Inspection on 12/02/07 for Franklyn Lodge 9 Grand Avenue

This inspection was carried out on 12th February 2007.

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

The inspector found 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

Franklyn Lodge 9 Grand Avenue 10/01/06

Franklyn Lodge 9 Grand Avenue 16/09/05

Franklyn Lodge 9 Grand Avenue 29/11/04

Franklyn Lodge 9 Grand Avenue 07/06/04

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

CARE HOME ADULTS 18-65 Franklyn Lodge 9 Grand Avenue 9 Grand Avenue Wembley Middlesex HA9 6LS Lead Inspector Julie Schofield Key Unannounced Inspection 12th February 2007 08:10 DS0000017452.V325297.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 DS0000017452.V325297.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. DS0000017452.V325297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Franklyn Lodge 9 Grand Avenue Address 9 Grand Avenue Wembley Middlesex HA9 6LS 020 8902 3070 020 8903 9860 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) Residential Care Services Ltd Dr Frank Eribo Dr Doris Esohe Ilobi Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000017452.V325297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Franklyn Lodge, Grand Avenue, is a care home providing personal care to 6 adults with learning disabilities. At the time of the inspection there was one vacancy. The house is in a quiet residential part of Wembley but close to the Harrow Road and with easy access to the shops on Wembley High Road. There are bus routes along the Harrow Road and there are underground stations relatively close by. The property is a corner plot and the house is slightly elevated from the road with steps in the front garden, leading from the pavement to the front door. There is off street parking for 2 cars and there is parking in the road outside the home. The house consists of 2 floors, ground and first floor, and the office is situated on the ground floor at the front of the house. There is also a resident’s bedroom (with en-suite bathroom), kitchen, staff sleeping in room (with en-suite toilet) and open plan lounge and dining area on the ground floor. The laundry room is situated in the back garden. On the first floor there is a bathroom (with toilet), shower room (with toilet), a separate toilet and five residents’ bedrooms (one of which has an en-suite shower room). Details of the fees charged may be obtained, on request, from the manager of the home. DS0000017452.V325297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Monday in February and consisted of 2 visits to the home. The first visit started at 8.10 am and finished at 10.00 am. The second visit started at 3.10 pm and finished at 6.05 pm. During the inspection discussions took place with the manager, deputy manager, members of staff on duty and with residents. The Inspector would like to thank all that took part in the inspection for their comments and assistance. The inspection also consisted of examining records and files, a tour of the premises and observing the preparation of the evening meal. The inspection continued at a later date with an examination of staff files and training records, which were viewed at a company office nearby and the Inspector would like to thank the member of staff who assisted. What the service does well: What has improved since the last inspection? A requirement was made during the previous inspection that the repair to the wall in the bedroom is painted over and made good. This has now been done. DS0000017452.V325297.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000017452.V325297.R01.S.doc Version 5.2 Page 7 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 DS0000017452.V325297.R01.S.doc Version 5.2 Page 8 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): These standards were not inspected as no new resident has been admitted to the home since 2005. EVIDENCE: DS0000017452.V325297.R01.S.doc Version 5.2 Page 9 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 Overdue internal review meetings need to be carried out as reviewing the care plan and the placement on a regular basis ensures that changes in the needs of residents are identified and can be addressed. The residents’ right to exercise choice in their daily lives is promoted and respected. Staff support residents to take responsible risks so that residents can enjoy an independent lifestyle. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ case files were examined. It was noted that each file contained a care plan from the local authority. Care plan assessments drawn up by the home were included in each file and these are available in a userfriendly format. There was evidence of review meetings being held. One file contained the minutes of an internal review meeting held in April 2006 and a DS0000017452.V325297.R01.S.doc Version 5.2 Page 10 review meeting convened by the funding authority in November 2006. The key worker, the resident (and their relatives) attended the review meetings. The second file contained the minutes for a review meeting convened by the funding authority in June 2006 and an internal review meeting was now overdue. Although there was a record in the visitors book that the reviewing officer from the funding authority had called to host a review meeting for the third resident in June 2006 these minutes were not on file. An internal review meeting for the third resident was also overdue. The manager said that the internal review meetings for the 2 residents had been deferred. The relatives of one of these residents were abroad at present. It was noted during the examination of the case files that these were bulky and in some cases contained letters that were over 5 years old. It was observed during the inspection that residents were given information to help them make decisions and exercise their right of choice. A resident spoke about the advice and support given to them by their key worker and by “Doctor Doris”, the manager. Residents are encouraged to make decisions and to become more independent and a resident said that they were now going shopping for their clothes and personal items, with support from a member of staff. Three residents need assistance with managing their finances and the home provides help if there are problems with benefits. The records relating to residents’ finances were inspected and were up to date and satisfactory. They included a breakdown of the costs of the recent annual holiday. Day to day records include a running total of the balance of money held and itemises expenditure. Records relating to savings accounts were also available. There was evidence on each of the 3 case files examined of risk assessments tailored to the individual needs of the resident. Risk assessments covered activities/behaviour such as knitting, using electrical appliances, climbing stairs, injuring others, feeling anxious and self-harming. The risk assessment included an evaluation of the risks involved, the likelihood of occurrence, the potential conflict with community care principles, how to reduce the risk, a plan of action and the date for review. There was evidence that all the risk assessments had been reviewed in 2006. DS0000017452.V325297.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16, 17 Taking part in activities, developing new skills and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. By maintaining contact with their family and friends the resident’s need for company and fellowship is met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Menus respect the cultural and dietary needs of residents and residents are encouraged to make choices that form part of a pattern of healthy eating. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The deputy manager confirmed that all residents have a day care programme that includes attendance at day centre. One resident attends the Franklyn Lodge day centre in Wembley on 3 days during the week and has activities arranged either inside or outside Grand Ave for the remaining 2 days. Another DS0000017452.V325297.R01.S.doc Version 5.2 Page 12 resident attends a day centre in Ealing on 2 days during the week and attends the Franklyn Lodge day centre on the other 3 days. The remaining 3 residents attend the Franklyn Lodge day centre on a Monday to Friday basis. On the day of the inspection all residents left during the morning to attend their day centres. On their return home in the afternoon residents confirmed that they had enjoyed their day. The activities record book demonstrated that residents have access to facilities and resources in the community. These included shops, restaurants, cinema and leisure centres. A resident said that they had visited Wembley market at the weekend. Two of the residents sometimes want to go to church on a Sunday and an escort is provided. A resident said that they use public transport or vehicles owned by the company. The company has 2 large 14 seater mini buses. All the residents’ names’ are entered on the electoral roll and the deputy manager said that residents vote at the elections, if they wish. The Inspector discussed holidays with the residents. Two of the residents had enjoyed a holiday with their relatives. All the residents had enjoyed a holiday at Minehead, which had been arranged by the company, although one of the residents said that they preferred to go to Bognor Regis. Several of the residents go swimming and all are able to go to the Gateway, Apple or Franklyn Lodge Leisure Club, if they wish. The company transport is used to take residents out to places such as the seaside, to parks and to markets. Social events are arranged in the home and residents from other homes are invited e.g. a barbecue. Two of the residents said that they enjoyed watching television in the evenings and were looking forward to seeing the “soaps”. Visitors to the home are asked to sign the visitors’ book and this confirmed that some residents enjoyed regular contact with their family. The deputy manager said that all the residents enjoyed contact with their families. Three residents said that relatives visited them in the home and the deputy manager said that the visits could take place either in the communal areas or in the residents’ rooms. A resident said that they looked forward to the visits from their family. They confirmed that when their relatives visited the home they were made welcome by the staff on duty. One resident spends most weekends with their family. Families are encouraged to play an active part in the life of the resident and they are invited to social events held in the home or those organised by the company. Four of the residents sometimes visit other care homes to have a meal with friends that they have made at day centres. It was observed during the inspection that residents took part in the day-today domestic routines and one resident was very happy to help in the kitchen with “cooking”. Residents are allocated daily tasks, according to their abilities and skills. One resident took responsibility for carrying the milk on the minibus to the day centre, another resident took rubbish out to the bin in the garden and a third resident set the table. Residents help with their laundry by bringing their laundry to go into the machine and then taking the clean clothes DS0000017452.V325297.R01.S.doc Version 5.2 Page 13 back to their room. Residents are encouraged to clear away their plates after they have finished eating. The residents’ right to privacy is respected and it was noted that staff knock on the resident’s bedroom door and call out before entering or wait until they are invited to enter. Residents are able to have time in their room without unnecessary intrusion by staff. They are also able to choose whether to take part in activities or to socialise. During the inspection an evening meal was prepared. Residents told the Inspector that as some people didn’t like potatoes there would also be rice. The member of staff on duty confirmed that although there was a menu it was the practice to check with residents whether this meal was acceptable or whether any changes were required. The meal was observed. It consisted of a chicken casserole, with vegetables, and the choice of rice or potatoes. It smelt appetising. Menus include dishes to meet the cultural needs of residents. A resident said that “Doctor Doris” made the best pasta bake and special fried rice dishes. The staff on duty confirmed that they had undertaken food hygiene training. One of the residents had been advised to lose some weight and showed the Inspector his monthly weight records. The resident was proud that he had made good progress since he was encouraged to make food choices to enable a pattern of healthy eating. DS0000017452.V325297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Residents receive assistance with or prompting with personal care in a manner, which respects their dignity. Residents’ health care needs are met through access to health care services in the community. The health and well being of residents is promoted through support with taking their medication at the time and in the dosage directed by the GP. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is always a female member of staff on duty, during the day and sleeping in at night so that female residents receive personal care from a member of staff of the same sex. Assistance with personal care is provided discreetly and respects the dignity of the resident. Residents were clean and tidy and smartly dressed. It was noted during the site visit that staff knock on the bedroom door before entering or wait for the resident to invite them into the room. One of the residents is deaf and communicates by signing and another resident communicates verbally and by using some Makaton signs. The members of DS0000017452.V325297.R01.S.doc Version 5.2 Page 15 staff on duty were able to respond appropriately to each of these 2 residents. The home has a system of key working. There was evidence on the 3 case files examined that residents had access to health care services in the community, including appointments with the GP, dentist, optician and chiropodist. Residents also had access to screening services e.g. blood tests and preventative medicine e.g. flu jabs, if they wished. Residents had out patient appointments with the psychiatrist for medication reviews etc and appointments for other services e.g. renal or genetic clinic. A letter from the hospital confirmed that the key worker accompanied the resident on the out patient appointment, if required. Specialist services are requested when this is needed and there was dietary advice on one of the case files. Two of the residents are currently receiving physiotherapy sessions and the physiotherapist visited the home on the day of the inspection. One of the 2 residents said that they had “exercises” to do. The storage of medication was satisfactory and the cabinet is kept locked. The medication records were inspected. It was noted that these were up to date and complete. The home follows a policy of 2 members of staff being responsible for the administration of medication. One member administers the medication and the other member of staff verifies that the procedure has been correctly carried out. Both members of staff initial the records. There were no residents that self-administer medication. There were medication policies and guidelines in place to support staff in both administering and recording medication. All staff members administering medication have received training. There was a record in the visitors’ book of a medication advice visit by the pharmacist taking place in February 2007. DS0000017452.V325297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The rights of residents are protected by a clear and simple complaints procedure. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure was on display in the home. The simple procedure included timescales for each stage of the procedure and referred complainants to the directors of the company, if the home’s manager could not resolve matters. Information regarding access to other agencies e.g. the CSCI was included, with the address and telephone number of the local office. The deputy manager said that no complaints have been recorded since the last inspection. There is a procedure in place in the home and they have a copy of the local authority interagency guidelines in the event of abuse. Each resident’s case file contains a leaflet which summaries the local authority’s multi agency policy and procedures in the event of abuse. The deputy manager said that no allegations or incidents of abuse have been recorded since the last inspection. There was evidence that staff have attended training in protection of vulnerable adults procedures and an external trainer carried this out. However, for 2 members of staff the date recorded on the training plan is more DS0000017452.V325297.R01.S.doc Version 5.2 Page 17 than 2 years ago. Staff have also received training in supporting residents with challenging behaviour. The manager said that restraint is not practiced in the home. DS0000017452.V325297.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Residents enjoy a comfortable and “homely” environment with pleasant communal and private facilities in which to relax. Some minor adjustment to the curtains in one of the bedrooms is needed. Residents live in a home where standards of cleanliness are good. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A site visit took place during the inspection. It was noted that the premises are safe and maintained to a good standard. The home is comfortably decorated and furnished and offers residents a “homely” environment. The premises were warm and adequately lit. Residents are able to access all of the communal areas. Each resident has their own single room. There are bedrooms on the ground and on the first floors. Two rooms have an ensuite toilet and bathing facility. DS0000017452.V325297.R01.S.doc Version 5.2 Page 19 Residents said that they liked their rooms and that they were sufficient in size. Each bedroom reflected the personality of its occupant and residents had purchased personal items and had photographs and ornaments etc. It was noted that on their return home from day centres some residents liked to spend some time in their rooms relaxing. Rooms were comfortably furnished and decorated although the curtain rail in one of the bedrooms was becoming detached, after the resident had pulled the curtains down. A site inspection took place and it was noted that the areas seen were clean and tidy and free from offensive odours. Staff on duty confirmed that they had undertaken training in infection control procedures and “refresher” training was given in 2006. Access to the laundry room is not through areas where food is prepared or consumed. The washing machine does not have a sluicing cycle as none of the residents have problems with continence. DS0000017452.V325297.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 NVQ training enhances the general skills and knowledge of carers and contributes towards the quality of service that the residents receive. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents. Residents are supported by staff that have access to a comprehensive range of training courses, enabling them to meet the residents’ needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 4 members of staff named on the rota, 2 members of staff have completed their NVQ level 2 or level 3 training and the deputy manager is currently undertaking NVQ level 4 training. The home has met the target of 50 of carers achieving an NVQ level 2 or 3 qualification. There was evidence that staff had received training in supporting residents with challenging behaviour and in autism awareness. DS0000017452.V325297.R01.S.doc Version 5.2 Page 21 A copy of the rota was available. Three staff are on duty in the mornings and 2 staff are on duty in the afternoon/evenings from Monday to Friday. Two members of staff sleep in at night, but are on call, and 1 member of staff is always female. Staffing levels at the weekends are adjusted if a resident(s) stays overnight with their family. Staffing levels are sufficient to meet the current needs of residents and there are sufficient staff for residents to take part in activities in the community. The staff team reflects the gender composition of residents and includes staff that reflect the cultural composition of residents. Two staff files were examined. Evidence of a satisfactory enhanced CRB disclosure for each member of staff was available. Both files included proof of identity (passport details) and evidence of right to work. The files also contained 2 references, a contract and a declaration of health. A copy of the training plan for the 9 Grand Ave, for the period 2006 to 2007, was available for inspection. The plan listed the names of the manager and the four members of staff working in Grand Ave and there was an up to date record of training courses attended. It included both statutory training and additional courses, which enabled staff to fulfil the aims of the home and to meet the needs of the residents. Staff files contained copies of training attendance certificates and it was noted that staff had attended courses in respect of safe working practices e.g. fire awareness, infection control, food hygiene, medication etc. They had also attended courses to enable them to support residents e.g. autism, challenging behaviour, epilepsy and protection of vulnerable adults. The Inspector has previously been provided with a copy of the new Skills for Care “Common Induction Standards Social Care (Adults)” Progress Log, which the home will use in connection with their induction training programme. A copy of the Personal Development Plan has previously been made available. This is used in the appraisal process and includes an identification of training needs. DS0000017452.V325297.R01.S.doc Version 5.2 Page 22 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 By establishing good working practices and monitoring the quality of care in the home the registered manager promotes a safe and enjoyable environment for residents. Service satisfaction questionnaires, meetings and individual discussions with residents help to monitor the quality of the service provided to residents and contribute towards the development of the service. The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents. As regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use, appointments need to be made when these are outstanding. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000017452.V325297.R01.S.doc Version 5.2 Page 23 The manager has completed her NVQ level 4 and RMA. The manager has undertaken a managing appraisals training course since the last inspection. Residents are able to give feedback on the quality of the service during discussions with members of staff, at their review meetings, at meetings with their key workers and at residents’ meetings, which are held on a monthly basis. Family members and representatives of the placing authorities can give verbal feedback during visits to the home and at review meetings. Comments made at review meetings are recorded in the minutes. Residents, members of staff and visitors to the home can use the suggestion box to leave comments. A service satisfaction questionnaire had recently been sent to relatives, stakeholders and to those residents in care homes owned by the company that would be able to complete them (with the support of an independent person, if necessary). A review of response rates to the previous questionnaire had led to its re-design. It was now just 2 sides of paper rather than the previous, lengthier document. The company intends to publish the results of the survey in a newsletter and to include a summary of the results in the annual development plan for the business. Staff have received training in safe working practice topics including training or “refresher” training in manual handling, fire safety and infection control, which took place in 2006. The last certificate for the testing of the portable electrical appliances was dated October 2005 and a new test is overdue. There was a valid certificate for the electrical installation and the Landlords Gas Safety record was dated February 2007. There was evidence that the fire precautionary systems and equipment are tested/serviced on a regular basis. Records demonstrated that the fire alarms and smoke detectors are tested on a weekly basis and that a fire drill, including an evacuation of the home, is also carried out on a weekly basis. DS0000017452.V325297.R01.S.doc Version 5.2 Page 24 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 X 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 3 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 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 3 X 3 X X 2 X DS0000017452.V325297.R01.S.doc Version 5.2 Page 25 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 Requirement Timescale for action 23/04/07 14.2&15.2 That the minutes of each review meeting are placed on file. (Previous timescales of the 1st December 2005 and 17th April 2006 not met). 14.2 16.2 That the overdue internal review meetings are carried out. That the curtain rail is securely attached to the wall or a system of Velcro tape is fitted to the top of the curtain which then attaches to a strip of Velcro on the curtain rail or wall so that they can easily be repositioned in the event of being pulled down by a resident. That a copy of a valid certificate for the testing of the portable electrical appliances is forwarded to the CSCI. 2 3 YA6 YA25 23/04/07 23/04/07 4 YA42 13.4 23/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000017452.V325297.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard YA6 Good Practice Recommendations That the content of case files is reviewed and information that was received prior to the 1st January 2005 is safely archived. That staff that completed their protection of vulnerable adults procedures training prior to March 2005 attend “refresher” training. 2 YA18 DS0000017452.V325297.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000017452.V325297.R01.S.doc Version 5.2 Page 28 - 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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