Inspection on 25/09/06 for Carlton Avenue (64-66)

This inspection was carried out on 25th September 2006.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carlton Avenue (64-66) 10/09/07

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 Ms Sue Barker Key Unannounced Inspection 25th September & 12th October 2006 09:10 Carlton Avenue (64-66) DS0000062165.V303201.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.V303201.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.V303201.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 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.V303201.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: 64-66 Carlton Avenue is a care home registered to provide care for nine adults who have a learning disability and of which five may have physical disability. The Registered Manager is Ms Donna Thompson. The registered provider is Care Management Group Ltd (CMG), which owns many care homes. The home is situated in a quiet residential area of Kenton, Harrow, close to amenities. Public transport is located near by although the home has an adapted vehicle to transport passengers in wheelchairs. The home is newly renovated and is light and airy. All bedrooms are single with ensuite facilities. Four bedrooms are located on the ground floor and five bedrooms are on the first floor. There is a passenger lift. The dining area opens onto a garden and patio area that service users can access. The care home was first registered on the 26th November 2004. The weekly fee for a residential placement in 64-66 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.V303201.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 9.10am on a damp September morning. It was completed on 12/10/06 when the Inspector also met with the Registered Manager, Ms Thompson. The Inspector was pleased to meet and greet /speak with residents and staff on duty. The unannounced inspection mainly included observation/evaluation of care practice in the home as most residents communicate by non-verbal means. In addition the Inspector considered the statutory records and viewed the building. The Inspector additionally followed up requirements arising from the previous unannounced inspection. There were 7 residents living in the care home at the time of the unannounced inspection. A further resident moved in to 64-66 Carlton Avenue prior to the Inspector’s second visit. Some residents went out during both of the Inspector’s visit. The care home has it’s own adapted vehicle for this purpose. Residents presented to the Inspector as at home and comfortable within 64-66 Carlton Avenue. The Inspector observed staff offering residents choices. The Inspector would wish to thank those in 64-66 Carlton Avenue for their assistance and patience during the unannounced inspection. The Inspector was made most welcome. What the service does well: Residents’ referred for placements in 64-66 Carlton Avenue participate in an assessment of their needs, which will include visits to the care home. Residents living in 64-66 Carlton Avenue have individual care plans that offer extensive guidance and advice on how to work with them in a consistent manner. Care plans cover aspects relating to residents’ needs in terms of their equality and diversity. Residents living in 64-66 Carlton Avenue were observed by the Inspector to be offered ordinary living choices by staff during the unannounced inspection. The home has completed assessments of those risks identified in respect of individual residents living in 64-66 Carlton Avenue. Residents are supported by staff to participate in a range of activities/pursuits both within the care home and the wider community. Inspection confirmed that residents living in 64-66 Carlton Avenue enjoy a range of family and personal contacts. Daily routines within 64-66 Carlton Avenue presented as being in place to accommodate resident’s individual lifestyles and daily occupation. Residents are supported/assisted by staff to choose and eat a range of meals within the care home. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 6 Residents’ personal care and support needs are met by staff in the care home and this aspect forms part of their care plans. Staff support residents to access preventative healthcare support and services within the community. Residents’ medication is stored and administered safely within the care home. Residents have access to information about how to complain. Residents are protected through the care home’s Protection of Vulnerable Adults from Abuse procedures. Residents present as being supported by a knowledgeable and caring staff group in 64-66 Carlton Avenue. Residents benefit from living in a care home that has a registered manager, whose focus is resident development and well-being. Residents, their representatives and staff have been consulted about their views on the quality of care available in 64-66 Carlton Avenue. This work is underway. 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. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ referred for placements in 64-66 Carlton Avenue will participate in an assessment of their needs, this will include their visiting the care home. EVIDENCE: The Inspector was advised that one potential resident was being assessed for a placement in the care home. The assessment included visits to 64-66 Carlton Avenue and the Inspector was advised that a further visit was taking place later in the week. The information held in the home about this resident included an old care plan from their current care home and the written observations of this potential resident taken during their 2 visits previous visits to the care home. Ms Thompson indicated that assessments of potential residents are carried out in conjunction with head office, which is where the organisation’s assessment information and the transitional plan were held. From reading the potential resident’s previous care plan and observations, the Inspector noticed some differences in the behaviours observed. The Inspector discussed with Ms Thompson whether the information held in the care home was sufficient to enable staff to work with the potential resident safely during the trial visits/stays. Ms Thompson subsequently advised the Inspector that all information held about potential residents was to be available to staff working in the care home. Care plans were in place for all residents living in 64-66 Carlton Avenue. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. 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 the service. Residents living in 64-66 Carlton Avenue have individual care plans that offer extensive guidance and advice on how to work with them in a consistent manner. Care plans cover aspects relating to residents’ needs in terms of their equality and diversity. Residents living in 64-66 Carlton Avenue were observed to be offered ordinary living choices by staff during the unannounced inspection. The home has completed written assessments of those risks identified in respect of individual residents living in 64-66 Carlton Avenue. EVIDENCE: The Inspector viewed a sample of 2 resident’s care plans in some detail. There was extensive care plan documentation/information about each resident. The care plans included information about the resident’s choices in terms of daily routines, activities, socialisation, personal care etc, all written in the first person. Care plans covered aspects relating to the individual resident’s personal care, communication, mobility, leisure activities etc. Care plans included some clear and detailed guidance for staff in terms of the resident’s personal hygiene needs. The care plans viewed clearly identified the individual Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 10 equalities and diversity needs of residents namely regarding their personal care and religious observance. There is clear indication of resident’s agreed long and short-term goals. Residents have named key workers from within the staff team. Key workers complete a monthly review of resident’s progress that includes such aspects such as general behaviours, day service progress and medical appointments attended. Care plans are reviewed annually, in addition to reviews held by the funding authority. Staff maintain daily notes of residents’ welfare and well-being. Care plans included evidence of consultation with resident’s families. The Inspector observed staff communicating choices to residents both verbally and non-verbally. This was regarding where they wished to be in the building or whether they wanted to eat. Information about an advocacy service was displayed in the care home. The Inspector viewed extensive individual risk assessment documentation within one resident’s care plan file. This related to risks identified both within the care home and in the community. There was evidence of risk assessments being reviewed on a monthly basis. The Inspector suggested that risk assessments should be signed and dated. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported by staff to participate in a range of activities/pursuits both within the care home and the wider community. Inspection confirmed that residents living in 64-66 Carlton Avenue enjoy a range of family and personal contacts. Daily routines within 64-66 Carlton Avenue presented as being in place to accommodate resident’s individual lifestyles. Residents are supported/assisted by staff to choose and eat a range of meals within the care home. EVIDENCE: Some residents went out to their day placement on the day of the unannounced inspection. Residents attend different day placements. Staff let the Inspector know that it was hoped to increase the number of sessions that some residents attend at their day placements. The home has its own vehicle that is used to take residents out into the community. Staff informed the Inspector that residents use taxis when there isn’t a driver on duty. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 12 One resident went out into the community with a member of staff during the unannounced inspection. The Inspector gathered that residents enjoy visits to the local park in better weather. Some residents are supported by staff to go swimming. Residents are registered to vote. Staff kindly let the Inspector know about individual resident’s particular choices in terms of religious and cultural observances. This included regular attendance at temple. The Inspector gathered that residents had recently enjoyed long weekends away on holiday. The home has a sensory room and during inspection the Inspector gathered that some residents enjoy spending time in it. In addition there were various games and activities for residents to enjoy in the care home dining room. The Inspector noted that music was played in the communal areas of the home. Some residents were heard to join in. One resident was observed watching a music channel on television in the lounge. Leisure activities formed one aspect of the sample of resident’s care plans viewed. Resident’s family and significant contacts were clearly documented within their personal files. Inspection of the visitor’s book indicated that there were a range of visitors to 64-66 Carlton Avenue. The Inspector observed that residents were addressed by their first names. In addition staff knocked on residents’ bedroom doors before entering. The Inspector observed staff using photos, symbols and signs to communicate with residents. Ms Thompson advised the Inspector that the development of residents’ individual ordinary living skills was to be considered as part of the care home’s care planning processes. Staff informed the Inspector that residents’ daily routines are determined by their planned activities and pursuits for the day. Some residents were eating their breakfast in the dining room when the Inspector arrived. Staff were assisting some residents to eat. Staff prepared residents a cooked lunch that consisted of pasta, chicken and vegetables. Inspection of the record of meals eaten by residents indicated that they enjoy a range of choices, with a take-away at the weekends. The food storage areas in the care home contained a range of foodstuffs. There are pictorial representations of meals and food items in order to enable residents to make choices. The menu for the day was displayed pictorially for residents in the dining room. Staff advised the Inspector that residents choose their menus. The Inspector observed staff asking residents if they would like lunch. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ personal care and support needs are met by staff in the care home and this aspect forms part of their care plans. Consideration must, however, be given to residents’ privacy and dignity during personal care provision. Staff support residents to access preventative healthcare support and services within the community. Residents’ medication is stored and administered safely within the care home. EVIDENCE: The Inspector judged that residents mostly require extensive support and assistance from staff with their personal care tasks. The Inspector noted that personal hygiene formed one aspect of a resident’s care plans viewed. This identified the resident’s individual personal choices in terms of dos and don’ts for the staff team. During the unannounced inspection the Inspector observed a personal care task being carried out in the care home’s lounge. The Inspector subsequently discussed this with Ms Thompson and the need to review staff practice regarding the provision of personal care support to residents in communal areas of the care home. Information and guidance is available for staff regarding the use of technical aids and equipment to care for residents. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 14 The Inspector viewed contact details for residents’ GP’s within the care home’s documentation. There was also recorded information about residents’ preventative health care checks. There were ‘Health Action Plans’ within the sample of residents’ care plans viewed during the unannounced inspection. Written guidance was available for staff in respect of residents’ medical conditions. A number of residents are fed through peg feeding tubes and Ms Thompson advised the Inspector of the health professionals who are accountable for this procedure. The Inspector viewed the medication storage facilities in the care home. Medication is stored in locked cupboards. The contracted pharmacist supplies resident’s medication to the care home. Staff hold medication on residents’ behalf and no residents self-medicated at the time of the unannounced inspection. A record is maintained of medication administered to residents by staff. This was fully signed to the day of the unannounced inspection. There were written instructions for staff on the circumstances in which medication is to be administered to residents on a PRN basis. The Inspector noted that the care home held supplies of medication for some residents. The Inspector advised Ms Thompson of the need to ensure that unwanted supplies of medication are returned to the pharmacist. This had been completed by the time that the Inspector concluded the unannounced inspection. Some medication is stored in a separate fridge and staff monitor its temperature. Medication training is available for staff employed in 64-66 Carlton Avenue. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. 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 the service. Residents have access to information about how to complain. Residents are protected through the care home’s Protection of Vulnerable Adults from Abuse procedures. EVIDENCE: “How to Complain” information is displayed pictorially for residents throughout the care home. The Inspector observed staff listening to a concern raised by a resident. A record is maintained of any complaints received by the care home. There had been no entries since the last unannounced inspection. The Inspector discussed the care home’s approach to Protection of Vulnerable Adults from Abuse with Ms Thompson. The care home has obtained copies of Harrow Council’s Protection of Vulnerable Adults from Abuse procedures. Ms Thompson was aware of the need to report any allegations of abuse. One member of staff kindly advised the Inspector that they had undertaken training in Protection of Vulnerable Adults from Abuse. The Inspector discussed the need to develop agreed strategies for working with residents who may challenge the service available at 64-66 Carlton Avenue. Ms Thompson advised the Inspector that residents do not currently present any such challenges. Staff hold monies on behalf of residents within a lockable facility. The Inspector observed staff recording transactions involving residents’ monies. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ live in a homely and comfortable building though attention needs to be paid to those areas identified within the requirements below. Residents’ environment within the care home is largely clean and hygienic. Attention must, however, be paid to the ventilation of the laundry. EVIDENCE: The unannounced inspection included a tour of the communal areas of the building and resident’s bedrooms. The building presented as comfortable with homely touches. It was found to be warm, bright and clean. The home was free of offensive odours. The décor is showing signs of damage and redecoration of the communal areas is required. Furnishing and fitments presented as of good quality. Other requirements are listed below. The home is close to community transport, leisure and shopping facilities in Kenton and Harrow. The house is in keeping with others in the immediate vicinity. Residents were observed accessing different areas of the ground floor of the building. The ground floor corridors are fairly narrow and do not allow enough space for more than one resident who uses a wheelchair to mobilise to pass through the corridor at a time. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 17 Ms Thompson advised the Inspector that she was working on a proposal to extend the building with the addition of additional ground floor communal space for residents. There is a large garden to the rear of the building that contained some seating for residents. In addition a large park is nearby. The premises were noted to be clean during the unannounced inspection and staff were observed undertaking cleaning tasks. The care home has a laundry that is located in an area of the home that does not require washing to be transported through areas where food is stored, prepared, served and eaten. The laundry is, however, very small in size and contains a commercial washing machine and dryer, with some shelving/storage facilities. The Inspector measured the temperature in the laundry, with the machines operating, as being in excess of 80ºC. In the Inspector’s view this room felt uncomfortable to be in with, even with the windows open and a ventilator. This must be reviewed. The Inspector observed supplies of protective clothing for staff to use. . Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents present as being supported by a knowledgeable and caring staff group in 64-66 Carlton Avenue. Residents are largely supported and protected by the care home’s recruitment procedures, though it must be ensured that the full range of required checks are carried out on successful applicants for employment in the care home. Residents are supported by a staff team that undertakes an induction when they start work in the care home. Subsequent training must be made available to staff in all required areas, including Protection of Vulnerable Adults from Abuse and moving and handling. EVIDENCE: The Inspector observed staff communicating with residents both non verbally and verbally. The Inspector observed two residents communicating what they wanted and staff replied. During the unannounced inspection, staff presented as knowledgeable regarding residents and their individual needs and preferences. One member of staff kindly spoke to the Inspector about one resident’s needs and preferences in terms of their religion and cultural heritage. Ms Thompson advised the Inspector that 3 members of staff have completed their NVQ Level 2 in care. Others are to undertake this required training. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 19 There were no staff vacancies at the time of the unannounced inspection, with there being a team of 23 care and support staff in post. Ms Thompson advised the Inspector that the care home was to recruit bank staff to work in 64-66 Carlton Avenue on an as/when basis. The care home’s staff recruitment procedures are supported by CMG’s HR and also line management. The Inspector viewed a sample of 6 staff files during the unannounced inspection. Recruitment largely presented as complying with requirements, though the following requirements were noted: • A full employment history for each member of staff, including dates, together with a satisfactory written explanation of any gaps in their employment. • There must be 2 written references in respect of each member of staff. There were copies of staff’s job description, contract and terms and conditions on their individual files. The Inspector viewed the staff training records for 64-66 Carlton Avenue. There was evidence of staff’s completion of an initial induction on their files. A range of training is available to the staff team including moving and handling, medication, POV A, communication skills, emergency first aid, food hygiene and Protection of Vulnerable Adults. Staff, however, had not completed all their required training. This requirement was discussed with Ms Thompson. Carlton Avenue (64-66) DS0000062165.V303201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a care home that has a registered manager, whose focus is resident development and well-being. Residents, their representatives and staff have been consulted about their views on the quality of care available in 64-66 Carlton Avenue. This work is underway. Residents’ health, safety and welfare are largely promoted and protected within the care home, with 2 requirements arising. EVIDENCE: Ms Thompson achieved registration as the manager of 64-66 Carlton Avenue in March 2006. Ms Thompson spoke to the Inspector of her management aims for 64-66 Carlton Avenue. This involved consideration of residents’ long-term goals, day care options and development of their independence skills. The care home presented as well run during the unannounced inspection. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 21 The Inspector viewed the quality assurance work for 64-66 Carlton Avenue. During 2006 a variety of questionnaires had been sent out to staff, residents and their representatives. The responses were held by the care home. Ms Thompson advised the Inspector that further work on the review of the quality of care available in 64-66 Carlton Avenue was to be completed. The Inspector requested a copy of the outcomes of this review, be forwarded to the Commission for Social Care Inspection, when available. The Inspector viewed information for staff around safe working practice displayed in the care home. Staff training in these areas is referred to previously. The Inspector viewed Certificates of Worthiness in respect of the various checks that had been carried out on the care home’s electrical and gas appliances and installation. A legionella check had been carried out within the care home on 18/5/06. Staff carry out a range of health and safety checks within the care home and record outcomes. In addition food, fridge and freezer temperatures are tested on a daily basis. The Inspector noted that on occasions the fridge temperatures were noted to be in excess of 10ºC. This was discussed with Ms Thompson. It must be ensured that food storage appliances in the building run at safe minimum temperatures. Staff also test the temperature of the hot water taps in the building, these were measured to be 43ºC or less as is required. There are secure places in the building for the storage of chemicals. Risk assessments are in place with regard to safe working practice. The care home’s fire bells were tested during the unannounced inspection. Inspection of the records indicated that such testing occurred on a weekly basis. Three fire drill/practices had been carried out in the care home since 13/1/06. The Fire Risk assessment had been reviewed on 26/2/06. The Inspector spoke to Ms Thompson of the need to ensure that the fire risk assessment includes any risk identifies for residents living in the care home. Staff maintain a record of any accidents or incidents that occur in the care home. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 3 x x 2 x Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? Previous 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 YA18 Regulation 12 Requirement Review staff practice regarding the provision of personal care support to residents in communal areas of the care home. The cooker extractor requires cleaning The kitchen door handle requires repair to ensure that the door closes positively in the event of a fire. The ground floor hall carpet requires stretching or replacement in order to avoid a trip hazard occurring. Arrange for the ground floor hall and dining room to be redecorated. Ensure that the toilet seat in the first floor bathroom is securely fitted. Ensure that Room G door closes positively. The first floor bathroom is quite small, and the Inspector gathered, is not much used by residents. Review the appropriateness of this facility in terms of the needs of residents with report to the Commission DS0000062165.V303201.R01.S.doc Timescale for action 23/12/06 2 3 YA24 YA24 23 23 23/11/06 23/11/06 4 YA24 13 23/11/06 5 6 7 8. YA24 YA24 YA24 YA24 23 23 23 23 23/12/06 23/11/06 23/11/06 23/12/06 Carlton Avenue (64-66) Version 5.2 Page 24 10 11 YA24 YA24 23 13 12 YA30 23 13 YA34 19 14 15. YA34 YA42 19 23 16 YA42 13 for Social Care Inspection. (Previous timescale 12/05/06 of not met.) Repair/redecorate damaged plasterwork on first floor corridor ceiling where water damaged. Ensure that trailing electrical leads are removed in order to prevent a trip hazard for residents. Review the lay out, ventilation and dimensions of the laundry to ensure that adequate space, storage and facilities are available to ensure the provision of a safe working space for staff and residents. (Previous timescale 12/05/06 of not met.) There must be a full employment history for each member of staff, including dates, together with a satisfactory written explanation of any gaps in their employment. There must be 2 written references in respect of each member of staff. Ensure that the fire risk assessment includes any risk identifies for residents living in the care home It must be ensured that food storage appliances in the building run at the safe temperature range. 23/11/06 23/11/06 23/01/07 23/11/06 23/11/06 23/12/06 23/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 25 1. YA37 The home does not have a computer and the Inspector would recommend this provision in order to facilitate the production and updating of complex ranges of information about residents and their needs. Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Carlton Avenue (64-66) DS0000062165.V303201.R01.S.doc Version 5.2 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. 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