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Inspection on 26/06/06 for Friern Residential Care Home

Also see our care home review for Friern Residential Care Home for more information

This inspection was carried out on 26th June 2006.

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 8 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 support staff have a good understanding of the residents and their associated mental health care needs. Through professional intervention, the staff team are ensuring that residents` mental health remains stable or gradually improves. The registered providers have the skills and experience to provide such a service and are ensuring that they impart their knowledge to the staff team. Staff retention is good and staff are happy with their working conditions. The staff team have ensured that residents are able to access all facilities in their local community.

What has improved since the last inspection?

The staff have ensured that seven of the eleven requirements from the previous inspection have been met. They have developed a comprehensive service users` guide and the residents are more motivated and participate in various chores and activities within the home and their local community. Medication administration recording is improving and complaints are being taken seriously and acted upon. All of the staff are receiving training appropriate to the work that residents perform in the home. Maintenance issues have been dealt with and the home is kept clean and tidy.

What the care home could do better:

Ten requirements have been made at this inspection, of these five have been restated from the previous inspection and five new requirements have been made. These requirements relate mainly to seeking the views of residents and the recording of information and dealing with maintenance issues. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The staff team must ensure that residents are consulted in all aspects of the day-to-day running of the home and policy making. Restrictions of movement to residents must not occur unless the restrictions have been discussed with the residents and recorded appropriately. Staff must ensure that all meals stored are correctly labelled and consumed by an agreed date, to ensure that residents are not put at risk and it must be recorded in resident`s care plans if they administer their own medication. To ensure that residents live in a more comfortable and homely environment, their bedroom must be maintained to an acceptable standard and their privacy and dignity maintained. All staff must receive training to ensure that residents are protected from abuse and robust recruitment procedures must be practiced to ensure that residents are not put at risk. Staff must receive regular supervision to ensure that their personal development is monitored and that they are being appropriately supported. There must be an effective method in place to obtain the views of residents, staff, relatives and other stakeholders as to the quality of service provided.

CARE HOME ADULTS 18-65 Friern Residential Care Home 26-30 Stanford Road Friern Barnet London N11 3HX Lead Inspector Anthony Lewis Key Unannounced Inspection 26th June 2006 08:40 Friern Residential Care Home DS0000010441.V292119.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 Friern Residential Care Home DS0000010441.V292119.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. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Friern Residential Care Home Address 26-30 Stanford Road Friern Barnet London N11 3HX 020 8368 6033 020 8368 6033 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) Mr Vevegananthan Thambirajah Mrs Bijaye Luxmi Thambirajah Mrs Bijaye Luxmi Thambirajah Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One exception for over 65 years Date of last inspection 20th February 2006 Brief Description of the Service: Friern Residential Care Home is a private care home, which opened in 1989 and is registered to provide care to eighteen adult men and women who have mental health problems. Mr & Mrs Thambirajah are the registered providers and jointly own the home. Mrs Thambirajah is the registered manager and Mr Thambirajah is the deputy manager. The stated aims of the service are to meet resident’s needs in a friendly and efficient way and to strive to preserve and maintain resident’s dignity, individuality and privacy. The premises have been converted from three adjoining houses. All bedrooms are on the ground and first floors. There are fourteen single and two double bedrooms. One of the single bedrooms on the ground floor and first floor have been arranged as self-contained flats with their own kitchen and bathroom. There are two kitchens, one of which is the main kitchen and the other for snacks. There are also two lounge areas and two dining rooms. To the rear is a garden and patio area. The home is in a quiet residential part of Friern Barnet, close to shops, and transport links. The fee range for residents living in the home is £450 - £590 per week depending on their needs. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Friern Residential Care Home DS0000010441.V292119.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, which took place on Monday 26th June 2006 at 08:40am and was completed at 5pm. The registered manager was not available for the inspection, however, the deputy manager, who is also one of the two registered providers, was available for the first part of the inspection. One of the senior support workers was available throughout the inspection and a further senior support worker was also available in the afternoon. To gather evidence for this inspection, seven residents files and five staff files were viewed along with various safety certificates, documents, other files and the pre-inspection questionnaire. Six residents were spoken to in private at various times throughout the day. Three members of staff and a pharmacist were also spoken to. A thorough internal and external tour of the home was conducted with a senior support worker. What the service does well: What has improved since the last inspection? The staff have ensured that seven of the eleven requirements from the previous inspection have been met. They have developed a comprehensive service users’ guide and the residents are more motivated and participate in various chores and activities within the home and their local community. Medication administration recording is improving and complaints are being taken seriously and acted upon. All of the staff are receiving training appropriate to the work that residents perform in the home. Maintenance issues have been dealt with and the home is kept clean and tidy. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 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. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 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 Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Robust assessments are being carried out with prospective residents to the home and the home is providing comprehensive information to enable prospective residents and their relatives to make an informed choice. EVIDENCE: A comprehensive service users’ guide has been developed, as per a requirement at the previous inspection. The service users’ guide contains a mission statement and the aims and objectives of the service. The deputy manager stated that the service users’ guide is available for all residents and prospective residents. The deputy manager stated that the registered manager is a qualified nurse and that she carries out the assessments of prospective residents to the home. The registered manager’s Personal Identification Number (PIN) was seen and was in date. The assessment form of the most recent residents to the home was seen and contained information on the resident’s medical history, current diagnosis, personal care, communication skills and various other relevant information pertaining to the resident. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Residents are not being consulted about the day-to-day running of the home and the reviewing of policies. Because of this, some residents do not feel that they have an option with regards to choices and preferences. EVIDENCE: The current and changing needs of the residents are continually assessed. The staff are ensuring that all residents receive at least one main review of their care needs per year. The deputy manager said that staff and health care professionals involved in the resident’s care are present at their main review. Several review records were viewed and all contained information on the residents’ physical and mental health care needs, activities that residents are involved in, how residents are motivated by the staff and the residents goals. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 10 The staff team are ensuring that residents are able to make decisions through holding regular residents’ meeting every two weeks. The minutes of the most recent meeting held on 12th June 2006, where residents discussed their views on the recent hot weather was seen. In addition a meeting on 13th June 2006 was seen and contained discussions regarding an up and coming barbecue at the home. At the previous inspection, a requirement was made that the residents must be involved in the day-to-day running of the home and a review of the recent no smoking ban is undertaken. When discussed with the deputy manager and the senior support worker, they stated that a review of the no smoking ban has not taken place. While touring the home, two residents were observed smoking in the back garden, even though it was raining heavily. When spoken to later in the day, one of the residents said, “I don’t like smoking outside but we’re not allowed to smoke indoors.” Another resident asked, “Is it alright for me to smoke in the house?” A further resident said, “I don’t like smoking outside when it’s raining or cold.” All of the residents spoken to said that they were not consulted about the no smoking ban. The new smoking policy was discussed at length with the deputy manager and later with two of the senior support workers. An immediate requirement is made that the registered persons must review, with the residents, the day-today running of the home and the smoking ban and a record made of the outcome and a report of the outcome sent to the Commission. Risk assessments were seen in each resident’s file. The risk assessments covered a range of everyday risks to the individual resident and how the staff would support the resident in managing the risk. The staff ensure that personal information regarding the residents are kept in their file which is kept securely in a locked cabinet in the office and the office is kept locked when not in use. The home also has a confidentiality policy and procedure. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Residents’ freedom of movement in the home is being restricted without proper consultation with them and their health is being put at risk due to food hygiene procedures not being followed. EVIDENCE: A resident spoken to said that in the past he has undertaken a variety of college courses. He said, “I went to college and did English, art and computing.” He went on to say, “I might do another course one day.” The senior support worker said that at present, none of the resident are in paid employment. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 12 Throughout the day, some residents were observed entering and leaving the home. It transpired that some were going to health care appointments, to the local shops and to their regular day activities. A resident who was not very motivated and a requirement made at the previous inspection, was spoken to at length. He said, “I go out to buy my fags but I prefer to stay indoors painting.” He went on to explain how the registered manager buys many of his paints, paper and brushes and that he enjoys sitting in his bedroom painting. Another resident said, “I like reading books, I’ve got lots of them.” His vast book collection was seen in his bedroom. Residents’ files contained information about their family and friends. When spoken to, the senior support worker stated that some residents’ family and friends visit quite regularly. A resident said that he visits his sister once a week and that they either do things in her home or go out together. Another resident said that she sees her sister now and again. Throughout the inspection, staff were observed knocking on bedroom doors and overheard speaking to residents in a courteous and supportive manner. A resident said, “The staff are alright, they’re quite helpful.” Another resident said, “I like the staff, I can talk to them and they help me.” Although the home has two kitchens, they are rarely opened at the same time, which restricts residents’ freedom of movement. While touring the home, the senior support worker had to get the key to open the smaller of the two kitchens. When the reasons for this was discussed with the senior support worker, she stated that for health and safety reasons, one kitchen is locked when the other is being cleaned. She also said that residents moving between the small kitchen and the dining room are at risk. The senior support worker went on to say that when meals/cooking is in progress in the main kitchen the small kitchen is opened to residents. The issues of the kitchens were discussed with the senior support worker and the options available were also discussed. A requirement is made that a review is conducted into the issues surrounding the two kitchens and the restriction of movement to residents. Residents were spoken to about the quality of meals in the home. One resident said, “I’m happy with the food, it’s alright.” Another resident said, “I’ll eat anything, the food’s ok.” The menus for the past two weeks were viewed and both contained a variety of meals with two choices for dinner, one of these being for vegetarians. Nutritional needs have been incorporated in the menu with a variety of vegetables, meats and sensible desserts. However, the fridges contained food that, according to the senior support worker, was prepared the previous day. There was also a cake plate with remnants of a cake, which was unwrapped. The foods were in various containers and wrappings but there was no evidence of when they were prepared and when they should be consumed by. A requirement is made regarding this. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 13 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 and 20. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Staff are ensuring that residents are being supported with their health care needs but they are not entirely ensuring that all medical administration practices are followed to ensure that residents are not put at risk. EVIDENCE: The senior support worker was spoken to about support from staff to residents with regards to their personal care. The senior support worker said that all residents are able to carry out their own personal care and that at times staff may prompt them when required. Residents were observed to be clean and appropriately dressed. At the previous inspection, the mobility health care needs and support of a particular resident were discussed at length with the registered providers. At this inspection, the resident was spoken to and he stated, enthusiastically, “The manager has been taking me to see a consultant, she’s taken me about three or four times now.” The care plans of five residents were viewed and all contained information regarding their health care appointments and according to the pre-inspection questionnaire, arrangements to see health care professionals are by appointment or when recommended. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 14 The Medication Administration Records (MAR) sheets of all of the residents were viewed. A requirement was made at the previous inspection about the incorrect recording of information. At this inspection, all (MAR) sheets were being correctly completed. A pharmacist visited the home on the day of the inspection to carry out a medication advisory inspection to ensure that medication is being stored and administered correctly and that there is a clear audit trail. When spoken to, the pharmacist stated that she was satisfied with the procedures being followed in the home. However, the senior support worker later stated that there are three residents who administer their own medicated body creams for various ailments. When their care plans were viewed, there was no record of them administering their own medicated creams. A requirement is made regarding this. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 15 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 and 23. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. The staff team are ensuring that all complaints are taken seriously and acted upon and that residents will be protected from abuse. EVIDENCE: At the previous inspection, a requirement was made that all complaints must be taken seriously and that the details are recorded. Since the previous inspection, a resident made a complaint and the details were sent to the commission. This was discussed with the deputy manager and the senior support worker. The registered manager investigated the complaint and a review of the resident’s care needs took place on 8th June 2006 and was attended by the registered manager, Community Psychiatric Nurse (CPN), psychiatrist and a support worker. Three residents were spoken to about the home’s complaint procedure and each said that they would talk to staff if they wished to make a complaint. The registered manager is investigating a new complaint made by a resident. The deputy manager also stated that the resident’s health care needs are being reviewed. Although a requirement was made at the previous inspection that all staff must receive adult abuse training, this has not as yet happened. However, confirmation was seen regarding the registered manager and a senior support worker receiving “train the trainer” training at a local college on 27th June 2006. This would enable them to provide training to staff that have not received such training. This requirement is repeated. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Although the staff are ensuring that communal areas are kept to an acceptable standard, they are not ensuring that all bedrooms are sufficiently maintained. EVIDENCE: Since the previous inspection, maintenance issues identified and made a requirement have been met in that various areas of the home have been redecorated. The entrance to the home has a new carpet fitted and hall walls have been painted to provide a more contemporary look. While touring the home and looking at some of the bedrooms, a number of maintenance issues were identified. In a bedroom that two residents share, the screen to provide their dignity and privacy only covered part of the room. In another bedroom, a resident, who enjoys artistic painting, had painted various parts of his carpet. A requirement is made that the registered persons must ensure that the maintenance issues identified in two bedrooms must be repaired and brought up to an acceptable standard. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 17 While touring the home at the previous inspection a number of communal areas were found to be untidy or unclean. While touring the home at this inspection, all communal areas of the home were found to be clean and tidy. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. An adequately trained staff team is supporting residents but the staff are not being adequately supervised. EVIDENCE: Throughout the inspection, staff were indirectly observed carrying out their duties. They were observed sitting with residents having discussions and overheard reminding residents of appointments. Staff spoken to were able to explain their roles and responsibilities and the needs of the residents. Two residents were spoken to about staff support. One said, quite enthusiastically, “The staff are marvellous, they help me a lot.” The other resident said, “There’s always someone to talk to.” The files of five staff were viewed and although all staff had Criminal Records Bureau (CRB) checks and other relevant information, the file of one member of staff did not contain information such as a photograph, application form, references and other information to identify the person. The senior support worker said that the information should be in the file but could not locate any of the required information at the time. The information was supplied to the Commission after the inspection. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 19 Staff files viewed contained a variety of training certificates such as: health and safety, food hygiene and Protection of Vulnerable Adults (PoVA). The Personal Identification Number (PIN) for the registered manager, who is a Registered General Nurse (RGN), was seen and was up to date. The training that staff are receiving is appropriate for the work that they perform in the home and to meet the needs of the residents. When staff files were viewed, supervision records showed that staff have been receiving sporadic supervision. Although many of the staff have received supervision for the month of April, one member of staff had not received any supervision this year except for one in April. In addition, there was no evidence to prove that two staff had received any formal supervision since the summer of 2005. A member of staff spoken to said that they have been working in the home for many years and cannot remember the last time they received formal supervision. A requirement is made regarding this. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The home is being managed by competent and adequately qualified management staff and the health and safety of residents and staff is being taken seriously. However, the staff are not ensuring that peoples’ views are sought as to the quality of service provided in the home. EVIDENCE: The registered manager and deputy manager have owned and managed the home since 1989. The registered manager has a National Vocational Qualification (NVQ) level 4, a Registered Managers Award (RMA) and is a Registered General Nurse (RGN). The deputy manager is a Registered Mental Nurse (RMN). Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 21 Although the staff have developed a questionnaire for residents, they have not ensured, as per a requirement at the previous inspection, that a suitable method of obtaining residents views is developed. There is also no method of obtaining the views of staff, relatives and other stakeholders as to the quality of service provided by the home. This requirement is revised and restated. The staff are ensuring that all health and safety checks are carried out regularly. Fire drills and tests have been occurring regularly and safety certificates such as gas, and water were up to date. The last London Fire and Emergency Planning Authority (LFEPA) visit to the home was on 8th August 2001 and the last Portable Appliances Test (PAT) was carried out on 13th April 2004. The next visits by the (LFEPA) and a (PAT) test were discussed with the senior support workers, who said that she would contact the appropriate authorities or agencies to carry out an inspection. Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 25 1 26 x 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 1 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 X 2 X X 3 x Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA8 Regulation 24 (1) (2) (3) Requirement Timescale for action 07/07/06 2. YA16 16 (2) (g) (h) 3. YA17 16 (g) (h) 4. YA20 13 (2) The registered persons must immediately ensure that residents are consulted about the day-to-day running of the home. The registered persons must ensure that a review of the smoking policy is undertaken and a record made of the outcome. (Timescale of 28/04/06 not met). This requirement is revised and restated. The registered persons must 27/07/06 ensure that a review of the kitchen procedures is undertaken and that residents’ views are ascertained and any restriction of movement in the home to residents is agreed and recorded. (Timescale of 28/04/06 not met). This requirement is revised and restated. The registered persons must 13/07/06 ensure that all foods opened or prepared are stored and labelled correctly. The registered persons must 27/07/06 ensure that where residents administer their own medicated creams that this is recorded in DS0000010441.V292119.R01.S.doc Version 5.1 Friern Residential Care Home Page 24 5. YA23 18 (1) (c) (i) 6. YA25 16 (2) (c) 7. YA36 18 (2) 8. YA39 24 (1a,b) (2) (3) their care plans. (Timescale of 17/03/06 not met). This requirement is restated. The registered persons must ensure that all staff receive training appropriate to the work that they perform in the home. (Timescale of 28/04/06 not met). This requirement is revised and restated. The registered persons must ensure that where residents share a bedroom, adequate screening is provided to ensure their privacy and dignity. The registered persons must ensure that all staff receive regular formal recorded supervision. The registered persons must ensure that a suitable method of obtaining residents’ views is established, with independent support where required. (Timescale of 28/04/06 not met). This requirement is revised and restated. 26/10/06 27/07/06 27/07/06 29/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Friern Residential Care Home DS0000010441.V292119.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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