CARE HOME ADULTS 18-65
Beulah Road (55) 55 Beulah Road Thornton Heath Croydon Surrey CR7 8JH Lead Inspector
Lee Willis Unannounced Inspection 11:00 31 October 2005
st Beulah Road (55) DS0000028139.V256530.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 Beulah Road (55) DS0000028139.V256530.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. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beulah Road (55) Address 55 Beulah Road Thornton Heath Croydon Surrey CR7 8JH 020 8653 6377 020 8653 6377 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) Care Management Group Limited Mrs Venise Marlene Browne Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: 55 Beulah Road is owned, managed and staffed by the Care Management Group (CMG), a specialist provider of services for adults with learning disabilities and behaviours that challange. The home is currently registered with the Commission for Social Care and Inspection (CSCI) to provide personal care and accommodation for up to seven younger adults (i.e. aged 18-65) with mild to moderate learning disabilities. Venise Browne continues to be in operational day-to-day control of the home where she has worked since 1999. Located on a busy suburban street near the centre of Thornton Heath the home is within easy walking distance of a wide variety of local amenities, including shops, cafes and pubs. The home is also close to numerious bus routes and a local train station with good links to central Croydon, London and the surrounding areas. The main house at 55 Beulah Road comprises of six single occupancy bedrooms, an open plan main lounge and dinning area, a small visitors/smoking room, kitchen, office and laundry facilities. There is also a one bedroom self-contained flat within the grounds, which has its own en-suite and cooking facilities. The garden at the rear of the property is laid to lawn, although there is a small patio area with some furniture. This space was recently enlarged following the removal of a delapidated garage from the side of the house. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 11.00 on the morning of Monday 31st October 2005. It took two and a half hours to complete. Since the homes last inspection the Commission has not received any comment cards in respect of this service, which is obviously deemed a poor rate of return for a home of this size. The majority of this inspection was spent talking to the homes manager, a member of staff who was on duty at the time and three service users who had just returned home from attending various activities in the wider community. The rest of this inspection was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although one vulnerable adult protection meeting has been convened by the Local Authority in this time. This allegation of abuse, which was later withdrawn, was not substantiated and the matter was successfully resolved to all the interested parties satisfaction. What the service does well:
Having met one of the homes most recent admissions, albeit briefly, it was immediately evident that the manager and the other member of staff who was in the house at the time of the inspection had both built up what appeared to be a very good working relationship with this individual in a relatively short period of time. Furthermore, the staff on duty at the time of this inspection were also able to demonstrate that they were able to effectively communicate with this particular individual in their preferred mode of communication i.e. makaton sign language. The home also demonstrated that staff take service users complaints seriously and will follow them up. The manager is commended for notifying all the relevant authorities without delay about the allegation of abuse made by a service and the part they played in helping to resolve the matter to everyone’s satisfaction. Finally, the service users have all benefited from the home experiencing relatively low rates of staff turnover in the past six months. The home has very few staff vacancies and the vast majority of the current staff team have all worked together for sometime, ensuring the service users receive support from extremely experienced and well qualified individuals who are familiar with their unique wishes, needs and daily routines. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection?
All the requirements identified in the homes last inspection report have been met in full. Since April 2005 protocols for the safe use of ‘as required’ (PRN) medication, which were lost in the recent fire, have all been re-established and another fire risk assessment for the building carried out. In keeping with the homes underpinning philosophy of promoting independent living whenever possible it was positively noted that both the existing and new service users continue to be actively encouraged and supported by staff to take ‘responsible’ risks and have even greater opportunities to engage in educational and social activities of their choice. For example, the majority of the service users now regularly attend a local social/sports club in the evening and most are enrolled on various courses at local colleges. It was also pleasing to note that the manager was already making enquiries about the availability college courses, which would be suitable for both the homes new admissions, which included a basic language course for the one service user whose first language was not English. Furthermore, recent admissions means that the vast majority of the service users currently residing at the home are of Black British Afro and Caribbean origin, which is reflected in the ethnic mix of the staff team, who are also predominantly black Afro and/or Afro-Caribbean British citizens. As previously mentioned, it was positively noted that ethnic and cultural diversity of the service users is respected by the home and reflected in the published menus and activity schedules. Finally, the manager and her staff team have done exceptionally well to ensure all the records and policies destroyed in the recent fire have, so far as reasonably practicable, been replaced and made available for inspection on request. All the maintenance work on the fire-damaged property has also been completed. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 7 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. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 8 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 Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 9 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): 1, 2 & 4 The home ensures prospective new service users and their representatives are supplied with all the information they need to make an informed decision about whether or not to move in. The admissions procedure is also sufficiently robust to enable staff to plan for and met new service users assessed needs, preferences and aspirations. EVIDENCE: A comprehensive Statement of purpose and guide is in place, which sets out in detail the homes aims and objectives, and the services and facilities provided. There is an appendix at the back of the document, which shows it was last reviewed in May 2005 and updated accordingly to reflect all the physical alterations that have been made to the home since the fire. The home is now fully occupied having recently accepted two new referrals. Full needs assessments were undertaken by senior managers representing CMG in respect of each person admitted. The homes manager said she played an active role in the admissions process and was very involved in the assessing whether not the prospective new service users would be compatible with the rest of the service user group already living in the home. Copies of the care management assessment undertaken by the relevant placing local authorities were also available on request. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 10 The homes most recent admission was able to meet the other service users and staff, as well as view their room, as part of a planned visit and over night stay, which was arranged before a decision to move in on a ‘trial’ basis was taken. This ‘trial’ period of residency was reviewed within three months in accordance with CMG’s admissions procedures and National Minimum Standards. The manager said the existing service users had been consulted about these two new referrals and felt they had both settled-in well in a relatively short period of time. Furthermore, the care plan for the homes other most recent referral had also been reviewed within three months of their arrival and another was already being planned involving the service user, their next of kin, care manager and psychiatrist. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans accurately reflect service users personal, social and health care needs, as well as their likes and dislikes, ensuring staff can plan for and meet them. Furthermore, risk management strategies generated from individualised assessments ensure the service users are appropriately supported by staff to take ‘responsible’ risks as part of a structured programme to promote their independent lifestyles. EVIDENCE: Care plans were in place for the homes two latest admissions. These plans had clearly been generated from their individual needs assessments, which as previously mentioned covered every aspect of their unique personal, social and health care needs, although the manager acknowledges that they are far from complete at this early stage of their placement. It was positively noted that a comprehensive set of risk assessments and management strategies had been established prior to the one new service users admissions, which detailed action to be taken by staff to minimise any identified risks and/or hazards. This included ratios of staff supervision to be provided while support this individual in the wider community and specific behavioural guidelines to be followed by
Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 12 staff to minimise the risk of potentially aggressive incidents and unplanned absences occurring. Records revealed that four service users meetings had taken place since April 2005. A wide range of topics were covered at these meetings and included menu and activity planning. One service user met said he liked attending these meetings as he gave him the opportunity to share his views about life at the home and talk about things that as he put it “were getting on his nerves”. Since the homes last inspection a service user has been appointed an independent advocate who is able to act on the individuals behalf and in their best interests. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 & 17 The number and range of social, leisure and recreational opportunities the service users have to engage in, both at the centre and in the wider community, are extremely varied and based on service users wishes. Dietary needs are well catered for and the meals provided are culturally appropriate and evidently based on personal preferences. EVIDENCE: On arrival six out of eight service users were out attending various colleges, day centres and social clubs, or visiting family. It was also positively noted that the manager and her staff team had in a relatively short period of time ascertained the homes two most recent admissions social interests and had already starting making enquires about what age and culturally appropriate activities were available in the local area for them to take part in. For example, the manager is looking into the possibility of enrolling one new service user, whose first language is Congolese, on an English language course at a local college. Furthermore, it was evident from the information contained in the other new service users care plan that they liked drama. Consequently, the
Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 14 manager is also looking for a suitable course for this individual to attend. Progress on these matters will be assessed at the homes next inspection. Since the homes last inspection, the majority of the service users have begun attending a local social club in the evenings, including the two new service users, were they have the opportunity to meet their peers and engage in all manner of leisure activities. The social club has pool tables and a badminton court. It was evident from the minutes of the initial care plan reviews undertaken in respect of the homes two most return admissions that their families are actively encouraged to attend these meetings and continue their involvement with their loved ones life’s. The manager said that the relatives of one of the homes most recent admissions have stayed for tea on numerous occasions since their loved one moved in. All the service users significant relationship links are recorded in their care plans and as previously mentioned one service user was out visiting a family member at the time of this inspection. The home has a separate, albeit very small, smoking/visitors room, where service users can entertain their guests in private. Service users can also see visitors in their own bedrooms and there are no restrictions on visiting. Based on assessments of risk a keypad device has been fitted to the front door, which only staff have access to the code, to minimise the risk of unplanned absences. All the service users are offered keys to their bedrooms, which can be locked from within. As previously mentioned, service users are actively encouraged to participate in household chores, and it was positively noted that one of the homes most recent admissions was being encouraged to cook for themselves. Furthermore, the home is commended for ensuring the ethnic and cultural diversity of the service users are well catered for. For example, a list of the food likes and meal preferences of one of the homes most recent admissions has been drawn up with the service user and their Congolese father. These preferences have now been incorporated into the published menus and recipes kept on file in the kitchen for referencing purposes. Some of the traditional ingredients often used in central African and Afro-Caribbean cuisine were visible in the kitchen and included such foodstuffs as Yams, fu-fu (a type of plantain) and fish. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 15 Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. The policies and procedures the homes has in place for handling medicines are sufficiently robust to ensure the service users are protected from avoidable harm and/or abuse. EVIDENCE: One service user met said they could choose what time they got up and went to bed. The homes accident book revealed that there had been no unplanned admissions to Accident and Emergency since the homes last inspection. Detailed records are kept of all the service users health care appointments with community-based professionals, including GP’s, psychiatric nurses, dentists, opticians and physios. Medication administration records sampled at random accurately reflected medication stocks currently held by the home at the time of this visit. Since the homes last inspection the medication cabinet destroyed in the fire has been replaced with a new lockable metal cupboard, which is securely attached to the wall in the ground floor office. As required in the homes previous report the manager has replaced all the protocols for the use of ‘as required’ (PRN)
Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 17 medication which were destroyed in the recent fire. Staff met were very clear who should authorise the use of PRN medication. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Complaints are handled objectively and service users met were confident that any concerns they may have about the home are taken seriously and acted upon. All staff ‘authorised’ to use physical intervention techniques, as a ‘last resort’ must refresh this training on an annual basis, to ensure the services users are protected from harm and/or abuse. EVIDENCE: The homes complaints procedure is conspicuously displayed on a notice board in the entrance hall and is available in a format that the majority of the service users are capable of understanding. One service user spoken with said staff were very approachable and always took his concerns seriously. The homes complaints record confirmed this and showed that staff had enabled one service user to make a formal complaint about the way a particular incident was handled. The home is commended for ensuring all the relevant authorities were notified without delay about the alleged incident of abuse. Croydons vulnerable adult protection team convened a strategy meeting to follow up the matter and it was promptly concluded that all the staff involved had physically intervened as a ‘last resort’ and used the minimum force consistent with safety, to successfully defuse the situation. It was agreed that it had been in the service users best interests to physical intervene on this particular occasion and the complaint/allegation of abuse, which was eventually withdrawn, was therefore not substantiated. This matter has now been resolved to the complainants’ and their representative’s satisfaction. However, staff training records revealed that although all the homes current staff team have all received training in CMG’s British Institute for Learning Disabilities approved Management of Conflict Training; two of the staff involved
Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 19 in the incident had not attended refresher courses in its use since 2003. In accordance with CMG’s own policies, all persons authorised to use physical intervention techniques must have their training updated on an annual basis. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 20 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 The home has now been completely restored and improvements made to its layout to ensure the service users live in a very homely and comfortable environment, which suits their needs and lifestyles. However, further improvements to the homes fire safety arrangements are still needed, especially with regard fire containment measures, to ensure the service users, their guests and staff are, so far as reasonably practicable, protected. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 21 EVIDENCE: All the ongoing maintenance work that was outstanding from the homes previous inspection report, the majority of which was caused by the fire, has now been completed. As previously mentioned, the homes new visitors/smoking room is now up and running and all the interior redecoration work complete. It was positively noted that CMG have introduced a maintenance book for staff to record any repair or decorating jobs CMG’s maintenance department needs to undertake. An officer from the London Fire and Emergency Planning Authority last visited the home on 25/08/05 and was satisfied with the homes fire safety arrangements. However, it was noted that the fire resistant office door was being wedged open at the time of arrival. Work to fit automatic release mechanisms to fire doors is clearly a work in progress. The service providers are reminded that fire resistant doors must either remain closed or have suitable holding devices fitted which enable to close automatically as soon as the fire alarm system is activated. Furthermore, it is recommended that all fire resistant doors be fitted with seals, which form effective barriers against the spread of smoke. Having tested the temperature of hot water used in the first floor bath at 1pm it was found to be a safe 43 degrees Celsius, although the thermometer used by the home was difficult to read. The manager should consider purchasing a more suitable device for monitoring hot water temperatures in the home. The floor and walls of the laundry room are readily cleanable. Since the homes last inspection the home has purchased a new washing machine, which is capable of cleaning foul and soiled laundry at appropriate temperatures, which meets infection control standards. The facility is suitably positioned so laundry does not have to be taken through any areas where food is prepared, stored or eaten. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 22 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 & 36 Sufficient numbers of suitably experienced, competent and qualified staff are currently employed to meet the health, welfare and communication needs of the service users. EVIDENCE: Staff training records revealed that three members of the homes current staff team had already achieved a National Vocational Qualification in Care Level 2 or above and that a further ten others were currently in the process of studying for theirs. The manager stated that at least 50 of her current staff team were well on the way to achieving this award by the end of 2005; in accordance with National Minimum training targets for care workers. Progress on this matter will be assessed at the homes next inspection. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 23 It was positively noted that in accordance with staffing levels previously agreed with Commission at least four members of staff, including the homes manager, were all on duty at the time of this inspection. Two members of staff were out with service users at the time of arrival. Minimum staffing levels remain adequate to meet the assessed needs of the service users. It was positively noted that the majority of the staff working at the home had recently received in-house training in the appropriate use of makaton sign language to enable them to communicate more effectively with one of the homes most recent admission, who was fluent in its use. Furthermore, a wide variety of drawings depicting matchstick people using Makaton signing to communicate certain words were conspicuously displayed in the ground floor office and main lounge. One staff met had a good understanding of these signs and was able to demonstrate a few signs on request. Over half the service users currently residing at the home are now of Black Afro or Afro Caribbean origin, which is reflected in the ethnic and cultural mix of the staff team, the majority of whom are also from the same ethnic minorities. As previously mentioned, this diversity is reflected in the published menus and some of the activity schedules. Since the fire when all the homes staff records were destroyed the manager has be able to replace most of them from information held at CMG’s central office. This includes copies of all staff criminal records and protection of vulnerable adults checks. The Commission appreciates that the task of obtaining copies of everyone’s written references may prove impossible and accepts that the service providers and their manager have done there best in extremely difficult circumstances. The manager was adamant that no new members of staff will be recruited unless they can supply CMG with all the information required by the National minimum standards and the associated care homes regulations (2001). Minutes of staff supervision sessions with the manager revealed that they are being arranged on a bi-monthly basis in accordance with National Minimum standards. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 24 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, 39 & 42 The homes health and safety arrangements are sufficiently robust to ensure potential risks to occupants, their guests and staffs health are, so far as reasonably practicably, minimised. EVIDENCE: The homes manager, Venise Browne, has been in operational day-to-day control of Beulah Road for sometime and having past five units of her registered managers award is hoping to complete it by early next year. Venise was able to produce a letter from CMG’s training department confirming the service provider’s commitment to helping Venise achieve this target. There are clear lines of accountability within CMG and the manager says her line manager is always on hand to offer support and advice as and when required. The home has a quality assurance system in place the results of which were last published in January 2005. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 25 Up to date Certificate of worthiness were in place as evidence that ‘suitably’ qualified engineers had checked the homes gas installations, portable electrical appliances and water outlets for legionella, in the past twelve months in accordance with health and safety regulations. A fire risk assessment of the entire building has also been carried out and reviewed in the last year. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 26 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 3 3 X 3 X Standard No 22 23 Score 3 1 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 2 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Beulah Road (55) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000028139.V256530.R01.S.doc Version 5.0 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13(6) & 18(1) Requirement All staff ‘authorised’ to use physical intervention techniques, as a ‘last resort’ must have their British Institute for Learning Disabilities approved training refreshed on an annual basis. Documentary evidence of this training must be available for inspection on request. Fire resistent doors may be propt open during the day providing suitable holding device are fitted which enable them to close automatically into their frames as soon as the fire alarm sytem is activated. Under no circumstances must fire resisdetn doors be ‘wedged’ open. Timescale for action 01/01/06 2 YA24 23(4)(c) 01/01/06 Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 28 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 3 4 Refer to Standard YA24 YA27 YA32 YA37 Good Practice Recommendations All fire resistant doors should be fitted with effective smoke seals. A more suitable thermometer should be purchased for monitoring hot water temperatures in the home. 50 of care staff to have achieved an NVQ level 2 or above in Care by the end of 2005. The manager should have completed the managment component of her NVQ Level 4 training in care by the early 2006. Beulah Road (55) DS0000028139.V256530.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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