Inspection on 17/04/07 for Amersham Park House

This inspection was carried out on 17th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amersham Park House 13/04/09

Amersham Park House 22/02/06

Amersham Park House 19/10/04

Amersham Park House 05/05/04

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

CARE HOME ADULTS 18-65 Amersham Park House 111 Amersham Road Harold Hill Romford Essex RM3 9JA Lead Inspector Harbinder Ghir Unannounced Inspection 17th April 2007 10:00 Amersham Park House DS0000027881.V336610.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 Amersham Park House DS0000027881.V336610.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. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amersham Park House Address 111 Amersham Road Harold Hill Romford Essex RM3 9JA 01708 704963 01708 704963 bobjfinlayson@hotmail.com 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) Mrs Lynne Griffin Mr Darren Griffin, Mr Robert Finlayson Mrs Lynne Griffin Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user category to include up to three people with associated mental health problems. 22nd February 2006 Date of last inspection Brief Description of the Service: Amersham Park is a home registered to provide care and support for three people with learning disabilities with overlying mental health problems. The house is situated in a residential area of Harold Hill close to local shops and transport routes. Accommodation is spread over three floors with the office, one toilet and one bedroom being situated on the top floor. The building is well maintained and service users are encouraged to become involved in day-to-day chores and the maintaining of the rear garden. Both the manager and deputy are also registered proprietors in respect of the home and work at the establishment on a daily basis as part of the staff team. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Regulation Inspector Harbinder Ghir. The inspection took place on the 17th April 2007 between 10.00am and 3.45pm. The manager and the deputy manager were available throughout the time to aid the inspection process. During the inspection the inspector was able to talk to the two service users residing at the home, staff, the manager and the deputy manager. No relatives or professionals were found to be visiting during the inspection. Four relatives and one healthcare professional were contacted via telephone. As part of the inspection the inspector toured the home, read records of people who use the service and examined documents in relation to the management of the home. At the end of the inspection the inspector was able to provide feedback to the manager and deputy manager of the home. Two Requirements were set at the previous inspection and for one of these the timescale has been met. The second Requirement has been partly met; so the new Requirement has been set to take account of this. Two Recommendations have been made at this inspection. The inspector would like to thank everyone involved in the inspection process. What the service does well: The home provides a homely and warm environment. The home is well decorated and furnished. Residents are supported to make active choices and decisions throughout their daily living and their quality of life is enhanced by the opportunity to participate in a range of activities. Care plans were clear, consistent and comprehensive. Staff receive adequate training that protects people who use the service from abuse. Staff are supervised regularly. Regular maintenance checks are completed by the home ensuring the health, safety and welfare of residents and staff are promoted and protected. The home works in partnership with relatives and professionals. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Amersham Park House DS0000027881.V336610.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 Amersham Park House DS0000027881.V336610.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): 1, 2, 3, 4, 5 Quality in this outcome area is good. Service users are provided with detailed information to enable them to decide whether they would like to live at the home. However, this information needs to be provided in formats suitable for the people for whom the service is intended. Service users needs are fully assessed prior to admission and they have access to specialist services if required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide were seen which were provided as two separate documents and are made available to all residents. Both documents are very detailed and are provided in text format with the exception of the Statement of Purpose, which also included photographs of the home, and the complaints procedure, which was in picture format to guide residents in making a complaint. However, the format of the rest of the documents is unsuitable to the communication needs of the residents at the home, as some service users cannot read or understand comprehensive literature. The documents should be considered to be provided in other formats, such as pictorial, video or DVD, which would make them more Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 9 appropriate to the communication needs of residents. This is Recommendation 1. Two case records and pre-admission assessments were examined. The manager carries out in-depth pre-admission assessments using the homes own assessment tools. Information included input from the referrer, family members and reports from health and social care professionals, including review documents from the Care Programme Approach. Case record evidence was seen of one resident who visited the home numerous times and stayed overnight before reaching a decision to move into the home. Relatives spoken to said that they also visited the home prior to admission when considering admission for their relative. One relative spoken to informed that the home worked in close partnership with her during the pre-admission process to ensure the needs of her relative could be met by the home. Residents can access specialist services, which are tailored to meet their individual needs. During the last inspection a requirement was set that the home signs the service user contract and requests that the resident or their representative sign it. This requirement has been met at this inspection. All service users had a individual contract setting out the statement of terms of conditions within the home which were signed by the residents and their representatives and the home. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8, 9 Quality in this outcome area is good. There is a comprehensive care planning system in place, which provides staff with the information needed to meet the needs of residents. However, formats in which care plans are presented need to be more appropriate to the communication needs of residents. Residents are consulted with on a day-to day basis and participate in the running of the home and are supported to take risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care plan case files were examined. Care plans of residents covered all aspects of personal, social, mental, healthcare, daily routines, emotional, communication and educational needs. Care plans included comprehensive information on the needs of residents and how these were to be met by the home. Residents are involved as far as possible in setting up the care plan and are encouraged to attend their care plan reviews. However, care plans were provided in written form except for an identity photo card of the resident, and Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 11 did not include photos or pictures to enable residents to understand the information compiled about them. It is suggested that care plans are provided in formats, which are appropriate to the communication needs of residents. This is Recommendation 2. Care plans set out specialist requirements and how they are met. For example one care plan set out a specialist requirement in agreement with the resident and health professionals in regards to meeting the nutritional needs of a resident who consistently refused food at the home but liked eating out. The home therefore paid for all meals the resident ate at a local café, with staff encouraging the resident to eat cooked meals at home in the evenings. The care plan also included an individualised programme to reduce challenging behaviour by the resident focusing on positive behaviour and de-escalating techniques to carm the resident. These approaches were working well for the resident as they had reached an ideal weight and the aggressive behaviour had reduced. All relatives spoken to informed that they were very happy with the quality of care provided by the home. One relative stated ‘this is the best home I have visited and wouldn’t want my loved one to be anywhere else’. Another relative stated ‘my loved one is now able to pick up the phone and make calls to me since being at the home and was never able to do this before’. Care plans were up to date and are reviewed on a three monthly basis by the home. Regular Care Programme Approach reviews are also completed. Comprehensive risk assessments are completed. Risk assessments were seen in relation to challenging behaviour, self-harm, going out alone, epilepsy seizures and the dangers of smoking. One resident had been placed on a restricted smoking programme with the agreement of the resident due to the risks to her health and the health and safety risks posed to other residents and the home. All risk assessments were up to date and had been regularly reviewed. Care plan files seen demonstrated that residents are enabled to take risks within a comprehensive risk management framework. Risk management strategies are recorded in individual care records of all residents and held on file. One resident spoken to informed that he was able to go out on his own and was not restricted from doing what he wanted to do. The individual daily records for residents and evidence via observation showed residents are involved in the daily running of the home as far as their abilities allow. Residents contributed to the running of the home by participating in domestic duties, such as cleaning their rooms, doing their laundry, making a shopping list, going out shopping and simple cooking. Individual records examined were accurate, secure and confidential and staff were aware of how to handle confidential information. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. Residents are provided with the support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life; enjoy a range of leisure activities and a varied and nutritional diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to informed that they regularly go out to local shops, cafés and participate in local leisure activities. One resident informed that they go out to a local volunteers club once a week where they have discos, are taken out for the day and participate in-group activities and attend aerobics classes. The resident informed that she loves watching videos, which were provided for her by the home. The other resident is given the opportunity to attend clubs and leisure activities but refuses and prefers to go out to the local café and shops. The range of likes and dislikes in relation to leisure are very different for Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 13 both residents but are very well catered for by the home. Detailed daily records of all participation in activities by residents were seen. Residents have personalised routines for example they can choose what time the go to bed or what time they want to get up. A resident spoken to informed that he doesn’t like to go to sleep early and is never told what time he should go to bed. Residents are provided with the option of a holiday outside the home every year, which they choose and plan. Residents informed that last year they went to Clacton for a week, which they enjoyed, and this year one of the residents has suggested a holiday to Pontins, which the manager of the home is to organise. Family and personal relationships are actively promoted by the home. Family can visit anytime. Transport is also provided by the home for residents when visiting family. One resident regularly visits family over weekends. Varied and healthy meals are provided by the home. Residents specify what they would like to eat and meals are cooked accordingly. One resident stated “staff cook lovely meals and I especially enjoy Chinese or Indian meals”. Residents’ are also supported to cook meals. A resident informed that they can make sandwiches and the other informed that they love baking cakes at the home. All dietary intake is recorded for each resident. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. Residents’ personal, emotional and healthcare needs are being met. Residents are protected by clear and comprehensive arrangements for the administration of medication within the home. However, medication policies must include procedures for staff to follow when medication is transferred with residents when they are away from the care home for short breaks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have a detailed plan of their daily routine including what support is needed in relation to personal hygiene. Attention is paid to personal preferences in relation to the provision of personal care. It is clear in one care plan that personal care is not to be provided by male staff. Personal support takes account of individual preferences and residents’ choice of dress and appearance is respected. Two relatives spoken to highlighted the high level of personal hygiene given to residents at the home and that they were very pleased with the way care was provided. All residents have a designated key worker to promote their privacy and dignity. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 15 Residents are supported by staff to attend appointments with healthcare professionals and their health is closely monitored and prompt referrals are made. A Community Psychiatric nurse for two of the residents spoken to informed that the home is very prompt in contacting him if any problems have arisen and that staff are very productive in working with health care professionals. There was evidence of staff taking a resident to well women checks and the involvement of multli-disciplinary healthcare professionals where required, e.g. dentists, chiropodists, GP’s, community psychiatric nurses. All medication was stored in a locked cupboard and in blister packs. All staff administering medication have undergone in-house training. Medication Administration Records (MAR) sheets examined were signed at all times of administration and were up to date. The home has a medication returns books, with all entries signed. The home has an appropriate medication policy and procedure in place, which protects all service users and ensures the safety of those who can self-medicate by using risk assessments where necessary. None of the residents at the home are able to self-medicate. The pharmacist is contacted for advice and instructions sought before transferring medication to go with residents when visiting relatives for short breaks, as the transfer of some medicines from the manufacturer’s packaging can be contraindicated. Two signatures of relatives accepting receipt of the medication had not signed the homes logbook. As with any medication taken out of the home a signature of the person accepting receipt and any return is required. This is Requirement 2. In compliance with Care Homes Regulations 2001 and The Administration & Control of Medicine Guidance the home must produce a written policy that includes the procedures to be followed and the precautions to be taken, including a witness to the transfer, when transferring medication to be taken out of the home. This is Requirement 1. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. The complaints procedure is in a format suitable to residents communication needs. There is a comprehensive adult protection-training programme for staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is clear, concise and easy to follow and is also provided in picture format in residents’ rooms. One resident spoken to was able to tell me about the complaints procedure by looking at the picture format. The complaints procedure is included in the Statement of Purpose and Service User Guide and meets all the requirements of The Care Standards Act 2001 and Care Homes Regulations 2001. A complaints logbook is kept by the home, which was viewed. There have been no recent complaints logged. The home also holds regular residents’ meetings. Records seen demonstrated that all concerns raised by residents were listened to and actioned. Residents spoken to informed that they were listened to and felt staff were very approachable. All staff attend POVA training and adult protection is comprehensively covered in the induction programme. The home follows adult protection procedures devised by The London Borough of Havering and the London Borough of Tower Hamlets. Staff spoken to at the home were able to demonstrate their understanding of adult abuse policies and procedures. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 17 Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. Residents’ benefited from living in a safe, well-maintained and clean environment. Décor, furnishings and fittings were of a good standard and provide a homely and pleasant living environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises were comfortable, bright, airy, clean and free from offensive odours. Furnishings and fittings in communal areas were of good quality, domestic and unobtrusive. The home provides a homely environment to meet the needs of service users. One relatives spoken with described the home as ‘very good and I would not want my loved one to be placed anywhere else’. The home provides a main lounge, kitchen and a conservatory, which is the only smoking area in the house. There are two bedrooms and a communal bathroom and toilet on the first floor. The second floor has a third bedroom, which is vacant at the moment, an assisted shower, toilet and staff office. The Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 19 grounds around the home were well maintained and were equipped with suitable garden furniture. Residents were in the garden relaxing during the afternoon of the inspection. One of the residents’ rooms was seen during the inspection. The room was comfortable with adequate furnishings and was also personalised by the resident. The resident stated that he liked his room. Both residents held a key to their room. All rooms were lockable and can be overridden by staff in an emergency. Specialist equipment for residents if required would be provided by the home. Amersham Park House DS0000027881.V336610.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): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good. Staff were aware of their and other’s job roles and responsibilities, providing clarity of roles to residents. There is a good match of qualified staff and stable staff team. Recruitment processes are robust and ensure the protection of people living at the home. The staff group receive adequate training to meet the needs of residents and receive supervision on a regular basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a stable staff team of six permanent members of staff and one bank staff. There are sufficient numbers of staff on duty per shift to meet the needs of residents and during the inspection it was observed that adequate numbers of staff were on duty. There is one waking night staff, and a minimum of one member of staff is on duty at all times supplemented by a second member of staff who supports residents in the community. The staff rota seen evidenced this. Staff who were on duty during the inspection demonstrated a sound knowledge of the needs of residents and how those needs are to be met on a daily basis. Staff were knowledgeable on the mental health needs of residents and the risks posed to them. Residents and relatives spoken to spoke very highly of the staff team and residents informed that staff were very Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 21 supportive and that they were very good to them. Relatives spoken to highlighted that the staff team always work in partnership with them and that they provide a service, which has promoted the quality of life for loved ones. One relative described the manager of the home ‘as part my family’. A random sample of three staff files were examined. They evidenced that the GSCC Code of Conduct is covered in the induction-training programme. Staff receive a comprehensive induction programme and attend mandatory training organised by the home. Forthcoming training organised includes training in POVA, Manual handling, and Mental Health. Other training staff had attended included training in food handling and hygiene, health and safety, adult protection, medication and first aid. The home has also contracted with an external company to provide relevant training as well as staff attending training provided by the London Borough of Havering. The staff team have a ratio of 50 of NVQ qualified staff. Staff training files viewed were up to date to reflect the training staff had attended and completed. It was evident from the activities in the home that the staff were highly motivated and committed to the service user group. Staff members spoke positively about working at the home and felt adequate training was provided by the home to provide them with the skills to meet the needs of residents. On inspecting the homes recruitment procedure, three staff files were viewed during the inspection. All three files were complete with all relevant checks made required by the regulations. Staff records examined identified members of staff were being supervised monthly to a two monthly basis and annual appraisals had taken place. Staff informed that supervision was consistent and that they were supervised formally and informally on a day-to-day basis. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. Residents’ benefit from an experienced manager who recognises their needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. Systems for service user consultation have been implemented since the last inspection but results from these consultations have not been communicated to residents. The welfare of staff and service users is promoted by the homes policies and procedures at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 23 The manager of the home holds a Diploma in Health and Social Care and completed her NVQ level 4 qualification in March 2006, evidence was seen. They have extensive experience of working with individuals with learning disabilities. The registered manager communicates a clear sense of direction, leadership and openness. Staff said they felt well supported and the manager was approachable. A member of staff stated that “management was easy to get along with and any issues that arose were resolved quickly’. Residents spoken to informed that the manager was very approachable and they thought the home was well run. A requirement was set at the last inspection that the home develops a formal quality assurance system in line with regulation 24. This requirement has been partly met at this inspection as evidence was seen of surveys completed by residents and their families. The manager informed that surveys had been sent out to stakeholders including Community Psychiatric Nurses and General Practitioners, but none had been returned. However, the home had not reported on the results of the completed surveys and had not informed residents, family or the Commission for Social Care Inspection of their findings. It is therefore Requirement 3 that the registered person shall supply to the Commission for Social Care Inspection a report in respect of any review conducted and make a copy of the report available to service users. Detailed records were seen of the homes resident meetings held every two months on seeking residents’ views on running of the home. All views and concerns were listened to and actioned appropriately. The manager and staff take overall responsibility for ensuring relevant maintenance checks are carried out throughout the home. It is clear from the records seen that all relevant legislation is complied with and reportable incidents are reported to the appropriate authorities. Fire signs, fire procedures and safety posters were evident throughout the home. The inspector examined the services insurance certificates, fire equipment checks; electrical services testing of appliances, which were all up to date. Fridge freezer temperatures seen were taken on a daily basis. All members of staff have health and safety training as part of the induction process. Amersham Park House DS0000027881.V336610.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 2 2 3 3 3 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 X x 3 x Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement In compliance with Care Homes Regulations 2003 and The Administration & Control of Medicine in Care Homes 2003, the home must produce a written policy that includes the procedure to be followed and the precautions to be taken, including a witness to the transfer, when transferring medication to be taken out of the home. Timescale for action 30/06/07 2 YA20 13 (2) 3 YA39 24 All medication taken out of the 30/06/07 home must be signed by the person giving it and by the person accepting receipt. It is required that the home shall 30/07/07 supply to the Commission of Social Care Inspection a report in respect of any review conducted for the purpose of improving the quality of care provided at the home, and make a copy of the report available to service users. DS0000027881.V336610.R01.S.doc Version 5.2 Page 26 Amersham Park House RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA1 Good Practice Recommendations It is recommended that care plans are provided in formats which are appropriate to the communication needs of residents. It is recommended that the Statement of Purpose and the Service User guide be considered to be provided in other formats, such as pictorial, video or DVD, which would make them more appropriate to the communication needs of residents. Amersham Park House DS0000027881.V336610.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Amersham Park House DS0000027881.V336610.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. 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