Inspection on 16/07/07 for Bedford Road 7

This inspection was carried out on 16th July 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 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

Bedford Road 7 11/11/08

Bedford Road 7 10/06/08

Bedford Road 7 19/05/06

Bedford Road 7 12/01/06

Bedford Road 7 29/11/05

Bedford Road 7 13/09/04

Bedford Road 7 26/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Bedford Road 7 London N15 4HA Lead Inspector Susan Shamash Key Unannounced Inspection 16th July 2007 12:30 Bedford Road 7 DS0000010716.V341757.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 Bedford Road 7 DS0000010716.V341757.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. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Road 7 Address London N15 4HA 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) 020 8800 2864 020 8800 2864 bedfordrhailltd@btinternet.com HAIL (Haringey Association for Independent Living Limited) Samuel Conteh Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD 2. Physical Disability - Code PD The maximum number of service users who can be accommodated is: 6 19th May 2006 Date of last inspection Brief Description of the Service: Bedford Road is a home registered to provide residential care to six people who may have learning disability or physical disability. The building is provided by Circle 33 Housing Association and the services are provided by Haringey Association for Independent Living (HAIL). The home is located in a residential area close to the Seven Sisters Underground and shopping facilities. There are six single bedrooms, three bathrooms/showers and three toilets. There is a lounge, a kitchen, a dining room and a large garden at the rear of the building. The ground floor of the home is wheelchair accessible even though the current people living at the home do not require this. The home has stated objectives of enabling people to live as independently as possible, with the same range of choices as any other citizen, mixing as equals with others and being members of their own community. Information about the home is including in the home’s brochure and the CSCI inspection reports are available from the home by contacting the provider or from the CSCI website – www.csci.org.uk. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 5 The weekly fees of the home depend on people’s assessed needs, but the average weekly fee is £1053.44 as of July 2007. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as a routine inspection of the home and lasted approximately seven hours. A new registered manager had been appointed to the home, however they were not working at the home on the day of the inspection. Instead I was assisted by the deputy manager and other staff working at the home. The majority of people who live at the home were out during the day, but returned to the home towards the end of the inspection. I had the opportunity to talk with and spend time with all people living at the home and spoke to two staff members independently. The inspection also included a tour of the building, assessment of people’s care files, staff files, health and safety records, rotas and menus and medication administration records. What the service does well: New people’s needs are assessed in detail before their admission to ensure that they can be met by the home. Comprehensive care plans and risk assessments are in place and these are reviewed regularly to ensure that people’s needs are met. A key working system is in place at the home, and monthly summaries of care needs and activities are recorded, to ensure that responsive care and support is provided. People live in a generally well maintained and pleasant environment and can access all communal areas. Their health needs are closely monitored and arrangements are made for them to see appropriate health professionals. The complaints procedures and the policies in relation to the protection of vulnerable adults from abuse are appropriate. The food provided is of good quality and meets the nutritional needs and preferences of people living at the home. The home is active in supporting people to access a variety of leisure, educational and other day activities according to their choices. An annual holiday away from the home, is arranged for residents, with staff support to ensure that they can be involved in activities of their choice. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Records of the storage and administration of medication must be improved to ensure that the medication needs of people living at the home are met safely. The window restrictor in an identified person’s bedroom required repair, although this was dealt with shortly after the inspection. However staff must also undertake regular checks to ensure that window restrictors are operating effectively, to ensure that people are protected from harm. A small number of improvements need to be made to the home environment to ensure the comfort of people living at the home. Hand-drying facilities must be replenished and an infection control audit should be undertaken to ensure that people are adequately protected from the spread of infection. All staff must receive current training in food hygiene, first aid and fire safety to ensure that people living at the home are protected from harm. Monthly unannounced visits must be undertaken on behalf of the provider organisation to ensure the quality of services for people living at the home. Electrical installation and portable appliances testing certificates must be obtained for the home to ensure people’s safety, and more regular fire drills Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 8 should be undertaken. A fault with the fire alarm switch box must be repaired and weekly fire alarm tests must be recommenced for the protection of people living and working at the home. 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. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. New residents can be confident that their needs are assessed by the home prior to their admission to ensure that they can be met. EVIDENCE: No new people had been admitted to the home since the previous inspection. All residents’ files that were inspected included detailed assessments of their needs by the home as well as assessment information from their social worker and health professionals. The assessments carried out by the staff included details of the physical, emotional, personal care, cultural, dietary and social needs of each person. The staff had also made observations of their opinions of prospective residents’ compatibility with the existing people who live at the home. Staff confirmed that they were provided with sufficient assessment information about all the people living at the home. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 11 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 and 9. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can be confident that their needs will be addressed appropriately and responsively. They are supported to make decision about their lives and to take informed risks to maximise their independence. EVIDENCE: Three people’s care files were inspected in detail and two further care files were examined briefly. At the previous inspection, none of the care plans were complete as they were being transferred to a new recording format, however old files contained detailed care plans and risk assessments. At the current inspection it was evident that care plans and risk assessments had been reviewed at least six-monthly and that there had been some consultation with families and representatives regarding support provided, where possible. The home operates a key working system and discussions with Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 12 the staff and an examination of the files indicated that each key worker writes a monthly summary of significant events and activities for people living at the home. Care plans and risk assessments were detailed, covering various areas of needs and how these are being met. It was clear from discussions that the home encourages people to realise their potential by adopting suitable methods of supporting each individual. However some care records were not dated, so that it was not always clear whether they remained current, or had been superseded. Records were generally worded appropriately however the wording in a small number of records was slightly unprofessional, possibly due to English not being the first language of the person completing the record. It is therefore recommended that all records kept on people’s care files should be dated (including the residential living skills assessments) and that the wording used in some care planning records should be reviewed to ensure that it is appropriate. From conversations with the staff it was clear that people are supported to take some risks as part of their independent living. Observations of staff interacting with people living at the home confirmed that they treated people with respect, maintaining their privacy, dignity and respecting their cultural and lifestyle choices whilst supporting them with personal, social and emotional care. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are satisfied with the range of activities organised and facilitated by the home including educational and recreational activities both inside the home and within the local community. They are supported to maintain contacts with friends and family and also enjoy an annual holiday away from the home with support from the staff team. The food provided at the home is of good quality and people’s dietary needs are met. EVIDENCE: All the people who live at the home attend day services five days a week. From their personal files and documents it was evident that the home liaises with day centres, and that staff support people to attend other activities within the local community. Records and discussions with the staff showed that people living at the home are supported to visit family members, go on day trips, go Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 14 shopping, swimming, cycling and to a disco club. Day trips recorded this year included visits to Lakeside, Highgate Woods, Finsbury Park and Dog Racing. There were also records of meals out, pub trips and walks in local parks. A week prior to the inspection, some of the people living at the home had been on holiday to Ipswich. Others are due to have a holiday later in the year. Discussions with people living at the home, staff working at the home and records of resident meetings confirmed that people who live at the home are supported to go to local shops, cafés and the parks. It was evident that people have opportunities to access communal areas in the home and there are no bedtime restrictions. All people living at the home require support with financial management. There are appropriate systems in place to safeguard people’s money being looked after by the home, and at the end of each shift staff check the money and records and handover to the staff on the next shift. Receipts are kept for all transactions with people’s monies and the home’s petty cash. Discussions with members of the staff team and an examination of care plans indicated that no people living at the home currently choose to attend a place of worship, although this option is available to them. It was also evident from people’s files and discussions with the staff that people living at the home enjoy visits by and to family and friends. The home has a four weekly rotating menu. The menu is displayed in the dining room. The staff spoken to gave satisfactory descriptions of how they support people to choose meals. The inspector noted that people appeared to enjoy the evening meal served at the home on the day of the inspection, and that the mealtime atmosphere was pleasant and unrushed. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 15 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 and 20. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs are met by experienced staff and clear procedures to ensure that they receive regular support from healthcare professionals. There remains room for improvement in the recording of medication administration to ensure that people living at the home are protected from harm as far as possible. EVIDENCE: The home monitors and records the temperature of the area where medicines are kept on a daily basis to ensure that this remains below 25˚C as appropriate. The home has a procedure for regularly updating people’s assessments and care plans and works closely with health professionals and day centre officers. It was clear from discussion with staff and an assessment of the home’s diary and people’s files that that people living at the home are supported to see their general practitioners, dentists, opticians and chiropodists on a regular basis. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 16 Examination of the records of medication administered, showed that there were some gaps in the records, although the monitored dosage systems indicated that these medicines had been administered as directed. This indicates that medication administration records (MAR sheets) are not signed for at the time of administration as required at the previous inspection. This requirement is restated, and further staff training and supervision is needed to ensure that these records are maintained appropriately. There were also no records of medicines received at the home for the last month and one medicine (an antibiotic) did not have clear guidelines as to how often it was to be administered. Discussion with staff indicated that they had been told verbally how often to administer this, however these instructions were not recorded with reference to the quantity and frequency at which the medicine should be administered. All medication must also be signed into the home and clear directions must be recorded for all medicines (not only ‘as directed’) to ensure that the medication needs of people living at the home are met. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 17 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 and 23. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures to ensure that people are protected from abuse and that their concerns and complaints are listened to and dealt with. EVIDENCE: The complaints procedure includes the address of the local CSCI area office and is written with pictorial illustrations for use by non-verbal people living at the home. A copy of the procedure is included in the home’s brochure and the statement of purpose. There have been no recorded complaints since the last inspection. Although certificates for adult protection training were not available within all the staff files assessed on the day of the inspection, copies of the certificates were forwarded to the local CSCI area office following the inspection. These had been copied from the staff files maintained at the organisation’s head office. It was therefore found that all of these staff members had undertaken the training as required at the previous inspection. Staff spoken to were confident of their knowledge of how to protect vulnerable people from abuse. They confirmed that they have read the home’s policies including the whistle blowing policy. There is also a copy of the placing authority’s adult protection policy and procedure within the home. Bedford Road 7 DS0000010716.V341757.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 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People generally live in a comfortably furnished and decorated environment. However there is room for a number of repairs and improvements to further improve their standard of living. The home is generally clean and hygienic, however a review of infection control procedures in the home is needed to ensure that they people living and working at the home are protected as far as possible. EVIDENCE: At the previous inspection it was noted that there were no hand-drying facilities in any of the toilet rooms and a requirement was made accordingly. Hand-towel dispensers had since been fitted in all these facilities, however none of them were stocked with hand towels on the day of the current inspection. This is required. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 19 The home has a policy on infection control however following a recent infection involving more than one person living at the home, this policy should be reviewed to ensure that all possible precautions are being taken. The premises were clean and bright and there were no offensive odours. There are handrails in the corridors, adaptations in bathrooms, toilets, and shower rooms and the radiators are guarded. Although all bedroom windows have been fitted with restrictors, I noted that the window restrictor of one front facing bedroom opposite the office, was broken at the time of the inspection. This potentially placed residents at risk of harm, and this was brought to the attention of staff on duty. Action was taken to ensure that this window was closed on the day of the inspection. The deputy manager contacted the CSCI to advise that the identified restrictor had been repaired by 20th July 2007. However staff must also undertake regular checks to ensure that window restrictors are operating effectively in line with each person’s risk assessment, to ensure that that they are protected from harm. The carpet on the first floor hallway was stained in places and should be thoroughly cleaned or replaced. A new oven and cooker had been purchased for the home but these had not yet been fitted. A new armchair must be provided in the identified person’s bedroom, as the chair that they have is stained and worn. Finally a schedule must be provided to the local CSCI area office for the replacement of the flooring in the ground floor wet room, and the first floor shower, as these are stained. Staff reported that no matter how they tried to clean these facilities, they were unable to shift the stains. Bedford Road 7 DS0000010716.V341757.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): 32, 34, 35 and 36. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected by improvements made in the recruitment procedures for the home. They can be sure that the staff team are suitably experienced and are supervised to ensure that they meet their needs appropriately. However there is room for improvement in some training areas to ensure that their needs are safely met. EVIDENCE: Since the previous inspection, improvements had been made in the home’s handover system and the communication between the home and day centres. Five staff files were inspected, alongside the training undertaken by a further two staff members. Assessment of the staff files, and information later sent to the local CSCI area office, showed that all staff members had current Criminal Records Bureau (CRB) checks from the current employer. The home had also obtained two written references for each member of staff. Files for the bank (as and when) staff are kept at the head office and therefore it was not possible to check if they have all necessary items in their files. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 21 Information provided within the pre-inspection questionnaire indicated that training in manual handling, first aid, medication, protection of vulnerable adults, support planning, health and safety and food hygiene had been provided within the last year in addition to induction training, and care training to NVQ levels 2 and 3. Further training planned included more NVQ training, infection control and autism training. However inspection of staff files indicated that several staff still needed to undertake training or updates in food hygiene, first aid and fire safety to ensure that people living at the home are protected from harm. Supervision records indicated that staff are now being supported appropriately, with regular one to one sessions. This was confirmed by staff members spoken to. Bedford Road 7 DS0000010716.V341757.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, 41 and 42. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected by the presence of a permanent registered manager with full responsibility and accountability to run the home. Appropriate quality assurance procedures are in place for the home, however insufficient monitoring visits by the provider organisation may compromise standards of care and support for people living at the home. Insufficiently rigorous health and safety procedures may place people living and working at the home at risk of harm. EVIDENCE: At the previous inspection it was noted that the home has been running for a long time without a registered manager. A new manager had commenced work at the home since the previous inspection, and he had successfully completed Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 23 registration with the CSCI. Staff spoken to indicated that they were working well with the new manager, however he was not working at the home on the day of the current inspection. A system of quality assurance is in place for the home, and regular staff and residents meetings were being held as appropriate. However records maintained at the home indicated that unannounced visits undertaken on behalf of the provider organisation were being undertaken sporadically and not monthly as required. Reports of these visits must be sent to the home and the local CSCI area office. The fire extinguishers had been serviced and a gas safety certificate was available for the home. Records showed that some fire drills had taken place at the home however these need to be held more regularly. There had been gaps in the weekly fire alarm testing for the home in the month prior to the inspection. A staff member advised that this was due to a problem with the fire alarm switch box, which had yet to be resolved by the fire safety contractors. This must be addressed without delay, and weekly fire alarm tests must be recommenced for the protection of people living and working at the home. As noted under Standard 24, it is required that regular monitoring be put in place to ensure that window restrictors are fully operational to ensure the safety of people living at the home. Current electrical installation and portable appliances testing certificates were not available for the home, however the deputy manager provided the CSCI with evidence that these tests would be undertaken shortly after the inspection. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 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 3 X 2 2 X Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13(2) Requirement The registered person must ensure that medication is appropriately administered to people living at the home and the medication administration records (MAR sheets) are signed at the time of administration by trained and competent staff. (Previous timescale of 30/11/06 not met). Medication administration must be monitored to ensure that there are no gaps in the MAR sheets. All medication must be signed into the home and clear directions must be recorded for all medicines (not only ‘as directed’) to ensure that the medication needs of people living at the home are met. The registered person must 03/08/07 ensure that the window restrictor in the identified person’s bedroom is repaired as soon as possible, and staff must undertake regular checks to ensure that window restrictors DS0000010716.V341757.R01.S.doc Version 5.2 Page 26 Timescale for action 10/08/07 2. YA24 13(4) Bedford Road 7 3. YA24 23(2bcd) are operating effectively in line with each person’s risk assessment, to ensure that they are protected from harm. The deputy manager contacted the CSCI to advise that the identified restrictor had been repaired by 20/7/07. The registered person must ensure that the carpet on the first floor hallway is thoroughly cleaned or replaced, The new oven and cooker must be fitted, a new armchair must be provided in the identified person’s bedroom, and a schedule must be provided to the local CSCI area office for the replacement of the flooring in the ground floor wet room, and the first floor shower for the comfort of people living in the home. The registered person must provide hand-drying facilities in toilet rooms, this includes ensuring that paper towel dispensers are replenished. (Timescale of 30/06/06, 30/11/06 and 15/02/06 not met). An infection control audit should also be undertaken for the home to ensure that appropriate safeguards are put in place to protect people from the spread of infection. The registered person must ensure that all staff receive current training in food hygiene, first aid and fire safety to ensure that people living at the home are protected from harm. DS0000010716.V341757.R01.S.doc 14/09/07 4. YA30 13(3) 17/08/07 5. YA35 13(4) 18(1ci) 23(4d) 28/09/07 Bedford Road 7 Version 5.2 Page 27 6. YA41 26 7. YA42 13(4) 23(4ce) The registered person must ensure that monthly unannounced visits are undertaken on behalf of the provider organisation and that reports of these visits are sent to the home and the local CSCI area office. The registered person must ensure that electrical installation and portable appliances testing certificates are obtained for the home and copies of these must be sent to the local CSCI area office. More regular fire drills must also be undertaken and the problem with the fire alarm switch box must be resolved. Once resolved weekly fire alarm tests must be recommenced for the protection of people living and working at the home. The deputy manager provided evidence that PAT testing was carried out on 30/07/07 and the periodic test is due to be carried out on 06/08/07. 31/08/07 17/08/07 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 YA6 Good Practice Recommendations It is recommended that all records kept on people’s care files should be dated (including the residential living skills assessments) and that the wording used in some care planning records should be reviewed to ensure that it is appropriate. Bedford Road 7 DS0000010716.V341757.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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. 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