Inspection on 31/10/05 for Alexandra Road Crisis Unit

This inspection was carried out on 31st October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alexandra Road Crisis Unit 24/03/09

Alexandra Road Crisis Unit 02/04/07

Alexandra Road Crisis Unit 18/08/06

Alexandra Road Crisis Unit 02/06/05

Alexandra Road Crisis Unit 03/02/05

Alexandra Road Crisis Unit 24/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Alexandra Road Crisis Unit 32 Alexandra Road Hornsey London N8 0PP Lead Inspector Peter Illes Unannounced Inspection 31st October 2005 10:30 Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alexandra Road Crisis Unit Address 32 Alexandra Road Hornsey London N8 0PP 020 8365 7287 88889829 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) London Borough of Haringey Janette Bryant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Younger Adults. Standards 24-30 - Environment or those equivalent Standard that may be published at the time, as required by Regulation 23 (1)(a); 23(2)(ap); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by April 1st 2005. In order to promote health and safety needs of service users living in Alexandra Road Crisis Centre, the provider must ensure that the home complies with all requirements contained in relevant Health and Safety legislation on an ongoing basis and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Younger AdultsStandard 42 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by April 1st 2005. The home may provide accommodation and personal care for up to 8 persons of either gender who are between the ages of 18-65 and who have Mental Health problems. 2nd June 2005 2. 3. Date of last inspection Brief Description of the Service: The Alexandra Road Crisis Unit is owned and run by London Borough of Haringey. The unit is unique in the borough and is not a full time residential service. It provides short-term emergency and respite services for up to eight people with mental health problems. Stays are typically from three days up to two weeks and may be an alternative to hospital admission. The unit is a three storey converted and extended domestic premises situated in a quiet residential street between Wood Green and Turnpike Lane. There are eight single rooms, several bathrooms and shower rooms, a choice of two lounges, a staffed kitchen, a separate dining room with facilities to make drinks and snacks, an attractive conservatory that is used as an alternative place to relax and to do artwork and a private garden. The unit has several aims, the focus of which is to provide good quality individualised support that is strengths and needs led. To facilitate personal development, to assist service users in development of alternative crisis responses and to foster appropriate coping strategies in order to return to their appropriate environment. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The registered manager had left the unit since the last inspection and recruitment is underway to this post. The unit also has three conditions of registration that are no longer needed for this home. Any further environmental or health and safety issues identified will be dealt with by statutory requirements and the home is registered for 8 service users with mental health problems. The home’s certificate of registration will be re-issued and CSCI documentation amended to reflect the above changes. This unannounced inspection took approximately four hours with the acting manager being present or available throughout. There were two service users accommodated at the home and six vacancies at the time. This was because the service was being temporarily being reduced to allow planned maintenance to be carried out to the building. The inspection included: independent discussion with one service user and independent discussion with three care staff. Further information was obtained from a tour of the premises and a range of documentation kept at the home. What the service does well: The unit provides specialist and sensitive short term care and support for service users that are in crisis and this is highly valued by service users. Records of service user’s needs and how they are to be helped to meet these is of high quality and reflects the specialist short-term nature of the work. Joint working with others from outside the home, including mental health workers enhances the service offered. This is especially relevant with regard to ensuring the frequent admissions to and discharges from the unit take place with the minimum of stress to service users. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective service users can be confident that their needs will be comprehensively assessed and agreed with them prior to admission to the unit. This is to ensure that these needs can be effectively addressed and to maximise the service user’s opportunities to obtain the maximum benefit from their short stay. EVIDENCE: The files of the two service users accommodated were inspected. Both of these contained: a multi-disciplinary pre-admission assessment including a detailed risk assessment coordinated by the referring agency; an in-house assessment of need, risk assessment and a risk management plan. There was evidence that the service users had been involved in and agreed to the above documentation. The service user spoken to confirmed that they had been involved in the assessment and admission process. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Service users needs and aspirations are set out in their care plans and these are reviewed most days with them to ensure that their changing needs continued to be met as their short stay progresses. Service users are supported to make as many decisions as possible for themselves to retain and maximise their independence. They are also supported to take responsible risks to assist keep them safe during their short stay at the unit. EVIDENCE: The two service user files inspected contained detailed care plans that included a range of agreed short term objectives with clear guidance for staff on how to assist the service user achieve these. The plans were informed by a range of assessment material and included a separate risk management plan that had been based on both external and in-house risk assessments. The plans seen had been reviewed on most days of the stay, there was also evidence on the individual contact sheets that the home had daily contact with external mental health professionals. The plans seen had been signed by the service users. The service user spoken to confirmed that they were fully involved in the writing of their care plan, reviewing it and in changes where these had been made. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 10 Both the service user files inspected contained a signed copy of a client agreement form that specified what to expect from staff and what staff would expect from them. This contained some restrictions on service users while staying at the unit such as the prohibition of alcohol and illegal drugs. The one service user spoken to stated that they were not keen on the rules regarding the actions the home would take if they did not return to the unit at the time they had agreed and if they did not contact the home to explain why they were delayed. The service user confirmed that they had agreed to this as part of the overall contract for staying at the unit but indicated that they were going to discuss this further with the multi-disciplinary team that they were meeting with later that day. Both the service user files inspected contained a detailed risk management plan that had been agreed and signed by the individual service user. This was based on a range of detailed information primarily obtained from risk assessments undertaken by external health and/ or social care professionals and by an in-house risk assessment completed by staff at the point of admission. The plan showed identified potential risks and gave clear guidance to staff in assisting to minimise these. These plans were reviewed at the same intervals as the care plans. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 Service users are supported to take part in a range of activities, including in the local community, where it is agreed that this meets their needs. Contact with friends and relatives is actively supported to the degree that the service user wishes. Service users are treated with respect and their rights and responsibilities are clearly stated with any limitations agreed with them. They also enjoy balanced and healthy meals that meet their needs and preferences although some routine maintenance is needed in the kitchen. EVIDENCE: The two service users accommodated had been admitted for respite during a period of crisis in their lives. The acting manager confirmed that where appropriate longer-term objectives such as to find appropriate employment or to continue their education and training can be included in service users care plans where this is helpful to maintain a service user’s mental health and stability in the longer term. The acting manager stated that the home provides a massage session, yoga session and a visualisation and relaxation group for service users weekly and that an ex resident runs a weekly working with clay session. The service user spoken to confirmed they had participated in one of Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 12 the above sessions and enjoyed it. The home is also allocated £3 per week per service user for activities of their choice. The inspector was informed that service users sometimes elected to pool this money and for example hire a DVD of their choice. The acting manager confirmed that service users are encouraged to continue to participate in the local community as they would do normally whilst at home if that assisted meet their needs at that time. One service user was attending an appointment in the community during the inspection. The service user spoken to also confirmed that they could come and go from the home as long as they kept staff informed of their plans although were not particularly happy about this as indicated in the Individual Needs and Choices section of this report. Service users are encouraged to maintain links with family and friends on terms that they can cope with. Where it is agreed with the service user the staff also support service users to maintain their privacy during their stay. The home has a weekly menu that is drawn up by the staff on the known needs of the service users who are likely to be in the unit on that week. The menu seen for the week of the inspection contained a range of balanced and healthy meals with a vegetarian option at each main meal where appropriate. Lunch on the day of the inspection included vegetarian samosas and salad. The inspector was invited to try these and they were delicious. The service user who also had lunch stated that the food at the unit was always good. The home has a full time weekday cook and a separate weekend cook that are responsible for the cooking of the main meals of the day. The weekday cook was knowledgeable and experienced and confirmed that the unit could cater for a range of special diets and also provide meals to meet the differing cultural needs of service users. He also stated that the unit would prepare alternatives if needed for individual service users. The inspector saw a kitchen comments book for use by service users that had a range of recent entries. One recent entry stated that the author especially “liked the rainbow trout with saffron and cream”. There were sufficient quantities of food including fresh fruit that was stored satisfactorily, was within its use by date and matched the menu. The inspector was pleased to see that food that had been removed from its original wrapping had been labelled to indicate when. This had been required at the last inspection. Food that had been removed from the freezer to defrost had also been labelled to indicate when it had been removed. The kitchen was well equipped and generally clean although dirt could be seen on the filters and fan blades in the kitchen’s extractor fan. The cook stated that he had reported that it needed cleaning professionally as it needed specialist knowledge to dismantle the fan to access the fan blades and filter inside. A requirement is made about this. It was also noted that the fluorescent light on Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 13 the kitchen ceiling did not have a diffuser and a requirement is made regarding this. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 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 Where service users need support with their personal care this is delivered in accordance with their needs and their individual preferences. They are also supported in meeting their physical and emotional health needs and to maintain as much control over this as possible for when they leave the unit. EVIDENCE: The acting manager confirmed that the majority of service users are generally independent with regard to their personal care. Where any personal care needs are identified these would be reflected in the individual’s care plan. Neither service user accommodated needed support with their personal care at this time. Staff support service users with any ongoing health care needs where they are identified in individual care plans. The acting manager confirmed that health care professionals who are involved with service users in the community would normally deal with any ongoing health issues. Because of the short-term nature of stays, service users keep their own GP’s. There was substantial evidence of mental health professionals input into monitoring and promoting service user’s mental and emotional health needs in partnership with the home’s support staff. There was a multi-disciplinary review meeting with one service user that was held during the inspection and a range of documentation from those professionals recorded on the service user files inspected. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users are able to express their views and concerns and have these appropriately dealt with by the unit. EVIDENCE: The unit has a satisfactory complaints procedure that was seen to be satisfactory and had been amended to include that complaints will be responded to within 28 days, as required at the last inspection. The inspector was informed that there had been no complaints received at the home since the previous inspection. The service user spoken to stated that she felt able to raise any concerns with the staff at the unit if they needed to. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Service users live in a home that is comfortable, well decorated and well maintained. Service users benefit from adequate numbers of toilets and bathrooms to meet their needs and these facilities are due to be refurbished in the immediate future. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home as well as for those that visit it. EVIDENCE: The unit remains safe, comfortable, well decorated, well maintained and is fit for purpose as a short stay unit. The unit has a pleasant garden that is overlooked by decking attached to the main lounge. The acting manager informed the inspector that the unit was going to effectively close for the following week to allow planned refurbishment to take place in identified areas within the unit. She went on to say that one of the two service users currently accommodated will remain for the next few days however and the home will maintain one emergency bed throughout this period. As part of the refurbishment all service user bedrooms will be supplied with new furniture, bed linen and curtains and an identified multi-purpose room will also be refurbished including removal of kitchen units that are currently in place there. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 17 A major part of the refurbishment will be to the shower, bath and toilet facilities on the first floor that serve seven of the eight service user bedrooms situated on that floor. Two separate and rather cramped shower rooms will be converted into one larger shower room. The bath/ toilet is being refitted but will remain the same size. The work to the shower and bath/ toilet had been previously identified by the provider organisation and the CSCI of their intention regarding this work. The work is to start within the planned timescale. The home was clean, tidy and odour free during the inspection. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 The unit has a well qualified staff team, in sufficient numbers, to support service users and to assist them in meeting their assessed needs. There is insufficient documentation kept at the unit to evidence a robust recruitment procedure is in operation to safeguard service users. Staff are offered a range of relevant training, including qualification training, to assist them in their own personal development and in meeting service users needs. However, further clarity is needed regarding one identified area of statutory training. EVIDENCE: There are nine residential support worker posts at the home. The inspector was informed that three staff in these posts have undertaken national vocational qualification (NVQ) level three in promoting independence and another three are currently undertaking that qualification. This was confirmed by one of the staff members spoken to. The above meets the requirement that fifty percent of the care staff hold NVQ level two or above by 2005. The staff rota inspected showed a minimum of three staff members on duty for the majority of the day shift with two staff members on duty for the remainder. One waking and one sleeping in staff are on duty during the night. This level of staffing was satisfactory to meet the needs of service users accommodated at the time of the inspection. The staff on duty matched the record on the rota. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 19 One new member of staff had been recruited since the last inspection and that staff member’s file was inspected. The file did not contain the majority of the documentation required to be kept in the unit to evidence a robust recruitment procedure. The file contained a completed application form and one reference. The acting manager was clear that the provider organisation does operate a robust recruitment procedure but that the documentation relating to this is kept at Haringey Council’s human resources department who are apparently reluctant to send copies to the unit. A requirement is made that the home must keep a copy of the staff member’s proof of identity including a recent photograph, two written references including a last employer reference, employment history and evidence that the person has a current criminal record bureau clearance and protection of vulnerable adults clearance. The acting manager showed the inspector a current staff training plan that listed the statutory training that had been undertaken by each staff member and when that was due for refresher training where appropriate. The permanent member of staff spoken to confirmed the training they had undertaken. There appeared to be a discrepancy over the recording of training for one identified member of staff regarding safe administration of medication training and a requirement is made regarding this. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 Service users benefit from a well run unit pending the appointment of a permanent manager who will need to be registered with the CSCI when appointed. Further improvements are needed to identified aspects of health and safety practice to ensure that service users and others that are employed at or visit the unit are properly protected. EVIDENCE: The acting manager told the inspector that the manager’s post had been advertised and interview dates for short-listed candidates had been set. A requirement is made that the registered provider must apply to the CSCI for a suitable person to be the registered manager of the unit. The acting manager had substantial management experience and told the inspector that she was currently completing her registered managers award. The acting manager was able to talk knowledgeably about the needs of the service users accommodated and regarding the complex management issues that arose in running a short stay crisis unit. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 21 Health and safety documentation was inspected at the last inspection and the majority of this was satisfactory. However, there was not evidence at the last inspection of satisfactory portable appliance testing or of a current electrical installation certificate. The inspector was pleased to see a current portable appliance certificate had been obtained as required at the last inspection. The home had also submitted a new electrical installation certificate to the CSCI since the last inspection although this was marked as unsatisfactory and recorded a range of work that needed to be undertaken before the electrical installation at the unit could be certified as satisfactory. The acting manager stated that the provider organisation’s maintenance department were aware that the work needed to be completed but had not been informed of when this would occur. The requirement about a satisfactory electrical installation certificate is restated. The inspector was pleased to see that regular unannounced fire drills were being undertaken at three monthly intervals as required at the last inspection. The acting manager stated that it was planned to remove the fire door closures to service user bedrooms following a serious incident that had occurred at the unit since the last inspection. She stated that the provider organisation health and safety officer had visited the unit and agreed that this was an acceptable risk as the other fire doors, including to the staircases, were still protected by door closures. There was no record of this effective re-assessment of the fire risk available for inspection. A requirement is made that a revised fire risk assessment must be completed regarding removal of the identified door closures and the fire officer consulted before the door closures are removed. Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alexandra Road Crisis Unit Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000035135.V253146.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA17 Regulation 23(2)(c) Requirement The registered person must ensure that the extractor fan in the kitchen is deep cleaned by a person competent to do so. The registered person must ensure that the fluorescent light in the kitchen is fitted with an appropriate diffuser. The registered person must ensure that the home keeps copies of the required documentation for each member of staff employed to evidence a robust recruitment procedure. This must include a copy of each staff member’s proof of identity including a recent photograph, two written references including a last employer reference, employment history and evidence that the person has a current criminal record bureau clearance and protection of vulnerable adults clearance. The registered person must ensure that all staff that administer medication have current training in safe administration of medication. DS0000035135.V253146.R01.S.doc Timescale for action 31/12/05 2 YA17 23(2)(c) 31/12/05 3 YA34 19(1&5), Sch.2&4 31/12/05 4 YA35 13(2) 31/12/05 Alexandra Road Crisis Unit Version 5.0 Page 24 5 YA37 8(1&2) 6 YA42 13(4) 7 YA42 23(4) The registered person must 31/12/05 ensure an application is made to the CSCI for an appropriate person to be registered as manager of the unit. The registered person must send 31/12/05 evidence to the CSCI of a satisfactory electrical installation certificate. (previous timescale of 30/6/05 not met) The registered person must 31/12/05 ensure that a revised fire risk assessment is completed regarding removal of identified door closures and the fire officer consulted regarding this before the door closures are removed. 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 Alexandra Road Crisis Unit DS0000035135.V253146.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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