Inspection on 06/12/06 for Chadwin Road (81-83)

This inspection was carried out on 6th December 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chadwin Road (81-83) 05/08/08

Chadwin Road (81-83) 28/11/05

Chadwin Road (81-83) 30/06/05

Chadwin Road (81-83) 29/11/04

Chadwin Road (81-83) 19/07/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Chadwin Road (81-83) 81-83 Chadwin Road Plaistow London E13 8ND Lead Inspector Nurcan Culleton Unannounced Inspection 6th December 2006 10:15 Chadwin Road (81-83) DS0000058206.V323082.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 Chadwin Road (81-83) DS0000058206.V323082.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. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chadwin Road (81-83) Address 81-83 Chadwin Road Plaistow London E13 8ND 0207 474 8378 0207 474 8378 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) Consensa Care Limited Mrs Chipo Kiss Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Newly registered home (Initial inspection). Brief Description of the Service: 81-83 Chadwin Road is one of a group of homes owned and managed by Consensa Care Limited and situated in a residential street off the A13. It provides twenty four hour support for seven people with severe or enduring mental illness who have high care support needs. Care staff support and facilitate individual service users in tasks associated with daily living, both within the house and in the community. Placements are permanent, however the aim is to encourage service users towards independent living. Previously 81 and 83 Chadwin Rd were two separately registered homes which merged into one home this year. The service is not registered to provide a service for service users with organic brain disease, learning difficulties or dementia. The service also cannot cater for people with a history of serious risk to themselves or others or who require high levels of nursing care. Current fees for the home are approximately £1190 per week, varying according to the service users’ needs. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a summary of an unannounced inspection which took place on 6th and 7th of December 2007. The registered manager was present during the course of the inspection. The inspector interviewed the manager, two staff members and two service users. The inspector examined three service user files, four staff files and relevant documents including policies and procedures. The inspector also toured the newly merged premises. This inspection is being treated as an initial inspection following the merge and therefore brings no previous requirements for review. What the service does well: What has improved since the last inspection? What they could do better: Confidentiality of service user records must be maintained. Service users’ activities could be reviewed more frequently. The complaints policy and procedure must be updated and improved. There major shortfalls in environmental standards. The home must significantly improve its commitment and response to maintaining high standards in the home’s general state of maintenance and repair as well as its state of hygiene and cleanliness, to maintain an appropriate, safe, comfortable and homely environment for all its service users. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 6 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. Chadwin Road (81-83) DS0000058206.V323082.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 Chadwin Road (81-83) DS0000058206.V323082.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, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have information available to them in order to make an informed decision about moving to the home. The home has a clear understanding of service users’ needs and demonstrates that it is able to meet individual needs following admission. EVIDENCE: The Statement of Purpose and Service Users’ Guide were examined. Both documents contained all items listed in Regulation 4 and 5 and Schedule 1. Service users’ files examined included pre-admission assessments and an assessment completed by the Registered Manager prior admission. The home’s assessments were signed by the service user and Manager and dated. Service users in still in the home who had spoken to by the inspector at previous inspections had confirmed they had visited the home prior to their admission. Service user contracts were not examined at this inspection but were seen at the last inspection and were satisfactory. The home has demonstrated that it has the capacity to meet service users’ needs, as evident in examples given in this report. For example, a Caribbean service user who speaks Patwah was assisted with his communication needs by ensuring a member of staff works in the home who could understand and communicate in his language. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to make decisions over their individual lives and group activities. Service users are consulted on their own assessments and care plans. The organisation has a positive attitude towards individuals’ risk taking as part of an overall approach to maintaining service users’ independence. The home must ensure that confidentiality of service users’ records are maintained at all times. EVIDENCE: Service user assessments completed by social workers and by the Manager were available in files examined. Individual care plans were comprehensive and detailed. They outline service users’ identified needs, the desired outcome, and actions required to meet the need. All care plans seen were signed by service users. Day notes produced by staff in service user files are written with the idea of monitoring each need identified and numbered in service user care plans. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 10 These include service users’ daily activities and any other needs such as dietary, medical etc. This system effectively enables staff to monitor any changes in need on an ongoing daily basis. The review date had not been entered in one care plan, though review dates were seen in the other care plans. Despite this it was evident that care plans were regularly updated. The Manager showed the inspector a revised template for care plans including an entry for the review date. Records kept in the home demonstrate service users’ involvement in all aspects of life concerning them. Documents related to service users were signed by them. Records showed that service users are involved in decisions made in the home. The home continues to run its weekly Express Yourself Group for service users as well as monthly residents meetings. Minutes seen showed active consultation with service users regarding a range of issues in the home. All service users are involved in activities according to their individual strengths and needs, such as communal meal preparation, shopping for milk, bread and newspapers, gardening and cleaning. Activities charts were seen in files detailing these activities and rotas. Service users continue to be involved in interviewing prospective support workers, whom the organisation refers to as Rehabilitation Associates. Risk assessments seen in files and activities supporting individuals to become independent showed a positive attitude towards risk taking generally. An issue regarding risk taking was brought to the attention of a the CSCI prior to the inspection by a professional visiting the home who was concerned about the front door being locked. The Manager informed that this was a Consensa Care approach prior to her management of the home and adopted by the home. This occurred where a service user was identified to be at high risk of absconding or in significant risk of harm and only for short periods during those times until the immediate risk was considered to be reduced. However the Manager informed that following a management meeting it was decided no longer to maintain this policy, in line with the home’s overall aims and objectives and to maintain service users’ freedom of choice and independence. The door was not locked during the inspection and service users were freely going in and out of the house, using a signing in and out system by the door. Confidentiality is generally understood and maintained by staff. However the inspector was concerned that a file was found in a cabinet containing a service users’ key worker sessions which also containing games in the lounge. Confidentiality of service users’ records must be maintained at all times. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 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. Service users participate in a range of activities both inside and outside of the home, to promote their ongoing personal development and to pursue their leisure interests. Service users are encouraged to make choices in their lives and to be involved in decision making in the home. EVIDENCE: Activities charts inspected and the daily diary contained details of individual and group daily and weekly activities including swimming, group outings, dancing, meals out, picnics and parties. However the activities chart in one file was dated January 2006. The Manager showed the inspector a new form which is now in place where service users will personally review each of their activities to state their satisfaction with them. The Manager informed that service users resident in the house are Christian and a weekly church service is provided by a visiting local pastor. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 12 Personal development is encouraged through sessions in budgeting, meal preparation (with one to one support) and assistance with shopping. The menu was satisfactory and prepared with service users according to the choices made by the service users. The Manager and staff spoken to considered that since the last inspection significant improvements had been made to the individual lives and development of service users. Service users are encouraged to attend college courses. The Manager and staff informed that attendance at college for three of the service users was a major personal achievement for those service users. One service user confirmed to the inspector that she does attend a maths and English course at college. This service user also told the inspector that she goes out for dinner, does shopping, and goes swimming. Also one service user’s users’ family who previously had little contact with her, have much closer involvement with this service user and take a keen interest in her affairs. As a result, her mental health has also improved, which has been evident through her drinking less, absconding less and travelling more independently. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are appropriately supported to receive assistance with their personal needs as identified in their Individual Plans. Arrangements are in place to meet service users’ physical and emotional health needs. Service users benefit from good systems in place to ensure the correct administration of medication including staff training. EVIDENCE: Care Plans outline service users’ personal support needs and wishes. An appointment diary records all health appointments and a variety of appointments are maintained, including clinic appointments for depot injections, dental appointments, smoking clinic, hospital and GP appointments and CPA meetings. Emotional support is offered by staff and the CPN who provides regular sessions for service users based at the GP surgery. Service users’ are encouraged to maintain some level of independence and responsibility around their medication and must remember to ask a member of staff for their medication. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 14 However none of the service users were self-medicating and staff sign the MAR sheets. The Boots (M.D.S) medication system is used. The medication administration records were satisfactory at the time of inspection. Service users are encouraged to administer their own medication. Boots provide medication training. New staff who have not received this training are closely monitored when assisting with medication. Service users’ files contained signed statements regarding their views on arrangements in the event of illness or death. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ views are encouraged, listened to and acted upon which reduces the need to make formal complaints. Staff are knowledgeable in adult protection issues and safe practices ensure that service users are protected from abuse and neglect. The complaints policy must be updated. EVIDENCE: The complaints policy seen must be updated to include a more detailed complaints procedure including response times. It must have the updated CSCI contact details on it. There were no recorded complaints. The service users confirmed to the inspector that they were happy with the service and no formal complaints had been made. A personal statement written by one service user was seen in her file which stated areas she was happy with, such as her room, her ability to have a bath morning and evening, helping the staff to cook and listening to music. She informed the inspector that she had no complaints. Staff spoken to said that service users were satisfied with the service. Service users informed that they knew how to complain and that the issues they raised were responded to in most cases. The home has a satisfactory Adult Protection policy and staff spoken demonstrated that they were familiar with its contents and of adult protection issues. Service users’ personal financial accounts were examined and deemed to be accurate. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were a number of major shortfalls in environmental standards. The home must significantly improve its commitment and response to maintaining high standards in the home’s general state of maintenance and repair as well as its state of hygiene and cleanliness, to maintain an appropriate, safe, comfortable and homely environment for all its service users. EVIDENCE: The inspector toured the premises and identified a number of environmental issues for attention. Four bedrooms were seen. Service users each have their own bedrooms. Bedrooms seen were clean with personalised items shown to the inspector, including personal possessions and items of furniture. Service users are encouraged to maintain their own rooms. All windows had restrictors in place. However the following issues required attention: Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 17 The lock on the ground floor toilet door was broken and needed repair The toilet seat of the first floor bathroom was broken and required replacement. It had been reported however it had been this way for nine days. The home narrowly avoided an immediate requirement to rectify this issue, however the inspector found the repairs to the toilet lock and seat underway on the second day of inspection. The ground floor toilet had a roller hand towel attached to the wall similar to those used in hospitals or clinics. This detracts from a homely feel expected of a small home and created an institutional appearance. It is recommended that this is removed and a standard hand towel is used instead. The extractor fan in one service users’ room was very loud (previously used in the smokers area before the merger of the two homes) and came on when the light was switched on. This service user informed that he was unable to open the window due to his hay fever and therefore required the extractor for air circulation. However and alternative, quieter extractor is required. A razor blade was left out on the side of the sink. Safety of such personal possessions must be ensured. The paintwork was chipped and the wallpaper torn in the hallway and requires decoration. The built-in cupboard in the hallway on the first floor needs decoration. There was a strong urine smell coming from around the toilet on the first floor. The radiator covers used in the home fully covered the radiators, including the valves, preventing service users from adjusting the temperature of the radiators without completely removing the covers, posing an unnecessary health and safety risk. Alternative covers must be provided. The bedding in all rooms seen needed replacing, however the inspector saw the new bedding ordered by the Manager. A couple of the bedrooms had completely bare walls. One had nothing but his activities for the week. The home is required to consult with service users about the decoration in their rooms and whether they also wish to have pictures or other adornments on their walls. The bin in the kitchen was broken, dirty and needed replacing on the first day of inspection. The bin was replaced on the second day of inspection. The cupboard storing the boiler near the kitchen sink looked old, grimy and needs repainting or replacing. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 18 The kitchen worktop needs replacing as it was worn out around the cooker. The tea caddies and area around the kitchen worktop had evidence of heavy grime (not attributable to recently made dirt) and needed cleaning. Cleaning in the kitchen generally needed to improve. The Kitchen wall needs repair and decorating where the wall is chipped. The step into the kitchen from the garden was worn and needs repair or replacing. Discarded and broken items of furniture had been dumped in the garden. The inspector was told that they were due to be removed by Head Office within the week. The home must ensure the prompt removal of unwanted items of furniture and appropriate storage for similar items in future to avoid their unsightly appearance in the garden. Chadwin Road (81-83) DS0000058206.V323082.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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. Service users benefit from staff who receive regular training and supervision and are aware of the needs of service users. The home operates good recruitment procedures for the protection of service users. EVIDENCE: There are currently twelve permanent staff members employed to work in the home, including one bank staff member, according to the Registered Manager. During the day the home is staffed with two staff members in addition to the Manager as seen in the rota and two staff members with the Manager on call at the weekends and at night. At night there are two waking staff members on duty. The inspector spoke with two staff members. The inspector was informed that staff are well supported, receive regular supervision, that they have a positive relationship with the Registered Manager and that they receive appropriate training to support them in understanding service users’ needs. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 20 Their views were that service users are being well supported in the home and that marked improvements were evident in some of the service users in terms of their overall development and mental health needs. The inspector viewed four staff records (Schedule 2 forms) containing personnel information. Records showed that each of these staff members had two references, CRB checks and relevant training with the training undertaken specified on each staff members’ form. Staff training includes adult protection, challenging behaviour, moving and handling, first aid and other health and safety courses and also preemployment training. The inspector was advised that a separate staff training and monitoring form is being developed to identify staff training received and training required. In addition, the identification of training is improving through development of a staff training programme, initially through staff supervision. The lead for this responsibility is being taken by one of the managers in another Consensa Care home. The Registered Manager has also sourced additional training from Hackney College. The Registered Manager advised that actual staff files and staff application forms were kept at head office. However where the Schedule 2 staff forms requested a yes/no response to medical clearance for staff, the response to this question for each staff member was recorded as “not currently required.” The Registered Manager informed that this question was interpreted by Head Office to mean that statements regarding fitness or further medical clearance were considered not to be required. For the purpose of inspection however it is recommended that a clear statement of fitness (yes or no) is recorded on the schedule 2 form to confirm whether the staff member is mentally and physically fit to perform their duties. A self declaration form by the staff member may be sufficient to determine fitness. Chadwin Road (81-83) DS0000058206.V323082.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is competent and experienced in the care industry and able to deliver the home’s stated aims and objectives. There is an open, positive approach to the home with a clear sense of leadership and direction. The health, safety and welfare of service users are promoted and protected. Service users benefit from ongoing improvements to their service. EVIDENCE: Since the last inspection, the Registered Manager is now an on an NVQ assessor and has an NVQ Level 4 and Registered Managers’ Award. She has also been awarded an I.L.M Diploma in first line management. Staff reported that they were comfortable to discuss any issues related to the service users and were supported with their individual developmental needs. The Registered Manager continues to use her management skills to improve the service, demonstrating her positive approach and leadership in the home. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 22 A staff handbook had already been developed, summarising key policies and procedures. The Manager informed that she was closely involved with service users where she felt it necessary, for example, encouraging relatives of one service user to have more contact with the service user as a result of her increased personal responsibility and attendance at college. This family contact was confirmed by the service user and recorded in her file. The inspector was shown a form developed to monitor the reactions of service users in the event of a fire drill to take into account risk factors during a drill. However the Manager informed that the organisation is aiming at unifying its policies and procedures and documents and improvements are discussed and agreed at the managers’ meetings where good practise issues are also shared. A range of policies and procedures are available in the home to support staff in their activities. Health and safety measures are taken to protect service users. The Registered Manager informed that repairs and maintenance issues were not within her direct control however issues regarding efficiency and speed of response to service requests had been raised in previous management meetings and were now being taken on board to improve the service. Service users’ personal allowances were checked and deemed to be in order. The petty cash system has improved by the use of a TAG system which affords more security to the system. General health and safety documents were checked and available. However a water safety certificate is required. A quality assurance questionnaire for service users has been devised to be implemented shortly. Chadwin Road (81-83) DS0000058206.V323082.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 3 ENVIRONMENT Standard No Score 24 1 25 1 26 1 27 1 28 3 29 N/A 30 1 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 1 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 1 3 Version 5.2 Page 24 Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc NO 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. 2. Standard YA10 YA24 Regulation 12 23(1)(2) Requirement Confidentiality of service users’ records must be maintained at all times. 1. An alternative quieter extractor fan is required for the service user as identified in this report. 2. The chipped paintwork and torn wallpaper in the hallway requires decoration. 3. The built-in cupboard in the hallway on the first floor needs decoration. 4. Alternative radiator covers must be provided in the home to enable service users to adjust the temperature in their own rooms without the need for assistance or to risk their health and safety. 5. The cupboard storing the boiler near the kitchen sink needs repainting or replacing. 6. The worn out kitchen worktop needs replacing. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 25 Timescale for action 25/02/07 25/02/07 7. General cleaning in the kitchen needs to improve. 8. The Kitchen wall needs repair and decorating where the wall is chipped. 9. The step into the kitchen from the garden was worn and needs repair or replacing. 10. The home must ensure the prompt removal of all discarded items of furniture. Appropriate storage for similar items in future must be provided to avoid their unsightly appearance in the garden. 3. YA42 13(4) Items presenting health and safety hazards, such as razor blades, must be kept in appropriate storage in bathrooms or in service users’ rooms. A water safety certificate is required. 25/02/07 4. YA42 13(4) 25/02/07 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 YA16 YA16 Good Practice Recommendations It is recommended that the roller hand towel is removed and a standard hand towel is used instead. It is recommended that cushions are provided for the armchairs in service users’ rooms for their further comfort. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 26 3. YA12 It is recommended that the home provides improved recorded evidence of consultation with service users about the decoration in their rooms and whether they wish to have pictures or other adornments on their walls. Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chadwin Road (81-83) DS0000058206.V323082.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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