Inspection on 30/05/07 for Conifers

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Conifers 04/07/06

Conifers 26/10/05

Conifers 16/05/05

Conifers 11/10/04

Conifers 05/04/04

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

CARE HOME ADULTS 18-65 Conifers 44 Broad Green Avenue West Croydon Surrey CR0 2ST Lead Inspector James O`Hara Key Unannounced Inspection 30th May 2007 09:15 Conifers DS0000025773.V341617.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 Conifers DS0000025773.V341617.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. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifers Address 44 Broad Green Avenue West Croydon Surrey CR0 2ST 020 8665 0237 020 8683 2329 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) Mr Milton Anthony Wilson Mrs Yvonne Wilson Mrs Yvonne Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified resident over the age of 65 to be admitted. 4th July 2006 Date of last inspection Brief Description of the Service: Conifers is located in a quiet avenue off a busy thoroughfare close to the centre of Croydon. There is access to local buses and trains, facilities and amenities are all easily accessible. The home has been registered to provide support to six people with learning disabilities. The home comprises of four floors with the living room, kitchen and laundry in the basement, two bedrooms and a bathroom with access to the back garden on the ground floor, two bedrooms and a bathroom on the second floor and two bedrooms a shower room and a toilet on the top floor. Most people who use the service have done so since the home opened and all know each other very well. The proprietor Mrs. Wilson is also the registered manager owns the property. The current fee charged at the home is £553.35 per week. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out over three hours between 9.15 am and 12.15 pm on a Wednesday morning/afternoon. Methods of inspection included a tour of the premises, observation of contact between staff and people who use the service and discussion with the registered provider Mrs. Wilson. Records examined included person centred plans, needs assessments, risk assessments, complaints, adult protection, staffing training, personnel, supervision, medication, finance, and health and safety. Requirements and recommendations from the previous inspection were also discussed with Mrs. Wilson. What the service does well: The home has a small well-established staff team that have worked together for a number of years, this has benefited people who use the service, providing stability and consistency while dealing with their individual needs. One new person moved into the home in February 2007. He had a full assessment carried out by a care manager and he was able to visit the home and stay for a weekend before deciding to move in. Social, leisure and employment opportunities for people to engage in both inside the home and in the wider community are well managed, age appropriate, and provide the people with daily variety and stimulation. Quality in this outcome area is excellent. One person works at the Big Bus Company. He said that the Big Bus Company had opened up a place in Dubai so went there last month on holiday. He said that the Big Bus Company arranged for him to be picked up from his hotel and he was shown around the new Big Bus Station. He said it was a great holiday and he wanted to go back. Another person said that things are going well for her and she is happy at the home, she said that she was happy with the new table and radio in her bedroom. She said that she sometimes helps with cooking meals and washing up at the home. In the homes own questionnaire the new person said, “I like living here because it makes me feel like it’s my home”. During the inspection he said that he was very happy at the home. A comment card returned to the Commission as feedback from a relative stated, “Our daughter is very happy with her room and surroundings and never complains. The staff do a wonderful job”. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 6 The arrangements for health care needs of people who use the service are good and they receive personal support in the way they prefer. The home has an appropriate complaints procedure in a format that people can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place so that people are so far as reasonably practicable protected from abuse. What has improved since the last inspection? What they could do better: The overall impression when visiting the home is that it is well managed. The management approach of the home creates an open, positive and inclusive atmosphere. There were four requirements and five recommendation set at the last inspection. All of the requirements and all but one of the recommendations have been met. As a result of this inspection there are two new requirements and five new recommendations. The home could do more to make sure that people who use the service have appropriate risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. The home could do more to improve its recruitment practices. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 7 Although it is very evident that people are encouraged to get involved in the running of the home more could be done so that they can formally record their opinions and views about the service. Mrs. Wilson could assess training attended by the staff and arrange for training or refresher training on health and safety, moving and handling and first aid. So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. The inspector would like to thank the people who use the service, the staff and Mrs. Wilson for their support in the inspection process. 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. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 8 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 Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 9 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): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: The home currently supports six people with learning disabilities. The fee charged at the home is £553.35 per week. The home has an admissions policy that states that people wishing to use the service must have a full assessment from the care management team, full physical and psychological assessments and involvement from family and advocates. One new person moved into the home in February 2007. A member of staff stated that the new person visited the home and stayed for a weekend prior to moving in. A care managers needs assessment was in place. Conifers DS0000025773.V341617.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and My Care Plans that include information on their needs and personal goals. The home could do more to make sure that people who use the service have appropriate risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: Requirement were set at the key inspection on the 4th of July 2006 that Mrs. Wilson must make sure that people who use the service have their placement reviewed by their care managers from the placing authority. Four peoples files were examined all had had their placement reviewed by their care managers from the placing authority. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 11 It was recommended at the key inspection that the date of the risk assessment review needed to be recorded on the risk assessment. Mrs. Wilson produced evidence that the date of the risk assessment review was recorded on individual risk assessments. It was also recommended that Mrs. Wilson and staff support people to complete their Person Centred Plans in a format appropriate to the service users understanding. Mrs. Wilson produced a My Care Plan for each person living at the home. Mrs. Wilson stated that this was the homes person centred planning approach to understanding and meeting people’s needs. The plan included the headings: • • • • • • • • • • What I like people to know about me. Who is important to me. What happened at my last review. Education, Training and Employment. What I need help with. My health care needs. Who helps me with these. My money. What I would like to do in the future. Other people’s views. Mrs. Wilson and staff/key workers had supported people to complete the plan. The subject of Equality and Diversity was discussed in relation to information recorded in care plans and My Care Plans. There appeared to be little reference to Equality and Diversity. So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. It was noted in the new persons care needs assessment that there were risks around him using public transport, meeting strangers, self-harming and that he may be a risk to children. Risk assessments completed for this person were not appropriate to the nature of these risks and did not indicate how the risk would be managed. Mrs. Wilson stated that had contacted the persons care manager in order to complete these risk assessments in particular the risk to children. Mrs. Wilson was advised that she needs to make sure that the new persons risk assessments and risk management strategies are set in place in relation the new person using public transport; meeting strangers, self-harming and in particular the risk to children. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 12 An adult protection strategy meeting took place in August 2006 after a person living at the home alleged that a member of staff had pushed him. He later apologised and stated that he had not been pushed. The chairperson at the adult protection meeting praised the excellent way Mrs. Wilson had conducted the case and the transparency and willingness to solve the matter in the most appropriate manner demonstrated the correct way to act. The chairperson also pointed out that keeping up to date, accurate documents and reviews regarding the person’s behaviour would be the best way to safeguard both him and the institutions good name. It is recommended that Mrs. Wilson follow this advice. A number of actions were agreed at the meeting. Some of these had been followed up. One action was to review and draw up a risk assessment for this person making allegations of abuse. However Mrs. Wilson stated that this had not yet been completed. Mrs. Wilson was advised that in order to protect this person and staff working at the home she needs to make sure that a risk assessment and risk management strategy is in place in relation to him making allegations of abuse. The registered manager must make sure that appropriate risk assessments and risk management strategies are set in place in order to protect the health and welfare of people who use the service. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using all the available evidence including a site visit to this service. Social, leisure and employment opportunities for people to engage in both inside the home and in the wider community are well managed, age appropriate, and provide people with daily variety and stimulation. EVIDENCE: People are encouraged to follow their own interests and hobbies. One person has an interest in trains and has a large model railway in his bedroom; he also attends a local model railway club and is a keen train spotter, he also works at the Big Bus Company. He said that the Big Bus Company had opened up a place in Dubai so went there last month on holiday. He said that the Big Bus Company arranged for him to be picked up from his hotel and he was shown around the new Big Bus Station. He said it was a great holiday and he wanted to go back. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 14 Mrs. Wilson stated that other people had planned to go on holiday to Butlins and Paris later in the year. One person said that he works as a gardener. He said that his bicycle had been stolen from the shed and that he had informed the police about it. He said that he is planning to move out of the home to a small flat. He said that Mrs. Wilson was aware of this and that he would really miss living at the home. Some people attend day services, college or the pop in club. One person helps out at the pop in centre three days a week. Another person said that she goes to the pop in centre three days a week; she said that things are going well for her and she is happy at the home, she said that she was happy with the new table and radio in her bedroom. She said that she sometimes helps with cooking meals and washing up at the home. The new person goes to college in Cranliegh on a daily basis. Mrs. Wilson stated that this is a long journey and he goes by taxi. His placing authority has funded this. This person has an interest in gardening and a gardening college has been identified in Wales for him to attend however this would be in two years time. It is possible that he could then move to Wales. However in the homes quality assurance questionnaire he stated, “I like living here because it makes me feel like it’s my home”. On the day of the inspection he said that he is very happy here. A comment card returned to the Commission as feedback from a relative stated, “Our daughter is very happy with her room and surroundings and never complains. The staff do a wonderful job”. People are involved in menu planning. A varied menu is on offer, which is sufficiently nutritious and takes individual tastes into account; there is also an opportunity for choice with an added menu running concurrently. Conifers DS0000025773.V341617.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 and 20. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The arrangements for health care needs of people who use the service are good and they receive personal support in the way they prefer. The homes policies and procedures for handling medicines in the home ensure that people are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: As recommended at the key inspection guidelines indicating one persons support needs and how staff should support her with personal care are now recorded on her care plan. All of the people who use the service are registered with a local General Practitioner. Health care needs including optical, chiropody and dental health are recorded in appointment monitoring forms located in their files. Medication is stored in a locked cabinet in the office. None of the people who use the service administer their own medication. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 16 Medication administration records were checked on the day of the inspection and were up to date and accurate. The home has the support of a pharmacist for advice and support. Mrs. Wilson evidenced that the pharmacist visited the home on the 31st of January 2007. Two members of staff had attended medication training in March 2007. Conifers DS0000025773.V341617.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 and 23. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has an appropriate complaints procedure in a format that people who use the service can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place so that people are so far as reasonably practicable protected from abuse. EVIDENCE: A requirement was set at the key inspection that Mrs. Wilson must make sure that all staff attends adult protection training. Mrs. Wilson produced evidence that all but one member of staff had attended adult protection training since the last inspection. Mrs. Wilson produced the homes complaints book and indicated that one complaint had been recorded at the home. However the complaint was in fact an incident when the new person living at the home self harmed after he had been upset at college. It is recommended that the registered manager keep a record of instances when the people self harm. Also see Standard 9 of this report. Conifers DS0000025773.V341617.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 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In general the people’s bedrooms were in good decorative order and had appropriate furnishing. The home was clean and free from offensive odours throughout. EVIDENCE: The home comprises of four floors with the living room, kitchen and laundry in the basement, two bedrooms and a bathroom with access to the back garden on the ground floor, two bedrooms and a bathroom on the second floor and two bedrooms a shower room and a toilet on the top floor. It was observed at the last key inspection that the hall stairs and landing had been redecorated, during todays visit the living room on the ground floor was being redecorated. Bedrooms are of good size and sufficient to meet people’s individual needs and lifestyles. Bedrooms have been decorated to their own personal choices. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 19 On the day of the inspection the premises was clean and hygienic and free from offensive odours throughout. Conifers DS0000025773.V341617.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 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service cannot be confident that they can be supported and protected until the homes recruitment practice has been improved. Staff now receives regular supervision so as to make sure that people who use the service can benefit from having a consistent approach to their needs. EVIDENCE: It was required that Mrs. Wilson ensure that staff files are updated to include all of the details as stated in Schedule 2 of the Care Homes Regulations. Mrs. Wilson stated that she had added a recent photograph of all members of staff. One new member of staff has started work in the home since the last inspection. This member of staffs personal file was examined. The file included a Criminal Records Bureau Check, an employment history, a recent photograph and two references however Mrs. Wilson did not obtain proof of identification or a statement as to the persons mental and physical health. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 21 The registered manager must make sure that all staff files include all of the details as stated in Schedule 2 of the Care Homes Regulations, amended. See below. 1 2 Proof of identity, including a recent photograph. Details of any criminal offences— (a) of which the person has been convicted, including details of any convictions which are spent within the meaning of section 1 of the Rehabilitation of Offenders Act 1974 and which may be disclosed by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions Order) 1975; or (b) in respect of which he has been cautioned by a constable and which, at the time the caution was given, he admitted. 3 Two written references, including, where applicable, a reference relating to the person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration. Where a person has previously worked in a position that involved contact with children or vulnerable adults, written verification of the reason why he ceased to work in that position unless it is not reasonably practicable to obtain such verification. Documentary evidence of any relevant qualifications and training. A full employment history, together with a satisfactory written explanation of any gaps in employment. A statement by the person as to his mental and physical health. Details and evidence of registration with, or membership of, any professional body. 4 5 6 8 9 It was required that Mrs. Wilson ensure that all members of staff receive supervision at least once every six weeks or eight times a year. Mrs. Wilson produced evidence that all members of staff are receiving regular formal supervision at least once every six weeks or eight times a year. It was recommended that Mrs. Wilson review staff appraisals. This recommendation was not examined during this inspection. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 22 The homes roster included only the first name of the member of staff on shift. The homes should include the full name and job title of the member of staff on shift. Staff training records indicate that some staff attended a fire safety lecture on 2nd of July 2004 and some staff attended food hygiene training in May 2004. During this inspection Mrs. Wilson arranged for all staff to receive fire safety training on the last week of June and food hygiene training on the 7th of June 2007. Training records also indicated that some staff attended training on health and safety, moving and handling and first aid however these took place some time ago. It is recommended that the registered manager assesses training attended by staff and arrange for training or refresher training on health and safety, moving and handling and first aid. Some staff has recently attended medication training and all but the new member of staff recently attended adult protection training. One member of staff holds an NVQ level 2 and is currently completing the NVQ level 3. Mrs. Wilson stated that another member of staff had completed an NVQ level 2 and is awaiting her certificate. Conifers DS0000025773.V341617.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, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall impression when visiting the home is that it is well managed. The management approach of the home creates an open, positive and inclusive atmosphere. Although it is very evident that people are encouraged to get involved in the running of the home more could be done so that they can formally record their opinions and views about the service. EVIDENCE: Mrs. Wilson has worked at the home since it opened in 1996. The home is well managed and creates an open, positive and inclusive atmosphere. Mrs. Wilson holds a City and Guilds Qualification in the Advanced Management in Care and a BTEC Award for working with people with learning disabilities. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 24 At the last inspection Mrs Wilson stated that she had contacted NESCOT and was completing Units RM1 and RM2 of the Registered Managers award. During todays visit Mrs. Wilson stated that she had started the Registered Managers Award and NVQ Level 4 in Care in February 2007 and hopes to complete this by the end of the year. Mrs. Wilson is in day-to-day charge of the home. Mrs. Wilson produced the home’s quality assurance system. This consisted of relatives and advocates and people who use the service questionnaires, a quality assurance audit and monthly management audits. One relative commented that there is a good family feeling about the home and a person living at the home commented, “I like living here because it makes me feel like it’s my home”. Mrs. Wilson stated that not all of the people living at the home had completed the questionnaire. She said that some people might find this task too difficult. It is recommended that the registered manager consider how people who use the service can be supported to express their opinions and views about the running of the home. All of the people who use the service with the exception of the new person have a bank account with Lloyds TSB. Some people’s financial records were examined and contained up to date monthly bank statements. Mrs. Wilson stated that when people wish to they could withdraw money from their accounts, this money is held in a cash tin in a locked cupboard, people sign a finance expenditure sheet when they take their money. Receipts for purchases are also sought and kept on the persons finance expenditure sheet. A number of peoples finance expenditure sheets were examined and were up to date and accurate. Mrs. Wilson provided a Landlords Gas Safety Certificate 09/05/07, Portable Appliance Testing Certificate 30/01/07 and legionellas testing/water tank chlorination was carried out in July 2006. The fire alarms call points are tested by staff on a regular weekly basis. An officer from London Fire & Emergency Planning Authority visited the home on the 15/06/06. A full fire drill was carried out on the 16/01/07 and an engineer from a company called Fire Fighting Equipment checked the fire alarm system on the 16/02/07. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 25 Mrs. Wilson produced a recent fire risk assessment for the home. Mrs. Wilson has arranged for all staff to receive training on fire safety in June 2007. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 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 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 27 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. Standard YA9 Regulation 12 (1, 2 and 3). Requirement The registered manager must make sure that appropriate risk assessments and risk management strategies are set in place in order to protect the health and welfare of people who use the service. The registered manager must make sure that staff files include all of the details as stated in Schedule 2 of the Care Homes Regulations. Timescale for action 30/06/07 2. YA34 19 (1). 31/07/07 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. Refer to Standard YA6 Good Practice Recommendations So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. It is recommended that the registered manager keep a record of instances when the people self harm. DS0000025773.V341617.R01.S.doc Version 5.2 Page 28 2. YA23 Conifers 3. 4. YA34 YA35 5. 6. YA35 YA39 The homes should include the full name and job title of the member of staff on shift. It is recommended that the registered manager assesses training attended by the staff and arrange for training or refresher training on health and safety, moving and handling and first aid. It is recommended that Mrs. Wilson review staff appraisals. It is recommended that the registered manager consider how people who use the service can be supported to express their opinions and views about the running of the home. Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Conifers DS0000025773.V341617.R01.S.doc Version 5.2 Page 30 - 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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