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Inspection on 11/08/08 for Great Western Road, Flat 3, 22-24

Also see our care home review for Great Western Road, Flat 3, 22-24 for more information

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

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 home has appropriate referral and admission procedures in place, which ensure that the needs of people who are moving into the home are well known. Care planning is person-centred, involves the resident and records are made accessible for residents. People who live in the home are involved in meaningful daytime activities of their choice and according to their individual interests, diverse needs and capabilities. Residents are supported to be part of the local community and the home is committed to the principles of inclusion.

What has improved since the last inspection?

Tracking hosts have been installed throughout the flat to support residents who require assistance with their mobility. The recording of complaints received, has improved to include action taken and the outcomes for people making complaints.The management of residents` finances has improved to ensure residents financial interests are protected.

What the care home could do better:

Risk taking policies must be reviewed regularly and especially when a person`s support needs change, to make sure that residents are cared for safely. Residents` health must be monitored through regular health checks, including dental checks. To ensure that residents are administered must be improved. protected, the recording of medicationStaff training records must be kept up-to-date to reflect the training undertaken by staff. The home`s new Manager must apply to the Commission for registration. Visits on behalf of the Registered Provider must take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. The standards of record keeping in the home must be improved to ensure that they are accurate and up-to-date. Fire alarms must be tested on a weekly basis and staff must clearly document the reason/error for the fire doors not closing properly. When a fault is identified in any of the fire doors, the fault must be reported immediately and the action taken to report and rectify the fault clearly documented. To protect residents from harm, the COSHH cupboard must be kept locked at all times. Staff must ensure that they follow guidelines for the safe handling and storage of food.

CARE HOME ADULTS 18-65 Great Western Road, Flat 3, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Ffion Simmons Key Unannounced Inspection 11th August 2008 09:45 Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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 Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 3, 22-24 Address 22-24 Great Western Road London W9 3NN 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) 020 7289 5041 020 8964 5507 The Westminster Society for People with Learning Disabilities Vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 25th June 2007 Date of last inspection Brief Description of the Service: Flat 3 is a purpose built, wheelchair accessible, first floor flat providing accommodation and care for men and women with a learning disability. There are currently 3 women and 2 men living in the home and there is one vacancy. The property is owned and maintained by Paddington Church Housing Association, and the care is provided by the Westminster Society for People with Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Park, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has his or her own bedroom. Communal areas, bathrooms and toilets are shared. The current weekly fee for the home varies from £1,101 - £1,660, with no additional charges. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The unannounced key inspection was carried out on the 11th August 2008 and lasted a total of 8 ½ hours. During the inspection, we spoke with residents and staff and observed care practices. We tracked the care of two residents, and in doing so we checked their personal records. A number of other records and documentation was checked during the inspection, including medication administration records, staff files, health and safety documentation, the home’s complaint records and quality assurance documentation. Questionnaires were sent to residents and professionals and staff to comment on the service. We did not receive any completed questionnaires. The Team Manager took time to complete and return the Annual Quality Assurance Assessment (AQAA), which has been used as evidence to inform this report. What the service does well: What has improved since the last inspection? Tracking hosts have been installed throughout the flat to support residents who require assistance with their mobility. The recording of complaints received, has improved to include action taken and the outcomes for people making complaints. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 6 The management of residents’ finances has improved to ensure residents financial interests are protected. What they could do better: Risk taking policies must be reviewed regularly and especially when a person’s support needs change, to make sure that residents are cared for safely. Residents’ health must be monitored through regular health checks, including dental checks. To ensure that residents are administered must be improved. protected, the recording of medication Staff training records must be kept up-to-date to reflect the training undertaken by staff. The home’s new Manager must apply to the Commission for registration. Visits on behalf of the Registered Provider must take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. The standards of record keeping in the home must be improved to ensure that they are accurate and up-to-date. Fire alarms must be tested on a weekly basis and staff must clearly document the reason/error for the fire doors not closing properly. When a fault is identified in any of the fire doors, the fault must be reported immediately and the action taken to report and rectify the fault clearly documented. To protect residents from harm, the COSHH cupboard must be kept locked at all times. Staff must ensure that they follow guidelines for the safe handling and storage of food. 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. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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 Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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): 2, People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has appropriate referral and admission procedures in place, which ensure that the needs of people who are moving into the home are well known. These procedures ensure that the needs of people moving in to the home can be met. EVIDENCE: No new residents have move into the home since our last key inspection, which took place on the 25th June 2007. Policies and guidelines are in place for assessing the needs of residents prior to them moving into the home. The Team Manager explained within the AQAA that they would expect to receive “an up-to-date full assessment of the needs of the individual such as a current care plan, OT assessment, and up to date risk assessment, a CPA plan if this is required” prior to making a decision about the suitability of the placement. We tracked the care of two residents during the inspection and noted that each had detailed needs assessments on their files. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs and personal goals are outlined within individualised care plans. The home involves people in planning the care they receive and ensure that care plans are person centred. Risk assessments are in place but they need to be regularly reviewed. EVIDENCE: During the inspection, we tracked the care of two residents and in doing so we checked their individual care plan. The home has changed the format for recording residents’ needs to make the information more person centred and accessible to residents. One of the care plans made good use of pictures. The Team Manager confirmed within the AQAA that, “Flat 3 staff and management team are now constantly updating individual care plans whenever there are changes in circumstances or support needs.” We were able to confirm this, as the care plans seen were up-to-date and reflected residents’ current personal care, health care and social care needs. The care plans also include reference to equality and diversity. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 10 The care plans clearly reflect that residents are supported to make their own decisions and choices about their lives. The AQAA also confirmed that “people living in the home attend regular house meetings to raise concerns that they feel necessary, and any other issues they would like to discuss all information is documented and any actions would be forwarded on users goals”. The two files checked during the inspection included risk assessments. The assessments covered a range of potential risks, including bathing, falls, personal and health care and fire safety. All assessments were well completed and included clear guidance for staff on minimising risks. For one of the residents, these had been recently been updated. Steps are currently underway to update the other residents’ risk assessments and staff must make sure that this is done so that any new risks to residents are assessed and minimised as far as possible. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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, 15, 16, & 17. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home are involved in meaningful daytime activities of their choice and according to their individual interests, diverse needs and capabilities. Residents are supported to be part of the local community and the home is committed to the principles of inclusion. The menu is varied and includes healthy options. EVIDENCE: During the inspection, we talked to people living in the home and checked the daily care notes completed by care staff for two residents. One of the residents told us about their weekly programme and their attendance at the day service, which provides them with the opportunity to spend time with their friends. Another resident showed us some of the artwork that they had completed whilst at the day service. Residents’ interests and preferences for social activities are clearly documented within their personal records. Although there were some gaps in the Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 12 recording, residents’ daily logs provided evidence that resident are supported to take part in age appropriate activities and are well supported to access the local community. A resident commented that they are supported by staff to attend Church service on Sundays. The Manager commented within the AQAA that “one person is visited weekly by a nun for communion”. Residents are supported to make decisions on various aspects of the running of the home. The AQAA highlighted that “some people have chosen to be involved in the interview process for hiring new staff members for the society.” Independence is promoted as much as possible in aspects of their day to day lives such as cleaning, laundry and food preparation with due consideration given to residents’ increasing needs. A copy of the weekly menu was on display in the kitchen area, which showed that residents are given a choice of nutritious meals. The mealtimes were observed to be flexible. Residents have access to dieticians for specialist advice. The staff are monitoring the fluid intake for one of the residents. Some gaps were noted in the recording of fluid intake for this resident. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have good support from the multi-disciplinary team, but require more support from staff to ensure they are offered regular health checks. Improvements are needed in the management of medication in the home so that residents are fully protected in this area. EVIDENCE: During the inspection we tracked the care of two residents living at the home and in doing so we checked their personal files. Each resident has a detailed support plan in place outlining their preferences for how they wish staff to support them with aspects of personal care. Residents are supported to maintain independence as far as possible in this area. The Westminster Society’s policy is to offer residents the option of same gender support wherever possible. Residents’ “My health” section within their personal files, outlining their health care needs was checked as part of the inspection. A Health Action Plan (HAP) was in place for the two residents case tracked during the inspection, however one resident’s plan was last undertaken in October 2006 and is due for an update. Details of the input from the multi-disciplinary team, is recorded in Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 14 residents’ personal file. This provided the evidence that residents have good support from the multi-disciplinary team and have access to GP, dentist, opticians, podiatrist, district nurses, speech and language therapists, Admiral nurse, psychologist, psychiatrist and dieticians. The records for one resident demonstrated that they were in need of a dental check, and steps must be taken to arrange this appointment. One of the residents currently has their fluid intake recorded. We checked their fluid charts and found that these were not being filled in consistently, with gaps appearing for long periods within the shifts. The home’s management of medication was checked during the inspection. The medication is received into the home mainly in blister packs. We could see evidence of regular audits being undertaken to check that the quantity of loose medication is correct against the Medication Administration Records (MAR). The Medication Administration Records during the inspection. A number of medication including tablets, creams and when medication was not administered clearly defined. for all five residents were checked gaps appeared in the recording of liquid medication. We also noted that the reason for this was not always There was secure storage for prescribed medication in the home. The home currently has controlled drugs in use and these were being recorded in a bound book. It is a recommendation that the home obtain a recognised controlled drug register book used specifically for recording the controlled drugs, which come into the home. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure that is accessible to people living in the home. Staff support residents to make complaints appropriately. EVIDENCE: The home has a complaints policy, which makes good use of pictures and symbols to make it accessible to people who use the service. Copies of the complaints policy was seen on the files of the two residents who we case tracked during the inspection. The home has introduced a computerised system for recording complaints that the home receives. The AQAA confirmed that, “electronic copies are forwarded to Senior Managers on a monthly basis”. A summary of the complaints received, are also kept in a written format and we found that the computerised records are now better completed. The Team Manager confirmed within the AQAA that, “people are supported to make complaints via tenants meeting and through contact with the support and management team, as well as in day services and other agencies.” We saw evidence that residents case tracked have been supported to voice their concerns, and copies of the completed electronic complaint records appeared on their files. Policies and procedures are in place for the management of residents’ finances and for safeguarding adults from abuse. The Team Manager confirmed within the AQAA that staff are also aware of the organisation’s whistle blowing procedures”. During this visit we checked the management of two people’s Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 16 finances. The person’s finances of both residents were well recorded and receipts were available for each transaction. We checked the accident and incident book during the inspection. This provided the evidence that incidents and accidents are recorded and where necessary have been reported to the Commission for Social Care Inspection. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is accessible to wheelchair users and provides specialist aids and equipment to meet the needs of the current residents. The home is comfortable, clean and hygienic. EVIDENCE: Flat 3 is a purpose built, wheelchair accessible, first floor flat, which is located in a residential area of Westbourne Park, close to shops and transport links. Each person living in the home has his or her own bedroom. Communal areas, bathrooms and toilets are shared. During the inspection we toured the building and viewed the communal areas and viewed two bedrooms. The home was comfortably furnished and well decorated. Since the last inspection, new flooring has been provided in the hallways, which are easier to keep clean. The carpet in the lounge is very stained and in need of replacing, and there are plans in place for doing so. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 18 Residents’ rooms are personalised and each person is supported to choose how their room is decorated. The Team Manager confirmed within the AQAA that, “residents are fully supported in choosing furnishings/decorations using samples and the organisations ‘choosing colour’ form.” There is a sufficient number of wheelchair accessible toilets and assisted bath / shower rooms available for residents. Since the last inspection, tracking hoists have been installed throughout the flat to support residents who require assistance with their mobility. There is a separate laundry room in within the flat, which is situated away from the kitchen/dinning areas. The laundry is equipped with machines, which have the required settings for washing clothes at correct temperatures. The home was clean, fresh and hygienic at the time of our visit. The home has a policy on place for preventing infection and managing infection control. The AQAA outlined that staff have attended training on the prevention of infection and management of infection control but records of staff training in the home did not reflect this. There is a need for the home to keep accurate training records. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff work well together to support residents, but there is a need to make sure that staff are appropriately trained and qualified. The home’s recruitment procedures include the involvement of residents in the selection process and are robust. EVIDENCE: On the morning of the inspection there were three members of staff on duty. Rotas were checked which also demonstrated that there are a minimum of two members of staff on duty at all times with mid shifts arranged to support residents to attend planned appointments, activities and outings. Each night there is a permanent waking night staff working in the home, who is supported if required by an on-call support worker who sleeps in the home. Currently there is one unfilled vacancy in the staff team, which at the moment is being filled using the Westminster Society’s bank staff. The recruitment of new staff, and the necessary pre-employment checks, are carried out by the Society’s Human Resources department. The preemployment checks include checks against the Protection of Vulnerable Adults list and a Criminal Record Bureau (CRB) check. During the inspection we saw Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 20 evidence that CRB checks had been undertaken on the current staff members working in the home. The Westminster Society’s recruitment procedures include the involvement of residents in the selection process. The AQAA confirmed that “two residents have been involved in recruitment during the past 12 months” and “recruitment will for Flat 3 will now take place from the service itself to allow for a more service orientated process and for more residents to meet prospective team members”. The AQAA indicated that 33 of the team hold a National Vocational Qualification in care at level 2 or above. A further 11 of the staff team are currently undergoing this training. The Service Manager confirmed that more staff will be enrolled on the training when places come available. The training records of four support workers were checked in the home during the inspection. Three of the four support workers did not have individual training records on their file. It was not possible therefore to evidence that staff are receiving all the necessary core training. Steps must be taken to ensure that staff training records are kept up-to-date and reflect the training undertaken by staff. It is a recommendation that the Manager considers introducing a training matrix illustrating training undertaken by staff and when they are due to have refresher training. The staff supervision records were not available during the inspection and so we were not able to check these. These records will be checked at our next inspection. Consideration should be given to providing Service Managers with access to these records in the absence of the Team Manager and the Assistant Team Manager. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has not had a Registered Manager for over two years, although the designated Team Manager has relevant qualifications and experience to run the home. The home’s quality assurance systems include seeking the views of residents, but a better system for self-monitoring is required to improve the home’s record keeping. The health and safety of residents are not always protected. EVIDENCE: There have been further changes to the Management of the home since the last Key inspection in June 2007. The current Team Manager has been in post since December 2007. On the 3rd January 2008, we undertook a random inspection of the service and a requirement was made that the new Manager must register with the Commission’s Regional Registration Team. The Team Manager confirmed within the AQAA that she has obtained a CRB through the CSCI. The service has now been without a Registered Manager for over two years. Steps must be taken to ensure that the Team Manager lodges an Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 22 application to register as the Registered Manager of the home without further delay. Information provided within the AQAA provided the evidence that the Team Manager holds the National Vocational Qualification at level 4 and the Registered Manager’s Award. She continues to update her skills and knowledge through attending various training courses and conferences in subjects such as the Mental Capacity Act and End of Life Care. The Service Manager confirmed during the inspection that in December 2007, the Westminster Society supported residents to share their views on what their “housing dreams” were. We checked the records of visits undertaken on behalf of the Registered Provider. No report was available for January, April and May 2008. Steps must be taken to make sure that these visits take place on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. During the inspection we checked a range of records, which included medication administration records, daily logs and fluid intake monitoring charts. We noted some gaps in some of these records. Steps must be taken to improve these. It is recommended that regular auditing of the record keeping in the home is undertaken to ensure that standards in this area is improved. The home’s health and safety documentation was checked and we noted during the inspection visit, that there were gaps in the weekly testing of the fire alarm. This issue was also identified at a random inspection visit to the home on the 3rd January 2008, where a requirement was issued. We noted that on the 07/08/08 during a fire drill, staff recorded that the lounge door was not closing properly when the fire alarm was sounding. It was not clear from the records what was the cause of the non-closure of the fire door when the fire alarm was sounding and the records did not clearly outline the action that had been taken by staff to rectify this problem. It was not possible to ascertain through checking the home’s records if this problem had been resolved or if the fire door remained faulty. We note that a resident smokes in the home and we are concerned in the event of a fire that should fire doors be faulty, and fail to close properly that residents and staff are put at serious risk. When we toured the home, we noted that the COSHH cupboard was left open with the key in the door. The laundry door where the COSHH cupboard is located was also open. An immediate requirement notice was issued to ensure steps are taken to rectify the issues identified above. During the tour of the building we noted that there was food in the fridge that had not been date labelled. We also noted that there was cooked food that had been left in the oven from the previous day. It was not clear from checking the AQAA or the staff training records held in the home, if staff have attended training in food safety and other core training. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 23 Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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 2 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 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X 2 2 X Great Western Road, Flat 3, 22-24 DS0000010877.V367939.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 YA9 Regulation 13 Timescale for action Managers and staff must make 01/10/08 sure that risk taking policies are reviewed regularly and especially when a person’s support needs change, to make sure that residents are cared for safely. Steps must be taken to ensure 01/10/08 that residents’ health is monitored through regular health checks, including dental checks. To ensure that residents are 01/10/08 protected, the recording of medication administered must be improved. When medications are not administered, the correct endorsements must be used and fully explained. Steps must be taken to ensure 01/10/08 that staff training records are kept up-to-date and reflect the training undertaken by staff. The home’s new Manager must 01/10/08 apply to the Commission for registration. Original timescale of 31/03/08 not met this is a repeat requirement. Steps must be taken to make 01/10/08 sure that visits on behalf of the Registered Provider take place DS0000010877.V367939.R01.S.doc Version 5.2 Page 26 Requirement 2. YA19 13 (1) 3. YA20 13 (2) 4. YA35 17 5. YA37 9 6. YA39 26 Great Western Road, Flat 3, 22-24 7. YA41 17 8. YA42 23 (4)& 17 17 & 23 (4) 9. YA42 10. YA42 23 (4) 11. YA42 13 (4) 12. YA42 13 (3) (4) on a monthly basis. The reports from these visits must be forwarded to the home promptly so that any necessary action identified during the visits can be taken without delay. The standards of record keeping in the home must be improved to ensure that they are accurate and up-to-date. Steps must be taken to ensure fire alarms are tested on a weekly basis. Immediate requirement Staff must clearly document the reason/error for the fire doors not closing properly. When a fault is identified in any of the fire doors, the fault must be reported immediately and the action taken to report and rectify the fault clearly documented. Immediate requirement Staff must ensue that the lounge fire door is fully operational when the fire alarm bell sounds i.e. that the door has been fixed and closes properly. Immediate requirement To protect residents from harm, the COSHH cupboard must be kept locked at all times. Immediate requirement Staff must ensure that they follow guidelines for the safe handling and storage of food. 01/10/08 13/08/08 13/08/08 13/08/08 13/08/08 01/10/08 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 YA20 Good Practice Recommendations The home should obtain a recognised controlled drug DS0000010877.V367939.R01.S.doc Version 5.2 Page 27 Great Western Road, Flat 3, 22-24 2. 3. YA35 YA36 4. YA41 register book used specifically for recording the controlled drugs, which come into the home. The Manager should consider introducing a training matrix illustrating training undertaken by staff and when they are due to have refresher training. Consideration should be given to providing Service Managers with access to supervision records in the absence of the Team Manager and the Assistant Team Manager. Regular auditing of the record keeping in the home should be undertaken to ensure that standards are improved in this area. Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Great Western Road, Flat 3, 22-24 DS0000010877.V367939.R01.S.doc Version 5.2 Page 29 - 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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