Inspection on 21/08/07 for Elmfield Way, 1-2

This inspection was carried out on 21st August 2007.

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

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

Other inspections for this house

Elmfield Way, 1-2 29/01/08

Elmfield Way, 1-2 18/12/06

Elmfield Way, 1-2 01/02/06

Elmfield Way, 1-2 03/03/05

Elmfield Way, 1-2 13/10/04

Similar services:

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Edenvale

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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 Elmfield Way, 1-2 1-2 Elmfield Way London W9 3TU Lead Inspector Tony Lawrence Key Unannounced Inspection 21st August 2007 09:00 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 Elmfield Way, 1-2 DS0000010873.V347861.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. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmfield Way, 1-2 Address 1-2 Elmfield Way London W9 3TU 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 7266 1200 020 7266 3412 info@yarrowhousing.org.uk Yarrow Housing Limited Caryl Anderson Care Home 6 Category(ies) of Learning disability (18) registration, with number of places Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 Brief Description of the Service: 1-2 Elmfield Way is a registered care home providing accommodation and personal care for six people with autism and/or challenging behaviours. At the time of this visit there were 4 men and 2 women living in the home and no vacancies. Kensington Housing Trust owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is located off Harrow Road, a busy main road. It is close to local shops and transport links. Originally built as two separate units, the home has been converted to provide spacious accommodation that is fully accessible to people using wheelchairs. The home is well staffed to provide intensive support to people with high care needs. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We visited the home on Tuesday 21st August 2007 from 09:10 – 15:45. We spent time talking with residents, care staff and managers. We reviewed the care of two people in more detail by observing staff who supported them during the day and checking care records kept in the home. We saw all the shared parts of the home and one person’s bedroom. What the service does well: 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. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 6 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 Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 7 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. People who may want to live in the home are given clear information that is produced in accessible formats. People’s needs are fully assessed before they move into the home. EVIDENCE: There were three men and two women living in the home when we visited and one vacancy. The Care Services Manager told us that staff are working with the local authority’s Learning Disability Services to find someone whose needs can be met in the home. The home has established referrals and admission policies and procedures to make sure that people who come to live in the home are placed in a home that meets their specific needs. We checked the personal files for two people living in the home and saw that each person had a Residents Agreement and separate Licence Agreement that explained the services provided in the home. We saw that the Residents Agreement made good use of photographs to make important information easier for some people living in the home to understand. Both of the files we checked included a Service Users Guide that also used photographs to make important information easier to understand. Both Service User Guides had been reviewed in July 2007, but Yarrow must make sure that information given to residents and their representatives refers to the Commission for Social Care Inspection and not the National Care Standards Commission. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 8 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are person centred and are agreed with each person or their representative. Plans are written in plain language, are easy to understand and look at all areas of the individual’s life. EVIDENCE: We saw that both of the people whose care we reviewed during this visit had a current care plan that described their abilities, aspirations and personal and health care needs. The Care Services Manager told us that the organisation is introducing a system of ‘person centred planning’ and we saw some evidence that staff are involving people in planning and evaluating the care and support they receive. This has involved the creative use of information technology to involve people in planning their care. We saw that one person used a DVD at a review meeting to present activities they had been involved in. We saw that both of the care plans had been reviewed in the past six months. We checked daily log books that staff use to record each resident’s daily life. We saw evidence in the log books that residents are supported by staff to take part in a range of activities, in the home and the local community. We also saw on the day we visited the home that staff supported each resident to go out for part of the day. One person went to a local authority day service and Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 9 other people went shopping or for walks. We also saw that people were offered choices by staff, including choice of food, clothes and activities. When we checked the finance records for two residents, we found that staff often make purchases on behalf of residents, rather than involving them in shopping for personal items. Items included clothes and toiletries and residents would benefit more from staff support to enable them to choose and buy these items themselves. During this visit, we checked risk assessments for two residents. All risk assessments were well written and covered general risks associated with living in the home and more detailed assessments where specific risks had been identified. Assessments covered a number of areas, including personal care, fire safety, medication and using amenities in the local community. We also spoke to the home’s Acting Manager and the provider’s Care Services Manager about the language that staff use when writing about residents in their personal logbooks. Managers in the organisation should support staff to think about the language they use to describe residents and their behaviours in records kept in the home. This will help to make sure that residents are treated with respect by staff at all times. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 10 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a strong commitment to enabling people to develop or maintain their skills. Residents have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: During this visit we saw that the staff team worked well together to support individual residents, often making sure that each person was offered choices about aspects of their daily lives. Staff told us that the five people living in the home have lived together for a number of years and their care needs were well known to permanent staff. People’s routines were well recorded in their care plans and staff knew the levels of support that each person needed and how each person expressed preferences and wishes. Each person had a programme of activities and staff worked well together to make sure that people were supported to take part in activities they chose. The two people whose care we reviewed during this visit each had a Communication Passport, written by a Speech and Language Therapist and staff from the home. The Passports were written in the resident’s ‘voice’ and clearly outlined people’s aspirations, routines and preferences. Although staff Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 11 we spoke to knew about the Passports, we saw that they had not been reviewed or updated for almost two years. Managers should make sure that important information about individual residents is reviewed regularly. We checked the logbooks for three people living in the home. Staff told us that people working in the mornings, afternoons and at night are expected to record information about each resident’s experiences. We found that one log book was well completed and included some good information about how the person spent time each day. The other two log books included significant gaps where staff on individual shifts had failed to record anything. For these two residents we found it difficult to evidence that people were involved in activities of their choice. Managers must make sure that all staff record details of how they support people on each shift. We saw evidence that staff support people to keep in touch with relatives and other important people. Contact details for these people were recorded in their care plans and each person had a ‘circle of support’ so that staff knew these details. Staff told us that some people spend time with their parents and other relatives during the week or at weekends. Staff told us that meals are prepared individually for residents, based on their known likes and preferences. During this visit we saw people eating a variety of foods and staff also made sure that people were involved in choosing what they ate and helped with the preparation. Staff told us that most people choose to eat in the lounge/dining room but could also have meals in other areas if they chose. We saw that one person preferred to eat their breakfast in the summerhouse and staff supported them to do this during our visit. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 12 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. Staff are aware that the way in which support is given is a key issue for people living in the home. Residents’ individual plans clearly record their personal and healthcare needs and detail how they will be delivered; these needs are also recorded in a separate Health Action Plan. EVIDENCE: During this visit we reviewed the care and support given to two residents. Personal and healthcare needs were recorded throughout both people’s care plans and each person also had an excellent Health Action Plan that had been completed in August 2007. We saw that the Plans were detailed and included information about each person’s healthcare needs and how they would be met by staff in the home and other people, including relevant health professionals. The two people’s care plans were reviewed in May and July 2007 and we saw evidence that residents were involved in review meetings, together with relatives and relevant health and social care professionals. Care plan reviews included health issues and it was clear that specific issues highlighted in the Health Action Plans had been followed up and referrals made to appropriate clinicians. We also checked the medication records for all five people living in the home. We found that the medication records were well maintained and each person’s record included their photograph. We saw that all prescribed medication is Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 13 securely stored and records of medication received into the home were accurate. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. There is no evidence of the service valuing complaints or improving outcomes for people as a result of complaints. There is a lack of knowledge around restraint and individuals living at the home may be at risk due to the inappropriate use of restraint. EVIDENCE: The home has a complaints procedure that we saw was provided in a format using photographs and Plain English that would make the procedures easier for some residents to understand and use. As with other documents kept in the home, Yarrow must replace references to the National Care Standards Commission with the Commission for Social Care Inspection to make sure that people have information that is up to date. Staff and managers told us that there have been no recorded formal complaints since November 2005. We felt that staff could do more to support individuals to make complaints about issues that affect them. For example, the failure to carry out essential repairs quickly or the effects that others residents’ challenging behaviours have on people living in the home. This would enable the organisation to respond positively and advocate for individuals with the intention of further improving services that are provided in the home. We saw that managers and staff have developed Behaviour Support Plans for the two people whose care we reviewed during this visit. We saw that both Plans were reviewed and updated in April 2007. The plans gave staff clear guidance on triggers that may result in challenging behaviours and agreed strategies for reducing and managing these behaviours. We felt that the plans should inform staff how people can best be supported, but there is a need for all staff to be aware of the guidance that is agreed by each resident’s care team. For example, we saw that one person’s multi-agency care team, Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 15 involving health and social care professionals, had agreed the use of a form of restraint to be used with one resident. The recommended hold is intended to reduce the risk of the person harming themselves or other people. The guidance for staff was reviewed recently following concerns that the technique used could result in injury to the service user. During this visit we asked 10 staff to demonstrate the technique that they are expected to use as a last resort. We were concerned that 6 members of staff either did not know about the technique or were using it wrongly. We were concerned that some of these staff were working with the client most likely to need this kind of support and restraint. Managers told us that the use of restraint in the home had been reviewed and new training would be provided for all staff but this has not yet been arranged. The organisation must make sure that all staff working in the home, including bank and agency staff, are aware of agreed care techniques, including restraint. We saw that the organisation has clear guidance for staff on recording significant incidents affecting residents, but these are not always followed by staff working in the home. The form used by staff includes guidance on the details to be recorded when restraint is used but forms sent to the Commission do not consistently include this important information. Earlier in 2007 the Commission was also notified by the local authority of a number of significant incidents that staff working in the home had not reported to the Commission. Although the reporting of incidents has improved, to make sure that residents are cared for safely the provider must make sure that all staff are aware of the procedures for safeguarding people living in the home and the Commission must be informed of any significant incident. We also checked the finance records for three people living in the home. We saw that staff record when residents spend their personal money and receipts are filed whenever money is spent. There is a need to make sure that all staff sign the finance record each time they support residents to spend their money and managers must check and sign the records regularly. Managers must also make sure that staff only spend residents’ money appropriately, it must not be used to pay for staff meals or bedding that should be provided by the home. Elmfield Way, 1-2 DS0000010873.V347861.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets residents’ specific needs. There is a need to make sure that repairs and refurbishment works are completed without excessive delays. EVIDENCE: 1-2 Elmfield Way is a registered care home providing accommodation and personal care for six people with autism and/or challenging behaviours. Kensington Housing Trust owns the property. The home is located off Harrow Road, a busy main road, close to local shops and transport links. Originally built as two separate units, the home has been converted to provide spacious accommodation that is fully accessible to people using wheelchairs. The home has a large, enclosed garden and an excellent summer house that provides additional space for residents to spend time alone or with staff. During this visit we saw all shared parts of the home and one person’s bedroom. Staff told us that each person has his/her own room and they are supported to choose their own furniture and décor. Managers and staff also told us that the shared areas and bathrooms / toilets are used extensively by people living in the home. Some people have challenging behaviours and as a Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 17 result, fixtures and fittings are regularly damaged and need repair. During this visit we discussed a number of issues with managers: • Many parts of the home look uncared for. We saw that some doors and skirting boards are damaged, walls around door frames are cracked, kitchen cupboards are in need of repair or replacement and some redecoration work is needed in some communal areas, bathrooms / toilets and hallways. We saw that the fire door leading from the lounge to the kitchen is damaged and does not close. Staff checked the home’s repairs book and damage to this door does not to have been reported. This is a high risk area and the door must be repaired or replaced. We saw that other fire doors in the home are also propped open and this places residents at risk in the event of a fire. 3 of the 4 toilets in the home cannot be used. We found that two of the seats have been broken and removed and one toilet bowl was broken three weeks before this inspection. The toilet bowl has been completely removed and the shower has also had to be disconnected. Managers told us that a surveyor from the Housing Association had visited to assessed the repairs and refurbishment works that need to be completed, but no date has been agreed for the work to be carried out. The provider must agree with the Housing Association arrangements for the prompt repair of damaged items in the home. All toilets and showers must be available for resident to use at all times and delays of three weeks are not acceptable. • • Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 18 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, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for the people using the service, and is not led by staff requirements. EVIDENCE: Information provided by the Care Services Manager is evidence that 33 of the home’s permanent care staff team have completed their National Vocational Qualification (NVQ) Level 2 or 3 training. 5 other staff are currently completing their NVQ Level 2 or 3. In addition, both Deputy Managers have completed their NVQ Level 3 and the registered Manager is completing the NVQ Level 4. Staff told us that they received induction training when they started work in the home. Staff also told us that they have good access to other training opportunities provided by the organisation. We felt that the levels of training and support available for staff will help to make sure that people living in the home receive good standards of care. We saw that the home’s rota shows that the home is well staffed to meet the high care needs of residents. The rota is planned to provide 1:1 or 2:1 staff support when residents take part in activities in the home and the local community. When we visited there was sufficient staff to make sure that each resident received the support they needed. Staff worked well together and all Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 19 were aware of their responsibilities during their shifts. We saw that all permanent staff working in the home have a Criminal Records Bureau (CRB) check before they start work. This helps to make sure that people are suitable to work safely with vulnerable people. The organisation also employs a ‘bank’ of staff who are used to cover vacancies, sickness etc and we saw that these staff also have a CRB check. A small number of staff are employed from employment agencies. It is recommended that a representative of the organisation asks to see the CRB checks of any agency staff before they start work in the home. The Care Services Manager told us that the organisation has attempted to recruit care staff to reflect the diversity of the resident group, but this has not been successful so far. The Care Services Manager told us that he would continue to work with the organisation’s Human Resources ‘to identify ways of recruiting staff that match service user group culture and ethnicity’ (extract from the provider’s Annual Quality Assurance Assessment). Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The AQAA was returned to us by the date it was requested. All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service. The Manager’s post has been vacant for some months and there is a need to make sure that a permanent manager is appointed as soon as possible. EVIDENCE: Before this inspection, the provider told us that the manager has been on sickness absence for more than two months. The provider agreed with us arrangements to cover the manager’s post temporarily. There is now a need to appoint a permanent manager, as the Care Services Manager told us that the registered manager would not be returning to the home. We felt that the lack of leadership from a qualified and experienced manager in recent months has resulted in a slippage in the care standards provided in the home. Although staff are working very hard to provide good outcomes for people, there is a need to appoint a permanent manager to lead the staff team, raise standards and monitor the implementation of the organisation’s policies and Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 21 procedures. We also checked the record of monitoring visits to the home by representatives of the provider. There is a need to make sure that reports are carried out each month, reports are sent to the home and the Commission and reports must cover all aspects of care in the home. Reports completed by finance or personnel managers do not meet the requirements of the Care Homes Regulations and the provider should review this practice. We saw that standards of record keeping in the home are generally good, but three requirements are made in this report to further improve practice in this area. We saw no health and safety issues during this visit, apart from the need to make sure that fire safety standards are maintained in the home and repairs are carried out promptly. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 22 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 2 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 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 1 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 2 X 3 3 3 3 2 Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 and 5 Requirement Yarrow must make sure that information given to residents and their representatives refers to the Commission for Social Care Inspection and not the National Care Standards Commission. Staff must make sure that they support residents to buy personal items themselves. This will provide residents with choices and opportunities to develop important social skills. Managers must make sure that all staff record details of how they support people on each shift. This will enable staff to make sure that people are receiving the support agreed in their care plan. Staff must do more to support individuals to make complaints about issues that affect them. This would enable the organisation to respond positively and advocate for individuals to improve the services they receive. The organisation must make sure that all staff working in the DS0000010873.V347861.R01.S.doc Timescale for action 31/10/07 2. YA7 16 31/10/07 3. YA12 15 31/10/07 4. YA22 22 31/10/07 5. YA23 13 30/09/07 Elmfield Way, 1-2 Version 5.2 Page 24 6. YA23 37 7. YA23 13 8. YA23 13 9. YA24 23 10. YA24 23 11. YA24 23 home, including bank and agency staff, are aware of agreed care techniques, including restraint. To make sure that residents are cared for safely, the provider must make sure that all staff are aware of the procedures for safeguarding people living in the home and the Commission must be informed of any significant incident. To protect people from possible financial abuse, all staff must sign the finance record each time they support residents to spend their money. Managers must check and countersign the records regularly. Managers must make sure that staff only spend residents’ money appropriately. It must not be used to pay for staff meals or bedding that should be provided by the home. To make sure that the home provides acceptable standards of accommodation for residents, refurbishment and redecoration works must be completed without further delay. To make sure that residents are safe in the event of a fire, the fire door leading from the lounge to the kitchen must be repaired. Fire doors must not be wedged or propped open as this places residents and others at risk in the event of a fire. The provider must agree with the Housing Association arrangements for the prompt repair of damaged items in the home. Toilets and showers must be available for residents to use at all times and delays of three 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 12. YA24 23 31/10/07 Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 25 13. YA24 19 14. YA37 9 15. YA43 26 16. YA43 26 weeks for repairs are not acceptable. To make sure that all staff are safe to work with vulnerable adults, a representative of the organisation should see the Criminal Records Bureau checks of any agency staff before they start work in the home. The provider must appoint a permanent manager to lead the staff team and monitor care standards in the home. The Manager must register with the Commission as soon as possible. Repeat Requirement. Original timescale of 31/01/07 not met. Where finance officers carry out visits on behalf of the organisation, the Manager must make sure that their reports are kept in the home. Repeat Requirement. Original timescale of 31/03/07 not met. Reports completed by finance officers must also include an assessment of other aspects of the care provided. Repeat Requirement. Original timescale of 31/03/07 not met. 31/10/07 30/10/07 30/10/07 30/10/07 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 YA10 Good Practice Recommendations Managers in the organisation should support staff to think about the language they use to describe residents and their behaviours in records kept in the home. This will help to make sure that residents are treated with respect DS0000010873.V347861.R01.S.doc Version 5.2 Page 26 Elmfield Way, 1-2 2. YA11 by staff at all times. Managers should make sure that important information about individual residents is reviewed regularly. Elmfield Way, 1-2 DS0000010873.V347861.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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