Inspection on 09/05/07 for Cavendish Road

This inspection was carried out on 9th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish Road 24/04/06

Cavendish Road 31/10/05

Cavendish Road 26/04/05

Cavendish Road 29/11/04

Cavendish Road 04/06/04

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 Cavendish Road 274 A&b Cavendish Road London SW12 0BS Lead Inspector Davina McLaverty Unannounced Inspection 9th May 2007 10:30 Cavendish Road DS0000010177.V336361.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 Cavendish Road DS0000010177.V336361.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. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish Road Address 274 A&b Cavendish Road London SW12 0BS 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 8675 9957 020 8675 9957 www.thresholdsupport.org.uk Threshold Housing & Support ****Post Vacant**** Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2), Physical disability (2), of places Physical disability over 65 years of age (0) Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21ST November 2006 Brief Description of the Service: Cavendish Road is a registered home for nine adults who have a learning disability, two of whom also have a physical disability. The home itself is two adjoining houses. There are two lounges, two kitchens and two separate laundry rooms. Parking for two cars is available. The property is situated within a ten-minute walk from Balham underground and main line station and high street. The home is owned and managed by Threshold and support a locally based housing association. At the time of this inspection the manager reported that the weekly fees were £869.19 per week. Additional charges are made for some outings and holidays. Residents are made aware of the inspection report at the residents meeting. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulatory inspector carried out this unannounced inspection over seven hours on the 9th May 2007. The inspector met seven of the eight residents currently living in the home. There is one vacancy. Communication with the majority of the residents was not possible, as they were unable to communicate verbally due to their learning disability. Three staff was spoken with and a sample of records was examined, which included residents care plans, staff records, medication and health and safety records. A tour of the premises also took place. Eight questionnaires were left for residents to complete, five relative questionnaires were left with the manager for her to distribute, on CSCI behalf, and ten questionnaires were left for staff to complete. Five professionals were sent questionnaires following the inspection. At the time of writing this report nine questionnaires had been returned. Generally, comments were positive and they have been integrated into the main body of the report. What the service does well: What has improved since the last inspection? The service user guide and statement of purpose have both been updated and are available in an easy read format with pictures and symbols to make them more easily understood. Communal areas have been redecorated, new flooring laid in the hallways and in two residents rooms. Broken drawers in the kitchen have been repaired. Staff are continuing to make improvements in the care planning system in place, however, there is still room for improvement. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 6 The amount of staff supervision has increased to help ensure that staff have the support and direction they need in their roles. 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. Cavendish Road DS0000010177.V336361.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 Cavendish Road DS0000010177.V336361.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has a relevant statement of purpose and service user guide, which provides residents and their representative with information on what they can expect from the service. Assessments are carried out on prospective residents before they move into the home. EVIDENCE: The statement of purpose and the service users guide have been developed to be specific to the home to help potential residents to decide if the home can meet their needs. Copies of the updated Statement of Purpose and Service User Guides had been forwarded to the Commission, as required, following the last inspection. The service user guide is in two formats, one written the other with minimum text and with more pictures/symbols, which is more appropriate for the resident group. The inspector recommended that these documents be dated and reviewed annually. Since the last inspection a new resident has been admitted to the home. The inspector saw evidence of an assessment from social services being carried out, as well as the home carrying out its own assessment. Due to the resident’s particular needs, evidence was seen on their file of comprehensive liaison with their previous placement. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 9 A series of visits to the home had taken place prior to their admission, thus ensuring that the home is the right place for the person and that their needs would be met. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Work on care plans continue to be developed, and improvements were noted. However, residents involvement, where possible, must be more clearly evidenced. Residents are encouraged to make their own decisions and choices where possible. Resident’s records are not kept securely in the home, with visitors possibly having access to resident’s records, without their consent. EVIDENCE: Residents have a care plan, which includes information for staff to meet individual needs. All staff have received training on care planning and the importance of recording. However, on examination of three plans, it was not clear as to the resident’s or their representative’s involvement. Some areas of the plans lacked dates and signatures and dates for review had past. Monthly Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 11 summaries were also not being completed. In discussion with the manager, she stated that she is addressing this in staff individual supervision, as well as at team meetings. The home operates a key worker system and time is allocated for one to one time for discussion and activities to take place. A resident spoken to knew who their key worker was and said that they met with them regularly. Staff spoken with were knowledgeable about residents needs, one staff said, “ by working closely with residents we get to know what they like and don’t like”. House meetings also take place, although due to the lack of verbal communication, the record of these meetings was brief. The resident spoken with said that they felt involved in the running of the home as they added meals to the menu, participated in doing some of the chores, as well as being involved in planning outings. Staff spoke of other resident’s involvement in the home e.g. cooking, deciding what to watch on television. General risk assessments were seen to be in place on the three files examined, as well as a risk assessment around residents using knives. However, in view of the ages of the residents in the home, risk assessments around falls must be in place. The home must also develop a “falls policy” to ensure that staff are clear on the action to be taken should a resident fall. Also, consideration must be given to support aids for use with residents who are falling in the home. Confidentiality in this home remains a cause for concern in that residents records e.g. care plans are not locked away and are accessible to visitors to the home. The requirement made at the previous two inspections remains outstanding. The manager reported that agreement had been given for a door to be put across the area where records are currently kept. Measurements had also been taken, and she failed to understand why the work had not been carried out. The requirement has been restated for the third time. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered opportunities to participate in domestic activities in the home. They need to be supported to enjoy more leisure activities particularly at the weekend. Dietary needs seem well catered for with consideration being given to cultural needs. EVIDENCE: One resident spoke of their involvement with domestic activities in the home, which included tidying their room and putting away laundry. This is also reflected in the care plans and comments made by staff. The manager said that two of the residents are supported to attend church. Six of the residents attend structured educational activities, Monday to Friday at a day service. Two residents choose not to attend; one due to their age Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 13 does not want to participate in very much. This resident recently celebrated their 84th birthday where a small celebration took place to which this resident’s brother and niece attended. The other resident, due to their needs is supported at home and is due to have her needs re-accessed as she has become increasingly frail and has had several falls within the home. Staff have a wheelchair for her use and will on occasion take her out to cafes and shops. Staff are very concerned about this resident and hope that the planned review will enable a clear plan of action to be drawn up as to whether this persons needs can be met by the home. Evening activities consist of the Gateway club for four residents, the Thursday club for one resident and a sports club, which again a couple of the residents will attend. Staffing levels in the home limit the amount of activities outside of the home that can take place and the manager is endeavouring to liaise with the placing authority regarding more support for the residents placed there. However as the residents do not have care managers this is proving difficult. Holidays are encouraged and residents are encouraged and supported to visit their relatives, although the manager said that due to the age of many of the relatives it was proving difficult for staff to maintain contact with them due to their poor health. Three questionnaires were received from relatives in which no concerns were raised. One relative said, “on a recent visit to Cavendish Road on my brother’s birthday, the staff made myself and daughter very welcomed and gave my brother a lovely birthday party, which included the other residents, who enjoyed it very much. Also my brother is very happy there”. Another relative said, “I have always been received with warmth and friendliness. My daughter often spends long weekends at home with me and the staff help her organise her things”. Relatives are encouraged to visit whenever they wished. Two service users have keys to their rooms and will choose to lock them on occasion. Resident’s privacy is respected and a resident said that staff will knock and wait to be invited in before entering their room. Staff were observed speaking to residents in a friendly and appropriate manner. The home has two kitchens. The inspector noted that broken cupboards highlighted at the last inspection had been repaired. However, inside both fridges shelves, were broken and the plastic support holders were missing. Food products were stored haphazardly on top of each other. Open meats were inappropriately stored, not wrapped or dated when opened. Fresh fruit was seen to be available. The manager must ensure that all staff have received training in Food hygiene. A copy of the menu was seen which was satisfactory. Residents are consulted at the residents meetings re the meals they would like. However, only one main meal is cooked. The manager said that this works better for staff as it means that only one staff member is involved in cooking, freeing the second Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 14 staff to spend time with the residents. She maintained that a choice is given and that if a resident does not want the cooked meal they will be given an alternative. The meal on the day of the inspection was tuna pasta bake and salad. It was nicely presented with residents enjoying the meal. A record of food provided was seen. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff endeavour to make sure that the physical, emotional and health needs of residents are met. Staff provide appropriate assistance with personal care tasks when required. Systems are in place for the safe administration of medication. EVIDENCE: One resident reported that staff are available to help with personal care tasks when required and that staff respect her privacy and dignity when supporting her. One staff spoken with stated that same gender care is given to female residents, although female staff will attend to male residents personal care in the absence of male staff. Health appointments are recorded in the diary and in residents care plans and staff will support residents with their appointments. Evidence was seen of Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 16 support being provided by the local specialist community team. A network meeting was due to take place on Monday in respect of one resident who has complex needs and whom staff are concerned about. The manager hopes that the meeting will produce a clear action plan as to how the home can continue caring for this resident who has lived at the home since it opened. Residents looked clean and were appropriately dressed. Where possible residents are encouraged to choose their own clothes, which reflects their personality. Medication records were examined and both requirements made at the previous inspection had been addressed. Medication Administration Sheets contained details of allergies, photographs of the residents, with exception of the newest resident, was seen and the controlled medication book is available. The inspector noted one gap in the Medication administration sheet (MAR). Medication was seen to be stored appropriately. A record of medication received into the home and returned to the pharmacy is kept. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure and Safeguarding of Vulnerable Adults procedure are in place. No resident raised concerns regarding the care they received or services provided in the home. All staff must receive training in the Protection of Vulnerable adults. EVIDENCE: The home follows the London Borough of Wandsworth Safeguarding Adults procedure and a copy of the new guidelines was seen in the home. Not all the staff team have received training in safeguarding adults. The organisation has its own whistle blowing procedures, which two staff spoken with was aware of. Threshold has a comprehensive complaints policy, which details timescales for responding to complaints. No complaints have been received by the home or at the commission since the last inspection of the home. A pictorial version of the complaint procedure was displayed in the home. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The accommodation meets its purpose and there is a good standard of hygiene and cleanliness. However, attention needs to be given to the furnishing and fittings within the home to ensure that it remains homely and comfortable for the residents. EVIDENCE: The home is divided into two units with their own kitchens, lounges, bathrooms and laundry areas on the ground floor. The home was seen to be comfortable with some areas having been recently decorated. Requirements made at the previous inspection had been carried out, in that new flooring had been laid in the hallway and three residents bedrooms had been decorated and new flooring put down. All communal areas had been redecorated, as well as the laundry areas. However, maintenance of the premises must continue as the furniture in house B, as stated in the previous inspection, has become shabby Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 19 and worn in appearance and requires re-covering or replacement. Plastic holders for condiments/milk were broken in both fridges and freezers and food substances were inappropriately stored. The inspector observed open packets of meat and cheese, which was not wrapped and dated as required. The laundry flooring needs replacing as it was badly marked and grubby in appearance. The extractor fan hose was damaged in House B laundry room. The back and front garden requires regular maintenance and consideration should be given to employing a gardener. Grass in the back garden had been cut back, but the front garden was overgrown and in need of attention. Bathrooms remain functional rather than homely. Staff maintain that this is primarily due to some of the residents needs and it not being safe to leave things in the rooms. The bath trim in one of the bathrooms upstairs was coming away from the bath and must be repaired. In view of the ages of the residents five over 60 years, the premises should be assessed by an occupational therapist or other suitably qualified specialist to ensure that the home has adequate aids, adaptations and equipment to meet the needs of the residents e.g. hoists, bath boards. The home was observed to be clean and hygienic and free from offensive odours on the day of the inspection. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents are not supported by staff that have all the necessary recruitment checks in place. Appropriate training must be provided for staff to do their jobs properly. Failure to achieve this potentially places residents at risk. EVIDENCE: The manager reported that staffing levels remain the same as at the previous inspection. That is three staff on each shift, one in each unit and one who “floats”. One resident currently receives one to one support from 4.00pm to 8.00pm Monday to Friday and on a Saturday 10.00am to 6.00pm. Dependency levels of the residents have increased, yet staffing levels have not changed. The roster has been reviewed with some changes made to try to make the shift operate more smoothly, however, the changes have been minimal and the manager feels that each house requires a minimum of two staff, which would then provide the flexibility for more person centred care to be provided. She also stated that with additional staffing, she believed residents could more easily be moved forward to achieve their full potential rather than being “maintained”, which currently was the case. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 21 The home currently has two full time vacancies, which were due to be advertised shortly. Currently, regular bank staff are being used, which provides consistency of care to residents. Two staff questionnaires were returned following the inspection. One stated that they would like to see more teamwork in the home. However, staff spoken with reported that teamwork was good in the home. The manager and staff team remain concerned about staffing levels in the home and are in the process of trying to get all residents reviewed due to their changing needs and increased dependency, however, as the majority do not have care manager this is proving difficult. The duty social worker is informed following significant incidences. One resident who needs have changed quite significantly was due to be reviewed next week. Staffing levels must be kept under review to ensure that residents needs can be met at all times. The manager must ensure that staff receive sufficient rest periods. Staff were seen to have a good rapport with residents at the time of the inspection visit. Staff meetings currently take place fortnightly, which helps to improve communication within the home, with staff keeping up to date with current issues. Meetings also focus on the importance of teamwork and the importance of working together to provide a good standard of care for people who live there. Currently, three staff have achieved their NVQ level 3 and two staff are undertaking their NVQ Level 2. The registered persons need to make sure that sufficient staff are provided with the appropriate training so that at least one qualified first aider is on duty at all times. Currently, the first aider is a staff member who works night shifts. The manager reported that all staff complete a one-day course on first aid. This was seen to be the case in the three staff files examined, although evidence of some of the other statutory training was not evident. All staff must also be provided with core training and refresher training in moving and handling, in particular, as five of the residents are over 60 years of age, two of whom have started to have regular falls The service has a recruitment procedure that meets the regulations. Recruitment is carried out centrally. Three staff files were examined, two contained current CRB checks, two lacked evidence that references had been obtained another failed to verify that the person was in good health. Staff files also need to be better organised so that the required information is easy to find. The registered persons must ensure that evidence is available in the home, which shows that all the required checks have been carried out. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 22 Evidence was seen that staff are having regular one-to-one supervision to help ensure that any training and development needs are identified. Staff spoken to report that they were receiving regular supervision and that they found this helpful. One staff questionnaire stated that they would like to have more courses on “care planning”. . Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not in place for a regular review of the service. All staff must be provided with training in key areas relating to health and safety and a record maintained. EVIDENCE: The manager has the relevant experience to run this service, and has been in over a year, however; the Commission has not received an application for approval as the home’s manager despite previous requirements. Staff spoke positively regarding her management style one returned questionnaire said, “ The manager is doing a good job”. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 24 A quality monitoring and assurance systems is still outstanding as well as any organisational review of the service and care provided. This requirement has been outstanding for the last three inspections and failure to meet it may lead to enforcement action being taken. First aid cabinets in the kitchens must be appropriately stocked and checked regularly. The date on one of the cabinet was 25/11/06.It is recommended that a list of the contents is kept so that staff can check that first aid boxes are kept fully stocked. Copies of the landlord gas safety certificate was seen as well as the portable appliance tests, and Domestic Electrical Installation Periodic Inspection Report all of which were in order. During the inspection the fire alarm went off unexpectedly and staff and residents were seen to act appropriately. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 X 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 2 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 26 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 14(2) & 15 Requirement The Registered Persons must ensure that continued work takes place on support plans to ensure that they are all up to date and that they are regularly reviewed and updated. (Previous timescale of the 30/07/06 not fully met) The Registered Persons must ensure that risk assessments are completed. (Timescale of the 30/07/06 not fully met) Resident’s records must be kept securely in the home. (Timescale of the 30/07/06 not met) Open food produced must be wrapped and dated. The Registered Person must ensure that all staff receive training in the protection of vulnerable adults. The settee and a resident’s adapted chair in the house B require replacing or recovering. DS0000010177.V336361.R01.S.doc Timescale for action 30/07/07 2. YA9 13 (4) 30/07/07 3. YA10 17(b) 30/07/07 4 5. YA17 YA23 13(2) (c) 13(6) 18 (c) 30/06/07 30/08/07 6 YA24 23(2) 30/10/07 Cavendish Road Version 5.2 Page 27 7 8 YA27 23(2) 16(2) (g) YA28 9 YA29 23(1) (a) 10 11. YA30 YA34 23(2) (b) 19 1(b) 12. YA37 8(1) The damage bathroom trim in the top bathroom in house A must be replaced or repaired. Fridges in both kitchens must be fit for purpose. Broken food holders and broken drawers in the freezer must be replaced. The home must have appropriate aids and adaptations for the people who live there. An appropriate assessment of the premises must be carried out. The flooring in house A laundry room requires replacing. Individual staff records are maintained as per requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation that all recruitment checks have been taken up. This includes agency staff. (Previous date of 28/2/05 & 30/12/05 and 30/07/06 not fully met). The acting manager must ensure that she submits her an application to the Commission be assessed as the homes registered manager. (Timescale of the 30/06/06 not met) A quality assurance system is put in place which takes into account the views of family, friends and other stakeholders and that the whole process of quality monitoring is consolidated. (Previous date of 31/3/05,30/07/05 & 28/02/06 & 30/07/06 not fully met.) All staff must receive statutory training in the following areas first aid, fire safety, health and safety, food hygiene, moving and handling, medication and the protection of vulnerable DS0000010177.V336361.R01.S.doc 30/08/07 30/08/07 30/09/07 30/10/07 30/07/07 30/07/07 13. YA39 24 30/07/07 14 YA42 18(1) (c) 13(3) 30/08/07 Cavendish Road Version 5.2 Page 28 adults. 15 YA42 13(4) Regular checks are carried out on the first aid cabinet to ensure that adequate materials are available. There must be a clear procedure in place in respect of the action to be taken following a resident having a fall. 30/06/07 16 YA42 Sch3 (o) 30/07/07 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 Refer to Standard YA34 YA33 Good Practice Recommendations Information in staff files should be organised that that required information is accessible. Staffing levels must be kept under review. Cavendish Road DS0000010177.V336361.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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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