenue. An ‘Annual Development Plan’ had been developed for 2006. This included aspects relating to business and financial management, customer focus, team excellence and compliance and control. Ms Roach planned to use questionnaires to seek the views from stakeholders on the quality of care provided by 8 Courtenay Avenue. This process must include seeking the views of residents. The Inspector viewed information for staff around safe working practice displayed in the care home. The Inspector viewed Certificates of Worthiness in respect of the various checks that had been carried out on the care home’s electrical and gas appliances and installation, though this did not include one to do with the testing of the care home’s portable electrical appliances. There was also no information regarding what steps had been taken to avoid the risk of legionella. Staff carry out a range of health and safety checks within the care home including the daily testing of fridge and freezer temperatures. The Inspector tested the temperature of the hot water taps in the ground floor toilet area that ran warm to the touch. A first aid box is located in the kitchen There are secure places in the building for the storage of chemicals and COSHH guidance is available to staff. Risk assessments are in place with regard to safe working practice. The care home’s smoke alarms are tested on a weekly basis. A fire drill/practices had been carried out in the care home on 14/10/06. Staff had attended fire safety training on 1/4/06, as had the residents. There was a workplace risk assessment for the building dated 23/1/06. Staff maintain a record of any accidents or incidents that occur in the care home. 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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 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 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 x 3 x 3 x x 2 x 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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 YA6 Regulation 13 Requirement Ensure that there is clearly agreed written guidance for working with residents who may challenge the service physically that is subject to a multidisciplinary approach. It must be ensured that there is a clear written account of medication received into the home within the blister pack (including when it is taken by the resident) and if it is returned to the pharmacist. Redecorate the first floor bathroom door. (Previous timescale of 29/01/06 not met) Ensure that residents are able to shut and lock the bathroom door. The door handle is also very loose. Repair or replace the lino flooring in the side extension where ripped and ensure that the flooring is sealed around the edges in order to create an impervious surface. Replaced cracked electrical socket covers in the kitchen. Ensure that the cleaning of the DS0000035899.V306383.R01.S.doc Timescale for action 24/01/07 2 YA20 13 24/01/07 3. YA24 23 24/01/07 4 YA24 23 24/01/07 5 YA24 23 24/01/07 6 7 YA24 YA30 23 23 24/01/07 24/12/06 Page 25 8 Courtenay Avenue Version 5.2 8 YA42 23 9 YA42 23 ventaxia units is included in the cleaning schedules for the care home. Ensure that a Certificate of 24/01/07 Worthiness is available in respect of the testing of the care home’s portable electrical appliances. Ensure that information is 24/01/07 available regarding what steps have been taken to avoid the risk of legionella in the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 Page 26 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 8 Courtenay Avenue DS0000035899.V306383.R01.S.doc Version 5.2 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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