Inspection on 25/05/06 for Cassini House

This inspection was carried out on 25th May 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cassini House 22/11/07

Cassini House 03/11/05

Cassini House 02/12/04

Cassini House 12/07/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Cassini House 13 Duckett Road London N4 1BJ Lead Inspector Peter Illes Unannounced Inspection 25th May 2006 10:15 Cassini House DS0000010730.V297780.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 Cassini House DS0000010730.V297780.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. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cassini House Address 13 Duckett Road London N4 1BJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8340 1633 020 8340 1633 Precious Homes Limited Mr Simon Keith Atkins Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Cassini House is owned by Precious Homes Ltd and is registered to provide residential care for six younger adults with a learning disability. The home specialises in supporting service users with autism and also service users with complex needs. Cassini House is a three-storey terrace house situated off Green Lanes, Haringey in North London. The home has six bedrooms and two bathrooms. The communal areas consist of a large lounge, a separate dining room and a kitchen. The garden area is of medium size with a paved area and access to the garden is via the dining room. The home is within easy access to local shops, restaurants, pubs, and public transport and near to Wood Green shopping city, Finsbury Park and Alexandra Park. Cassini House was registered in June 1998. The home’s stated mission is to be dedicated to creating a safe enabling environment in which individuals can experience respect, dignity and positive valuing and thereby sustain meaningful and fulfilled lives. The home also states that it seeks to provide high quality support in a residential care setting to adults with learning difficulties and challenging behaviour. This support reflects the individual service users unique needs and aspirations and cultural values, promotes autonomy and self-determination and enables the service users to lead their preferred way of life. The registered manager stated that the home charges from £990 to £2,300 per week depending on the service user’s assessed needs. The registered manager also stated that that CSCI inspection reports are made available, including to prospective service users and their representatives on request. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately six and a half hours with the registered manager being present or available throughout. There were six service users accommodated at the time of the inspection and no vacancies. Three new service users had been admitted to the home since the last inspection. The inspection included: meeting and speaking to five service users, one of them independently, the inspector spoke to the other four service users during the inspection but this was limited because of the communication needs of these service users; a telephone conversation with a day service manager; discussion with the registered manager; discussion with the provider organisation’s Director of Operations and independent discussion with the home’s staff team manager and two support staff. Further information was obtained from a tour of the premises and documentation kept at the home. What the service does well: The home continues to provide good quality support and care to service users with a range of complex needs. Service users needs are well assessed and clear care plans are produced with guidance to staff on how to meet these needs. The current service users have a range of differing cultural and religious support needs and the home is working hard to sensitively address these. Service user’s health needs are well addressed and they live in a wellmaintained and pleasant domestic scale environment. The home continues to work hard to assist service users access and enjoy the diverse resources and facilities in the local community. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 6 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. Cassini House DS0000010730.V297780.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 Cassini House DS0000010730.V297780.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 this service. The needs of prospective service users are assessed in significant detail to ensure that the home can meet these. Once admitted service users needs are reassessed on a regular basis to assist the home continue to meet their changing needs. EVIDENCE: Three new service users had been admitted to the home since the last inspection. These three service user’s files were inspected along with the file of one service user that had been accommodated for a longer period. All the three new service user’s files contained a range of assessment information that was available prior to the person’s admission to the home. All three files contained multi-disciplinary assessment information from the person’s referring authority in addition to assessment information obtained by the home as part of the admission process. There was evidence of significant in-house assessment activity over a period of months for one of the new service users prior to their admission. This was to try to minimise disruption for that service user and took place over an extended period because of the person’s particular needs. The inspector was informed that the admission process had been successful for all the three new service users to date. There was also evidence that the needs of the service user that had been accommodated for a longer period of time were reassessed at regular Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 9 intervals. This was assisted by the home introducing allocated key workers to each service user. The allocation of new key workers to service users had been reviewed as a result of significant staff turn over since the last inspection. Staff spoken to were clear about their key worker role and able to discuss the needs of their allocated service user in detail. Key worker reports on the files inspected indicated that the system was positively contributing to work with service users including reviewing their needs. The registered manager stated that he was keen to develop the key worker system as both a means of both promoting more personalised care to service users and to assist in developing the staff teams skills. Cassini House DS0000010730.V297780.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 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 this service. Service users assessed and changing needs are well documented in their care plans to assist the home’s staff and relevant others in meeting these needs. However clearer evidence is needed to show who reviews the care plans and when. Service users are also assisted to make as many decisions for themselves as they can to maximise their independence. Service users are supported to take appropriate risks in their lives to assist them to safely achieve their aspirations. However, there again needs to be clearer evidence to show who reviews their risk assessments and when. EVIDENCE: The three service users admitted to the home since the last inspection had care plans in differing stages of development depending on the date of their admission to the home. Two of these service users had been accommodated for a number of months with the third having only recently been admitted prior to this inspection. The two service users that had been accommodated for a Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 11 number of months had support plans that described a range of support the person needed including for their cultural and religious needs. They also had a separate and detailed care plan that showed a range of assessed needs with clear guidance to staff on how to meet these needs. One of these care plans had been signed by the service user. The third new service user had only been accommodated for a short period prior to this inspection and evidence was seen that their care plan was in the process of being developed. The fourth service user that had been accommodated for a longer period also had a detailed care plan that was seen. This care plan showed evidence that it had been reviewed and a list was seen attached that had been signed by all staff to show that they had read the revised plan and were aware of the service users current needs. However, the record of this review did not show who had undertaken it or the date of the review. A requirement is made regarding this. Five of the six service users have significant communication needs making meaningful communication with the inspector difficult. Evidence was seen that efforts were being explored to maximise communication between staff and service users. One service user is Kurdish speaking and a list of Kurdish phrases was seen on their file. The registered manager stated that the home is not an appointee for any of the service users finances with the provider organisation dealing directly with referring authority’s regarding payment for the placements. The home does hold service user’s personal allowances for them with separate record sheets and individual wallets for cash seen. Three of the service users have separate bank accounts for their individual accumulated personal allowances. A number of restrictions have been agreed regarding all six service users and these were clearly recorded on their individual risk assessments. Each of the four service user files inspected contained a range of relevant risk assessments that were used to inform their care plans and/ or care practice. Individual risk assessments seen related to such areas as: vulnerability, personal hygiene, community access, medication and dealing with aggression. These risk assessments were detailed and gave clear guidance to staff on how to minimise the identified risks. The risk assessments for the service user that had been accommodated at the home for a longer period were seen to have been reviewed on a regular basis. Attached to the latest review of this service user’s risk assessments was a list of dated signatures that indicated staff had read the review. As with the review of this person’s care plan however the review of the risk assessments had not been signed or dated to indicate who had reviewed them and when. A requirement regarding this is combined with the requirement about signing and dating care plan reviews. Cassini House DS0000010730.V297780.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 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 this service. Service users enjoy appropriate activities including within the local community with efforts being made to access local minority ethnic community resources. Contact with relatives and friends is maintained and encouraged in accordance with the service users wishes. Service users rights are responsibilities are respected and promoted within their daily lives. Service users also enjoy balanced and varied meals that meet their needs and preferences. EVIDENCE: Two service users attend external day services, one five days and the other four days a week. A third service user attends a work placement scheme three days a week. The registered manager stated that identified service users also attended cookery sessions run externally by the provider organisation to support other service users in supported living projects. The inspector spoke to one service user independently at their day service and the service user stated that they enjoyed attending the day service. The inspector also spoke to the day service manager who indicated that communication with the home was good. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 13 Service users are encouraged to use the facilities in the local community with an identified service user visiting local shops during the inspection. One service user told the inspector that they liked going to the cinema. One of the service users is a practicing Muslim and another is a non-practicing Muslim. Evidence was seen that these service users are assisted with their religious observances to the extent that they wish. One of the new service users is Kurdish speaking. The registered manager described efforts made by the home to link this service user in with local Turkish community resources in the area. These efforts were ongoing with the inspector being informed that the service user would continue to be supported with this. The home had recently run a Karaoke evening to which relatives and friends had been invited. The inspector was informed by one of the service users and by staff spoken to that this had been a great success. A letter was seen from one of the service user’s relatives thanking the registered manager and staff from the home for running the event and that they had enjoyed it. All six service users have regular contact with relatives. Three have regular contact including visiting relatives homes regularly at weekends. The other three have varying contact with relatives including relatives either visiting the home or service users visiting them. Staff were observed interacting meaningfully and respectfully with service users throughout the inspection. The registered manager stated that service users had access to keys to their rooms, which was confirmed by one of the service users spoken to. Service users were also seen to spend time in their rooms or in the communal areas of the home as they chose. The home has designated itself a non-smoking environment and this is included in the service users guide. One service user smokes and staff were seen to advise and assist them appropriately regarding this. The home had a satisfactory menu with key workers assisting service users choose what meals they would like to eat. The registered manager stated that the home can cater for a range of needs regarding food, including meeting service user’s varying cultural needs and preferences. The home currently provides Hal-al meat for the service user that is a practicing Muslim. Service user’s needs regarding diet and their individual preferences were also seen recorded in their care plans or on their individual files. The registered manager confirmed that the bulk of the food stored in the home was still kept locked because of identified service user needs and this remained recorded on service user’s documentation. The kitchen and dining room were clean and tidy. Cassini House DS0000010730.V297780.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 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 good. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate personal support in accordance with their needs and preferences. Their mental and physical healthcare needs are met including through referrals to a range of community based health professionals as required. Service users are also generally well supported with their medication although a minor improvement is needed in this area to ensure that service users remain fully protected in this area. EVIDENCE: All six service users need support with their personal care with some needing physical assistance with this. Guidance for staff on how to provide this care was recorded on the individual care plans seen and issues relating to personal care were also recorded on risk assessments where appropriate. One service user spoken to stated that they were comfortable with the assistance they received from staff in this area. One Afro-Caribbean service user had been allocated a key worker from a similar ethnic background who was assisting that service user with their personal care. This included assisting the service user purchase culturally appropriate products for skin and hair care. The Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 15 inspector was informed that this service user had made great strides with their personal care and appearance since they were admitted to the home. Service users are all registered with a G.P. and evidence was seen on files inspected that service users are supported to attend a range of appointments with relevant healthcare professionals as required. These appointments included with their: G.P., psychiatrist, chiropodist and a range of hospital appointments including a referral for a hearing aid. All service user files inspected included a health action plan that outlined strategies to actively promote the individual’s good health. The medication and medication administration record (MAR) charts for three service users were inspected. These were generally satisfactory except that the frequency of one medication that one service user was prescribed had been changed by their G.P. This was clearly noted on the MAR chart but not on the medication container. This medication had been dispensed since the change in frequency of the medication was prescribed so that the dispensing chemist should have put the correct frequency on the label on the medication container. A requirement is made that the home ensures that the labelling on prescribed medication is correct when it is received in the home. A requirement had been made at the last inspection under Staffing that all staff that administer medication have up to date training in the safe administration of medication. The inspector was pleased to see that this had been complied with. Cassini House DS0000010730.V297780.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 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 this service. Service users and relatives are able to express their views and concerns and have these appropriately dealt with by the home. Service users are also protected by satisfactory adult protection policies and procedures that staff are aware of. EVIDENCE: The home has a clear and accessible complaints policy that was seen in the service user guide with a summary displayed by the front door to the home. There had been one complaint recorded since the last inspection and records indicated that the registered manager had satisfactorily dealt with this. The inspector was also shown a letter of compliment that the home had also received since the last inspection. The home has a satisfactory adult protection policy and also has a copy of the London Borough of Haringey’s adult protection procedure, the local authority for the area the home is situated in. There was also a flow chart displayed in the office showing action required using that authority’s procedures should an allegation or disclosure of abuse be made. Staff spoken to were aware of the action they needed to make should an allegation or disclosure of abuse be made. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 17 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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is comfortable, well decorated and well maintained and meets service users needs although two identified areas of maintenance need attention. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home as well as for those that visit it. EVIDENCE: The home is a converted three story domestic premises that remains generally well decorated, well maintained and which continues to provide a pleasant environment to meet the current service users needs. The home’s recently appointed team leader escorted the inspector on a tour of the premises. She explained that she had just undertaken an audit of the physical environment and had reported a range of recommendations to the registered manager for consideration. The home was generally well decorated with evidence of a satisfactory and ongoing redecoration and maintenance programme in place. During the tour of the building however it was noted that the kitchen was in general need of redecoration with attention also needed to identified repairs to the kitchen floor. It was also noted that although there were hand washing facilities in the home’s laundry and the two bathrooms there were no hand Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 18 drying facilities. Although these items had been noted in the team leader’s audit of the premises requirements are made in relation to decorating the kitchen, repairing or replacing the kitchen floor covering and to providing the identified hand drying facilities. The home did have satisfactory hand washing and hand drying facilities in the home’s toilets. The home had satisfactory laundry facilities and storage for chemical cleaners. The home was clean and tidy throughout during the inspection. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team are deployed in sufficient numbers to properly address service users needs. A robust recruitment procedure contributes towards service users protection. Service users are also supported by staff who are appropriately trained and supervised to assist them further in meeting service users needs and in there own personal development. EVIDENCE: A requirement was made at the last inspection that a minimum of fifty percent of care staff must have achieved, or be registered on, national vocational qualification (NVQ) level 2 training in care by the end of December 2005. The inspector was pleased to see that this requirement had been complied with. It was also noted that the team leader appointed since the last inspection had already achieved the registered managers award that comprises NVQ level 4 in both management and care. The home has undergone significant staff turn over since the last inspection. The inspector discussed the reasons for this with the registered manager and there did not appear to be any specific reason for this that would cause concern. The home had been successful with recruiting new staff and had reviewed the staffing structure by creating a team manager post that would Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 20 assist the registered manager with a range of management tasks. The current staffing at the home consists of: two support staff on early shift, three support staff on late shift and one waking and one sleeping-in support staff at night. The registered manager’s working hours are in addition to this. The registered manager also stated that he had the budget agreed for an additional support staff to be appointed to supplement the staff team during the working day and also to appoint a cleaner for ten hours a week. The staff on duty during the inspection matched those recorded on the rota. The home also has a satisfactory disciplinary procedure that had been effectively utilised since the last inspection although this did not appear to be related to the recent high staff turnover. As indicated above the home had recruited a number of new staff since the last inspection. The staff files of three of these newly appointed staff were inspected at random. Each showed evidence that the home operated a satisfactory recruitment procedure with each file seen including a satisfactory application form, proof of identity and two written references. Two of the files contained satisfactory criminal records bureau (CRB) check that included a protection of vulnerable adults (POVA) clearance. The third file contained a POVA first clearance while the home waited for the full CRB clearance to be received. The registered manager confirmed that this member of staff was being supervised at all times until the full CRB clearance was obtained. A requirement was made at the last inspection that a copy of the recruitment documentation, which is specified in the national minimum standards, is kept at the home for inspection. The inspector was pleased to see that this had been complied with. Evidence was seen that the newly appointed staff had undergone satisfactory induction training and three staff spoken to confirmed that this was useful. Evidence was also seen that the home is working to ensure that these staff undertake the necessary core training within six months and that all staff have refresher training in these areas as required. Staff spoken to stated that they had undertaken training in infection control, safe administration of medication, breakaway techniques and communication awareness since the last inspection. A requirement had been made at the last inspection regarding safe administration of medication training and the inspector was pleased to see that this had been complied with. Staff spoke to also confirmed that they were receiving structured and recorded supervision at least every two months. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 21 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 this service. Service users benefit from clear leadership by the registered manager in managing the home effectively. Service users also benefit from the homes quality assurance system that incorporates their views on the service and that contributes to improving the service offered by the home. Effective health and safety procedures contribute to protecting service users, staff and visitors to the home. EVIDENCE: The home has an effective registered manager who continues to effect positive change within the home. He was able to demonstrate a clear grasp of the needs of service users with complex needs as well as the management issues involved in running the home. The inspector also met and spoke to the provider organisation’s Director of Operations who visited the home during the inspection. She also had a clear grasp of the management issues in the home and presented as being very supportive of the registered manager. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 22 The home had conducted a quality assurance survey in July 2005 and this had contributed to the current objectives of the home. The registered manager stated that he had also sent a copy of the quality assurance questionnaire to one of the new service user’s family. He went on to say that he was intending to send out questionnaires to the other two new service user’s families in the near future. The provider organisation’s Director of Operations conducts regular unannounced visits the home to assist monitor quality. Reports of these visits are sent to the inspector and show detailed evidence of the checks she undertakes and the recommendations she makes. A range of satisfactory health and safety documentation was inspected that included: a gas safety certificate, electrical installation certificate, portable appliance testing as well as servicing and testing of the home’s fire fighting equipment and fire evacuation procedures. The home’s accident book recorded five accidents since the last inspection all of which had been dealt with appropriately. A requirement was made at the last inspection that all fire doors in the home must close effectively when released. The inspector was pleased to find that fire doors tested at random at this inspection closed effectively when released. Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 23 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 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 3 3 2 X 3 X 3 X X 3 X Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA9 YA6 Regulation 13(4), 15(2) Requirement Timescale for action 30/06/06 2. YA20 13(2) 3. YA24 23(2) 4. YA24 13(4), The registered persons must ensure that all care plan and risk assessment reviews are signed and dated by the person undertaking the reviews. The registered persons must 30/06/06 ensure that the labelling on prescribed medication is correct when it is received in the home. The registered person must 31/10/06 ensure that the home’s kitchen is decorated and the kitchen floor replaced or repaired. The registered persons must 30/06/06 ensure that there are hand drying facilities provided in the laundry and the two bathrooms. 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 Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 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 Cassini House DS0000010730.V297780.R01.S.doc Version 5.2 Page 26 - 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. 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