Inspection on 02/10/08 for Adepta John Paul House 7-9 Pound Lane

This inspection was carried out on 2nd October 2008.

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

Other inspections for this house

Adepta John Paul House 7-9 Pound... 30/09/09

Adepta John Paul House 7-9 Pound... 02/10/07

Adepta John Paul House 7-9 Pound... 25/05/06

Adepta John Paul House 7-9 Pound... 18/11/05

Adepta John Paul House 7-9 Pound... 13/06/05

Adepta John Paul House 7-9 Pound... 09/12/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

CARE HOME ADULTS 18-65 Adepta John Paul House 7-9 Pound Lane John Paul House 7-9 Pound Lane Willesden London NW10 2HS Lead Inspector Andreas Schwarz Key Unannounced Inspection 2nd October 2008 10:00 Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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 Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta John Paul House 7-9 Pound Lane Address John Paul House 7-9 Pound Lane Willesden London NW10 2HS 020 8451 6843 020 8343 8876 dorretta.mcgregor@adepta.org.uk www.pentahact.org.uk PentaHact Ltd trading as Adepta 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) Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2007 Brief Description of the Service: John Paul House is one of a number of care homes formerly managed by Hillstream Care Limited. The organisation merged with Pentahact in September 2004. The home is registered to accommodate 8 adults with learning disabilities. At the time of the inspection there was no vacancy. The weekly fees range from £62.35 to £ 94.45 per week. The property is situated on Pound Lane and there are good links with public transport. There are a number of shops close by. The property is detached and has a large driveway for off street parking. There is a large garden at the rear. The property consists of two floors and on the ground floor there are two bedrooms, a shared toilet and bathroom. There is an office, laundry room, lounge and large kitchen/diner. On the first floor are 6 further bedrooms for residents, bathroom with toilet, another toilet, a storeroom and a staff bedroom. Residents attend local day services and are supported to use community facilities such as leisure centres, parks etc. The home has its own transport Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The outcomes for people using the service are good; this is a two star service. This key inspection took place in October 2008 and lasted 7 ½ hours. The manager and operation manger was available during this inspection. An expert by experience accompanied us, the findings of the expert are included in this report. We send out staff and service users surveys, three service users surveys and two staff surveys were returned to us. The home returned a completed Annual Quality Assurance Assessment, which contained basic information about the home and support provided. We spoke to one service users and two members of staff during this inspection. We would like to thank everybody involved in this key inspection. What the service does well: What has improved since the last inspection? The home has met all fourteen requirements made during the last key inspection. The service users or their representative sign assessments. A signatory list of staff competent administering medication is in place and all staff are booked to go on refresher medication training. The home has a complaints book and has received no complaints since the last inspection. All staff has or work towards achieving their National Vocational Qualification in Care. The home has re-carpeted and re-painted communal areas since the last inspection. Requirements made in regards to improving the environment and do minor repairs have been met. Cleaning material is locked away safely. The manager is at the final stages of her application being registered with the Commission for Social Care Inspection. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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 Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 2 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. Prospective individuals are given the opportunity to spend time in the home. EVIDENCE: You told us in your Annual Quality Assurance Assessment: • The home had no admission in the past year. • Adepta has a full admission policy and all prospective residents are fully assessed to ensure the service is meeting their needs. This is what we found during this inspection: The home did not have any new admission since the last key inspection and has currently no vacancies. We looked at one assessment, which has been done in 1985, the assessment was detailed and provided good information about the resident. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 6, 7 and 9 during this inspection. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plan is a working document reviewed regularly involving the person and their representatives, as appropriate. Staff will be able to communicate with people using the service, and understand what their needs are. However, communication methods are basic, with little understanding of innovative or individual communication styles. The management of risk is positive in addressing safety issues while aiming for improved outcomes for people. EVIDENCE: You told us in your Annual Quality Assurance Assessment: Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 10 • • • We support tenants to make decision that effect their everyday life, such as the things they do, where they go and what activities they take part in. All tenants have a detailed care plan that identifies their personal needs and risk assessments are also in place. All care plan are reviewed quarterly and annually, changes are made when needed. This is what we found during this inspection: We assessed two care plans during this key inspection. Both records were detailed and looked at the person’s care and support holistically. One of the residents told us that he knows about his care plan and informed us that he is meeting with his key worker to discuss his care plan. The majority of residents living in John Paul House are non-verbal and we felt that care plans do not use a variety of communication aids. The home must use more pictures, symbols and photographs to involve residents in the care planning process. We observed residents moving around the home freely and choices if they want to go out or stay in the home are recorded in daily records. We assessed financial records, which were correct. Residents are unable to manage their own finances. We noted that one of the residents was contributing £47.00 to the use of the car, during the same period he spend £110.50. We asked the manager about this, she informed us that the home has only two drivers and if residents want to go out and a driver is not on duty they need to pay for a taxi. We think this practice is not fair and told the manager that residents’ contribution to the car must be reviewed. Risk assessments are of good standard and a number of risks have been assessed and staff is provided with a detailed risk management plan. Behavioural specialist have assessed residents who have behavioural problems and behaviour management plans are put in place. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 12, 13,15,16 and 17. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents access day services and the community, this does not happen always due to staffing shortages. Residents can meet friends and built or maintain friendships and relationships. The home provides and healthy, nutritious and culturally appropriate diet, which can be chosen by the residents. EVIDENCE: You told us in your Annual Quality Assurance Assessment: • People we support have meaningful activities in the community, go on holidays, dinning out, cinema, and social clubs and go for walks with friends. DS0000062635.V372620.R01.S.doc Version 5.2 Page 12 Adepta John Paul House 7-9 Pound Lane • We arrange and encourage residents to make choices. We support and encourage the people we support to maintain their emotional, independent living skills. This is what people told the expert by experience: • • Residents have a choice of food, and the menu is available in pictorial format, making it easy for the residents to choose. One resident said he was happy in the home and the staff is good. He has a choice of going out for activities; this was evident during this inspection. He had said he did not want to go to the day centre because he was not happy and chose to stay in his room all morning. A resident said he would tell the manager or a member of staff, if he was not happy about anything in the home. One staff member I spoke to said, “we are short staffed most of the time. When we plan activities with the residents we end up cancelling them as there are not enough of us to support the residents and do the housework”. • • This is what we found during this inspection: Residents living at the home attend various day services on various days based in Brent. None of the residents are currently in paid employment and are to their disability are not able to access colleges. The manager and staff told us that the home has good relationships with their neighbours. We viewed a timetables in both care plans, a range of activities are recorded in the timetable, i.e. eating out, Gateway Club, Church, aromatherapy, etc. We spoke to one resident about these activities and he told us that he goes there if he feels like it. The home is providing community based activities for one resident on Tuesday and Thursdays, during the inspection, which fell on a Thursday, three members of staff are on duty. The person requires two people to access the community. We discussed this with staff, which informed us that due to the current staffing situation it is very difficult to provide community based activities for residents. The home has a vehicle, service users contribute to the vehicle, but due to the lack of drivers, residents are not able to access the vehicle for outings or other chosen activities. Some residents have family members involved, who visit the home and take part in care plan reviews. One of the residents has an advocate. The home has a relationship policy and residents’ access day centres and Gateway clubs to make and maintain friendships and relationships. Residents informed us that they can choose when to get up, go to the day centre, sit in their room, etc. This was observed during this inspection. We noted that the kitchen was locked during this inspection. This was discussed with staff, who told us that this is for peoples safety. Risk assessments in the Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 13 home did not state this and records viewed showed no evidence that the kitchen has to be locked for people’s safety. Staff told us that residents take part in household activities; this however depends on their ability. We observed residents clearing the table during this inspection. The home has a menu plan, which uses pictures and photographs allowing residents to choose what they want to eat. The fridge and freezer was adequately stocked. The manager told us that shopping is done during the day of this inspection. The home is providing a range of cultural and English dishes and food eaten is separately recorded. A resident told us that he likes the food in the home. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 18, 19 and 20 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action plan. Residents have access to healthcare and remedial services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: This is what you told us in your Annual Quality Assurance Assessment: • We ensure that the people we support have regularly health checks, encourage and assist them in maintain their independence when supporting them around their personal care. DS0000062635.V372620.R01.S.doc Version 5.2 Page 15 Adepta John Paul House 7-9 Pound Lane This is what the expert by experience found during this inspection: • • • The toilet and bathroom doors were not marked or signed with a picture symbol. The dignity of the residents does not seen to be respected. One resident was wearing her nightdress and dressing gown in the lounge throughout our visit. Residents’ privacy does not seem to be respected. A resident was sitting on the toilet with the door open and a staff member stood by the open door. This is what we found during this inspection: We viewed personal care guidance in peoples care plan files. Staff spoken to demonstrated understanding of how to support people around their personal care. We discussed with a member of staff and the manager the issue of a service user not being dressed appropriately. We were informed that over the past months the person has started to refuse getting dressed. This has been picked up and the home is planning to assess the person by the in-house behaviour intervention team and look at triggers and ways to change this new behaviour. Residents appeared to know were bathrooms and toilets are located in the home. We had however difficulties finding the toilet during this inspection. We observed one resident sitting on the toilet with the door open; staff told us that the person does not close the door when she is using the toilet. We recommend looking at a self-closing mechanism for the toilet and bathroom door ensuring peoples privacy and dignity. Residents are supported to access health care professionals such as dentists, doctors, opticians, chiropodists, psychiatrist, behaviour specialists, etc. Visits are documented and recorded in people’s files. Residents are registered with their local General Practitioner. We viewed in one file clear and detailed epilepsy guidance and records of epileptic seizures. We checked the Medication Administration Sheet, which had no gaps. The home has a medication policy in place. Staff and training records confirmed that they have received training in the administration of medication. A signatory list of staff competent to administer medication is in place. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 22 and 23 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are encouraged and know how to voice satisfaction and dissatisfaction about the care and support provided by the home. Residents are protected by procedures and skilled staff from abuse and live in a safe home. EVIDENCE: This is what you told us in your Annual Quality Assurance Assessment: • • We respond rapidly to any complaints received. There is a clear policy on how to deal with and respond complaints in place. This is what people told the expert by experience: Resident spoken to said he would tell the manager or a member of staff if he were not happy about anything in the home. This is what we found during this inspection: Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 17 The home has a complaints policy in place, which is compliant with National Minimum Standards. The home has received four anonymous complaints since the last inspection. We have been informed about this complaints and have received satisfactory documentation demonstrating how the complaints have been investigated and dealt with. Staff spoken to demonstrated understanding of reporting and recording procedures of safeguarding adults’ allegations. The home did not make a safeguarding adults referral since the last key inspection. The home forwarded us an up to date training list. The list showed that only 47 of staff have received Safeguarding adults training in the last four years. The manager told us that Safeguarding adults training is ongoing, which is evident in the training programme viewed during this inspection. In addition to this all staff except staff recently starting to work at the home has National Vocational Qualification in Care, one of the mandatory units within this qualification is adult protection. We however recommend providing Safeguarding adults to all staff employed. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 24 and 30 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, clean, culturally appropriate and homely environment. EVIDENCE: This • • • is what you told us in your Annual Quality Assurance Assessment: We listen to the feedback about the environment. The service is now decorated and the lounge area has been re-carpeted. We plan to purchase new sofas, new furniture and fittings, and personalise the home according to the wishes of the residents. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 19 This is what the expert by experience found during this inspection: The garden is not accessible for wheelchair users as there are steps from the kitchen to the garden. One resident uses a wheelchair and a walking frame to support his mobility. This is what we found during this inspection: The home has been repainted and the lounge and communal area has been recarpeted. During the tour of the home we noted at all previous requirements have been dealt with. None of the residents invited us to see their rooms. The home has received a good report following the Health and Safety audit undertaken by Perry Scott Nash in September 2007. The home continues to feel very cramped, this can however not been solved easily and no further requirement has been made regarding this. The lounge was nicely decorated and pictures relevant to people’s culture and ethnic background were displayed. The home was clean and free of any offensive odours. Staff receives Health and Safety training and were observed cleaning the home. The utility room was locked and appropriate facilities such as washing machine and clothes dryer are in place. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 32, 34 and 35 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is providing staff from different backgrounds with different skills and qualifications. An ongoing training programme ensures skilled staff supports people using the service. Robust recruitment checks ensure only staff that are safe working with vulnerable clients is employed. EVIDENCE: This is what you told us in your Annual Quality Assurance Assessment: • • • We provide training for staff, at all levels. All staff has now completed their National Vocational Qualification in Care level 2. One new staff member is in the process of commencing their National Vocational Qualification in Care Level 2. DS0000062635.V372620.R01.S.doc Version 5.2 Page 21 Adepta John Paul House 7-9 Pound Lane This is what a member of staff told the expert by experience: • “We are short of staff most of the time, when we plan activities with residents we end up cancelling them as there are not enough of us to support the residents and do the house work”. A member of relief staff said she would like to do some training in supporting people with challenging behaviour, but this was not offered. • This is what we found during this inspection: During the day of this key inspection three staff were on duty in the morning. Three residents were at home; one of the residents did not get up before lunchtime. Staff was observed to be busy but did not appear to be rushed of their feet. There was permanent and relief staff on duty. Training, annual leave and sickness is covered by permanent relief staff. The home has employed one new member of staff since the last inspection. Staffing files are kept in the homes head office, which was agreed by the Commission for Social Care Inspection Providers Relationship Manager. The manager informed us that staff records are kept in the home for staff who were recruited after January 2008. Staff interviewed confirmed of having had an interview and having to provide references, before employment was offered. The manager informed us that all but one member of staff hold or work towards their National Vocational Qualification in Care. Staff can access training provided by the agency and a rolling training programme is available to staff to choose from. We viewed training records which demonstrated that staff have attended various training, which was provided by internal and external training providers. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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): We looked at National Minimum Standards 37, 39, and 42 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is working towards being qualified to run the Home. The home has access to professional business and financial advice and has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. The home has a consistent record of meeting relevant health and safety requirements. EVIDENCE: Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 23 This is what you told us in your Annual Quality Assurance Assessment: • • • The organisation is providing training for managers. The current manager has worked for Adepta for the past six year. At present the manager is completing her Registered Managers Award. This is what we found during this inspection: The manager has started her registration with the Commission for Social Care Inspection. She is in the process of completing her National Vocational Qualification in Care. Staff spoken to was overall very positive about the help and support provided by the manager. One member of staff told us that she would like the manager to be a bit stricter with staff in particular if there are problems. We have viewed the most recent business plan, which focuses on people using the service, staff and the environment. People using the service have regular meetings and records were available for inspection. The home returned an Annual Quality Assurance Assessment within the given timescale, information provided in the Annual Quality Assurance Assessment was basic, information from the Annual Quality Assurance Assessment is included in this report. Staff is meeting monthly to discuss issues with residents and any business relating to the home. We looked at Safety check certificates, which were all up to date. Fire safety checks such as regular drills, fire point checks, fire alarm checks are done regularly and are up to date. Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.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 3 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(a) Requirement The responsible person must ensure the home is using more ways to communicate with residents, e.g. pictures, symbols and photographs to involve residents in the care planning process. The responsible person must review service users contribution to the car in particular id drivers are not available. The responsible person must ensure that there are adequate staff on duty enabling residents to access the community if the choose to do so. Timescale for action 01/12/08 2. YA7 13(6) 01/12/08 3. YA13 17(2) 01/12/08 4. YA16 16(2)(m) The responsible person must 01/12/08 ensure that residents can access the kitchen at all times or provide records and assessments why it is not safe for them to do so. The registered person must provide a ramp enabling residents with mobility problems DS0000062635.V372620.R01.S.doc 5. YA24 23(2)(n) 01/01/09 Adepta John Paul House 7-9 Pound Lane Version 5.2 Page 26 to access the garden independently from the kitchen. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations The registered person should display signs or pictures on doors ensuring that residents and visitors know were the door will lead to. The registered person should look into ways, which ensures peoples privacy when using toilet and bathroom facilities. The responsible person should continue to provide Safeguarding adults training ensuring staff have a good understanding o reporting and recording procedures. The registered person should provide training to permanent and relief staff ensuring that a skilled workforce supports people using the service. 2. YA19 3. YA23 4. YA35 Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Adepta John Paul House 7-9 Pound Lane DS0000062635.V372620.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!