Inspection on 01/10/07 for Garthowen

This inspection was carried out on 1st October 2007.

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

Other inspections for this house

Garthowen 09/05/07

Garthowen 14/11/06

Garthowen 16/05/06

Garthowen 06/01/06

Garthowen 14/06/05

Garthowen 28/01/05

Garthowen 06/08/04

Garthowen 12/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Garthowen 78 Barrowgate Road Chiswick London W4 4QP Lead Inspector Sarah Middleton Unannounced Inspection 1st October 2007 09:25 Garthowen DS0000022889.V349529.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 Garthowen DS0000022889.V349529.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. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Garthowen Address 78 Barrowgate Road Chiswick London W4 4QP 0208 995 9702 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) www.together-uk.org Together Working for Wellbeing Post Vacant Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2007 Brief Description of the Service: Garthowen is a detached, three storey building situated in a residential area in Chiswick, close to local facilities and transport. The home is registered for twelve residents with mental health problems. The London Borough of Hounslow is the main purchaser and has blocked purchased seven of the bed places. The home is owned and managed by Together Working For Wellbeing. The accommodation has nine single bedrooms on the first floor. There is a selfcontained flat on the ground floor and two flats on the second floor. Residents who are ready to move on to more independent living use the latter. Smoking is permitted in resident’s bedrooms and in the garden. The dining room can be used as a quiet area in between meals. There are no lifts in the building so it is only suitable for service users with good mobility. Residents are expected to participate in cooking, looking after their own laundry and helping with some domestic tasks around the home. After a settling in period, residents are expected to become more involved in some form of activity outside the house during the day. This is specified in their care plans. Key workers support residents to learn new skills and work in conjunction with other professionals in helping them to move on to independent living. Fees range from £600 per resident, per week. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 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. The inspection visit was from 9.25am-5.50pm. The Manager Designate is in the process of applying to be the Registered Manager and she assisted with the inspection. The Manager Designate completed an Annual Quality Assurance Assessment that provided information about the home. We met with the interim Area Manager during the inspection and the Manager Designate assisted with the inspection process. Two residents and one member of staff were spoken with as part of the inspection process. Residents also returned four postal surveys. Equality and diversity issues are acknowledged by the home and this has been commented on in this inspection report. Six of the eight previous requirements were met and one new requirement was made. All of the key National Minimum Standards were inspected. The home has continued to make significant progress over the past year and this is reflected in the inspection report. What the service does well: The home provides residents with choices and opportunities to develop daily living skills. The staff team is small and has built positive professional relationships with the residents. Residents are encouraged and supported to contribute to the running of the home. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Garthowen DS0000022889.V349529.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 Garthowen DS0000022889.V349529.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available for residents. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: We viewed the updated Statement of Purpose. This document outlines the home’s aims and objectives, including information on how each resident’s needs are reviewed and supported with the aim for residents to move on within a specific timescale. The Manager Designate is aware that the home is not for residents needing long- term support but that it is a stepping-stone towards gaining more daily living skills. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 9 There have been two new residents move in since the last inspection. We read through one of the resident’s pre-admission assessment. The Manager Designate confirmed that she along with another member of staff always assess prospective residents. The pre-admission assessment covers a range of areas such as, health needs, daily living skills, finances, cultural needs and plans for the future. This assessment includes the prospective residents views. In order to meet the other residents and members of staff, prospective residents are encouraged to visit the home prior to moving in. Postal surveys indicated that residents had been involved in the pre-admission process. Initial care plans and risk assessments are then completed once the new resident moves in on a trial basis. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and recorded in their care plans. Residents are supported to make decisions about their lives. In order to safeguard residents and others, potential risks are assessed and recorded. EVIDENCE: We viewed the two new residents care plans. Initial care plans are reviewed more frequently during the first few months. As staff get to know the residents’ needs amendments are made to the initial care plans. The care plans seen were detailed outlining various areas such as the residents’ health, personal care needs, social interests and abilities. Residents had contributed their views about how they saw his/her goals and recorded how these goals could be achieved. Those residents spoken with confirmed they meet with their keyworker and were able to freely talk about any issues they might have. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 11 We were impressed with the opportunities residents have to consider their needs. The home records residents’ comments, even if these disagree with the information staff have written. The second care plan viewed recorded the basic information needed to support the new resident and the Manager Designate confirmed that the keyworker would be updating this care plan to provide further details. Samples of daily records were seen and these recorded resident’s activities and any significant behaviour. Care Programme Approach (CPA) reviews are held to monitor the residents’ mental health and medication. Residents and staff are involved in attending these meetings and reviews are generally held every six months. On the day of the inspection a resident was moving onto a new home. This had been planned as the resident’s identified needs could no longer be met by the home. The Manager Designate is aware of those residents’ who need support in planning a move to more suitable accommodation. Those residents who were asked about the home said they liked it and were happy to remain living in the home. The residents currently living in the home do not have independent advocates. Most have contact with family or friends who provide support to the resident. Staff encourage and support residents to manage their own finances and this is monitored to ensure the resident is managing this task effectively. Staff had concerns about one resident’s finances and this issue had been shared with Social Services with the hope that the problem can be resolved. The home supports residents to make daily decisions. These are often made at the daily morning meeting, where residents discuss the day ahead. Samples of risk assessments were viewed. These are also updated every six months or whenever there has been a change in needs. Those seen were detailed and considered the potential, current and historical risks the resident could present to himself/herself or towards others. Staff complete an initial risk checklist, which then informs the development of a risk management form that breaks down into more detail the potential risk and how to manage and minimise the risk. Again evidence was seen that residents are involved in the completion of risk assessments and can make comments if they do not agree with what has been recorded. The home carries out weekly room checks with the resident and records were seen of these checks as each resident presents with different risks and staff look for these identified risks when searching rooms. Those residents asked confirmed that staff check their rooms to ensure they are not keeping anything that could harm themselves or others. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 12 Keyworkers meet with residents every month and records of these meetings were seen. The aim of these meetings is for both the member of staff and the resident to talk through any issues and to look at care plans and risk assessments. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are encouraged and residents can take part in activities both in the home and in the community. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Residents’ rights are respected and acknowledged by the home. The food provision in the home is good, offering variety and choice, thus meeting residents’ individual needs. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 14 EVIDENCE: Each resident has different interests, needs and motivation. The home makes every attempt to support residents to take part in tasks and chores within the home. Meeting new people and accessing places in the community is encouraged. One resident spoke of her week and how she spent her time, such as cooking at a drop in centre. Other residents go out independent of staff to College or to leisure centres, often walking or using public transport. The home is in the process of looking into having the garden landscaped so that residents can then work in certain areas, growing herbs and vegetables. The Manager Designate discussed the difficulties some residents have in engaging in daily structured activities. One resident spoken with described how it could be difficult to “concentrate on doing things”. Overall we were satisfied that although some residents isolate themselves and do very little with their time, the staff team are aware of these particular residents and do all they can to ensure they are available to support these residents as and when needed. Social contact with family and friends is encouraged. The Manager Designate said that as long as it does not affect the other residents, guests could stay overnight. Some residents see their relatives on a regular basis whilst others have less contact. One resident said they have a mobile phone and can contact people whenever she wanted to. The Manager Designate said there were plans to inform and train residents on relevant subjects such as food hygiene. The completed Annual Quality Assurance Assessment stated that those residents interested would also be supported and trained to assist with the recruitment of new members of staff. Residents confirmed they had keys to the front door and to their bedrooms. All residents receive their own personal mail. Staff were seen to interact with residents and not exclusively with each other. Residents can spend time alone or with others, with staff monitoring those residents who tend to isolate themselves. The Manager Designate said that eventually the kitchen would be replaced and updated, although there were no timescales when this work would occur. Food opened was now dated when opened and kept in secure storage containers. Residents take it in turns to cook meals for everyone and each week residents decide on the main evening meal. Staff are mindful that the meals need to be varied and incorporate fresh produce. Main meals are recorded, although this does not include breakfast or lunch as these are often eaten outside of the home. Two residents are diabetic and staff prepare meals appropriate for this special diet. Meals also consider the cultural preferences of some of the residents. Overall the residents spoken with said they liked the meals in the home. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 15 One resident was briefly observed cooking the main meal for all the residents’. Staff provide minimal support to this resident, as she is competent and confident in the kitchen. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents need minimal personal care support from staff. Health needs are assessed, recorded and were being met. Shortfalls in medication management and recording could place residents at risk. EVIDENCE: The residents currently living in the home need minimal support with their personal care. All are capable of carrying out this task independent of staff, although some residents might need reminding to change or wash their clothes. The community psychiatric team are available to support the residents and staff. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 17 Health needs are assessed and noted on care plans. All residents have GP’s and dentists and where necessary see other health professionals. Any medical appointments are recorded along with any prescribed treatment. Systems are in place to clearly inform staff of any outcome or important information that needs to be shared to ensure the residents’ needs are being met. The home respects the privacy of the residents’ as some do not want relatives to know if there are health concerns. The Manager Designate confirmed that she would look into the residents having their cholesterol levels checked. Some residents attend health appointments without staff and the expectation is for the resident to inform staff of the outcome of an appointment. A sample of the home’s medication was assessed. This is stored in safe and secure storage. There were no controlled drugs at the time of the inspection. The home supports residents to work towards self-medicating. This is planned in conjunction with residents, staff and health professionals. Staff consider the risks and ensure residents can keep their medication in secure storage. Evidence was seen that weekly checks are carried out on all medication, including the residents who self-medicate. Two staff administer and witness medication being taken. Staff receive training on handling medication by shadowing existing members of staff, using the workbooks provided by the Pharmacist and any other available training. During the inspection a small sample of medication was counted and checked. One resident’s medication indicated an error had occurred, either through poor recording and/or checking the medication. In addition, two gaps were seen on the Medication Administration Records. This was brought to the attention of the Manager Designate and a requirement was made for medication systems to be more robust. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their complaints will be listened to and acted on. Systems are in place to protect residents from abuse. EVIDENCE: The complaints procedure is freely available. The home had not received any complaints. Those residents asked said they would speak to staff if they had any concerns. There have been no adult abuse concerns in the home. Staff receive training on this subject and the home follows it’s own procedures in conjunction with the Local Authority’s. During the inspection two residents personal finances were counted and checked. The money counted was correct at the time of the inspection. Staff check the money held in the home every day. Some residents manage their own finances and the Manager Designate said that staff would be made aware if a resident had an issue with his/her finances. As noted earlier, staff have expressed their concerns relating to one resident’s finances and it is hoped this will be looked into by Social Services and any problems identified would be addressed. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the internal and external environment is of a fair standard, thus providing a clean, comfortable and homely environment for residents to live in. Plans are in place to address the shortfalls in the environment in order to maintain a good standard throughout. EVIDENCE: We carried out a tour of the home with the Manager Designate. The communal areas had been painted since the last inspection, but not the woodwork. There is a five-year plan to address the ongoing maintenance issues, however the Manager Designate is hopeful that this will be achieved in the next twelve months. Assessments have been carried out on each room to determine what work needs to be completed, for example, new furniture and painting. The fridge and freezer is to be replaced and the Manager Designate is waiting for the living room ceiling to be painted, as there had been a water leak. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 20 The environment is slowly improving, such as new flooring in the small hall leading to the kitchen, but there is still scope to make a difference. The Inspector found some areas that needed attention, • The ground bath and top floor bath still needs re-enamelling or replacing. • In the living room on one of the light fittings there was a missing glass light fitting. The living room is dark and would benefit from more suitable lighting. • Room 5a had no light fitting. • The woodwork in communal areas needs to be painted. • The toilet seat in the ground floor toilet was broken. Although a new seat had been purchased it had not been fitted. The blinds in this room were also dirty and the room in general needed painting and brightening up. Therefore a re-stated requirement was made for the environmental shortfalls to be addressed. The interim Area Manager and Manager Designate are aware there are areas still to be addressed and that this is an ongoing priority. The home has a new cleaner who works weekdays three hours per day. Staff and residents clean the home at the weekends. Overall the home was clean, although the home is large with many small areas and hall areas that need to be continuously maintained. The Manager Designate should consider if the hours the current cleaner works are sufficient to keep the home and clean from dirt. The home was free from unpleasant odours at the time of the inspection. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place and protect residents. Permanent staff have received appropriate induction training and further training in various subjects to provide them with the basic skills and knowledge to meet the needs of the residents. However the relief/casual staff were not up to date with training and this needs to be addressed. EVIDENCE: Staff working in the home have either obtained an NVQ in care or are in the process of gaining this qualification. Staff have a range of skills and experience and interactions seen between staff and residents was positive. Residents said the staff team were helpful and approachable. The staff team are also a mix of gender and ethnicity, thus providing a balance of understanding and awareness for the residents living in the home. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 22 The rota was viewed. Where there are vacant hours, as one member of staff recently left and another is on maternity leave, permanent staff aim to cover some of these hours. In addition, relief and regular external agency staff are also used. The interim Area Manager and Manager Designate are looking to increase the staffing levels, as currently two members of staff work on each shift, with one member of staff sleeping in. The aim is to increase staffing numbers both during the day and night. This would provide additional support for the residents and staff. The increase in staffing levels could benefit all those concerned. During team meetings, the Manager Designate is planning to introduce relevant topics each month. This would be seen as ongoing professional development and all staff would be encouraged to present subjects for discussion to the staff team. One new staff employment file was viewed. This member of staff transferred from another home owned by the same Registered Provider and only worked a few weeks before moving on to another home, again with the same Registered Provider. The Manager Designate explained that as this was an internal transfer there was only one reference from the previous Manager. The usual practice is to also obtain a reference from Human Resources department and this was obtained following on from the inspection. The Criminal Record Bureau check was seen along with a completed application form. Another staff employment file was viewed in order to check there was a completed application form and health declaration available. These documents had been absent from this file at the previous inspection. This information was now in place. The home has in place a training plan, which is based on the training needs of the staff. New staff receive an induction to the home, where they have the opportunity to shadow existing staff and get to know the residents and routine of the home. A workbook is used to record the areas new staff have worked through, such as considering values and adult abuse. The training programme offers staff mandatory training and additional more specialist training courses, relating to mental health. The Manager Designate is aware of the need to ensure staff are up to date with the necessary skills and information in order to successfully meet residents’ needs. One regular relief member of staff had not attended training for approximately three years. This needs to be addressed and a requirement was made for all relief staff to attend relevant training courses. The Manager Designate was made aware of the Mental Capacity Act 2005. Staff have not received information or training on this new legislation. A recommendation was made for staff to know more about this important subject and how to implement it into their daily working practice. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the skills and experience to manage the home. Systems for quality assurance are in place and the views of residents are considered. Good systems are in place for the management of health & safety checks, thus protecting the residents. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Manager Designate has worked in the home for just over a year, initially as Deputy Manager and is now in the process of applying to become the Registered Manager. Over the twelve months she has made numerous improvements and alternations to the running of the home and this is reflected in the recent inspection visits and reports. We are confident that the Manager Designate will continue to reflect on the practice and care provided in the home and make changes where appropriate. The Manager Designate has completed NVQ level 3 and has just begun to study for an NVQ level 4. The home has a quality assurance system in place. Each month the Area Manager completes a monthly report looking at various aspects of the home. Annual surveys are sent to residents, relatives and health professionals and the findings of these are looked at with an action plan completed to address any issues identified. An open day is in the process of being planned to invite residents, relatives and professionals to meet with staff and raise any concerns they might have. The home seeks to involve residents through regular meetings to consider their contributions to the general running of the home. Once a year the Manager Designate will complete a summary outlining the reviews and improvements that have taken place along with aims and objectives for the forthcoming year. Samples of health and safety records were viewed. Those seen, such as Gas Safety record, testing for Legionella and Fire equipment were all up to date. Fire drills are held with all staff and residents at regular intervals and at different times of the day and night. The fire risk assessment was viewed and is reviewed every year, covering areas of the home where there is a risk of fire, such cooking and smoking. Fire zones had been written out and individual fire capability risk assessments are completed on all residents. Water temperatures are taken and adjustments are made where the water is too hot or cold. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 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 3 3 2 x 3 x 3 x x 3 x Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 01/10/07 2. YA24 23(2)(d) To safeguard residents, medication must be administered as prescribed and Medication Administration Records must be used accurately. Attention needs to be paid to 30/04/08 areas in the home that need work and/or updating. Monitoring the environment is crucial in order to provide a pleasant home to live in. (Previous timescale 01/08/07 not met). To ensure a knowledgeable and competent staff team support the residents’ the training programme needs to meet the needs of all staff, including relief staff. (Previous timescale 30/09/07 not met). 30/04/08 3. YA35 18(1) (c)(i) Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations It is recommended for staff to receive information and training on the Mental Capacity Act 2005. Garthowen DS0000022889.V349529.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 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. 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