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Inspection on 06/04/06 for Faraday House

Also see our care home review for Faraday House for more information

This inspection was carried out on 6th April 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service continues to offer the service users a stable, calm and pleasant home to live in. The staff team is small and has been the same since the service users moved into the home, enabling service users and staff to build on a trusting relationship. The staff team are keen to learn and acquire new skills to ensure they are meeting the needs of the service users.

What has improved since the last inspection?

The home has made attempts to identify more activities for service users and to encourage some to become more independent and to access local community facilities. The Inspector recognises the difficulties there can be when trying to motivate service users with mental health needs and has seen over the past year a slow improvement with how staff support the service users. There is still scope for further developments and the Inspector is confident that the staff team will seek additional activities and promote day trips in order to provide a varied life for the service users. Food that is opened or prepared now has dates written on it to ensure service users welfare is protected. Medication administration records had been completed correctly and all medication systems were robust. The home no longer assists service users financially, by giving them a loan. The staff team plan ahead to ensure there is always money available for service users from their personal accounts. Staff now have a training programme, which ensures all courses attended are documented and any future training needs are recorded and met. Staff have also received training and information on mental health and alcoholism to enable staff to have up to date skills. The home has made steps to devise a quality assurance system. This enables staff to examine service users opinions, look at areas needing work to meet standards and areas that the home feels are working well. The home should provide clear evidence of how they have reviewed the way the home operates and use this tool to continuously assess how well the home meets service users needs. Finally the home had ensured that cleaning products are stored in a secure and locked cupboard.

What the care home could do better:

Care plans have greatly improved but all must be consistent and demonstrate service users individual health needs and how these are to be met. Any support or encouragement needed for service users must be documented to ensure staff work in the same way. Risk assessments must be completed on any activity or behaviour relevant to a service user. These must be detailed and reviewed on a regular basis to ensure the home has considered all possibilities and sought to minimise any potential identified risk to the service user or others. The Inspector was encouraged to see the home has moved forward in promoting more independence for all the service users, however before such steps are decided the appropriate risks must be fully contemplated and recorded to safeguard all concerned.The health and safety of service users must be paramount at all times and therefore water temperatures must be taken and recorded in all areas of the home where service users access.

CARE HOME ADULTS 18-65 Faraday House 16 Faraday Road Acton London W3 6JB Lead Inspector Sarah Middleton Unannounced Inspection 6th April 2006 09.25 Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 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.V286802.R01.S.doc Version 5.1 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.V286802.R01.S.doc Version 5.1 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 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.V286802.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents to be accommodated on ground and first floor only. Date of last inspection 4th October 2005 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. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of just over five hours, 9.25am-2.30pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service user plans, staff files and maintenance records. Two service users and two members of staff were spoken with as part of the inspection. There were no visitors at the time of the inspection. The staff team comprises of the Registered Provider, Registered Manager and their son. The Registered Provider, Mr Sunjith Gopal, assisted with most of the inspection, he is not the Registered Manager, his wife is, however he usually takes the lead when an inspection takes place. The home is considering making an application for a major variation to change the living room, currently used by staff, into a fourth bedroom to accommodate a fourth service user. The Inspector discussed the impact this would have on the home as the current living room on the first floor would not be sufficient in size to accommodate four service users. In addition the staffing levels would need to be reviewed should the number of service users increase. An additional visit on the 19/01/06 was conducted for the purposes of following up the requirements from the previous inspection report and as part of the ongoing monitoring of the home. All of the previous eight requirements were met and three new requirements were made following this inspection. Overall the home has continued to work towards meeting the requirements made and to improve the standards and quality of life for service users. What the service does well: What has improved since the last inspection? The home has made attempts to identify more activities for service users and to encourage some to become more independent and to access local community facilities. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 6 The Inspector recognises the difficulties there can be when trying to motivate service users with mental health needs and has seen over the past year a slow improvement with how staff support the service users. There is still scope for further developments and the Inspector is confident that the staff team will seek additional activities and promote day trips in order to provide a varied life for the service users. Food that is opened or prepared now has dates written on it to ensure service users welfare is protected. Medication administration records had been completed correctly and all medication systems were robust. The home no longer assists service users financially, by giving them a loan. The staff team plan ahead to ensure there is always money available for service users from their personal accounts. Staff now have a training programme, which ensures all courses attended are documented and any future training needs are recorded and met. Staff have also received training and information on mental health and alcoholism to enable staff to have up to date skills. The home has made steps to devise a quality assurance system. This enables staff to examine service users opinions, look at areas needing work to meet standards and areas that the home feels are working well. The home should provide clear evidence of how they have reviewed the way the home operates and use this tool to continuously assess how well the home meets service users needs. Finally the home had ensured that cleaning products are stored in a secure and locked cupboard. What they could do better: Care plans have greatly improved but all must be consistent and demonstrate service users individual health needs and how these are to be met. Any support or encouragement needed for service users must be documented to ensure staff work in the same way. Risk assessments must be completed on any activity or behaviour relevant to a service user. These must be detailed and reviewed on a regular basis to ensure the home has considered all possibilities and sought to minimise any potential identified risk to the service user or others. The Inspector was encouraged to see the home has moved forward in promoting more independence for all the service users, however before such steps are decided the appropriate risks must be fully contemplated and recorded to safeguard all concerned. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 7 The health and safety of service users must be paramount at all times and therefore water temperatures must be taken and recorded in all areas of the home where service users access. 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. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 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.V286802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Service users are assessed prior to admission into the home to ensure the home can meet their needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: There have been no new admissions into the home since the last main inspection and so this Standard could only be partially inspected. However the Registered Provider informed the Inspector they would assess prospective service users and that they use a pre-admission assessment that covers a wide range of issues to identify service users needs. The Inspector was informed that the last service user admitted into the home had trial visits and any prospective service user and their representative would be encouraged to visit and meet with other service users and staff prior to moving in. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The personal and social needs of service users had been identified and were being met. However health needs had not been fully outlined on all of the care plans viewed and work is needed in this area to ensure staff are aware of the support each individual service user requires on a day-to-day basis. Service users are encouraged to make decisions about their lives, with the support from staff. Staff have made improvements in promoting service users to take risks as part of an independent life. However work is needed to ensure that risk assessments are holistic and relate to each service user and the risk they might potentially pose to themselves or others. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these continue to show improvement and detail how the service users’ identified personal and social care needs would be met. However on one care plan viewed there was no evidence of the service user’s health needs and how much support and encouragement the service user requires from staff. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 11 The care plans must include all aspects of a service user’s life to include health related issues and a requirement was made regarding this subject. Daily records had also improved and contained details regarding service users, for example what activities they had engaged in, what personal care they had carried out that day and any other relevant information necessary to share with staff. The home has worked to promote service users independence and have begun to encourage service users to make small snacks such as sandwiches for their evening meal. Those service users asked said they enjoyed making a meal now and then. One service user likes to go out unaccompanied and the home recognise the need for this service user to have time away from the home and to visit local facilities and friends. This service user also manages their own finances and staff do not monitor this aspect of the service user’s life. The Inspector discussed with staff that if no one reviews this service user’s finances, then they could become in debt and then struggle to maintain independence. This is an area the home should consider and could examine ways to support service user’s choice whilst balancing this against their duty of care. Risk assessments were in place and were up to date and covered a wide range of areas, such as personal safety, road safety and personal relationships. However staff had not completed a risk assessment on one of the service user’s who has recently been encouraged to go out into the community for a coffee with another service user. This service user has in the past posed a possible threat to others, in particular children and although they have not been involved in any incidents since living in the home, staff must ensure they have procedures in place and have considered all potential risks for this service user to go out without a member of staff. A requirement was made that this assessment must be completed before this activity takes place again. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 There has been an improvement in the activities the home provides for the service users and how staff have developed weekly activities to offer service users occupation and stimulation. This must continue to ensure service users are motivated by staff. The service users have little contact with family but if they wished to or were able to the home would encourage contact to maintain family connections and relationships. Service users rights are respected and their privacy and choice are acknowledged and met, within the home’s capabilities. The meal provision offers service users a healthy and well balanced diet to maintain optimum health. EVIDENCE: The service users living in the home do not have jobs and occupy their time in a variety of ways. There had previously been ongoing requirements made regarding the home being able to demonstrate their commitment to providing a range of activities for the service users. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 13 However at this inspection the Inspector noted that the home had been making attempts to address these shortfalls. Evidence was seen regarding how the home is promoting service users to be more independent and to engage in tasks around the home as well as accessing local community resources. The home had organised a day trip with all three service users which overall was a success and service users asked said they had enjoyed going out for the day. One service user is independent and attends various college courses that they are hoping might eventually lead to employment. The staff team have also been liaising with Social Services with the hope to identify activities possibly in local mental health resource centres. Evidence was seen to indicate that the home had asked for meetings to discuss the options available for one of the service users. Some of the service users watch religious services on the television and the Inspector suggested to the staff team that they could explore the idea of service users having the opportunity to attend local church services. There were no relatives present during the inspection. Staff explained that there is minimal contact with family for various reasons, although the home said they would encourage any contact with family or friends. One service user does have some friends that they see in the community but the friends rarely visit the home. Service users spoken with confirmed that staff are respectful towards them and that they do not invade their privacy. Service users are offered a key to their rooms, although for one service user due to their health risks, this is no longer possible. The Inspector asked this service user if they understood why they did not have a key, they said they did but would still like one. Service users receive their own mail and can access most areas of the home. Staff were seen to interact with service users in a positive and respectful manner. The kitchen was clean and tidy at the time of the inspection. Menus were viewed and incorporated service users preferences. The menus offered a variety of choices and service users asked stated they enjoyed the food offered to them in the home. Individual meals are recorded if they differ from the set menu. Mealtime was partially observed and was a relaxed in formal occasion. The meal looked freshly cooked and well presented. Fridge temperatures had been taken on a daily basis and were within an appropriate range. Food opened or prepared had dates of opening written on them. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users are mainly independent regarding their personal care routines. On occasion service users need prompting from staff to maintain good personal hygiene. Overall service users health needs are being met, although care plans must evidence exactly what the health needs are of all service users to ensure they have been identified and then can be met. Medication systems in the home are robust and protect the service users health and safety. EVIDENCE: One service needs assistance in monitoring their personal care, the others are more independent and do not require assistance other than possibly prompting to change their clothes. Times for getting up and going to bed are flexible. One service user prefers to go to bed early in the evening and their choice is respected. The home had introduced forms to evidence when service users had attended health appointments. These are working well and clearly indicate that service users are seeing the relevant health professional to meet their needs. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 15 As noted in Standard six, health needs must be clearly outlined on care plans to ensure all members of staff are aware of areas that might require additional support and encouragement and areas that need specialist knowledge and assistance. The home are currently concerned about one service users health and whether they can continue to meet their needs due to their alcohol misuse. The home is in contact with the relevant community teams, however progress is slow in the community team identifying a suitable in-house detox centre. The home is aware of how to respond if the alcohol intake affects the service user’s diabetes but staff are worried about the impact this is having on the service user. The Inspector reminded the Registered Manager and staff that the home must always be able to demonstrate their abilities to meet the needs of the service users and if they have any doubts they must consider the next appropriate steps through consultation with the relevant local authority and the service user. Samples of the medication administration records were tracked. All those viewed had been correctly completed. The medication was stored in a safe locked cupboard. No controlled drugs were stored in the home and service users do not self-medicate. Staff received training from a local Pharmacist and are looking into identifying a new resource to receive ongoing regular training and information. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a clear complaints procedure and service users feel their views would be listened to. Systems were in place for the protection of vulnerable adults. EVIDENCE: The complaints procedure was viewed and was freely available in the main hall and in each service users bedroom. The Inspector recommended that the procedure should outline that complaints will be addressed within 28 days. Service users asked stated they would feel able to complain to the Registered Manager and that they concerns would be addressed. The home has not received any complaints. The CSCI has not directly received any complaints. The home had previously loaned money to a service user who was not regularly receiving their money, however this practice has now stopped. Staff are fully aware of the problems loaning money can cause, as clear records must be kept to ensure no errors occur. One service user manages their finances. The Inspector asked staff if they were aware of whether this service user was in debt or managing their own money. Staff stated it was difficult to discuss money with this particular service user. Staff should try and identify a way to support the service user to ensure they are managing their money effectively, whilst balancing this with respecting the service users right for privacy. The Inspector counted and checked two service users monies these were found to be correct at the time of the inspection. Staff had attended training on safeguarding adults. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Service users live in a comfortable, bright and homely environment. Service users bedrooms offer them the space and privacy they need when they choose to be alone. The home was clean and free from malodours offering service users a welcoming place to live in. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. These were being maintained satisfactorily. The home is near to public transport and local shops and libraries for easy access for service users. Furnishings and fittings were adequate for the service users and overall the home offered service users a pleasant environment to live in. The communal lounge, as noted in the summary of this report, is small and would not be suitable if the home were to increase the service user numbers. Two service users showed the Inspector their bedrooms and these were large spacious rooms. Each service user had personalised their rooms as much as they wanted to. One service user enjoys reading and showed the Inspector the books they keep. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 18 Overall there were no problems identified regarding the environment and the home was clean, tidy and free from odours at the time of the inspection. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Service users are supported and cared for by a small competent staff team, who have the opportunity to study for NVQ’s in order to be up to date with relevant knowledge and skills. Recruitment procedures must be followed if any new employees join the staff team to ensure service users welfare is protected. Staff have received appropriate training to understand service users needs. Staff are well supported and have the guidance and advice they need to be confident and caring in their roles. EVIDENCE: Two members of staff are currently in the process of completing their NVQ’s. Staff were seen to interact with service users in a comfortable and relaxed way. Service users spoken with spoke highly of one of the members of staff who they felt understood them and spent time with them. The home is family run and the staff team, who live and work with the service users, demonstrate an awareness of the abilities and needs of the individual service users. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 20 The staff employment files do not contain all the necessary documentation. However this Standard is difficult to inspect as only three people work in the home and have done so since the home was established, except for the son of the Registered Manager/Provider. All staff have Criminal Record Bureau checks carried out on them but they do not have completed application forms or references. The Inspector reminded the staff team that any new employees recruited must have all the required documentation, as outlined in Schedule 2 of the Care Standards Act 2000, prior to their commencement of work in the home. Staff have recently received training on mental health and alcoholism. Staff spoken with were happy with the level of training provided to them. The Inspector made a recommendation for the Registered Manager to explore training on Dementia and Diabetes, as these two areas are relevant to the service users living in the home. Staff now have a training plan that identifies the training staff have attended and the training they wish to attend in the future. Staff asked confirmed they received regular one to one supervision. Support and sharing of communication is also carried out on a daily basis as the teamwork together every day. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 40 Service users benefit from a well managed home, the Registered Manager and Provider have worked and owned the home for many years. Systems are in place to review the running of the home. The home obtains the views of the service users and it is recommended the findings of reviews and questionnaires are put into a more detailed report. There were shortfalls in the servicing and health and safety records. These must be addressed to ensure the home safeguards service users, staff and any visitors. EVIDENCE: The Registered Manager has started studying for an NVQ level 2 and will then be seeking to study level 3. The Registered Provider, Mr Gopal, intends to study NVQ level 4 in management and care in 2007. Both Registered Providers/Manager support each other and their son who works with them. The home must be clear that if Mr Gopal wishes to be known as the Registered Manager then he must apply for this position with the CSCI. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 22 The home has been developing their quality assurance checks. Service user questionnaires are completed and a report had been carried out by the home, although the format was a checklist with no comments on areas working well in the home and areas needing further attention. However the home was able to evidence areas where they had made several improvements over the past twelve months, such as introducing new formats for health appointments and care plans. Therefore the Inspector made a recommendation that the overall report needs to alter, to show more detail of areas reviewed by the staff team and what has or has not worked over the past twelve months. The report should also include a summary of the views of the service users. The staff team had made significant improvements in many of the areas of the home that had previously been ongoing requirements and it is hoped that this way forward will continue. Servicing records were viewed at random. Fire drills were held on a regular basis and the Gas Safety record and Portable Appliance Testing were all up to date. The home had been taking temperatures of the bath water but not service users hand basins. The Inspector made it a requirement that all areas where service users have access to water must be tested and recorded on a regular basis. Finally the home now locks the cupboard where cleaning products are stored. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 3 x x 2 x Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Timescale for action 31/05/06 2. YA9 3. YA42 Care plans and any other relevant documentation regarding a service user must clearly outline the service users health needs and how these are to be met. 13(4)(b)(c) Risk assessments must be 28/04/06 completed on any activity that is identified as a possible risk to the service user or others. The assessment must identify the risk and how this is to be minimised. 13(4)(a)(b)(c) Water temperatures must be 28/04/06 taken and recorded in all areas where service users have access to water. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 25 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. Refer to Standard YA22 YA35 YA39 Good Practice Recommendations The complaints procedure should outline that all complaints would be dealt with within 28 days. The Registered Person should explore training on Dementia, Diabetes and any other relevant course to meet the needs of the service users. The overall quality assurance report should contain the work the home has done to make improvements and areas that still need to be addressed, with any action that is to be taken. Faraday House DS0000027704.V286802.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 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.V286802.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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