Inspection on 30/09/09 for Essex Park 49

This inspection was carried out on 30th September 2009.

CQC found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Essex Park 49 21/10/08

Essex Park 49 26/10/07

Essex Park 49 04/07/06

Essex Park 49 02/11/05

Essex Park 49 17/05/05

Essex Park 49 02/11/04

Essex Park 49 03/06/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Essex Park 49 Finchley London N3 1ND Lead Inspector Tom McKervey Key Unannounced Inspection 30th September 2009 09:00 Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Essex Park 49 Address Finchley London N3 1ND 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 8346 3860 020 8346 3860 essexpk@walsingham.com www.walsingham.com Walsingham Sally Jane Green Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2008 Brief Description of the Service: Essex Park is a home for six adults of either gender who have learning disabilities. The home is owned and managed by Walsingham Community Homes, an organisation that provides special needs housing in other parts of the U.K. The home is a detached, two storey building, located in a pleasant residential area of Finchley in North London. It is close to shops and many other amenities. The residents’ bedrooms are located on the ground and first floor. The communal lounge, dining rooms and kitchen are located on the ground floor. There is a large attractive garden at the rear of the property which is accessible to all residents. A car is provided for the purpose of taking the residents out on various shopping trips and excursions. Information about the home including the service users’ guide and the CSCI inspection reports are available from the home by contacting the provider. The fees for the service range from £1065 to £1236 per week, depending on the assessed needs of the residents. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over a period of five and a half hours. The visit was part of the Commission’s inspection programme to check compliance with the key standards and to look at how the home was progressing in meeting requirements from the last inspection, which took place on the 21st of October 2008. We found that the manager had left the home in August 2009. We were concerned that the Commission had not been informed about this, which is a significant event and should have been communicated to us under the regulations. However, the operations manager responsible for Essex Park, contacted the inspector after the inspection and apologised for this oversight. Written confirmation of the new management arrangements was also received later, which is that Walsingham installed a “crisis management team” consisting of a manager and two deputies from other Walsingham homes for a period of six months. We were informed that this strategy is intended to improve practice and administration in the home which they deemed had been unsatisfactory. The new acting manager was not present during the inspection, but the deputy manager was there and the inspector wishes to thank her and the staff for affording him every assistance and cooperation with the inspection process. The Commission received the home’s Annual Quality Assurance Audit, (AQAA), which is a self-assessment of the service and was completed by the registered manager before she left the home.. This document is required to be sent to us annually to provide information about how well outcomes are being met for people who live in the home. It also gives some numerical information about the service. The information in the AQAA was comprehensive and provided appropriate details about the service. We also sent out surveys to residents and staff prior to the inspection. We received responses to the surveys but it was apparent that residents’ surveys were completed by staff on their behalf. Two members of staff returned their own surveys. Reference is made to the AQAA and the surveys in various sections of this report, as evidence of some of our findings. The inspection process included visiting all areas of the home, reading residents’ case files and other records, and talking to residents who were verbal about their experiences of living in the home. Staff were also interviewed about their work and how they were supported. At the end of the inspection, we provided feedback about our findings to the deputy manager. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Walsingham senior managers must inform the Commission in a timely manner when significant events take place, in this case specifically, when a registered manager leaves the home. Care plans need to be improved and updated to accurately reflect residents’ current needs and who their key worker is. We have drawn the management’s attention to the need for improvements for the comfort and appearance of two specific residents by providing lampshades and replacing handles on their bedroom furniture. We have also advised the staff to seek advice from the diabetic nurse about the normal range of blood glucose. This will help staff if they get abnormal readings when they test the resident with diabetes. The home should seek advice from the local authority fire safety officer about the status of the ground floor bedroom doors. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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 Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 &3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including looking at residents’ records. Potential users of this service can be confident that their needs will be thoroughly assessed to ensure that the home is suitable to meet their needs. EVIDENCE: At the time of this inspection, there were five people living in the home and there was one long-term vacancy. We were informed that several people had been referred to the home but after assessing them, it was decided that the home was not suitable for their needs. The most recent admission to the home was in 1999, so the current residents have lived together for a long time. Two residents’ case files were examined in detail. Pre-admission assessments were comprehensive and covered all aspects of the person’s needs. This included for example, health, mobility, sleep patterns and eating. People’s sexuality was also assessed in relation to dress and appearance. One resident’s mobility has deteriorated following a hip fracture. A special chair was provided and we noted that this resident has a ground floor bedroom. This ensures that the home continues to meet this person’s needs. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 10 There was evidence that the staff review residents’ needs every six months. If a resident attends a day centre, the day centre staffs’ views are also included in the resident’s case file. We noted that annual care reviews were also carried out by local authority care managers. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, looking at care plans and records. EVIDENCE: We looked at two care plans in detail. There is an intent by staff to make the care plans person-centred by writing in the first person, for example; “I like to be called “X”. Unfortunately however, the large folders containing the “care plans” were full of outdated information; for example, key workers were identified who no longer worked at the home and peoples’ current ages were not accurate. A resident has a mobility problem, which is not properly documented in their care plan. (We acknowledge that reference is made to this in daily records etc) Much of the information in the care plan folder was several years old and we were unable to determine which care plan staff were following. We recommend Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 12 that all old documents be archived and only current information is used to form care plans. The case files contain a “personal safety assessment”. This document identifies areas of risk, for example; lack of road sense and incidents that might occur when travelling in the home’s vehicle. The risk assessments were accompanied by guidelines for staff about what to do if an incident occurs and what action to take to support the person. This ensures that people are not prevented from enjoying various activities in the community. The majority of the residents are not able to communicate verbally, but we were able to converse with one person who told us they were well treated and that the staff were very caring. Our observations of how the staff interacted with the residents confirmed this. We were informed that residents are consulted about the décor of their rooms. We saw minutes of residents’ meetings which indicated that they are involved in how the home is run. We were informed that the weekly menu is decided at these meetings in accordance with the residents’ preferences. The AQAA states; “Existing staff have been working in the service for many years and do have extended knowledge of the service users needs”. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: All these standards were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including observation and examining residents’ records. EVIDENCE: All the people who live at the home attend a day centre or college on various days of the week. On the days when residents are at home, they have a programme including doing their laundry, cleaning their room and going shopping. Residents who attend colleges are awarded certificates of achievement, which are kept in the home. We observed staff knocking on residents’ doors before entering and staff were respectful in how they addressed the residents. The home has its own vehicle, but staff also support the residents to use public transport as much as possible. The manager stated in the AQAA; “Service users use the local facilities and use the public transport. A couple of service users are aware of the local facilities Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 14 as they are able to show you the way to the local shop and the GP surgery but they do need support further a field in the local community ie Churches of various denominations. Day centre changes have been made to meet individuals changing needs and preferences. Activities include, bowling, swimming, cinema, day trips into London”. No holidays had taken place this year, but we were informed that this is currently being planned. Some residents have no known relatives. We saw evidence in the visitors’ book that some families do visit the home regularly. We saw individual daily records which showed a good range of outings such as going to shops, cafés and pubs. The residents are supported to make use of the local amenities, such as bowling and swimming. At the weekly meetings, the staff support the residents to choose the menus which showed a good variety of meals that were well balanced and nutritious. The fridges and freezers contained food that was clearly labelled with expiry dates and was stored safely. We noted that fresh fruit was available in the kitchen. All staff have attended training in food hygiene. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that they will be treated with dignity and respect in their personal care. Staff ensure that residents receive a full range of health services to safeguard their wellbeing. EVIDENCE: The case files we looked at, provided information about the person’s medical history and how they prefer to be supported with their personal care. At the time of the inspection, all the residents were said to be in good general health and they were clean and appropriately dressed for the time of the year. All appointments with health professionals, eg the GP, out-patient clinics etc, were recorded in individual files. We witnessed staff arranging an x-ray for a resident who recently had a suspected injury after a seizure the previous night. This had been reported to the G.P but there was some delay in the doctor visiting, so the staff decided to Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 16 take the resident to the A&E department where a fracture was diagnosed. This justified the staffs’ concerns and confirmed they had taken appropriate action. We noted that there was comprehensive information in the home about swine flu and the company has a strategy to deal with an outbreak of this disease. One resident who has mobility problems has been provided with a special chair and a walking frame, following an assessment by an occupational therapist. Each person’s weight is recorded monthly and charts are kept to record seizures for those who have epilepsy. A resident who is diabetic, has their blood monitored by staff each week, however, the information available to staff did not identify the normal range of blood glucose. We recommend that the diabetic nurse is asked to provide advice about this. None of the residents are able to administer their own medicines. We saw records of staffs’ signatures who are trained and authorised to administer medication. The home informed the Commission the last time when a medication error occurred, as a result of which they implemented improved procedures, including better monitoring. We observed a member of staff checking that the administration of medicines records – (MAR’s) had been correctly completed by the previous shift. This is good practice because it detects any errors quickly. The consultant psychiatrist reviews each person’s medication at out-patient appointments. The inspector examined the medication stock and found that it was stored safely and securely. There were no gaps in the MAR sheets. The amount of medication supplied by, and returned to the pharmacy, was recorded. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including looking at complaints records and talking to residents and staff. In order for residents and relatives to be confident that complaints are addressed appropriately, there needs to be more accurate records kept. However, there are good systems in place to protect residents from abuse. EVIDENCE: At the time of the inspection, the residents appeared happy and looked well cared for. The atmosphere in the home was relaxed and friendly. The home has a procedure about how to deal with complaints. There is also a pictorial version available for residents to help them understand this. The last complaint received was apparently in January 2009. We saw a copy of a letter from the manager in response to this. However, there was no record of what the complaint was about, or when the complaint was made, so it was not possible to ascertain if this was dealt with within a reasonable time period. We have made a requirement to address this. With the exception of one person, staff records showed that all the staff have been trained in the protection of vulnerable adults form abuse, and there is a policy in place about whistle blowing if staff suspect abuse. In our discussions with individual staff, they demonstrated a good knowledge and awareness of issues of abuse and how to report any concerns. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 18 The person in charge informed us that no residents are subject to restraint under the Mental Health Capacity Act. The AQQA identifies and area where the home needs to do better as; “To have staff trained in deprivation of liberty safeguards. Service user involvement with computer finances”. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visiting all areas of the home. People who live in the home can be confident that their environment is about to be greatly improved by major refurbishment. However, some minor improvements are needed in some specific residents’ bedrooms to improve their comfort. EVIDENCE: All areas of the home, including three residents’ bedrooms were inspected. We were pleased to see evidence that major refurbishment of the home was about to start, including redecoration of bedrooms and replacement of carpets throughout the property. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 20 The bedrooms contained personal items, including family photographs and mementoes. The AQAA informs us that; “There has been a lot of maintenance completed in the last year ie new heating system, bathrooms decorated etc.” However, we identified additional issues that need to be addressed as follows; • In an upstairs bedroom, there were no lampshades and handles were missing from a chest of drawers. • In a ground floor bedroom, knobs were missing from the resident’s dresser. • We noted that there were doors to the outside which appeared to be fire exits because they had break-glass mechanisms on the doors. We recommend that the home seeks advice from the local authority fire safety officer about the status of these doors as fire exits. • There were no plugs in some of the sinks in bedrooms and toilets. (This was also a finding at the last inspection). We noted that all other requirements about repair and maintenance issues at the last inspection had been met. The lounge and dining room were comfortably furnished and the large garden was attractive and well maintained. The home smelled fresh and there were no offensive odours. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including speaking to staff and examining their records. EVIDENCE: We looked at the staff rota, which showed that there are normally three staff on the morning shift, two in the evening and one awake at night. The rota matched those staff who were present during the inspection.The manager is not included in these numbers. We were informed that currently, there are three staff vacancies which are covered by agency staff. These agency staff have worked for a long time in the home and know the residents well. At the time of the inspection, the home was actively recruiting to fill the vacancies. It is stated in the AQAA; “Most staff have the required health and social care qualification to meet their job requirements and all staff receive support through supervisions and monthly appraisal monitoring. We ensure that new agency staff are inducted into the service and that the agencies have carried out all the relevant checks. Mandatory training is updated yearly and any other training relevant to meet legislation and the service needs”. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 22 The inspector observed the staff handover at which the progress of all the residents was discussed. A shift planner is used for allocating various tasks and the diary was used as a reminder for residents’ appointments etc. We saw certificates of training in relevant subjects in the staff records and in the surveys that staff sent back to us, they expressed satisfaction about the amount of training available to them. One new member of staff has been employed since the last inspection. Recruitment records are held at Walsingham’s head office and are not available for inspection in the home. This arrangement has been agreed with the Commission. However, the Commission’s performance relations manager will examine these records in due course. The manager assures us in the AQAA, that proper checks are carried out when new staff are recruited, including CRB clearances and references. There were records of regular supervision in staffs’ files. The staff who were spoken to said they found this to be a positive experience which afforded them an opportunity to discuss their work with their line manager. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that the current management arrangements will lead to an improvement in the service. The Walsingham organisation must ensure that the Commission is informed promptly when a manager leaves the home. Residents are supported to air their views at meetings, which enables them to have a say in how the home is run and there are good systems in place to safeguard residents’ health and safety. EVIDENCE: Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 24 When we visited the home, we found that the registered manager had left and was now managing another Walsingham home. A “crisis management team”, consisting of a manager and two deputies from other homes had been put in to run Essex Park. The Commission was concerned that we had not been informed when the manager left. Subsequent to this inspection, the operations manager contacted us and apologised. She stated that there were concerns about shortcomings in the management of the home and sent us details of Walsingham’s strategy to address this, which is expected to last for about six months. A deputy manager was on duty and assisted with the inspection process. The deputy confirmed that there were shortfalls in how the home had been run, but showed evidence of a commitment to improvement in practice and administration procedures. The staff we spoke to, were generally in favour of the management arrangements and acknowledged that improvements were needed. The staff said their morale had not been adversely affected by the changes and felt the new managers were constructive and supported them well. They also said that the residents had not been affected and did not seem concerned. We were told that senior managers held a meeting with staff and residents in August to inform them about how the home was to be managed. We saw evidence that monthly meetings take place between residents and staff, which showed that residents are supported to have an input into how the home is managed and they are supported to make their views known. We were told that an audit of residents’ and stakeholders views had been carried out in the past year, but at the inspection, the results of this audit were not available. There were good health and safety procedures, including regular testing of temperatures of the fridges and freezers and the area where the medicines are kept. We saw satisfactory service records for the gas boiler and portable electrical appliances. A fire risk assessment has been carried out of the building, however, as we noted under the Environmental Standards in this report, we recommend an assessment of the two ground floor bedrooms is carried out by the Fire Safety Officer. The fire alarms are tested weekly and regular fire drills are carried out. There is a valid insurance certificate on display. Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X X 3 X Version 5.3 Page 26 Essex Park 49 DS0000010437.V377957.R01.S.doc Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15, Schedule 3(1)(b) 16 (2)(c) 16(2)(c) Requirement Timescale for action 31/10/09 2. 3. YA25 YA25 Residents’ care plans must be updated to ensure that they are current and appropriate to meet residents’ needs. Lampshades must be replaced in 31/10/09 those rooms where these are missing. All washbasins in residents’ 31/10/09 bedrooms must be fitted with plugs. This requirement is restated. The previous timescale was 01/11/08 In two specific bedrooms, drawer 31/10/09 handles must be replaced. 4. YA25 16(2)(c) 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 YA19 Good Practice Recommendations We recommend that the diabetic nurse is asked to provide advice about the normal range of blood glucose to guide staff in the care of a resident with diabetes. DS0000010437.V377957.R01.S.doc Version 5.3 Page 27 Essex Park 49 2. YA42 We recommend that the home seeks advice from the local authority fire safety officer about the status of the ground floor bedroom doors. Old records and documents should be archived so that it is easier to understand which ones are currently being used. 3. YA41 Essex Park 49 DS0000010437.V377957.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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