Inspection on 11/04/07 for Booth Road 82

This inspection was carried out on 11th April 2007.

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

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

Other inspections for this house

Booth Road 82 18/08/08

Booth Road 82 26/07/06

Booth Road 82 04/10/05

Booth Road 82 28/04/05

Booth Road 82 07/04/04

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Booth Road 82 Colindale London NW9 5JY Lead Inspector Caroline Mitchell Key Unannounced Inspection 11 & 27th April 2007 10:30 th Booth Road 82 DS0000010411.V333119.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 Booth Road 82 DS0000010411.V333119.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. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Booth Road 82 Address Colindale London NW9 5JY 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 8200 8504 F/P 020 8200 8504 www.pentahact.org.uk Adepta ** Post Vacant *** Care Home 8 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 4 adults who have a learning disability (LD) and who may also have physical disabilities (PD) and have associated nursing needs. Specific Service User One specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. 26th July 2006 Date of last inspection Brief Description of the Service: This home is owned and run by Adepta, previously known as PentaHact. It comprises two houses that are side by side and are adjoined by an open corridor. Numbers 82 and 84 Booth Road were previously registered as two homes. They have now been amalgamated and operate as one home, with a manager and two deputy managers. 82 Booth Road is no longer registered as a care home providing nursing care. On the ground floor of each house is a lounge, kitchen diner, toilet and laundry room. On the first floor, there are walk in showers, an assisted bath with a toilet and four bedrooms. On the second floor there is an office shared by both houses, a storage room and a meeting room. There is a small parking area at the front of the home and a garden at the back. The home is situated close to Colindale station on the Northern line, a short walk to Colindale hospital and approximately a mile away from Edgware Hospital. It is close to the shops, restaurants and public transport facilities that are located along the Edgware Road. The stated aim of the home is to provide twenty four hour care and support for people with profound learning disabilities to enable them to live as independently as possible within the community. Placements at the home costs around £1,336 for each person per week. People are expected to pay separately for some toiletries. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to the people who use the services and other stakeholders. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over two days. The inspector was assisted by the manager, Mrs Christine Balachandre during the inspection and also had the opportunity to meet several members of staff. The inspector looked at the care plans and risk assessments for three people s in some detail, and a number of the written records that are kept in the home including staff records, training records, team meeting minutes, supervision records, health and safety records, the record of complaints, and some policies and procedures. It is difficult to gain some of the people s’ opinions, as they do not communicate in conventional ways. However, the inspector was able to meet and observe several people s during the course of the inspection and they appeared happy and relaxed in their home. The standard of care is good. However, there are some areas identified for improvement with regard to management, the environment and health and safety and the inspector is confident the provider will manage these issues effectively. What the service does well: What has improved since the last inspection? There were a number of improvements in progress at the time of the inspection. The office has been provided with better shelving, and the manager was reorganising the records for both sides of the house so that they would be better integrated. The residents’ meeting are being facilitated by someone with learning disabilities, who is on work placement in the home. Some care plans have been made more accessible for the people living in the home. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 6 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. Booth Road 82 DS0000010411.V333119.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 Booth Road 82 DS0000010411.V333119.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have a needs assessment carried out before they are admitted to the home so that their needs and preferences are known to the home. The admission process is sensitive and adapted to the needs and circumstances of the individual. EVIDENCE: The inspector reviewed the written records of one person, who had moved in quite recently. The manager explained that the admission had been from hospital, and had not included as much time as is usual for the staff at Booth Road to get to know the person. However, some good quality, clear assessment information had been provided about the person’s needs and the manager went to meet the person, whilst they were in hospital and undertook a brief assessment there. Additionally, the person concerned has Autism and can get upset when there is a lot of change. In order to smooth the transition for the person, members of the staff team from the home that they had previously lived in came to be with the person every day for about a week. They spent time helping the person settle in to their new home and passed on information about the person’s needs, preferences, and how to work with The inspector was able to speak with the person’s new key worker at Booth Road, who said that it had been very useful to meet and spend time with the previous key worker as it had the move less upsetting for the person and a lot of useful information had been handed over to the team at Booth Road. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are person centred and are agreed with the individual. The plan is written in plain language, is easy to understand and looks at all areas of the individual’s life. Staff have skills and ability to support and encourage residents to be involved in the ongoing development of their plan. Staff make the process interesting and use a variety of ways to help individuals make a worthwhile contribution. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. Where limitations are in place, the decisions have been made with the person and are recorded. EVIDENCE: The inspector reviewed all of the written records kept for two of the people who live in the home, one of whom had moved in quite recently, and also reviewed the personal plans of five others. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 10 The inspector noted that the records available for the person who had recently moved in were sufficient to enable staff to be familiar with their needs and the risks that were specific to their needs, lifestyle and behaviours. This information had been provided by the home where they had previously. Good progress was being made in reviewing the risk assessments and creating a new plan for them, that would be more relevant to their new home. Each of the other plans reviewed were of a good standard and set out each persons’ needs and preferences. One plan had recently been reviewed and was of a particularly high standard. It was clear, in a large print and very well set out. It was made more accessible to the person themselves with photographs of themselves and their home. It was clear that these improvements were gradually being introduced for each of the people living in the home, to make their plans more accessible and relevant to them. A recommendation is made in relation to this. The registered persons must ensure that a risk assessment is developed regarding the use of metal bed rails for each resident for whom it is relevant. The inspector noted that a risk assessment had been produced that referred to the risks to residents if the rails were not used. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a commitment to enabling people to develop their skills, including social, emotional, communication, and independent living skills. People have the opportunity to develop and maintain important personal and family relationships. Staff promote individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. Support with communication skills is given by the staff team, both within the service, and when accessing the community. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. People are involved in the domestic routines of the home, they are supported to be involved in cleaning their room, menu planning and cooking meals. The menu is varied with a number of choices including a healthy option. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of individuals using the service. EVIDENCE: Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 12 One person seemed to be pleased to be able to tell the inspector that they were going to be making dinner the next day. The quality of plans of care at Booth Road remains good. These plans are detailed and include methods of communication used by residents, all aspects of resident’s behaviour and how this is managed, relationship maps and other information relevant to building a holistic picture of people . The plans seen are reviewed and amended regularly as needs change. Each of the people who live in the home has a schedule of activities. These include activities in the home to encourage people to be involved in the ordinary domestic tasks such as cooking and washing. As the people who live in the homes and staff interacted with each other throughout the day, the inspector saw evidence that people s were encouraged to make decisions that are relevant to them. Encouraging people’s independence was also a feature of the plans and risk assessments that are in place for each person. Some people were out at the time of the inspection, being at their regular daytime activities. One person came home proudly showing a rosette that they had been awarded for achievement that day. The inspector noted that the people that live in the home that are from a Jewish background have activities on their schedules that are designed to meet their needs in relation to this. The inspector was pleased to note that the residents’ meetings are now being facilitated by someone with learning disabilities, who is on work placement in the home. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person’s plan; they give a good overview of their health needs. The delivery of personal care is individual and is flexible and person centred. Staff respect privacy and dignity and are sensitive to changing needs. People are supported and helped to be independent and to take as much responsibility for their personal care needs as possible. People have access to healthcare services. People have the aids and equipment they need and these are well maintained to support both people who use services and staff in daily living. Staff has access to training in health care matters and are encouraged and given time to attend seminars on specialist areas of work. The home understands the need to comply with the administration, safekeeping and disposal of controlled drugs. Where one staff member has not followed good practice or safe practice guidelines, the registered person has responded appropriately. EVIDENCE: Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 14 The majority of the people who live in the home don’t communicate in conventional ways, some have specialist health care needs and a number are wheelchair users, having adapted wheelchairs suited to their needs. One person has a catheter and a peg feed. Others have behaviours that may cause risks to their health. One person is diagnosed as having MRSA and the inspector noted that specific infection control procedures are in place, and was being followed by staff. The records seen indicated that there is a great deal of thought and good joint working with the heath professionals involved around people’s health care needs and clear records are kept of heath care in put and advice. One person’s dental hygiene was noted by the inspector as needing to be addressed, and their written records did not include an indication that they had recently had a dental check-up. This issue was addressed at the time of the inspection. The home had a policy and procedure for the administration of medicines. Medication is stored appropriately locked medicine cupboards. Staff responsible for administering medication had been provided with the required training. No controlled drugs were prescribed to people at the time of the inspection as one person’s prescription had recently ceased. However, the inspector reviewed the record of controlled drugs and found it to have been completed appropriately, including two staff signing at the time that medication was administered, and a running total kept of the remaining medication. On the manager’s request, the pharmacist had recently undertaken an audit of the arrangements for the storage, recording and administration of medication in the home and the feedback was very positive about the system of management that is in place. However, at the time of the inspection the manager was dealing with an issue of recent errors made in the administration of one person’s medication, by one staff member. This was being addressed in a professional, thorough and competent manner. A requirement is made for a written report of the incident, investigation and any resulting action to be forwarded to the Commission. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand to help anyone living at, or involved with, the service to complain or make suggestions for improvement. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. The service responds within the agreed timescale. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. Training of staff in the area of protection is regularly arranged by the Home. EVIDENCE: The inspector noted that there was evidence on staff files that they had undertaken training in the protection of vulnerable adult from abuse. Because of the nature of their disabilities the people who live in the home were unable to advise the inspector of their opinions in relation to the complaints process. However, comment cards from relatives indicated that on the whole relatives and visitors were aware of the complaints procedure and how to use it. The inspector reviewed the record of complaints that is kept in the home and noted that some concerns raised by one person’s relatives about the person’s activities and development had been acknowledged and addressed appropriately. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance tends to be reactive rather than proactive. There are a number of areas identified for improvement in the kitchens and bathrooms. People can personalise their rooms. The home is clean, warm, well lit and there is sufficient hot water. There has been some consultation with people about the décor, especially for their own rooms. Bathrooms are accessible to people using the service. Toilets for the use of people using the service are appropriately located within the home, are easily accessible and in sufficient numbers. EVIDENCE: During the tour of the building the inspector noted that one of the offices had been provided with better shelving, and improvements were being progressed Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 17 in relation to the storage and organisation of the written records and policies. The carpets had been cleaned throughout the shared areas in both houses. The people who live in the home each have a bedroom of their own and these are decorated and equipped to suit their needs, personalities and interests. One person is keen on horse riding has a lot of things reflecting this, and a mural featuring horses on their wall. Where people have behaviour that is challenging, people have still managed to decorate and equip their rooms in a way that reflect their interests, whilst maintaining their safety. In response to a restated requirement about the kitchens needing to be refurbished some progress had been made in that the work surfaces had been replaced. However, despite repair, the kitchen cabinets continue to deteriorate, and are crumbling due to damage, in places. These need to be properly refurbished or replaced and, this requirement is re-worded for the sake of clarity, and restated as part of this report. The home had sufficient toilets and bathrooms. There are two assisted communal bathrooms with toilets and two walk in showers with toilets. The inspector noted that the two adapted shower rooms smelled of damp. It is likely that water is penetrating behind the tiles, as in one in particular they seem to be lifting away from the wall in places. The manager told the inspector that this shower room is the more used of the two. Additionally, the floor covering in one of the adapted bathrooms is cracked. Requirements are made in relation to these issues. The inspector noted that the home was clean and smelled fresh. There were special arrangements in place to prevent the spread of infection for one person who has MRSA, and appropriate facilities were readily available for hand washing. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service recognises the importance of staff training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. There is acceptable use of any agency or temporary staff that doesn’t adversely affect the quality of the individual support that people that use the service receive. EVIDENCE: Improvements in the staff team are ongoing and five new staff have been recruited and appointed since the last inspection, thus avoiding the use of asand-when staff as frequently, and improving the consistency within the team. The inspector reviewed the records of sixteen staff in relation to the preemployment checks that they underwent prior to being employed and noted that the manager has made progress in organising the written personnel records for each staff member, although there is still some work to do to complete the task. The organisation that run the home, Adepta have a clear recruitment procedure. At the last inspection the registered persons were Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 19 required to ensure that CRB applications, which include POVA checks, are submitted to the Criminal Records Bureau, for all staff who commenced employment since July 2004. At this inspection the inspector found that this had been addressed. However, the inspector noted that some of the CRB checks that are in place for some of the other staff had been undertaken more than three years ago and, although there is no deadline for these to be updated, this is included in this report as a good practice recommendation. The inspector reviewed the written records of 3 staff regarding their training records. It was evident that they were receiving a good level of training, and where there are training needs these are identified and train is planned with the needs of the people who live in the home in mind. Progress is being made with NVQ training. At the last inspection it was recommended that staff be provided with a training update regarding infection control and this had been addressed. Additionally, the records of one-to-one supervision with staff were well maintained and reflect that staff receive support of this kind on a regular basis. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the Home; they are aware of and work to the basic processes set out in the NMS. The manager trains and develops staff who are generally competent and knowledgeable to care for the people who use the service. The service is planned to be user focused, to take account of equality and diversity issues, and generally works in partnership with families of people who use the service and professionals. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. The manager is aware of the need to promote safeguarding and has developed practice regarding health and safety that generally meets health and safety requirements and legislation. The manager has highlighted areas where they need to make improvements with regard to the fire safety in the home and is attempting to address this. Checks show that records are generally up to date although some qualitative issues were identified. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is ion the process of applying to be registered with the Commission. She demonstrates commitment and competence in her management of the home. The manager ensures that all the homes policies and procedures are read and understood by staff. These are discussed in staff meetings. There is open communication between the staff and the manager, and staff are clear about the manager’s expectations in relation to the smooth running of the home. During the course of the inspection the inspector noted that there remains a qualitative difference between the organisation and records between the two parts of the house. A review needs to be undertaken of management arrangements and work practices in relation to these issues, and action taken in order to improve the management structure and the system of record keeping, in order to ensure consistency between the two houses. A requirement is made in respect of this. The manager explained that she is revising the fire risk assessments and the emergency plan due to new guidance from the fire authority. Additionally, she expressed concern about the arrangements for evacuating the people who live in the home, who are wheelchair users. A requirement is made in respect of this. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 25 X 26 3 27 2 28 1 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 2 X X 2 2 X Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The registered persons must provide a written report of the incident concerning errors in the medication administered to one person, the investigation and any resulting action to be forwarded to the Commission. The registered persons must ensure that the kitchen units are properly refurbished or replaced in both houses. The previous timescales of 01/05/06 and 1/10/06 were not met. The registered persons must ensure that the floor covering in one bathroom is properly refurbished or replaced. The registered person must ensure that water damage in two shower rooms be investigated and remedial action taken to address the damage that has resulted. The registered persons must ensure that a review of management and work DS0000010411.V333119.R01.S.doc Timescale for action 01/06/07 2. YA28 16(2)(h) 23 (2)(c) 01/07/07 3. YA27 23 (2)(b) 01/07/07 4. YA27 23 (2)(b) 01/06/07 5. YA41 YA38 17 01/07/07 Booth Road 82 Version 5.2 Page 24 arrangements and practices is undertaken and action taken in order to improve the management structure and the system of record keeping, to ensure consistency between the two houses. 6. YA42 23 (4) The registered persons must ensure that advice be sought from a properly qualified fire safety consultant, in order to support the manager in revising the fire risk assessment and emergency plan, in the light of new guidance from the fire authority. 01/06/07 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. 2. Refer to Standard YA6 YA34 Good Practice Recommendations It is recommended that the team continue to develop more accessible plans for all of the people who live in the home. It is recommended that the registered persons apply for updated CRB checks for all staff whose current CRB information is more than three years old. Booth Road 82 DS0000010411.V333119.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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