Inspection on 09/01/07 for Coleraine Road 30 & 37

This inspection was carried out on 9th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coleraine Road 30 & 37 27/02/06

Coleraine Road 30 & 37 09/08/05

Coleraine Road 30 & 37 04/05/04

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 Coleraine Road 30 & 37 London N8 0QJ Lead Inspector Susan Shamash Key Unannounced Inspection 9th January 2007 01:30 Coleraine Road 30 & 37 DS0000010714.V322003.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 Coleraine Road 30 & 37 DS0000010714.V322003.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. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coleraine Road 30 & 37 Address London N8 0QJ 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 8888 4348 020 8342 8161 kamrul4@hotmail.co.uk Mr Edward William Marcus Mr Edward William Marcus Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 8 adults with a learning disability (LD) not to exceed 4 accommodated at 30 Coleraine Road and 4 accommodated at 37 Coleraine Road. 27th February 2006 Date of last inspection Brief Description of the Service: The Coleraine Project is made up of two mid-terraced houses located opposite each other in Coleraine Road. The project is located in a residential area of Wood Green North London, less than a 100 yards from Wood Green High Road and the extensive shopping, transport and leisure facilities that the area has to offer. The two houses, which comprise the project, are registered as one care home offering personal care and support for up to eight residents whose primary need for care is that they have a learning disability. There are four bedrooms in each house, and the communal areas include a lounge, kitchen diner, utility room and back garden. Both houses have a ground floor toilet, and first floor bathrooms and additional toilet. Neither house has been adapted to provide for residents with a physical disability. The registered provider both owns and manages the home. The staff team of the project work in both houses to ensure that they become familiar with and to all the residents. The aim of the service is to provide a home, which encourages and supports residents to build a home life and participate actively in a lifestyle, which reflects their values and preferences. In addition, the home aims to promote the independence and integration of residents within the local community from a secure and homely base. As at January 2007, the range of fees for the home are £700 - £1500 per week depending on the level of need. The most recent inspection reports can be obtained from the main office at the home and from the CSCI website www.csci.org.uk Coleraine Road 30 & 37 DS0000010714.V322003.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 five hours. The deputy manager for the home, Mr Kamrul Hassan-Shiblee, was present or available throughout. Mr Hassan-Shiblee has been delegated significant areas of responsibility for managing the home on a day-to-day basis. He remains extremely knowledgeable about both the management issues in the home and the needs of the residents. There were eight residents accommodated at the home and no vacancies. The inspection consisted of: meeting five residents and independent discussion with four of them, detailed discussion with the deputy manager and discussion with four other staff members, independently. Further information was obtained from a tour of the premises and a range of documentation kept in the homes. Feedback forms were also received from eight residents, two health or social care professionals, six care managers and four relatives/visitors to the home. These generally provided very positive feedback about the home. What the service does well: This is an extremely well managed home that provides high quality support and care for residents which they appreciate. Some of the residents have complex needs and the home has developed some very good quality documentation to assist in how residents can be supported in meeting these. The home is sensitive to residents’ cultural and religious needs. The home involves residents at all stages in working on more effective ways of helping them as individuals gain the skills and confidence to be more independent in their daily lives. Residents continue to enjoy a wide range of activities including opportunities to develop their skills in the home, in the community and on exciting holidays abroad, most recently to Borneo. Staff have a wide range of training and development opportunities including effective induction and other core skills training when they are first recruited. Staff receive a high standard of support and supervision from management to ensure that they work in line with best practice. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 6 A very high standard of health and safety documentation is maintained at the home and clear systems are in place to address maintenance issues as these arise. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coleraine Road 30 & 37 DS0000010714.V322003.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 Coleraine Road 30 & 37 DS0000010714.V322003.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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive sufficient information about the service prior to admission and can be confident that their aspirations and needs will be assessed to ensure that these are met when they move into the home. Each resident is protected by an individual statement of terms and conditions with the home. EVIDENCE: No new resident had been admitted to the home since the last inspection. The files for four residents were inspected and these included a comprehensive range of multi-disciplinary assessment information. This included the current legal status of each resident under mental health legislation. There was also evidence that the home had undertaken significant assessment work of its own to make sure that it had the necessary resources to meet the residents needs. From records seen and from discussion with staff, it was also evident that work had been undertaken to minimise any potential disruption to other residents and to facilitate a smooth transition for all. Each file also included a signed contract of terms and conditions with the local authority and with the home as appropriate. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 9 Residents were spoken to independently and all were positive about the admission process and about the home. They confirmed that they had been given copies of the service users guide on admission to the home and that it contained useful information as appropriate. Inspection of the home’s service users guide indicated that it contained all the information required under the Care Homes Regulations 2001. It is recommended, however, that the manager consider producing this guide in a pictorial or video format, to ensure that all residents are able to access it easily. Coleraine Road 30 & 37 DS0000010714.V322003.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ changing needs as well as their personal preferences, are well documented to assist staff and relevant others to meet these needs and wishes. They are supported to make informed decisions about their daily lives with any restrictions being agreed with them and recorded. They are also supported to take appropriate risks in their lives in order to safely achieve their aspirations. EVIDENCE: Care plans for four residents were inspected in depth. All the care plans seen were detailed, current and were broken down into assessed needs with clear guidance for staff on how to meet these needs. The plans were also informed by relevant risk assessments; had up to-date monthly summaries of progress made in meeting the identified needs and had been signed by the resident to evidence that they had been involved in making and monitoring the plans. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 11 Work had also been undertaken to develop person centred plans (PCP’s) for each resident. These included: a record of the latest assessed needs for the person taken from the last review; the care plan, an individual support plan; a person centred plan; a communication passport; a heath action plan and the latest resident involvement questionnaire regarding the quality of support in the home. The service is commended for work in this area as it evidences a high degree of resident participation in the process. This was confirmed by independent discussion with residents. Residents spoken to confirmed that they were supported to make decisions for themselves. The majority can and do travel independently in the community. Where restrictions are placed on this, these are clearly recorded including discussions with those residents on the implications of these restrictions. As noted under care planning above, the home undertakes a range of relevant risk assessments for residents and these were sampled at random. The home has a number of generic risks that are assessed for all residents on an individual basis. These include: issuing of front door keys, travelling independently in the community, window restrictors, use of hot water and smoking. These are supplemented by additional risk assessments for residents where other risk factors have been identified. There was evidence that the risk assessments are generally reviewed regularly with each resident to ensure that they are up to date and that the guidance for staff on how to minimise these risks remains effective. However some risk assessments had not been reviewed within the last six months, and a requirement is made accordingly. Coleraine Road 30 & 37 DS0000010714.V322003.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 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of appropriate activities at home and within the local community. The service is commended for providing residents with support to enjoy regular holidays to long haul destinations abroad that significantly contribute to enriching their life experiences. They are supported to maintain relationships with friends and family members and their rights and responsibilities are respected. They enjoy balanced, healthy and varied meals of their choice. EVIDENCE: Residents attend a range of relevant daytime activities within the local community. This includes day services and attendance at local education facilities. One resident, who is a practicing Muslim, is supported in their cultural choices, including staff support to attend their Mosque for worship. The resident advised that this support was given in a sensitive and supportive way. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 13 Evidence was seen that staff had worked with individual residents to develop their communication passports as referred to in the Individual Needs and Choices section of this report. Residents had recorded in these their likes and dislikes as well as their aspirations for the future. The inspector was informed that the process of developing the communication passports allowed staff and residents to explore options for residents to try out new experiences including identifying valued daytime activities for them to undertake. Evidence was seen that residents are able to access the varied local community resources including shops, pubs, restaurants, cinema and recreational facilities. Other activities enjoyed by residents included playing pool and snooker, handball, football, swimming, horse riding and attending a local leisure centre, college, work experience, daycentres and visits to places of interest around London. Cable television, a playstation and table football are also available to residents in the home. Residents continue to be supported to go on holidays abroad each year, often to exotic long haul destinations. In previous years residents have been supported to go on holiday to Malaysia, Croatia, Mexico, Thailand and Goa. The inspector was shown photos from the residents most recent holiday to Borneo in April 2006 and residents told the inspector how much they had enjoyed it. The home had a four weekly menu with evidence that residents were involved in planning this at monthly resident meetings. The home can cater for different dietary requirements and cultural needs and food stocks in the home and menus recorded confirmed this. Meals are prepared, cooked and eaten in the kitchens/dining rooms at both houses. Residents are actively encouraged to be involved in the preparation and cooking of meals. The kitchens in both houses were inspected and were clean, tidy and satisfactorily equipped. The food was stored appropriately and matched the menu including Halal meat for Muslim residents. Satisfactory records of fridge and freezer temperatures were seen. Coleraine Road 30 & 37 DS0000010714.V322003.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive personal support to meet their physical and emotional needs according to their preferences. Residents are protected by robust polices and procedures regarding medication and its administration and are encouraged to take as much responsibility for administering their own medication as possible to promote their independence in this area. EVIDENCE: Care plans, daily notes and health need summaries for each resident indicated that their health care needs are being met appropriately. This was confirmed by residents spoken to. They also confirmed that they are supported to see health care practitioners on a regular basis. The manager advised that the SPELL model structure is used by staff working with residents. This includes a Structure, Positive approaches, Empathy, Low arousal and Links with the other professionals within the community. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 15 Medication and medication administration record (MAR) charts were inspected in both homes. These were found to be satisfactory and showed evidence that residents are encouraged to take as much control over the administration of their medication as possible. Evidence was seen that, where appropriate, identified residents are monitored controlling their own medication rather than having staff administer it directly. Evidence was also seen from staff files sampled that staff are trained in the safe administration of medication. The senior support worker confirmed that after staff are first recruited they are trained in this area as a matter of priority and also confirmed that all staff undertake regular refresher training in this area. The inspector also saw evidence that the deputy manager monitors the administration of medication process closely taking clear management action if this was not undertaken to his satisfaction. When particular residents are being supported outside of the home, ‘as and when’ (or PRN) medication is carried by staff in case it should be needed. It is recommended that this should be recorded in and out of the home on each occasion (including the number of tablets taken out of the home and returned) so that a clear audit trail of residents prescribed medicines is maintained. Use of the symbol ‘F’ on MAR sheets should also be explained on each occasion. Coleraine Road 30 & 37 DS0000010714.V322003.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are able to express their views, concerns and complaints and be confident that these will be taken seriously and appropriately dealt with by the home. Robust policies and procedures and staff training protect residents from abuse. EVIDENCE: The home has a robust complaints policy and procedure that was seen. Four concerns had been raised by residents in the last year and had been dealt with under the home’s complaints procedure. Evidence was seen that these had all been thoroughly investigated by the home within the required timescales with appropriate action taken to address them. The manager advised that thorough investigation of complaints and their resolution was also a clear part of the home’s quality monitoring process. A clear adult protection policy was available for the home and staff spoken to were aware of the action to take in the event of suspected abuse. Staff files evidenced that appropriate Protection of Vulnerable Adults (POVA) training had been undertaken by all staff as appropriate. The manager had produced a POVA training file for the home for staff to use. Staff had also received training in non-violent crisis intervention. Coleraine Road 30 & 37 DS0000010714.V322003.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is comfortable, well decorated and well maintained. They also benefit from well-equipped bedrooms that they are supported to personalise to their taste. The home was clean and tidy throughout creating a pleasant environment for those who live and work there as well as for those who visit it. EVIDENCE: The home consists of two separate mid-terrace houses in a residential area close to the main Wood Green shopping centre with good public transport links. All accommodation is for residents who are physically able and there are no facilities for residents with physical disabilities. Evidence was seen that the home had a planned maintenance and redecoration programme. One house had been redecorated since the previous inspection. The inspector had the opportunity of seeing five bedrooms with the permission of the residents involved. These were appropriately decorated, furnished and Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 18 personalised to the extent that each resident wished. All residents spoken to indicated that they were happy with their bedrooms. Both houses were clean and tidy throughout with appropriate laundry facilities for the needs of the residents. The deputy manager advised that the outside of number 37 would be redecorated over the summer. The gardens of both homes were in a reasonable state of repair and residents advised that they enjoyed using these areas during the summer. Coleraine Road 30 & 37 DS0000010714.V322003.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): 32, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment procedures that are robustly implemented. Staff are offered a wide range of relevant training, including good quality induction training, to assist them in their own personal development and in meeting residents’ needs. They are provided with appropriate support and regular supervision to ensure that they work in line with best practice. EVIDENCE: Four staff files were inspected including two staff who had commenced employment at the home since the previous inspection. Records indicated that the home continues to implement a robust recruitment procedure throughout the process. All files contained: satisfactory enhance criminal records bureau (CRB) checks that included protection of vulnerable adults (POVA) checks; two written references that were verified where it was felt appropriate by a follow up telephone check; identification with a photograph; an employment history; a contract of employment and a health questionnaire. The files inspected also showed substantial evidence that the home is also committed to staff training. A detailed induction checklist was seen on each file Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 20 with each element being signed by both the staff member and a manager. Evidence was also seen that these staff had undertaken a range of core skills training since being employed. This included: fire safety, food hygiene, safe use of medication, infection control, communication skills and first aid. Fifty percent of staff were trained to NVQ level 2 or above as appropriate. All staff had also undertaken non-violent crisis intervention training and the deputy manager advised that he was now an accredited trainer for this subject. The inspector spoke with two staff members at each home (four in all) including a staff member who had only newly been appointed. All indicated that they had found the training provided to be useful, relevant and that it had assisted them in supporting the residents in their daily lives. Where video training is used, they are asked to complete questionnaires, and they are also given the opportunity to attend external training when this becomes available. They spoke highly of the support and supervision provided to them by the home’s management. Appraisal records indicated that a 360 degree approach is being used, incorporating feedback from colleagues, for which the service is commended. All staff were receiving supervision sessions at least two-monthly, or more often if required as appropriate. Coleraine Road 30 & 37 DS0000010714.V322003.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): Standards 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected and supported by an effective and proactive system of management in the home. Their views are taking into account in reviewing the home’s strengths and areas for development as appropriate, and their best interests are safeguarded by the home’s rigorous record keeping procedures. However they could be further safeguarded by improved recording of residents’ possessions kept by the home for safekeeping. Health and safety procedures are maintained to a very high standard within the home so that residents’ safety is safeguarded as far as possible. EVIDENCE: It was clear throughout the inspection process that the registered provider/ manager had delegated a significant amount of the day-to-day management responsibility for the home to the deputy manager. The deputy manager stated Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 22 that the registered provider/manager monitored his work and that he was very much supported by him. The deputy manager had completed his Registered manager’s Award and recently became registered as the manager for another home owned by the provider. The inspector was impressed by his overall knowledge about the home and the residents demonstrated, and evidence of decisive management action that had been taken regarding staff performance issues. Although the high standard of management of the home indicate that the deputy manager is coping extremely well with both roles. It is recommended that the registered manager should ensure that the deputy manager has sufficient time to work at this service and the other service for which he has been appointed as ‘registered manager’ and provide adequate support as appropriate. Staff and residents spoken to throughout this inspection were positive and complimentary about the management of the home. They also indicated that they continued to appreciate the positive and optimistic ethos that this generated. Detailed quality assurance procedures were in place for the home. In addition to regular staff meetings and resident meetings, surveys of each residents’ views of the home had been undertaken. The deputy manager also carries out ‘mock inspection visits’ on a regular basis as part of the quality assurance procedures for the home. The deputy manager was reminded that the results of the quality assurance audit for the home should be sent to the CSCI at least annually. The inspector was very impressed with the records maintained at each home for residents and staff. Financial records for monies looked after by the home on behalf of residents, were recorded appropriately. However there were insufficient records of the valuables kept in the office for residents e.g. passports, bank books etc. A requirement is made accordingly. Health and safety records for the home were inspected, including fire safety records, electrical and gas installation and portable appliances testing certificates. All were found to be in order alongside general risk assessments about the home and appropriate staff training in food hygiene, first aid, health and safety and manual handling. Refrigerator and freezer temperatures as well as cooking temperatures were being recorded daily as appropriate. No areas of concern regarding health and safety were observed in either house during the inspection. Coleraine Road 30 & 37 DS0000010714.V322003.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 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 3 X 2 3 X Coleraine Road 30 & 37 DS0000010714.V322003.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 Regulation 13(4) Requirement The registered person must ensure that all risk assessments for service users are reviewed at least six-monthly. The registered person must ensure that a current and accurate record is maintained of any valuables kept in the office on behalf of service users. Timescale for action 09/03/07 2. YA41 17(2) Sched 4(9) 16/02/07 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 YA1 YA20 Good Practice Recommendations It is recommended that the service users guide be produced in a pictorial or video format in order to be accessible to all prospective service users. It is recommended that a record be maintained of all prescribed PRN (as and when) medications taken out of home in case service users need these whilst away from the home, and the number returned. The use of the symbol F on medication administration records should also be explained. It is recommended that the registered manager should DS0000010714.V322003.R01.S.doc Version 5.2 Page 25 3. YA37 Coleraine Road 30 & 37 4. YA39 ensure that the deputy manager has sufficient time to work at this service and the other service for which he has been appointed as ‘registered manager,’ and provide adequate support as appropriate. The registered person is reminded that the results of the most recent quality assurance audit must be sent to the CSCI at least annually. Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Coleraine Road 30 & 37 DS0000010714.V322003.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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