CARE HOME ADULTS 18-65
Aldenham Road 122 122 Aldenham Road Bushey Hertfordshire WD2 2ET Lead Inspector
Louise Bushell Unannounced 23.07.05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Aldenham Road 122 Address 122 Aldenham Road Bushey Hertfordshire WD2 2ET 01923 237770 01923 237770 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Walsingham Mr Albert Adomakoh Care Home 6 Category(ies) of LD LD Learning Disability - 6 registration, with number of places Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: There are none. Date of last inspection 22.11.04 Brief Description of the Service: 122 Aldenham Road is a large, two-storey, detached, family style house located in a residential area of Bushey. It offers accommodation to six adults who have learning disabilities.On the ground floor, accommodation comprises a large entrance hall, a bedroom, a bathroom with toilet, the lounge, a kitchen/dining room and a conservatory. The first floor consists of the remaining five bedrooms, a bathroom, a toilet and a small office/sleeping-in room. There is a covered outdoor area where service users may smoke if they choose, a small recreation room and an outhouse that houses the laundry and the freezers.There is a mature garden to the rear of the property and a small garden with additional space for four cars to park at the front. The house is situated on a main road and has easy access to Watford town centre. There are also local shops that are within walking distance. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of the year for the home. The inspection was conducted during the weekend to ensure that maximum service user consultation and input occurred throughout the process. The inspection only focused on several key standards and actively seeking service user feedback. This was a positive inspection in terms of the provision of care provided for the service users. The home is progressive in terms of internal management systems and an increase in the staff numbers to ensure service user needs are met. What the service does well:
During the inspection the staff within the home were observed to interact well with all service users. Some service users had specialist needs and proactive guidelines are in place to support in the management of behaviours within the home. Staff were observed to follow guidelines and were respectful of all service users individual needs. All service users appeared to be comfortable within their home environment and the home further supports this by presenting as a homely atmosphere. During the inspection a senior member of staff was leading the shift, due to unforeseen circumstances a new agency member of staff was required to work within the home. The home provided a detailed first day induction, which covered suitable areas. Following discussion with the agency member of staff it was apparent that they felt that the verbal initial induction phase was beneficial and ensured that immediate needs of all service users could be met. Many positive annotations were received from the service users throughout the inspection. These were displayed through verbal communication, facial expression and physical gestures. Topics discussed included meals, holidays, service users bedrooms and visitors. Positive practices were observed with the administration of medication within the home. Each service user has signed and agreed consent to administered medication. This held on the medication file and is present with a photo of each service user. The home has recently transferred its medication management system to another company, which is working extremely well within the home. Regular pharmacy monitoring visits also occur. Records were well maintained and an effective management system of the storage, administration, receipt and disposal is in place. The home has a vehicle on site that can support service users links with the local community and access to community based activities. Fridge and freezer temperatures are well maintained within the home ensuring positive food
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 6 hygiene practices are occurring. The home is currently introducing new pictorial systems within the home ensuring that they are meeting individual communication needs. The home already has a pictorial tenancy agreement on the service users file, which encourages opportunity of understanding within the home. Staff are currently working on a new care planning system within the home, this involves all care plans being person centred and goals orientated. Currently the plans are in their early developmental stage however steady progress will continue. The home is ensuring that individual care plans are being provided and delivered to the service user in a method and format to meet individual need. Examples of the different styles of care plan to be implemented include, pictorial / symbol format, large pictorial format on display in a service users bedroom and on audiotape. Although these systems are not up and running currently once implemented they should be person centred and effective. What has improved since the last inspection?
Following the last inspection the home has had an entire new kitchen fitted. This now presents as an organised suitable communal space for all service users and staff. A number of bedrooms have been redecorated within the home. Discussions with one service user determined that he had been supported in making informed choices over the colour of the paint. Medication processes and practices within the home have been developed and sound systems now appear to be in place. The home has recently changed pharmacy providers and now has a proactive working relationship with the new provider. A new complaints procedure has been devised within the home and has recently been sent out to all families, friends and representatives. All service users are being informed of the procedure at the next service users meeting. Care plans are being developed within the home, ensuring that a person centred approach is achieved for all. The plans are in their early stages currently, however steady progress is being made. Work is occurring within the home on the implementation of a structured appraisal system ensuring consistent review and development of all staff. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 7 What they could do better:
The home is currently experiencing staffing shortages and attempts to recruit additional bank staff have occurred and the home is awaiting clearances. There is a need for recruitment to continue within the home, as currently there still remains a high usage of agency staff. On the day of the inspection there was one regular member of staff and two agency staff, one of whom had not visited the home before. All cleaning materials must be kept locked away when not in use. Due to the complex needs of the service users within the home there is a need for the home to complete a risk assessment regarding the use of gloves within the home. The home is awaiting a compliance certificate and check of the water system to ensure safety mechanisms are in place regarding Legionella disease. Once the works are complete on the 16th August, a copy of the certificate must be forwarded to the Commission for Social are Inspection. There are several areas within the home that require redecorating; this includes service users bedroom, the conservatory and the main hallways. Following discussion with the deputy manager it was determined that the home has received quotes for the works to be completed. The kitchen blind requires mending in order to ensure the home presents as a well maintained environment. A full renewal and redecoration plan is required by the home. Care plans within the home are currently being devised and developed. There is a need for the home to ensure that the progress made continues to ensure service user changing need is identified and monitored. Care plans must be concise and ensure that they are signed once implemented. All guidelines pertaining to the service users must be signed on implementation. The home should also implement further communication systems in the home to encourage and empower active participation and opportunity of understanding for all within the home. The menus within the home could be displayed in a user-friendly visual format encouraging choices for all. This was discussed at length with a member of staff and how best the project could be achieved. It is recommended that advocacy services are contacted to ensure that the rights and choices of the service users are supported and represented at all times. Risk assessments are present within the home, however they do not present as active working documents. There is a need for the home to complete a detailed fire risk assessment to ensure all areas are suitably covered and standard procedural checks within the home are meeting identified need. Information was past to the deputy manager regarding the completion of the fire risk assessment. Risk assessments must be reviewed and all signed upon completion and implementation. Walsingham have a five year plans and an “Our News” magazine that is published periodically the encourage service user involvement and participation. Within the home there was no evidence of these being on display despite them being new documents. Staff must encourage service user involvement within the home.
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 8 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. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4 & 5 Prospective service users needs are assessed prior to and during assessment at the home, ensuring all areas of individual living is assessed in order to ensure a service provision can be tailored to meet individual need. Each service user is issued with a contract of terms and conditions ensuring that service user rights are supported at all times. EVIDENCE: The home currently supports five service users within the home due to a vacancy in occupancy. The home has a well-structured and planned referrals and admissions policy to the home. All polices within the home had been reviewed following the last inspection. The home ensures that detailed assessments are carried out with the service user prior to them arriving at the home and whilst they are staying at the home within a trail period. The trial period ensures that the home can meet the service users\individual needs but also enables and empowers the service user to make an active choice regarding whether they wish to continue living at the home. The trial period within the home offers a variety of different stays over different periods of time, for example a prospective service user may visit the home for the day or for tea, followed by an overnight or weekend stay. The trial visits within the home are developed and implemented to meet individual need. Assessments are held on the service users file and cover a range of topics. The home then adapts a care plan from the assessment, which is continuously reviewed ensuring needs and preferences are being met at all times.
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 11 Relevant professionals assess service users requiring specialist interventions and documentation is held on file and adapted into a programme of care as required. Each service user is issued with a contract of tenancy that outlines the residency agreement between the home and the service user. The contract contains all require details and information to ensure that service users right and needs are protected and empowered. The contract is in a pictorial format and is suitable to meet the needs of the service user. All contract are signed either by the service user if able or by a representative and the registered manager. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 &10 Service users are not discouraged from engaging in activities that pose risk and are effectively managed to ensure that service users are supported as part of an independent lifestyle. Service users changing needs are identified within a care plan, thus ensuring that changing need, aspirations and goals are met and reviewed. EVIDENCE: Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 13 All service users have an individual care plan and an allocated key worker to support them in the home. Individual daily notes and guidelines for the service users where observed within the home. All service users are supported within the Care Management Framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The ethos within the home promotes that the care plans of each individual are owned by the individual. Care plans within the home are currently being devised and developed. There is a need for the home to ensure that the progress made continues to ensure service user changing need is identified and monitored. Care plans must be concise and ensure that they are signed once implemented. All guidelines pertaining to the service users must be signed on implementation. The home should also implement further communication systems in the home to encourage and empower active participation and opportunity of understanding for all within the home. The home holds service user meeting. However, due to complex needs of the service user group, at times seeking views is achieved through body language and facial expression and verbal communications. The home is linked to an external advocacy group and referrals have been made. The home has currently one vacancy for occupancy. Referrals have been received from prospective service users. It is recommended that advocacy services are contacted to ensure that the rights and choices of the service users are supported and represented at all times. The home holds a variety of risk assessments that are service user specific and generic. There is a need for the home to ensure that the risk assessments present as active working documents and are accessible to the reader. Service users are supported to take risks as part of an independent lifestyle and have good information on which to base their decisions. Risk assessments are in place for specific service protocols and specialist risk management area such as epilepsy and behaviours that may challenge. Risk assessments are required within the home for the use of gloves and a detailed fire assessment. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 & 17 Service users are encouraged to maintain family links thus encouraging individuality empowerment to make active choices in their lives. All service users are offered a healthy diet thus ensuring a supply of nutritious, varied and balanced diet. The method used within the home to display the menu needs is developing to ensure that service users are able to make active choices and have the opportunity to understand the available meals. EVIDENCE: Visitors are welcomed into the home at any reasonable time. Feedback determined that a number of the service users have visitors to the home and also are encouraged to visit people out side of the home. Advocacy services are used within the home but appear infrequent. The home should ensure that appropriate levels of external advocacy support services are utilised within the home to encourage user self-determination and active choices. The menus within the home could be displayed in a user-friendly visual format encouraging choices for all. This was discussed at length with a member of staff and how best the project could be achieved. Meals within the home are offered on a flexible basis and meal preparation encouraged service user involvement. Nutritional needs are initially assessed and the home reviews
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 15 individual circumstances and monitors closely specific areas as required for the promotion of health of the individual. Menus were available and the home has a four-week rolling seasonal menu, which appeared well balanced. Records are maintained of food consumed and offered. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 & 21 All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. The management of medication is effective within the home ensuring that service users are protected and supported in the process. EVIDENCE: All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. All care provided is individual and tailored to each person, with service users needs, choices and preferences being promoted. Assessments and reviews are continuously completed, through the Care Management Process, ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users needs are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. The home has a robust policy and procedure in place to support the safe administration, storage and receipt of medicines. All staff receive training prior to being deemed competent to administer medication. The home has actively
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 17 commenced seeking the views and wish’s of service users with regards to ageing and illness. Information was observed being available on a service user plan of care. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not fully assessed on this occasion. EVIDENCE: Not fully assessed on this occasion. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 28 & 30 The home is in need of some continued maintenance, redecoration and works throughout, to ensure it functions as a homely, comfortable, safe environment for the service users showing compliance with relevant legislation. Each service users individual space within the home is well decorated and maintained, reflecting individual choices and preferences. EVIDENCE: Shared space both compliments and supplements service users individual space ensuring that individual space is tailored to personal style and taste. All bedrooms within the home are well maintained and decorated. All service users are supported and empowered to decorate their individual rooms to their own taste and personalities. Toilet and bathing facilities ensuring that choices and preferences can be met, and specialist equipment is available as per individual service user need. There are several areas within the home that require redecorating; this includes service users bedroom, the conservatory and the main hallways. Following
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 20 discussion with the deputy manager it was determined that the home has received quotes for the works to be completed. The kitchen blind requires mending in order to ensure the home presents as a well maintained environment. A full renewal and redecoration plan is required by the home. The home has ample shared space available and this includes a detached area for smoking, an activities room, large lounge, large Kitchen diner, conservatory and a well maintained garden area. Suitable laundry facilities are available and service users are encouraged to complete their own laundry tasks with appropriate support available to them. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 & 36 All permanent staff are clear about their roles and responsibilities, thus ensuring that service users benefit from a consistent approach to duties. The home does not provide sufficient staffing with complimentary skills to meet the needs of the service users at all times and thus a consistent approach, with the high use of agency staff within the home, is difficult to meet and effectively manage. EVIDENCE: Each member of staff has access to and is aware of their roles and responsibilities. The home has a copy of the job description and duties of all staff within the home available. Permanent staff have read and signed the document to ensure that they are aware of their duties and responsibilities. The home uses a high number of agency staff. During the inspection a senior member of staff was leading the shift, due to unforeseen circumstances a new agency member of staff was required to work within the home. The home provided a detailed first day induction, which covered suitable areas. Following discussion with the agency member of staff it was apparent that they felt that the verbal initial induction phase was beneficial and ensured that immediate needs of all service users could be met. Due to the vulnerability and complex needs of the service users there is a need for the home to ensure that suitable staff are working in such numbers and skill mix to ensure the well being and the safety of the service users at all times. The home does provide a high
Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 22 percentage ratio of service users to staff, however it is the skills and the knowledge of the staff that is paramount in order to meet diverse and complex needs of the service user group as opposed to numbers of staff. Recruitment must continue to ensure a consistent familiar approach within the home. Regular staff meetings occur within the home and minutes are maintained. Following discussion with a member of staff it was determined that regular supervision does occur within the home. Due to it being a weekend and the managers not being at the home, it was not possible to access to supervision records and this standard was not fully assessed. The member of staff explained the supervision process within the home and commented on its usefulness with professional and personal development. Information was provided on the day of the inspection with regard to the appraisal system within the home being developed. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 & 42 Systems for effective health and safety management are in place, works are still required within the home to ensure the safety is maintained. EVIDENCE: Systems for effective health and safety management are in place, there is a need for risk assessments to be reviewed and implemented to ensure the welfare of service users is continuously monitored. The home has a vast range of policies and procedural guidelines in place. Staff are requested to read and sign risk assessments and polices. The home has a multitude of risk assessments in place. All risk assessments must be actively reviewed and held as working documents. There is a need for the home to develop a detailed fire risk assessment and glove use risk assessment to ensure that all area’s of the home are assessed and periodically reviewed. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 24 All cleaning materials must be kept locked away when not in use. Due to the complex needs of the service users there is a need for the home to complete a risk assessment regarding the use of gloves within the home. The home is awaiting a compliance certificate and check of the water system to ensure safety mechanisms are in place within the home regarding Legionella disease. Once the works are complete on the 16th August a copy of the certificate must be forwarded to the Commission for Social Care Inspection. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x x x x 3 x 2 Standard No 31 32 33 34 35 36 Score 3 x 2 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Aldenham Road 122 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x x 2 2 x I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 26 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 6 Regulation 15 Requirement The registered person must ensure that all service users have a current and up to date person centred plan. (Carried forward from last inspection). The registered person must complete a detailed fire risk assessment and a risk assessment for the use of gloves within the home. Involvement of advocacy services within the home for those who have limited networks must occur. The development of a choice system for meals must occur to enable a flexible provision of suitable food which is varied. The home must have a planned maintenance renewal programme for the fabric and decoration of the premises with records kept. The registered person must ensure that at all times there are suitably qualified, competent and experienced persons working at the home. (Carried forward from last inspection). The registered person must ensure that the use of Timescale for action 30th September 2005 21st August 2005 2. 9 & 41 13 (4) 3. 17 12 (2) & 16 (2) (i) 30th September 2005 4. 24 23 30th August 2005 5. 33 18 (1) (a) On going 6. 33 18 (1) (b) On Going
Page 27 Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 7. 41 17 8. 42 13 (4) temporary/agency staff does not prevent service users from receiving continuity of care. (Carried forward from last inspection). Sufficent checks must occur within the home for Legionella testing. Once complete this must be forwarded to the Commission. All COSHH items must be locked away, or a risk assessment completed determining the management of the risk within exceptable levels. 21st August 2005 21st August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that all risk assessments are presented as active working documents to enable good practice by all staff. Aldenham Road 122 I52_s19263 Aldenham Road v239733 230705 stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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