Inspection on 28/06/05 for Briarwood Drive, 69

This inspection was carried out on 28th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Briarwood Drive, 69 30/11/06

Briarwood Drive, 69 19/12/05

Briarwood Drive, 69 14/09/04

Briarwood Drive, 69 05/05/04

Briarwood Drive, 69 23/02/04

Briarwood Drive, 69 22/07/03

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 Briarwood Drive 69 Santa Care Homes 69 Briarwood Drive, Northwood Hills Middlesex HA6 1PW Lead Inspector Gavin Thomas Unannounced 28 June & 1 July 2005 at 12.30pm th st 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 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 Stationary 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. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Briarwood Drive 69 Address Santa Care Homes, 69 Briarwood Drive, Northwood Hills, Middlesex, HA6 1PW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 429 1971 santacare@hotmail.co.uk Ms Santa Bapoo Ms Santa Bapoo Care Home 3 Category(ies) of Learning Disability registration, with number of places Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One named service user who is visually impaired can be accommodated, as agreed by the CSCI, on 27 June 2005. The condition of registartion will only apply for as long as the service users assessed needs can be met. The home must advise the CSCI when the service user no longer resides at the home. Date of last inspection 14 September 2004 Brief Description of the Service: 69 Briarwood drive is a three - bedded care home for service users with Learning Disabilities. It is a semi - detached house situated in a residential area close to a parade of shops at Northwood Hills and to transportation. Medical services are provided by a local GP and within walking distance. The home is owned and managed by a sole Proprietor. The home is in keeping with local ambience and provides off street parking for up to 2 vehicles. An attached garage is used primarily as a storage facility. The home has a rear garden, most of which is laid to lawn. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place for the duration of seven hours. The Inspector spoke with one service user recently admitted to the home. The service user said that they had settled into the home. The service user said they liked the home and had established a good relationship with staff. In particular, the Deputy Manager and the sleeping – in staff. The staff member spoken to said they were supported by the management team. The staff member also confirmed the types of training they have attended. The Inspector observed positive interactions between staff and the two service users. What the service does well: What has improved since the last inspection? There have been many improvements in the home since the last inspection as follows: • The home has done well in meeting requirements made at the last inspection. • The standards of the physical environment have improved with a view to refurbishing the attached garage for use by one service user with a visual impairment. • Records examined were of a better quality. • Quality assurance and monitoring systems have now been instigated. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 The Statement of Purpose and Service User Guide were well written with only minor amendments required. The format of the Service User Guide must however, be kept under review for the benefit of service users. The assessment process must indicate if the home suitable in meeting the needs of the service user. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The complaints section in the Statement of Purpose must include the contact details for the CSCI. The font size of the Statement of Purpose was judged to be too small. This must be reviewed to ensure that it could be easily read. The Service User Guide was incorporated in the Statement of Purpose. The Service User Guide must be a separate document as required under Regulation 5 of the Care Homes Regulations 2001. Given the needs of the current service user group, the format of the Statement of Purpose and Service User Guide must be produced in formats suitable to the needs of the service users. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 9 An assessment process was in place. All initial assessments are recorded. The assessment process must include if the home is able to meet the service user’s needs and how these needs would be met. The outcome of the assessment must determine if the home is able to offer a placement. This must be confirmed in writing to the service users and/or their representative. An assessment was carried out with the service user most recently admitted to the home. However, it was noted that a full needs led assessment was not carried out by the Placing Authority. This was not judged to be good practice. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 The quality of care plans and risk assessments were good. However, care plans must be amended and updated when changes have been identified at service users reviews. EVIDENCE: There were two service users accommodated in the home at the time of this inspection. Care plans were in place for both service users. Both care plans were detailed with procedural guidance for supporting service users with specific tasks. Care plans were reviewed six monthly and more frequently when required. The contents of the care plans were not updated when changes were identified in care plan reviews. Care plans must be amended and updated when changes have been identified. The procedural guidance for physical intervention as set out in one care plan was not judged to be appropriate. This must be reviewed as a priority to demonstrate more appropriate methods of physical intervention. Risk assessments were in place for both service users. Risk assessments were reviewed regularly. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Links with the community are good with adequate staff support to enable service users to develop their social skills. Systems for consulting with service users on their interests and preferences were good with some evidence that service users views are sought and acted upon. EVIDENCE: The two service users were engaged in daytime activities. Activities are normally carried out with service users on a one to one basis. The Deputy Manager said that activities are determined by service users on a daily basis. This was observed at the time of the inspection. All activities carried out are recorded on service users daily records. The Deputy Manager said the home is continuously exploring a wider range of activities for the service users to take part in. One service user was still in the process of settling into the home. The service user was being introduced to local amenities such as the library, cafes and parks. On the day of this inspection, the service user told the Inspector that they were going to the hairdresser with the Registered Manager. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 12 Given the assessed needs of one service user in particular, the home was advised to review the methodology on how activities are currently planned and recorded to ensure consistency and continuity before introducing new activities to the service user. The Deputy Manager said that both service users socialise with service users in another home owned by Santa Care Homes. The Deputy Manager was of the opinion that this is a positive way for both service users to interact with other people. Arrangements for contact with relatives were set out in individual care plans. The Deputy Manager explained that contact arrangements are agreed with relatives to enable them to maintain positive contacts with the service users. The home does not have a private room for service users to meet with relatives or other visitors. Service users may use their bedrooms for entertaining visitors. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Personal support is offered in such way to promote and protect service users privacy, dignity and independence. Overall, the home is doing well in maintaining established routines with services users. However, it was clear that staff do need to learn more about Autism to support one service user when changes to their routine are introduced. The home is making good progress in improving the management of medication. EVIDENCE: Guidance and support is given to service users for personal hygiene and intimate care. The required levels of support were set out in service users care plans. The home had established a daily routine with one service user. This included times for getting up, personal care, activities and meal times. The home was still establishing routines with one service user most recently admitted to the home. Staff were knowledgeable about service users needs and their routines. However, further opportunities must be explored for staff to learn more about Autism. This will enable staff to support one service user more successfully through transitional periods, when the service user is being introduced to new situations. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 14 One service user has the ability to communicate their needs via British Sign Language. The Deputy Manager said that the service user prefers not use sign language and communicates with staff through exchange of notes. This was observed at the time of the inspection. Service users health needs were set out in their care plans. Appointments had been made for the service user most recently admitted to the home to be seen by four health care professionals. Both service users were registered with a GP. Both service users had access to primary health care treatments. One service user informed the Inspector that they often get into a depressed state. The service user explained the reasons why they feel this way. The service user gave the Inspector examples of how they cope with these feelings. An appointment had been made for the service users to see a relevant health care professional regarding their mental health needs. Medication was kept in a locked cupboard. The Medication Administration Record examined was satisfactory. The home was in the process of finalising a contract with a local Pharmacy for the Monitoring Dosage System. The contract would also include routine Pharmaceutical audits at the home and medication training for the staff team. A copy of the contract was seen for inspection purposes. The contract referred to this establishment as a Dual Registered Nursing Home. This error was brought to the attention of the Registered Manager who arranged for the contract to be amended on the day of this inspection. Only one service user was receiving prescribed medication. The Registered Manager said that the medication was due to be reviewed by the GP once the service user has been assessed by another health care professional. A record for the disposal of medication was in place. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home had a satisfactory complaints system in place. Systems were in place for safeguarding service users from abuse or possible risk of harm. However, staff must be kept abreast of current practices through regular training. EVIDENCE: A complaints policy and procedure was in place. The Deputy Manager said that the home had not received any complaints since the last inspection. The service user most recently admitted to the home told the Inspector they had no concerns about the quality of care. The service user said that they would speak to the Registered Manager or the Deputy Manager if they had any concerns or complaints. An adult protection policy was in place. The policy was very limited and did not include the different types of abuse and action to be taken in the event of suspected or known abuse. The policy must be updated to include these details. The home must obtain a copy of the Department of Health – No Secrets guidance document. The home was in receipt of the London Borough of Hillingdon’s adult protection procedures. The Deputy Manager had attended recent training on adult protection. Arrangements must be made for other members of the staff team to attend adult protection training. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 29 & 30 Recent investment has improved the appearance of this home creating a more comfortable and safe environment for those living there. Steps have been taken to provide a safe environment for one service user with a visual impairment. However, adaptations and the installation of any aids to support this service user must be more appropriate for the reasons as stated below. EVIDENCE: The home is in keeping with local ambience. Improvements had been made to the physical standards in recent months. New flooring has been laid in the lounge/dining room. The bathroom has been redecorated with new flooring and the chimney- breast has been removed from the dining room for the safety of one service user. A handrail has been fitted on the staircase for the benefit of one service user who is visually impaired. The handrail was painted in the same colour as the wall. The handrail must be painted in a different and more suitable colour to raise an awareness of its presence. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 17 The home was also advised to paint to step leading out into the garden in a suitable colour to raise an awareness of its presence. The attached garage is currently used for general storage and houses the washing machine. The Registered Manager intends to convert the garage into an en suite bedroom for the service user with sensory needs. In addition to statutory requirements to change the use of this part of the home, the Registered Manager was advised to consult with a relevant professional such as an Occupational Therapist on the appropriateness of any adaptations which may be required for the service user’s medium to long term needs. The programme of routine maintenance had been abolished and replaced with a health and safety checklist of the premises. A planned maintenance and renewal programme for the fabric and decoration of the premises must be reinstated. The home was clean and well presented throughout. A policy on the control of infection was in place. The Deputy Manager said that a new washing machine was installed in May 2005. The home must arrange for a water assessment to be carried out by an approved contractor. An action plan must be drawn up to address any shortfalls identified. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 & 36 The home has made good progress in providing training and development opportunities for the staff team. However, A proper training and development programme is still required. EVIDENCE: The staff team consists of the Registered Manager, one Deputy Manager, two Support Workers and one sleeping – in staff. The home was in the process of recruiting two additional care staff. There are normally two staff on duty throughout the day. One to one support is provided for carrying out activities with service users. Staff training and development profiles were in place. The Deputy Manager said that staff training needs are identified in one to one supervisions and annual appraisals. Staff had attended training in First Aid, Food Hygiene, Medication, and Autism. Forthcoming training had been scheduled with the RNIB, British Sign Language and permissible forms of restraint. A training and development programme was not in place. This must be devised and implemented. One member of staff spoken to confirmed that they were working towards an NVQ Level 2 in care. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 19 Induction and foundation training modules were in place. This included LDAF (Learning Disabilities Award Framework) training. The Deputy Manager confirmed that one to one supervisions are carried out with staff every two months. Supervisions were not being recorded. Supervisions must be recorded, which takes into account the criteria as set out in standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65). Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41 & 42 Good progress was being made towards the implementation of quality assurance and monitoring systems. The management of health and safety records could be improved upon. EVIDENCE: The home was in the process of developing quality assurance and monitoring systems. This included an annual development programme, collating the views of others with regards to the quality of the service and reviewing management systems. Progress towards the implementation of quality assurance and monitoring systems will be monitored at the next inspection. Policies and procedures were in place. These were in the process of being reviewed. The Deputy Manager confirmed that the home was registered under the Data Protection Act 1998. Health and safety monitoring systems were in place. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 21 The home must arrange for a legionella test to be carried out. The opening of the window in one of the bedrooms on the first floor was too wide. Although this bedroom was not occupied, it was unlocked and accessible to another service user. The opening of the window must be restricted to ensure service users safety at all times. A record of fire drills was in place. The Deputy Manager was advised to add the actual time of each drill. The record was amended at the time of the inspection to include these details. A fire risk assessment was in place. A fire emergency route planner was not in place. This must be devised and implemented. An approved contractor serviced fire extinguishers in March 2005. The fire detection system was last serviced in July 2004. An approved contractor last serviced the gas system in May 2004. The Registered Manager confirmed that the gas system was scheduled for servicing within a month from the date of this inspection. Potable electrical appliances were last tested in September 2004. The electrical wiring installation was last serviced in 2004. The Fire Officer last inspected the premises in November 2002. The Environmental Health Officer carried out a food safety inspection in May 2004. Reports for both visits indicated that the home was in compliance with relevant legislation. The Registered Manager confirmed that a thermostat was fitted to the bath in April 2004. Hot water delivered to the bath is tested periodically. Records of these tests indicated that the temperature of hot water is delivered within in a safe range. Although records were available to evidence the above findings, a considerable amount of time was taken to locate the records required for inspection purposes. The filing system for these records should be reviewed to ensure that records relating to health and safety systems are more easily accessible. This was discussed with the Registered Manager and the Deputy Manager at the time of the inspection. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 2 2 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 x x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briarwood Drive 69 Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 3 2 x G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 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 1 Regulation 4(1)(c ) Schedule 1(14) 4(2), 6(a) Requirement The complaints section in the Statement of Purpose must include the contact details for the CSCI. The font size of the Statement of Purpose must be reviewed to ensure that it could be easily read. The Service User Guide must be separated from the Statement of Purpose. The format of the Statement of Purpose and Service User Guide must be reviewed and produced in formats suitable to the needs of the service users. The current method of assessing prospective service users must indicate if the home is able to meet the service users needs and how these needs would be met. The outcome of the initial assessment must determine if the home is able to offer a placement. This must be confirmed in writing to the service user and/or their representative. Timescale for action 31/8/05 2. 1 31/8/05 3. 1 5(1)(a)(b) (c) (d)(e)(f) 5(2), 6(a) 31/8/05 4. 1 31/8/05 5. 2 14(1) 31/8/05 6. 2 14(1)(d) 31/8/05 Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 24 7. 6 15(2)(c ) 8. 6 13(7) Care plans must be amended and updated when changes to the service users needs have been identified. The procedural guidance for physical intervention as set out in one care plan must be reviewed and amended with more appropriate methods of physical intervention. The home must review the methodology on how activities are currently planned and recorded to ensure consistency and continuity before introducing new activities to one service user. Further opportunities must be explored for staff to learn more about Autism. The adult protection policy must be updated to include the different types of abuse and action to be taken in the event of suspected or known abuse. The home must obtain a copy of the Department of Health – No Secrets guidance document. Arrangements must be made for members of the staff team to attend adult protection training. The handrail on the staircase must be painted in a different and more suitable colour for the benefit of the service user who has a visual impairment. The step leading out into the garden must be painted in a suitable colour for the benefit of the service user who has a visual impairment. A planned maintenance and renewal programme for the fabric and decoration of the premises must be reinstated. 31/8/05 31/7/05 9. 12 12(1)(b) 31/7/05 10. 11. 19 23 18(1) (c )(i) 13(6) 31/8/05 31/8/05 12. 13. 14. 23 23 24 13(6) 13(6) 23(2)(a) 31/8/05 31/8/05 31/7/05 15. 24 23(2)(a) 31/7/05 16. 24 23(2)(b) (d) 31/8/05 Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 25 17. 30 13(4)(c ) 18. 35 18(1)(a) (c)(i) 18(1)(a) 19. 36 20. 39 24(1)(a) (b) 13(4)(c ) 13(4)(a) 21. 22. 42 42 23. 42 23(4)(b) The home must arrange for a water assessment to be carried out by an approved contractor. An action plan must be drawn up to address any shortfalls identified. A training and development programme must be devised and implemented. (Timescale of 1/2/05 Not Met). Supervisions must be recorded, which takes into account the criteria as set out in standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65). Further progress must be made towards the implementation of the quality assurance and monitoring systems. The home must arrange for a legionella test to be carried out. The opening of the window in the bedroom on the first floor must be restricted to ensure service users safety at all times. A fire emergency route planner must be devised and implemented. 31/8/05 31/7/05 31/08/05 30/9/05 31/8/05 31/7/05 31/7/05 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 42 Good Practice Recommendations The filing of health and safety records should be reviewed to ensure that these records are more easily accessible. Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Briarwood Drive 69 G61-G10 S27085 Briarwood Drive V229472 28.06.05 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!