Inspection on 31/05/07 for Faraday House

This inspection was carried out on 31st May 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faraday House 18/03/09

Faraday House 04/06/08

Faraday House 06/04/06

Faraday House 04/10/05

Faraday House 06/04/05

Faraday House 09/09/04

Faraday House 30/04/04

Faraday House 15/01/04

Faraday House 07/07/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Faraday House 16 Faraday Road Acton London W3 6JB Lead Inspector Sarah Middleton Key Unannounced Inspection 31st May 2007 09:30 Faraday House DS0000027704.V335197.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 Faraday House DS0000027704.V335197.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. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faraday House Address 16 Faraday Road Acton London W3 6JB Tel: 0208 248 4599 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) Mrs Solony Gopal Mr Runjith Gopal Mrs Solony Gopal Mr Runjith Gopal Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents to be accommodated on ground and first floor only. Date of last inspection 6th April 2006 Brief Description of the Service: Faraday House is a home for three service users with mental health needs. The home is situated in a residential area and in close proximity to Acton town centre, a mainline railway station and major roads into London. The Proprietors/ Registered Managers and their immediate family reside at the home, occupying part of the ground floor and top floor of the building. Service users are accommodated in single bedrooms. There is a small lounge, bathroom and separate toilet for service users on the first floor. There is a small garden to the rear of the home. The home offers twenty-four hour support and care to the service users, accessing local resources such as the Community Mental Health Team. Other community amenities, such as shops and libraries are also available near to the home. Fees range from £ 520-£560 per resident per week. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previously term “service user” has now been replaced by the term resident and refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.30am- 4.50pm. The Inspector met with three residents and three members of staff, which included the Registered Manager. Samples of care plans, a staff employment file and maintenance records were viewed. Three residents completed postal surveys. The Registered Manager, who is also the Registered Provider, along with her husband, recently purchased a large house next door to the current registered care home. It is the intention for this new home to also become a registered care home for up to six adults with mental health needs. The Registered Provider/Manager has not decided if the new home will be a separate registered care home or will be amalgamated into the existing care home. The home is aware that the existing staff team will need to expand to support any additional residents. Equality and diversity issues are acknowledged by the home and where identified have been included into the inspection report. Two of the three previous requirements were met and eleven new requirements were made at this inspection. All of the key Standards were assessed at this inspection visit. What the service does well: The home is small with the Registered Manager and her family working as part of the staff team. The staff team live in the home and have detailed knowledge about the needs of the residents. At times staff are able to provide one to one support to the residents. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans did not demonstrate how residents are included in the development of their care plans. Privacy and confidentiality must be respected at all times. Information regarding residents must not be discussed in front of other residents. The home must consider and evidence the reasons for restricting the rights residents have to freedom and privacy, for example not providing a bedroom or front door key. When residents’ needs change, suitable assessments and adaptations must be provided. Regular medication spot checks must be carried out in order to monitor the medication systems and to identify any medication errors. As there are occasions when visitors stay over in the home. The home’s policy and procedure on adult abuse must include details regarding how the home safeguards the residents in their own home. The environment must be well maintained in order to provide a welcoming home for the residents. To ensure the staff team is competent and well informed an induction programme for new members of staff must be developed. The training programme must be detailed and able to offer staff the information and skills they need to support the residents appropriately. The home must regularly consult with residents and obtain their views about the home. In order for improvements to be recognised and shortfalls to be addressed, regular monitoring and reviewing of the resident’s needs must take place. A report evidencing the work the home has carried out needs to be developed and made available for inspection and for residents. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 7 The Portable Appliance Test must be up to date and evidence of this must be available for inspection. 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. Faraday House DS0000027704.V335197.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 Faraday House DS0000027704.V335197.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: There have been no new admissions into the home for several years. The Inspector viewed the home’s pre-admission assessment. This covered a wide range of areas, such as, background, health needs, mental health needs and daily living skills. The home was aware of the importance in obtaining as much information from the referrer, the resident and by carrying out an initial assessment. The Inspector was satisfied that the home has a pre-admission procedure in place. Faraday House DS0000027704.V335197.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, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans did not evidence if residents are fully consulted and able to contribute to their care plans. Residents are supported to make decisions about their daily lives. The risk assessments in place detailed potential hazards, without restricting the residents’ right to an independent life. Private and confidential information had been shared amongst residents. Residents need to know information about them will not be shared with others. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Inspector viewed a sample of care plans. These have been developed and worked on to clearly indicate residents’ needs and how these are to be met. Care plans were individual and looked at a range of areas, such as, physical needs, handling finances and emotional needs. Monthly summaries are completed and every six months the main care plan is updated. There was no evidence regarding how the home consults with and supports residents to contribute to their own care plan. The Inspector discussed with the staff team ways to enable residents to contribute to the development of their care plan and a re-stated requirement was made for this to be addressed. Daily records were also viewed and these contained relevant information about each resident. Meetings are held with the residents to discuss any issues they have or comments they wish to make. See Standard 10 regarding the information discussed at some of these meetings. Residents are encouraged to make decisions about their daily lives. One resident spoken with said he was not allowed to go out without staff, whilst another said they could come and go, within reason. Staff informed the Inspector that each resident has different capabilities regarding going out alone. None of the residents have advocates, although one resident has a keyworker from a local mental health resource centre, who visits on a regular basis. A sample of risk assessments were viewed and found to be comprehensive. These documents contained information on various identified risks. Risk assessments are updated every six months or when residents’ needs have changed. Staff could also consider the possibilities of including residents’ views when completing a risk assessment. The Inspector read the minutes from residents meetings and it was noted that on several occasions staff have spoken about private and confidential information about a resident in front of another resident. This was discussed with staff as the Inspector felt such matters must be talked with the relevant resident in private. Where behaviours and issues affect all residents, discussions must be held in a sensitive manner. The need to consider what is necessary to disclose to others must be paramount at all times. A requirement was made for privacy to be upheld for all residents. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities that meet their individual preferences. Residents are encouraged to maintain social relationships. The home needs to consider and record when restrictions have been put in place, as there was no evidence to indicate why residents did not have a key to their bedroom or to the front door. Residents receive a well balanced diet that meets their individual choices and health needs. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home continues to identify activities for residents, although there are some days where residents might not wish to engage in any meaningful activity. There has been progress regarding the residents accessing the local mental health centre. Here they can socialise and take part in the activities provided there. One resident now attends the centre twice a week and sees a keyworker, who has been assigned to him. Staff commented on how this particular resident, who in the past did not regularly interact with others, now has developed a positive relationship with the keyworker. Another resident informed the Inspector that he likes to go out alone and visit the local library. He is also keen to attend College. Staff record any significant activities in order to review activities that are taking place. There are times when residents choose to watch television or read. The home should continue to explore options for residents to ensure they all have a varied and stimulating life. Occasional day trips are offered to the residents and it is hoped with the warmer weather that these trips will occur once again. Family contact is irregular. One resident is unaware of his family contact details and the Inspector discussed with the staff team the possible options in locating his family. Staff will look into supporting this resident to make contact again with his family. Another resident recently initiated contact with his sister and staff told the Inspector that they saw this as a positive step. Residents would be able to see friends or family both in the home or outside in the community. The Inspector was informed that the one resident who goes out independently, no longer has a front door key as he had lost it. This resident, due to specific health needs, also no longer has a key to his bedroom door. The Inspector acknowledged the difficulties in balancing the risk to the home and others, along with the residents’ right to independence and choice. The Inspector also spoke with another resident who also said he did not have a key to his bedroom door. The Inspector spoke with staff and made a requirement for the home to clearly record why a resident is unable to hold their own key to the front and/or bedroom door. Residents receive their own personal mail and usually residents then pass their mail on to staff. Staff were observed to interact with residents and not exclusively with each other. Staff consult with residents about the meal provision to ensure individual preferences are provided. The home records alternative meals, should a resident choose to eat something else. Staff continue to encourage residents to make their own lunch twice a week. The Inspector discussed with staff the benefit of encouraging residents to make more meals, for example their own breakfasts. Staff acknowledged the benefits in supporting residents to develop further daily living skills. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 14 Those residents with diabetes have their diets monitored closely. The Inspector briefly viewed lunchtime and found this to be relaxed and unhurried. Those residents asked commented favourably on the meals provided in the home. The Inspector viewed the kitchen and found it to be clean and tidy. Food opened in the fridge was covered and dated and fresh produce was available for residents’. Fridge and freezer temperatures had been taken and were within an appropriate range. Faraday House DS0000027704.V335197.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 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had not provided adaptations for the residents’ changing needs. The residents and staff safety would not be compromised if suitable equipment were provided. Residents’ health needs are recorded and were being met. Medication procedures did not include carrying out regular spot checks on the medication, thus errors could occur undetected. EVIDENCE: Residents’ personal care needs are met through a variety of ways. One resident has mobility issues and staff need to assist him to get out of the bath safely. Staff informed the Inspector that a referral for an Occupational Therapist assessment had not been requested. Therefore currently the home did not have any adaptations to assist the resident when bathing. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 16 In addition, the staff team were not trained in safe moving and handling techniques. The Inspector made a requirement for the home to make a referral to the Occupational Therapist and to support the resident in a safe manner. Careful consideration needs to be given when resident’s needs change as both the resident and staff team could be placed at risk. All residents have a GP and recently staff referred a resident for Physiotherapy. Medical appointments are recorded separately in order for staff to review appointments and any treatment planned. One resident chooses to go to most health appointments alone. Staff stated they are kept aware of any significant outcomes following on from these appointments. Regular weight checks are also carried out to monitor any sudden changes. The Inspector viewed the medication systems. Medication was stored in safe and secure storage. One member of staff usually administers the medication. The majority of medication is provided in blistered packs. Medication Administration Records viewed had been completed correctly. The residents living in the home do not self-medicate and the home did not have any controlled drugs. The home did not carry out spot checks on the loose medication. The Inspector made a requirement for regular checks to occur and evidence must be available of these spot checks. Faraday House DS0000027704.V335197.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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ views are listened to and comments are acted on. The home did not have up to date polices and procedures regarding protecting the residents from abuse. EVIDENCE: The home has a complaints policy that is freely available in the home and the policy is kept in each resident’s bedroom. Those residents asked stated they would talk to the staff team if they had any concerns. The Inspector viewed a general informal complaints book where concerns raised by residents are recorded. The home has a detailed complaints document that would be used should a formal complaint be raised. The home and the CSCI have not received any complaints. Staff received training on adult abuse in 2006, the Inspector advised staff to keep this training up to date. The home had visitors at the time of the inspection and the Inspector was informed that throughout the year for usually no longer than a week, visitors stay from abroad. It is strongly recommended for the staff team to ensure they do everything to safeguard the residents from potential abuse. In addition, the home should consider that residents might not want visitors staying in their home. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 18 The Inspector made a requirement for the home to update the policies and procedures on safeguarding the residents, to include information on visitors staying in the home. In addition, the Inspector made a recommendation for the home to ensure they have the current Local Authority’s policies and procedures and the Department of Health’s No Secrets document. The Inspector viewed a sample of residents’ personal monies. The home collects residents’ money from the post office, usually with the resident. Receipts are kept and financial transactions are recorded. The samples of money counted were found to be correct. Staff informed the Inspector that some residents have limited finances and so cannot take part in some activities such as holidays and frequent trips out. Where possible the home supports residents to budget their money. One resident, due to his particular needs, has restricted access to his money each day. This had been recorded on his care plan and staff told the Inspector that since this practice had been introduced the resident was benefiting from having more positive health. The Inspector spoke with this resident who spoke about receiving small amounts of money. He was not entirely happy with the amount of money he now has each day, but was aware that staff had spoken with him about this. The Inspector was satisfied that in the interests of the resident, this restriction was necessary. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has maintenance issues that need to be addressed in order to provide residents with a safe and welcoming place to live in. Overall the home was clean and free from odours. EVIDENCE: The Inspector carried out a tour of the home and noticed areas that needed attention. •The ground floor bathroom had some floor tiles cracked and in general the bathroom needed attention. •On the first floor the seal around the bathroom was mouldy and needed replacing. • Bedroom five, the carpet was not laying flat on the floor and this needs rectifying. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 20 The staff explained that residents rarely use the ground floor bathroom. The Inspector discussed with staff that although they live in the home it is a registered care home for the residents who have access to most areas, including the ground floor bathroom that is situated just off from the kitchen. As noted in Standard 18, the home needs to consider areas where adaptations might be needed for the benefit of the residents. The Inspector spoke with staff about the benefit in developing a maintenance programme in order to identify where major maintenance work will be needed. This will be important to develop if the home is to expand. Staff clean the home with some input from residents. Residents’ laundry is done outside of the home at the local launderette. The home was clean and tidy at the time of the inspection. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team support the residents. Robust recruitment procedures are in place to safeguard residents. The training and induction programme for staff fails to fully meet the needs of the residents. EVIDENCE: As highlighted earlier the staff team is small and the three members of staff are in the process of obtaining an NVQ. One member of staff has just completed NVQ level 2. The Inspector saw staff interact positively with residents throughout the inspection. Staff are available for residents to seek support or advice day and night. As the staff team have known the residents for some years they have an awareness of the residents’ needs. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 22 Staff have worked closely with other external professionals when seeking to support the residents. One resident has specific issues that affect his health and staff had been concerned about his placement. After consultations and meetings with the relevant professionals, the staff team, along with the resident, made some adjustments in the care they provided. Often residents receive one to one support to take part in activities either in or out of the home. As mentioned in the summary, the staff team live with the residents. This arrangement is rare and can pose difficulties, as there has to be a balance for the residents and staff. The staff team meet on a regular basis and each member of staff is in charge of certain areas of the home. The home has not employed any new members of staff since the last inspection. The Inspector viewed a staff employment file and this contained all the necessary information. All members of staff have Criminal Record Bureau Checks. The Inspector spoke with staff regarding the need to ensure robust recruitment checks are in place should the staff team increase in size. The home currently has no structured induction programme in place for new members of staff. The Inspector stressed the importance of having a clear induction programme for any new member of staff so that they are aware of how to work in the home. A requirement was made for an induction programme to be developed and available for inspection. The home continues to explore ways to obtain appropriate training. Some training is accessed through a local registered nursing home and staff attend training days at this home. The Inspector suggested to the Registered Manager that details on the trainers are obtained so that she can be sure the trainers are qualified and experienced to provide suitable training to the staff team. Staff had not attended training on moving and handling, infection control or fire awareness. A requirement was made for mandatory training to be provided and refresher training made available for all members of staff. The Inspector spoke with the staff team about the new Mental Capacity Act 2005. It was strongly recommended for the staff team to obtain information on this act and to identify training. It is important for the staff team to be aware of the impact this legislation might have on the residents and how staff support the residents. Faraday House DS0000027704.V335197.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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well managed home. The home had not obtained the views of the residents about the home. Systems were not in place to evidence how the home monitors and updates the care provided in the home. The welfare of the residents would be safeguarded if health and safety records were kept up to date. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager is also the Registered Provider and both her and her husband have owned and managed the home for many years. The Inspector was aware that the husband of the Registered Manager is looking to apply to become the Registered Manager. The current Registered Manager has obtained an NVQ level 2 and her husband is to enrol to study for the Registered Manager’s Award in 2007. The Inspector discussed with the staff team the importance for the Registered Manager to obtain a management qualification. The home does not have in place a system to review the quality of care offered to the residents. The quality assurance policy was not available for inspection. The Inspector advised that this must be developed and updated to reflect how the home monitors and reviews the care being provided. The Inspector was shown a quality assurance report that was two years out of date. Since then there have been no attempts to evidence the work and improvements the home has been doing or the future aims and objectives of the home. A requirement was made for procedures to be put in place and a quality assurance report made available for inspection and residents. In addition, the home had not obtained the views of the residents for some time. A requirement was made for this shortfall to be addressed. Discussions took place with the staff team about the need to develop continuous reviews of the home and to assess areas working well and areas needing attention. Action taken by staff should be proactive and not reactive. The staff team acknowledged there is outstanding work to be done to address the shortfalls identified in this inspection. The Inspector viewed a sample of maintenance records. The Gas Safety Record was up to date. The Portable Appliance test was not available and a requirement was made for this to be up to date and available for inspection. The Inspector spoke with the staff team about the benefits in having paperwork and maintenance records stored in the same area so that records are easy to locate. The Inspector viewed the fire risk assessment and found this to be satisfactory. A recommendation was made for the home to arrange a visit from the local fire officer, as new fire Regulations were introduced in 2006. Furthermore a recommendation was made for individual fire risk assessments to be carried out on each resident to assess their capability to respond effectively to a fire. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x 2 x x 2 x Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 26 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(1)-(2)(c) Requirement Timescale for action 31/07/07 2. YA10 3. YA16 4. YA18 5. YA20 Care plans must evidence that residents have been consulted about their care plans and where able to, or agreeable to, their opinions have been included into the care plan. (Previous timescale 29/12/06 not met). 12(4)(a) The Registered Person shall ensure that the home is conducted in a manner that respects the privacy and dignity of the residents. 12(3)(4)(a) Evidence must be available to demonstrate why restrictions have been placed on a resident, such as not providing a bedroom key or front door key. 13(5)23(2)(n) Suitable adaptations and equipment must be identified and provided in order to meet the changing needs of the residents. 13(2) In order to safeguard the residents, regular medication spot checks must be carried out and evidenced. 01/06/07 30/06/07 31/07/07 01/06/07 Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 27 6. YA23 13(6) 7. YA24 23(2)(b)(d) 8. YA35 18(1)(c)(i) 9. YA35 18(1)(a)(c)(i) 10. YA39 24(1)(2) 11. YA39 24(3) 12. YA42 13(4)(a) To protect residents the home’s policy on adult abuse must be updated to include information on visitors that stay in the home for short periods of time. For the benefit of the residents the environmental standards of the home must be well maintained. In order for new staff to appropriately support the residents, a structured induction programme must be developed. In order to meet the residents’ needs staff must receive training for the work they are to perform. Residents would benefit from the Registered Person establishing a system for reviewing and improving the quality of care provided in the home. A report of such a review must be available for inspection and for residents. In order to provide the care and service the residents want, residents views need to be sought, considered and acted upon. To safeguard residents, the Portable Appliance test must be up to date and evidence must be available to demonstrate this has been completed. 30/06/07 31/08/07 31/07/07 28/09/07 31/10/07 31/10/07 30/06/07 Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA22 YA23 YA35 YA42 YA42 Good Practice Recommendations It is recommended for the home to obtain the Local Authority’s current policies and procedures on adult abuse. It is strongly recommended for the home to consider safeguarding the residents when visitors are staying in the home. It is strongly recommended for the home to obtain information and training on the Mental Capacity Act 2005. It is recommended for the home to arrange a visit from the local fire officer. It is recommended for the home to complete a fire capability risk assessment regarding each resident. Faraday House DS0000027704.V335197.R01.S.doc Version 5.2 Page 29 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 Faraday House DS0000027704.V335197.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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