Inspection on 10/09/07 for Carlton Avenue (64-66)

This inspection was carried out on 10th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carlton Avenue (64-66) 25/09/06

Carlton Avenue (64-66) 12/01/06

Carlton Avenue (64-66) 29/08/05

Carlton Avenue (64-66) 02/03/05

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 Carlton Avenue (64-66) 64-66 Carlton Avenue Kenton Harrow Middlesex HA3 8AY Lead Inspector Tony Lawrence Key Unannounced Inspection 10th September 2007 09:20 Carlton Avenue (64-66) DS0000062165.V347641.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 Carlton Avenue (64-66) DS0000062165.V347641.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. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Avenue (64-66) Address 64-66 Carlton Avenue Kenton Harrow Middlesex HA3 8AY 020 8907 4918 020 89073370 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Management Group Ltd Miss Donna Marie Thompson Care Home 9 Category(ies) of Learning disability (9), Physical disability (5) registration, with number of places Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: 64-66 Carlton Avenue is a care home registered to provide care for nine people with a learning disability. The registered provider is Care Management Group Ltd (CMG) and the home was first registered in November 2004. The home is situated in a quiet residential area of Kenton, Harrow, close to shops and other amenities. Public transport is located near by and the home has an adapted vehicle to transport passengers in wheelchairs. All bedrooms are single with ensuite toilets and wash hand basins. Four rooms also have an ensuite shower, although these are little used. Four bedrooms are located on the ground floor and five bedrooms are on the first floor. There is a passenger lift. The dining room opens onto a large and accessible garden and patio area. The manager confirmed that the weekly fee for a residential placement in 6466 Carlton Avenue ranges from £1,300 to £1,600. The actual fee is determined though assessment of the potential resident’s needs. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Monday 10th September 2007 from 09:20 – 15:30. The Inspector spent time talking with residents, care staff and the home’s manager. He also observed staff supporting residents, toured the building and checked care records kept in the home. The Inspector checked the care of two people living in the home in more detail by checking their care records and talking with staff. What the service does well: What has improved since the last inspection? 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. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 6 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 Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 7 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 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. EVIDENCE: ‘We have a dedicated referral and assessment team who are responsible for screening, gathering information and assessing all new referrals. It also gives service users and family an opportunity to consider what services are available and to ascertain if it is appropriate’. (Extract from the provider’s Annual Quality Assurance Assessment). During this visit the Inspector checked the care plan files of two people living in the home, including the last person to move in. Both files included a full care needs assessment, completed either by a senior member of staff from the home or a local authority care manager / social worker. Both assessments were detailed and included information about each person’s care needs and how they would be met in the home. One excellent assessment had been completed by an assessment officer from Care Management Group and the home’s Manager. The assessment was detailed and clearly showed that the resident, their relatives and other significant people had been involved as much as possible. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 8 Both care plan files checked during this visit included a Residents’ Agreement that outlined the terms and conditions of residence. These included the need for a full care needs assessment before admission and an initial 12-week trial period for each person moving into the home. The Residents’ Agreement was produced using clip art to make the information more accessible to some people living in the home. Carlton Avenue (64-66) DS0000062165.V347641.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 and 9. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. 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. EVIDENCE: ‘Given that our service users are mostly non-verbal, we rely on other methods of communication, for example communication cards, photos or expressions for yes and no. It has been very useful to involve family members and external professionals when developing care plans as a means of gaining a full understanding of the person’s likes and dislikes around, for example, personal care, daily activities or meals’. (Extract from the provider’s Annual Quality Assurance Assessment). During this visit the Inspector checked the care plan files for two people living in the home. Both people had a current care plan, but only one of these was dated. The Inspector also found other assessments and reports in both people’s files that had not been signed or dated. The Manager must make sure that staff in the home and external agencies sign and date essential Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 10 assessments and reports. This will help to make sure that current information is available about each resident and that all information is regularly reviewed. The care plans of both residents were detailed and covered their personal and health care needs, communication and activities. One person’s care plan was very good at considering their cultural needs and how these would be met in the home and the wider community. Strategies included identifying a specialist day service and providing staff with words from the person’s first language to help them to communicate. Both care plans included Individual Action Plans with agreed goals and how staff would support individual residents to achieve these. The Inspector felt that the goals identified were appropriate and these included support with personal care, nutrition, mobility, making choices and developing language skills. Some Action Plans had been written in October and November 2006, but there was no evidence that they had been reviewed. Other Action Plans were not dated but had been reviewed in July 2007. As with other records kept in the home, the manager must make sure that Action Plans are signed and dated. Some information, in particular one person’s ‘All About Me’ was very person centred and was written in the resident’s ‘voice’. This gave a vivid picture of the person’s history, likes, dislikes and aspirations. The manager should support staff to make sure that other assessments and reports are written in a person-centred way. The Inspector saw very good risk assessments on each person’s care plan file covering, bathing, swimming, use of wheelchairs, night care and use of the hoists. The assessments accurately assessed the likelihood and possible severity of the risk and included strategies for staff to minimise potential risks to individual residents. Carlton Avenue (64-66) DS0000062165.V347641.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): 12, 13, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. People who use the service have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: One care plan reviewed by the Inspector during this visit included detailed information about the resident’s cultural needs and how these would be met in the home. As well as providing a list of basic words in the person’s first language for staff, the home had arranged for the person to go to an Asian day centre. Daily reports also showed that the person’s family had visited for Diwali and culturally appropriate food was provided at each meal time. Both care plans included a weekly programme of activities for each person. The activities were based on the assessment of each person’s likes and dislikes and known routines. They included gender specific activities for a female resident. The Inspector checked the daily records for each person and while these described the physical care that each person received, there were fewer Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 12 mentions of social activities, outings, family visits etc. The manager should make sure that staff also record the social care and support that people living in the home receive. For example, one person’s care plan said that they enjoyed swimming, but daily records showed no evidence that the person had been supported to go recently. Staff were also unable to recall when this activity had last taken place. The Inspector saw that the details of residents’ relatives, friends and other significant people were recorded as part of their care plan. The daily records kept by staff showed that residents are supported to keep in contact with relatives and friends. Visits by family and friends are also recorded in the daily logs. During the day, all eight people were supported to go out. Four people went to their planned day services and four other people went for a drive in the home’s adapted vehicle. The Inspector saw that the home has a large, attractive dining room that has room for all those people who use wheelchairs. When the Inspector arrived, most people had finished their breakfast but one person was supported to choose cereals and a drink. Staff also prepared a lunch of fish in white sauce, fresh vegetables and potatoes for those residents who were not at day services. Carlton Avenue (64-66) DS0000062165.V347641.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 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan. Personal support is responsive to the varied and individual needs and preferences of the people who use services. EVIDENCE: The Inspector saw that the individual personal and health care needs of two people were well assessed and recorded in the care plans checked during this visit. Some people living in the home have significant health care needs. These are well recorded in their care plans and specialist equipment is provided where needed. Both bathrooms in the home are equipped with assisted baths and fixed hoists. Nursing beds are provided in residents’ rooms. Three people living in the home need specialist support with feeding. The manager confirmed that the home has good links with the hospital dietician and a trained nurse employed by Care Management Group provides regular training and support for staff in the home. The Inspector saw that both care plan files included a Hospital Assessment for People with a Learning Disability. The assessment detailed important information about the person, including their routines, likes and dislikes. Staff told the Inspector that the assessments are taken to hospital when residents Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 14 have appointments and are particularly useful if people have to stay in hospital overnight or for longer periods. During this visit the Inspector checked the prescribed medication for all eight people living in the home. All prescribed medication is provided in blister packs by Boots and secure storage is provided in the office. The Inspector checked the Medication Administration Record (MAR) sheets for all eight residents. The Inspector found a small number of gaps in individual record sheets. This was discussed with the manager and she agreed that staff would be reminded to use agreed codes on the administration sheets when medication is not given to residents. Carlton Avenue (64-66) DS0000062165.V347641.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 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. Training of staff in the area of protection is regularly arranged by the Home. EVIDENCE: During this visit, the Inspector saw copies of the provider’s complaints procedure in the two care plan files checked and also displayed around the home. The procedure made good use of photographs to make the information more accessible for some people living in the home. The procedure also referred people to the Commission and the local authority if they need support to make a formal complaint. Staff who spoke with the Inspector were aware of the local safeguarding adults procedures and said that they would speak to the manager if they had concerns about the care of someone living in the home. The manager confirmed that there had been one protection of vulnerable adults (Pova) investigation since the last inspection. While the Inspector felt that the incident had been managed well by the home’s manager and Care Management Group, the manager must confirm that a decision has been taken with Social Services regarding possible referral of the member of staff to the Pova register. During this visit the Inspector also checked the financial records for two residents. Records of expenditure are well maintained. Two staff sign the expenditure record each time a resident spends their own money and the manager regularly audits individual’s records. Carlton Avenue (64-66) DS0000062165.V347641.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, 25, 26, 27, 28, 29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet the care needs of the residents. EVIDENCE: The home is situated in a quiet residential area of Kenton, Harrow, close to shops and other amenities. Public transport links are located near by and the home has an adapted vehicle to transport passengers in wheelchairs. All bedrooms are single with ensuite toilets and wash hand basins. Four rooms also have an ensuite shower, although the manager and staff said that these are little used. Four bedrooms are located on the ground floor and five bedrooms are on the first floor. There is a passenger lift. The dining room opens onto a large and accessible garden and patio area. The home has two accessible bathrooms with assisted baths and fixed ceiling hoists. During this visit the Inspector saw all nine bedrooms, communal areas, bathrooms and toilets. Overall, the home provides a good standard of accommodation. Because of the number of people who use wheelchairs, some parts of the home were showing some signs of ‘wear and tear’ but all rooms Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 17 were comfortably furnished and well decorated. In particular, residents’ bedrooms were comfortable, well furnished and highly individual. Residents and staff had worked well together to provide bedrooms that reflect each person’s interests and personality. A requirement was made at the last inspection that the hallway and dining room were redecorated. This work had not been completed and the requirement is reported in this report. The garden was spacious and had ramped access for people using wheelchairs. The manager told the Inspector that she hoped to begin work to provide a sensory garden. There was a sufficient number of bathrooms and toilets, although one assisted bathroom on the first floor was smaller and staff said that most people preferred to use the larger, ground floor bathroom. Staff said that four bedrooms had ensuite showers, but these are also little used. The manager said that staff worked with residents to make sure that people do not have to wait for extended periods to have access to the bathroom. It is a recommendation of this report that the provision of baths and showers in the home is reviewed to make sure that there is a sufficient number of fully accessible facilities for residents. Carlton Avenue (64-66) DS0000062165.V347641.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): 31, 32, 33, 34 and 35. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The provider recognises the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. EVIDENCE: ‘Just over 50 of our staff team hold NVQ Level 2 or above, others hold degrees in other areas and some have vast experience in other care settings. All staff have CRB and POVA checks prior to commencing employment within the home. Following the interviews candidates are invited to meet out service users’. (Extract from the provider’s Annual Quality Assurance Assessment). During this visit the Inspector checked the personnel files of two people working in the home. Both files included a job description, application form, 2 written references and full employment history. A requirement to improve the quality of pre-appointment information had been met. There is a need to make sure that references are verified, especially if they are not provided on headed paper or stamped by the agency providing the reference. There is also a need to make sure that staff provide evidence of visa renewal applications to show eligibility to work in the UK. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 19 Both staff files also included confirmation of Criminal Records Bureau (CRB) and PovaFirst checks that had been completed before the staff began working in the home. The Inspector checked the staff rota and this showed that there are consistently enough staff on duty to support residents. There was a minimum of 4 staff on each morning and afternoon shift. Throughout the day, the Inspector saw that all staff worked well together to make sure that each person’s care and support needs were met promptly and appropriately. The manager should make sure that the rota shows the actual hours worked by staff, rather than ‘early’ or ‘late’. The Inspector saw that the manager has developed a clear recording system that shows training courses that staff have completed. This enables the manager to make sure that people are referred to essential skills training courses when they become available. Staff who spoke with the Inspector were very positive about the training opportunities provided by Care Management Group. Carlton Avenue (64-66) DS0000062165.V347641.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, 39, 40, 41 and 42. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualification/s and experience and is competent to run the home. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. EVIDENCE: The home’s manager told the Inspector that she had been in post for 2 years. She has experience of residential care, has completed the NVQ Registered Manager’s Award and is registered by the Commission as a ‘fit person’ to manage the home. The Inspector felt that the manager has a clear vision for the future development of the service and the ability to support staff to provide good standards of care for people living in the home. Information pro0vided by the manager in the Annual Quality Assurance Assessment (AQAA) is evidence that the home has developed all of the policies and procedures needed to meet the National Minimum Standards. Managers from Care Management Group (CMG) carry out unannounced themed Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 21 inspections every three months to check compliance with the organisation’s policies and procedures. The manager also confirmed that CMG managers carry out monthly monitoring visits to the home. The visits are unannounced and reports are sent to the home after each visit. The provider sends annual quality assurance questionnaires to residents, their relatives and other significant people. The manager told the Inspector that staff, relatives or independent advocates would support residents to complete the questionnaires. The completed questionnaires are collated by CMG and an annual quality assurance report is produced. The manager said that the report compares the home’s performance with other services provided by CMG and is used to develop practice. During this visit the Inspector checked a variety of records kept in the home, including care-planning records, finance and medication records. Overall standards of recording in the home are good. No health and safety issues were noted during this visit. Carlton Avenue (64-66) DS0000062165.V347641.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 3 36 X 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 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 3 3 X Carlton Avenue (64-66) DS0000062165.V347641.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 YA6 Regulation 17 (3) Requirement The Manager must make sure that staff in the home and external agencies sign and date essential assessments and reports. This will help to make sure that up to date information about each resident is available in the home. To make sure that medication is administered safely, the manager must make sure that staff use agreed codes on the administration sheets when medication is not given to residents. To make sure that people are cared for safely, the manager must confirm that a decision has been taken with Social Services regarding possible referral of an ex-member of staff to the Protection of Vulnerable Adults register. Arrange for the ground floor hall and dining room to be redecorated. Repeat Requirement. Original timescale of 23/12/06 not met. Timescale for action 31/10/07 2. YA20 13 (2) 31/10/07 3. YA23 19 31/10/07 4. YA24 23 30/11/07 Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA7 YA13 YA27 YA34 YA33 YA34 Good Practice Recommendations The manager should support staff to make sure that assessments and reports are written in a person-centred way. The manager should make sure that staff record the social care and support that people living in the home receive. The provision of baths and showers in the home should be reviewed to make sure that there is a sufficient number of fully accessible facilities for residents. There is a need to make sure that employment references are verified, especially if they are not provided on headed paper or stamped by the agency providing the reference. The manager should make sure that the rota shows the actual hours worked by staff, rather than ‘early’ or ‘late’. There is a need to make sure that staff provide evidence of visa renewal applications to show eligibility to work in the UK. Carlton Avenue (64-66) DS0000062165.V347641.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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