Inspection on 02/07/08 for Carlingford Road, 181

This inspection was carried out on 2nd July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carlingford Road, 181 14/11/07

Carlingford Road, 181 19/04/07

Carlingford Road, 181 03/10/06

Carlingford Road, 181 24/11/05

Carlingford Road, 181 17/05/05

Carlingford Road, 181 16/09/04

Carlingford Road, 181 20/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Carlingford Road, 181 181 Carlingford Road South Tottenham London N15 3ET Lead Inspector Jackie Izzard Unannounced Inspection 2nd July 2008 10:40 Carlingford Road, 181 DS0000060630.V365537.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 Carlingford Road, 181 DS0000060630.V365537.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. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlingford Road, 181 Address 181 Carlingford Road South Tottenham London N15 3ET 020 8888 8916 020 8299 4818 choicesupport@choicesupport.org.uk www.choicesupport.org.uk Choice Support 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) no registered manager Care Home 4 Category(ies) of Learning disability (0) registration, with number of places Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2007 Brief Description of the Service: 181 Carlingford Road is a residential care home registered to provide personal care to up to four people over the age of eighteen and who have a learning disability. The home is situated in a residential area of Tottenham in North London, with good public transport links and close to Wood Green shopping and leisure facilities. The home is a converted mid-terrace house, arranged over three storeys, with four bedrooms, two bathrooms, a garden, lounge and kitchen. On the 1st April 2004, Choice Support took over the registration of the home, and Sanctuary Housing Association provides the housing support. Choice Support is a charitable organisation that has been in business for 20 years supporting people with learning disabilities in the community. The home provides 24 hour care and the stated aim is to provide the people living there with a secure, relaxed and homely environment in which their care, well being and comfort is of the prime importance. People living at the home are expected to pay a contribution towards food and activities, such as holidays, transport, activities, eating out, take away meals and rental of a water cooler. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to people living at the home and other stakeholders. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from Choice Support. At the time of this inspection, there were three men and one woman living at the home. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. Two inspectors visited this home and stayed for one day. We talked to the four people who live at the home, the staff and the area manager. We also talked to the social worker for one of the residents to ask for her opinion of the homes and we sent surveys to the home for staff to give to residents and relatives so that they could give their views in writing if they were able. The residents returned their surveys to us which staff had completed for them. We also spoke with the relative of one resident. All this information was included as part of the inspection. We looked around the home to see if it was clean and safe, we looked at what was written in the files in the office to see if people were being looked after properly and we spent time with residents to see if they were happy in the home. What the service does well: What has improved since the last inspection? At the last inspection of the home in November 2007, Choice Support were asked to do eight things to improve the service offered by this home. They have completed five of these. Two others (new sofa and bathroom floor) are about to be completed. They have improved in writing about peoples health appointments and what they have to pay for. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 6 They have also asked people living at the home and their families what they think of the home and are going to plan to write a report about this. The area manager make sure she checks up on the home every month and writes a report telling the manager what is going well and what improvements need to be made. In June 2008, staffing during the night improved. There used to be one staff sleeping in the home at night and now a staff member stays awake all night so that they can support anybody who needs help during the night. The service has improved in all areas over the last year and is still improving for the benefit of residents. What they could do better: At the end of this report, are a list of things that the home needs to do to make the home even better for the people living there. There are five requirements which Choice Support must do and two recommendations. Choice Support and Sanctuary Housing should be quicker in repairing things that are broken in the home. Inspectors saw that the upstairs bathroom is being fitted with new flooring in a few days time and that Choice Support have given the home money to buy a new sofa. This has taken a long time. The shower now needs to be repaired and the other bathroom needs a new floor. The home has not had a registered manager for a few years. A new manager is going to start on the 17th of July and must be registered with the Commission for Social Care Inspection. People living at this home need to be assessed to see how able they are to make decisions for themselves, for example about their finances and medical matters. This is to make sure they get the best possible support with their money and their health and so that everyone working with them knows whether they can make these decisions for themselves or whether they need help. We have asked that they update one resident’s risk assessment to state that he needs two staff to support him when he goes out. We have asked the area manager to carry out a risk assessment about male and female staff and make sure there is always a male staff on duty as this is what some of the residents prefer. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 7 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. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 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 Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples needs and aspirations have been assessed and they have individual written contracts explaining the terms and conditions of living at the home. EVIDENCE: As the four people living in this home have lived here for a number of years, their pre-admission assessments were not inspected. These have been inspected on previous occasions. Each resident has an individual Service User Guide and contract. These specify the terms and conditions of the placement and what they are responsible for paying for. We saw that a requirement to include the money that residents are charged every month for the rental of the water cooler is included in the contract. The area manager told us that these will be signed by relatives on behalf of the residents in the very near future. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents of this home can feel assured that their assessed and changing needs are known by staff and recorded in their individual risk assessment and care plans. This helps staff to support the residents and meet their needs and preferences. EVIDENCE: To assess these standards, we inspected three residents’ files; including their person centred plans, risk assessments and other records and in addition we spoke with three residents in an attempt to get their views. Risk assessments for individual needs were in place. We saw that the support plans were comprehensive and were updated on a regular basis. Cultural needs assessments were also in place for residents. All these documents explain residents’ needs and wishes to staff. Two risk assessments had been very recently updated. The third risk assessment needed to be updated as this stating that the resident could be supported by one member of staff when going out in the community. We were told by staff that this person requires Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 11 two members of staff to support him when he goes out. A requirement is made to update this risk assessment. In practice, staff said that two people did always go with the resident. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a varied lifestyle in accordance with their individual preferences. They are supported to maintain relationships with their family and are given a healthy diet which meets their health and cultural needs. EVIDENCE: We met with one of the residents in private and asked what activities the person took part in and what activities he/she enjoyed. This resident was able to say what activities took place and which ones he/she liked. The resident said that s/he liked drama and playing football but did not like trampolining. Those residents who like trampolining are supported to go on a weekly basis. This resident said that he/she liked cycling and we were told that all four residents attend a supported cycling club every Saturday. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 13 Each resident has an individual activity programme. As part of the monthly monitoring of the home, senior staff from Choice Support record what activities each resident has taken part in the previous week. This is a good way of monitoring that people are getting out into the community and taking part in valued activities. Staff were able to tell us that three of the four residents had regular contact with their family. The residents attend different day services according to their own needs so have contact on a daily basis with other people with whom they do not live. They also mix with other people at clubs and activities so that they have contact with a range of different people. We looked at residents’ support plans to see what type of food they like and compared this with the menus to see what meals have been provided in the three weeks prior to the inspection. Staff keep detailed individual records of food eaten so that they can monitor each person’s diet. This is good as it helps ensure people are given a healthy diet. The menu was healthy and varied and included different cultural foods which reflected the background of the people who live at the home. We asked one resident if s/he liked the food and he/she said yes. We gave each resident the opportunity to spend time with us in private to see if they wanted to say anything about the service provided at this home. Residents have limited communication skills due to their disabilities however we were able to see that two residents appeared relaxed and happy. One told us that s/he did not like some of the other residents but liked to eat fruit (there was a good supply of fresh fruit when residents got home in the afternoon) and liked to kick a ball in the park, ride a bike and go to drama. All these activities were recorded as taking place regularly. A third resident was unsettled but this was being addressed by a multidisciplinary team. The fourth resident gave some written comments to us in answer to our questions about whether s/he felt happy and safe in the home. Unfortunately we were not able to read the comments. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home receive personal support in the way that they prefer and their physical and emotional health needs are met by staff and external health care professionals. They are protected by safe procedures regarding medication. EVIDENCE: There is an individual risk assessment for medication error, which lists medication and the consequences of that particular medication not being given or been given in error. There were health action plans in place and clear records of health appointments. There was evidence in a letter from the GP for one resident that he will be having an medical review on 11/07/2008 to review medication and health generally. There was evidence in place that a recommendation from a resident’s recent review that an opticians appointment be made was done. The resident saw the optician on 30/06/08 and was issued with a new prescription. Staff have recorded that the glasses will be delivered within two weeks. The health checks in three files seen are regular and up-to-date. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 15 The area manager said that residents were receiving some education appropriate to their understanding from a district nurse about blood tests as all four residents refused to have these tests. No evidence of this work was recorded. This work needs to be carried out to try and reassure residents about blood tests. We checked a sample of medication administration charts and found these to be completed clearly by staff. We also observed a staff member giving a resident medication and saw that this was done safely and appropriately to meet the residents needs. In recent months staff have been seeking the help of professionals in reviewing the health needs of one resident who has been having a difficult time. All appointments were clearly recorded along with the outcome so that staff were well-informed on any changes needed in the way that they work with this person. Staff were observed interacting with the residents and it was evident that the staff on duty had good relationships with all residents. They interacted in a positive and calm way. We sent surveys to the home for all residents and for their relatives so that they could give their views on the care provided by the home. The relatives surveys had not been given to relatives so we asked the area manager to ensure relatives were contacted and invited to contact us if they wanted to give any comments about the home. We received comments in a telephone call from one resident’s parent. This person said that the care was generally “OK.” Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The company’s policies protect residents from abuse. EVIDENCE: Choice Support have written a new safeguarding adult procedure dated March 2008 to advise staff of the steps to follow in the event of any abuse taking place and staff have signed and dated that they have read this changed policy. There is a policy on physical intervention and restraint. The company policy is restraint is not be used. The home’s complaints book was not available on the day of the inspection as this had been mislaid. We were informed that there have been no complaints in the last year. Staff have received training in the protection of vulnerable adults. There have been no safeguarding referrals since the last inspection. We discussed the challenging behaviour of one resident with the area manager and a staff member. We were informed that although their windows had been broken by this resident, none of the residents had been assaulted in any way. We saw that there is a written policy regarding physical intervention which guides staff on what to do and what not to do . Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 17 A requirement is made to assess the capacity of each resident to make decisions for themselves. It is not clear from meeting residents and from reading their support plan and risk assessments whether they are able to give informed consent on medical and financial matters and it is important to establish this. All four residents refuse to have blood tests and staff are not clear whether they can give informed consent or not. Similarly it is not clear whether a resident has given informed consent for two Choice Support employees to act as his agents when withdrawing money from his account. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a house which is homely and safe and is kept clean and tidy for them. Repairs and replacements to the furniture and fittings are sometimes slow which means that people have to live with less homely items for long periods. EVIDENCE: We looked at every room in the house plus the garden. The house was being kept clean and tidy by the staff for the benefit of residents. Staff support residents to look after their own rooms but do not interfere with their possessions. Staff were able to say that one person leaves his possessions in a particular place each morning when he leaves the house and it is important to him that nobody moves his things. Staff respect this. There were two broken windows at the time of the inspection which had been broken by a resident. These were boarded up safely. One window would not open because Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 19 of the boarding and this room was too hot for comfort. When we pointed this out to staff they went out with the resident to buy a fan for the room. Requirements made at the last inspection to remove paint stains from the sofa and to replace the bathroom flooring had not been complied with in the timescale given. This means that residents have had to use these for a long period. We were given evidence that the home was in the process of buying new sofas and getting the flooring replaced. The ground floor bathroom flooring also needed replacing with a more homely and practical floor covering. This was about to take place. The shower was mouldy and not fit for use. A requirement is made to repair or replace the shower. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are supported by staff who have been properly recruited and are being provided with appropriate training. Choice Support is aware of the individual residents’ staffing needs and preferences and tries to meet these at all times. EVIDENCE: To assess these standards, we spoke with the area manager about staffing and each resident’s staffing needs. We also inspected staff rotas and training records and read residents’ risk assessments to establish any staffing needs and issues. We were unable to inspect staff records as staff records were locked away and were not available on the day of the inspection. We asked that the recruitment records relating to two new staff were forwarded to us for inspection. This took place a few days after the inspection and we were able to confirm that staff did not start work until a Criminal Records Bureau disclosure and two references had been received. This protects residents from risk of unsuitable people being employed. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 21 Three staff have training which exceeds NVQ level 2 including one who has NVQ level 3. and three staff are enrolled on the NVQ training. Staff have been provided with training which is relevant to their work in this home. This training includes autism, epilepsy, challenging behaviour, breakaway techniques, Person centred planning and medication. It was evident from discussion of one resident’s needs, that it is currently necessary to have one male staff on duty at all times. While in practice the home usually does achieve this, there have been occasions where there are solely female staff on duty. A requirement is made to undertake a risk assessment to determine whether male staff need to be on duty at all times in order to support a resident’s needs and preferences and ensure that this is provided at all times if assessed as needed. We were informed that extra staffing has been agreed by the placing authority, Haringey, for fifteen extra hours per week to support one of the residents. On 11 June 2008, the night time staffing support in this home changed. There had been one staff member asleep in the home on-call at night. Due to the needs of a resident changing, waking night staff were needed. CSCI were informed by a representative from Choice Support that a resident needed support during the night and that Choice Support were not providing this level of staffing. We made a requirement that Choice Support undertake an urgent risk assessment to confirm whether waking night staff were needed and if so, to provide this immediately. This was done and Choice Support have provided waking night staff every night since. We noted on one resident’s review minutes that it stated that CSCI had been monitoring the night staffing and the area manager was asked to contact the person writing the minutes to inform that Choice Support are responsible for monitoring and providing night time staffing and that CSCI had not been monitoring the night time staffing. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home have their welfare monitored by Choice Support and their health and safety promoted. The addition of a competent registered manager will be of benefit to residents and should ensure further improvements in the service. EVIDENCE: Choice Support have operated this home without a registered manager for some time which is of concern. We have been informed that a new manager has been recruited and will start work on 17 July. Due to the long period of time that the home has been without a registered manager a requirement has Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 23 been made that this person submit their application for registration within a week of starting employment. The area manager said that she is in the process of writing the results of the most recent quality assurance audit for the home and will forward this to CSCI when it is completed. We contacted a care manager for one of the people living at the home who is unable to speak for himself. This care manager said that s/he had been concerned when the previous manager started and left within a short time but that staff were supporting the resident well and there were no concerns about how they were working with him. The home is being monitored on a monthly basis and a report written on the conduct of the home by senior staff from Choice Support. Requirements from CSCI reports are not specifically monitored and a recommendation is made that these requirements are monitored as part of the monthly reports as this will help Choice Support to ensure requirements are met within the given timescale. It was of concern that Choice Support did not introduce waking night staff as soon as they realised that this was needed, but they did respond immediately and do so when the Commission for Social Care Inspection became involved and asked for this to be addressed. There is an acting part time manager at the time of the inspection as the new permanent manager will be starting on 17 July. The area manager said she is visiting the home regularly and phoning them daily to offer support and advice during this period. Staff confirmed that this was the case. Some of the policies and procedures in the home were not the current policies used by Choice Support and therefore need to be replaced with the up to date policies to ensure staff have access to the current guidance. A recommendation is made to do this. A sample of health and safety records were inspected. Fire drills are held every three months and staff test the fire alarm every week and record the outcome. Portable electrical appliances an gas appliances have been inspected this year as well as fire fighting equipment. The home’s insurance was seen to be within date. This indicates that the health and safety of staff and residents is promoted. Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 2 X 3 x Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 25 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. Standard YA9 1. Regulation 13(4)(c) Requirement Timescale for action 01/08/08 2. YA23 12(2)(3) 3. YA24 23(2)(d) 4. YA33 18(1)(a) The registered persons must ensure that risk assessments reflect a residents up to date needs. This refers to a resident whose staffing support needs were not recorded correctly in his risk assessment. The registered persons must 01/09/08 arrange for residents’ capacity/ability to give informed consent on financial and medical matters is assessed so that their support needs in these areas can be addressed and their best interests safeguarded. The registered persons must 31/08/08 ensure that the ground floor shower is repaired so that residents can use it if they choose to. The registered persons must 31/08/08 ensure that a risk assessment is undertaken to determine whether there needs to be a male staff member on duty at all times to support residents’ needs and preferences. If the outcome of the risk assessment shows this is needed, then this must be provided by Choice Support. DS0000060630.V365537.R01.S.doc Version 5.2 Page 26 Carlingford Road, 181 5. YA37 9 The registered persons must ensure that a manager applies to the Commission to be registered. This requirement is restated. Previous timescales have not been met. 31/07/08 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 YA39 Good Practice Recommendations The registered persons should show evidence of monitoring CSCI requirements as part of Regulation 26 visits. This should help ensure requirements are met within the timescale given. The registered persons should ensure that this home is provided with a copy of up-to-date policies and procedures. This is to ensure that all staff are aware of the most current procedures they should be following. 2. YA40 Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carlingford Road, 181 DS0000060630.V365537.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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