Inspection on 28/11/07 for H.C.S. (Enfield) Ltd (Holtwhites Hill)

This inspection was carried out on 28th November 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

H.C.S. (Enfield) Ltd (Holtwhites... 12/01/07

H.C.S. (Enfield) Ltd (Holtwhites... 27/10/05

H.C.S. (Enfield) Ltd (Holtwhites... 27/09/04

H.C.S. (Enfield) Ltd (Holtwhites... 09/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 H.C.S. (Enfield) Ltd (Holtwhites Hill) 221 Holtwhites Hill Enfield Middlesex EN2 8BX Lead Inspector Jane Ray Key Unannounced Inspection 28th November 2007 9:30 H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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 H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service H.C.S. (Enfield) Ltd (Holtwhites Hill) Address 221 Holtwhites Hill Enfield Middlesex EN2 8BX 020 8342 0537 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) H.C.S.(Enfield) Ltd Aisha Bibi Cassam Capina Care Home 8 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to eight adults of either gender with a learning disability (LD) who may also have a physical disability (PD). 12th January 2007 Date of last inspection Brief Description of the Service: Holtwites Hill is a care home for eight younger adults with a learning disability. Four of these places are also registered for younger adults with a physical disability. The home is owned by M.H.J. Crausaz, which is a company specialising in the care of people with learning disabilities, which also owns other homes in the Enfield area. The service is located near to Enfield. The house is detached and there is a downstairs extension offering fully disabled accessible bedrooms. Two of these rooms have an en suite shower room and there is a separate disabled accessible bathroom. There are a further four bedrooms upstairs. There is a comfortable lounge, a dining area and a conservatory. Upstairs there is a small multi sensory room. The staffing of the home consists of the manager, deputy manager and a team of care workers. There are three to four care staff working on a morning and late shifts and the night shift is covered by two waking night staff. All the people who live at the home have a day activity provided either at a day centre or at the home. At the time of the inspection there were seven residents living in the home. Fees charged at the home range between £900 and £960 per week. A copy of this Inspection report can be requested directly from the home or via the CSCI website (web address can be found on page 2 of this report.) H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 28 November 2007 and was unannounced. The inspection lasted for four hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to speak to and observe the support given to five of the seven current service users. The inspector was also able to spend time talking to the manager as well as two members of care staff who were working in the home. The inspector did a tour of the premises and also looked at a range of records including service users records, staff files and health and safety documentation. The home had provided the inspector with a completed selfassessment questionnaire (AQAA) prior to the inspection. What the service does well: The home provides a high standard of care and support to a group of residents who have a range of complex physical care needs. The home by working consistently and professionally with the people living in the home in partnership with other care professionals is able to support them to keep well and make progress on an individual basis. The manager and staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their communication needs. The residents were also observed to have a good relationship with the staff. The residents are supported to have their individual needs met by a key working and care planning system. They are also supported to access a range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well-established and very stable team of staff who are being supported by a manager. The home is very comfortable and homely and the residents each have a single bedroom that is personalised to their taste. The home also has access to a vehicle that is helpful in facilitating some of the community activities. The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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 H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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): Standards 1,2,3,4 and 5 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will be assessed and that the service can meet their needs. The service recognises the needs of the residents and works with other care professionals to provide training in these areas. EVIDENCE: I read the statement of purpose and service user guide. Both of these documents are in a user-friendly format and are clearly written, accurate and contain all the necessary information. I inspected four case notes for people living in the homes and these all contained detailed assessments as part of the person centred plans prepared by the home. This information was comprehensive and provided a good basis for the care plan goals that were in place. In addition the residents also had assessments provided by social services. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 9 I discussed the current needs of the people living in the home with the manager and the care staff. One of the women living in the home has recently been diagnosed as having diabetes. The healthcare professionals monitor this healthcare need. The manager explained that she has spoken to the district nurse and is trying to arrange training for the staff team on diabetes. No new people have moved into the home in the last year. The admission process is in the statement of purpose. This explains that potential people wishing to consider moving to the home are able to make visits to the service as part of this process. I looked at the contracts between the home and the residents for four people who live in the services. They all had a contact in place that included all the necessary information and was correctly signed. This again was in a clear userfriendly format. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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): Standards 6,7,8 and 9 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to have a person centred care plan that reflects their individual wishes. They are supported by the staff to express their views and make choices in their daily lives. EVIDENCE: I inspected four case notes for the people living in the home. Each person has detailed individual person centred care plans. These incorporate goals that are realistic and clear. Everyone living in the home had their care plan goals reviewed in the last six months. All of the people living in the home had participated in a review meeting with their care manager in the last year. The record of this meeting had been prepared and was available in each persons case notes. It was positive to see that where action had been agreed at the meeting that this had been implemented and the details had been recorded in H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 11 the persons care plan. This included ongoing work with care professionals, having more activities and purchasing new items. The residents have a file in their bedroom that includes the person centred plan. From looking at these files it could be seen that some of this information is out of date and needs to be replaced with the most current data. The four people living in the home all had a named key worker. Two members of staff when asked about their key worker role were able to describe fully how this is implemented, including going out with the resident and attending their review meetings. None of the residents have challenging behaviours but the person centred plans place a strong emphasis on understanding the resident’s non-verbal communication and linked behaviour issues to communication difficulties. Clear guidelines are in place to support improved communication with the residents from understanding their gestures and facial expressions to the use of pictures to support people making choices. The four residents whose case notes were inspected all included individual risk assessments covering all areas of potential risk and these identified what action the home would take in response to the identified risks whilst at the same time promoting each persons independence. These had been reviewed and were up to date. Each person living in the service has a record of the individual arrangements in place to support them to manage their personal finances. Throughout the inspection the staff were observed interacting with the residents and I could see that the residents felt relaxed and were enjoying the contact. Staff responded quickly to non-verbal requests from the residents and could tell when they wanted a drink or to listen to music. The staff explained that they do have meetings to plan birthdays or activities and use pictures or magazines to help people make choices. The manager said she has approached a local advocacy service to provide additional support at the residents meetings but unfortunately no-one is available at present. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12,13,14,15,16 and 17 People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to have full and active lifestyles that reflect their interests and offer opportunities for the development of new skills. They also enjoy contact with their relatives. EVIDENCE: The manager explained that the people living in the home access a range of activities based on their individual needs and interests. This includes going to a number of day centres, with two residents attending full-time and four parttime. The manager explained that one of the people in the home is being referred to a service that can meet his specific needs relating to his visual impairment. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 13 The leisure activities the residents participate in include going to shows, shopping, bowling and eating out. Each person has a daily record and four were inspected and these showed that they were enjoying an active lifestyle and being supported to access local community resources. On the day of the inspection three of the residents went bowling. The residents have access to a company vehicle that is wheelchair accessible. The staff explained that one of the residents practices her Muslim religion through daily prayers and not eating pork. They also observed that some of the residents who are Christian enjoy listening to hymns on the television. The manager and staff explained that three residents went this year to Eurodisney and six went to Blackpool. The manager is planning a weekend break for two of the other residents. The staff explained that the residents are supported to participate in daily living skills in line with their individual care plans. One resident can bring her washing to the laundry and help take her dirty cup to the kitchen. The home organises creative activities including cookery where residents are supported to feel the ingredients and help mix the food. Their individual care plans also included how they were being supported to develop their independent living skills. The staff explained that all the people living in the home have contact with their families. They are made welcome in the home or the residents are supported to go to their family homes. They also said that whilst they do not have specific friendships they do feel that some of the residents are very close to each other. It was observed that there was a comfortable atmosphere in the home with the staff communicating appropriately with the residents. The residents were observed to be relaxed with the staff, smiling and making good eye contact. The manager and staff explained that the routine depends on each person and their activities. One resident likes to stay up later. The resident’s who go to bed earlier in the week as they go to the day centre, may choose to stay up later at the weekend. It was observed at the start of the inspection that people had got up slowly and had been supported with their personal care at a relaxed pace. I looked the four-week rolling menu that offers healthy choices. Three of the residents are at risk of choking and need the food to be very soft and finely chopped. One resident who is diabetic is offered sugar free drinks and follows a healthy eating menu. I observed the residents having breakfast and the staff supported them slowly and communicated with them throughout the meal. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 and 21 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will be assisted to access healthcare appointments to get the support they need. Medication systems within the homes are well organised although a few improvements are needed to the recording. EVIDENCE: I observed during the inspection that the people living in the home were given support with their personal care based on their individual needs. Everyone was appropriately dressed and had nice haircuts. It was also noticed that everyone had been offered a shower or a bath. The staff were observed cutting one residents nails in the lounge and it would have been better if this had taken place in his bedroom. The healthcare records were inspected for the four people living in the home. They had all been supported to access the GP, dentist and optician for their H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 15 primary healthcare checks in the last 12 months. In addition the resident’s receive input for their specialist healthcare needs and it is also positive to note that a number of other therapy services including physiotherapy, occupational therapy, dietician and speech and language therapy have been accessed as required for specialist advice. The residents also have input as required from the district nurse. The home uses a blister pack medication system supplied by a local pharmacist. None of the residents self-administer their medication. The medication administration records were inspected. The medication entering the home is not always recorded appropriately on the medication administration record. There is a separate record for medication returned to the pharmacist. One person takes their lunchtime medication for the whole week on a Monday to the day service and this needs to be recorded on the medication administration record. The medication available was correct and was not out of date. Some of the residents have PRN medication and clear guidelines are in place for when this should be given. Training records were inspected and all the permanent daytime staff had received medication training. The medication storage cupboard is in the office and the temperature is monitored daily. Since the last inspection one of the residents in the home has sadly died after a short illness. He was in hospital but support was provided by staff from the home. Some of the staff and residents attended the funeral. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the correct systems are in place should they need to complain and that staff training and procedures are in place to protect them from the risk of being abused. EVIDENCE: The inspector looked at the complaints record and saw that there had been no complaints since the previous inspection. The complaints procedure was also inspected and this was in a format accessible for the residents. The inspector saw that the home had a protection of vulnerable adults procedure prepared by the London Borough of Enfield. The staff training records were inspected and showed that whilst only seven of the permanent staff had received training on the protection of vulnerable adults, further training is booked in two months time. I spoke to two staff during the inspection and they both showed a good knowledge of the complaints and adult protection procedures. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 17 The inspector looked at the personal finances for two service users where the company acts as their appintee. These showed that their benefits were being paid directly into their building society accounts. There are records of expenditure with receipts available. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,27,28 and 30 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are benefiting from an environment that is clean, tidy and homely. Work is needed to refurbish the upstairs shower room and bathroom. EVIDENCE: I did a tour of Holtwhite Hill and looked at all of the bedrooms. The home was clean and tidy throughout. The laundry is on the ground floor and the soap dispenser on the washing machine was broken and the manager said the machine is being replaced. There is adequate communal space available in the lounge, conservatory and kitchen. The downstairs of the home is designed to be fully accessible for H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 19 people with a physical disability and has an accessible bathroom and two ensuite shower rooms. Each resident’s bedroom was well furnished and was homely and personalized. A sensory room is available on the first floor. Since the last inspection the home has replaced some bedroom carpets, redecorated some bedrooms, replaced the kitchen work surface and some of the electrical equipment in the kitchen. I observed that the upstairs bathroom and shower room is in need of refurbishment. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a very stable and experienced team of staff who are supported with an ongoing programme of training. Care must be taken to ensure all the recruitment checks are in place and that staff have access to regular supervision. EVIDENCE: The inspector looked at the staff rota. The staff team consists of a manager, a deputy manager, a cleaner and a team of fifteen carers and one bank carer. The staff turnover is low with only two staff leaving in the past year and most staff working at the home for a number of years. The manager explained that the home does not use agency staff. During the day there are usually four staff working. At night there are two waking members of staff. The manager explained that twelve of the staff have completed the NVQ level 2 in care and two other staff have started the course and are due to complete H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 21 the qualification shortly. This means that the home has more than 50 of the care staff who have completed an NVQ level 2 in care. The recruitment checks were inspected for four staff. One member of staff had a CRB disclosure from a previous employer. The manager explained that this had been an oversight and the new CRB was complete and being sent to the home. One other member of staff did not have a copy of her ID or contract in the file held in the home. The manager said these documents were probably in her file at the Head Office. The manager needs to ensure the staff records in the home are all complete. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. The staff members spoken to during the inspection confirmed they attended these meetings. The induction record was inspected for one new member of staff. This consisted of a comprehensive induction checklist to work through based on the Skills for Care guidance and had been appropriately completed. The staff training records were inspected for four staff. These showed that staff had received most of the essential training. The training programme arranged by the company was also inspected and this provides a rolling programme for staff to access as required. It was however noted that some staff need to receive epilepsy training, especially staff working at night. The staff supervision records were inspected for four staff. The staff had all received individual supervision but this had not taken place on a regular basis. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,38,39 and 42 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home is overseen by an experienced and appropriately qualified manager. Their health and safety is protected by the appropriate measures being in place although work that has started to update the fire safety risk assessment and emergency plan needs to be completed. EVIDENCE: The manager has completed the registration process and was observed managing in the service in a knowledgeable and capable manner. The staff H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 23 said that they feel confident they can raise issues with the manager and these will be addressed. The manager also explained that she has completed the registered managers award but needs to undertake the NVQ level 4. The registered person monthly monitoring visits to the home have been delegated to other managers and are taking place as required with the reports being sent to the CSCI. The latest quality assurance information was inspected. This was completed in August 2006. Questionnaires had been completed by staff acting on behalf of the service users and by staff themselves. The outcomes from this have been summarized in to action plans. The manager explained that this years questionnaires had been sent out and replies were being sent to the Head Office. The health and safety training records were inspected for all staff. They had mostly completed this training and where there were gaps further training sessions were planned. It was however noted that five staff need fire safety training and only one person who works at night had completed first aid training and no further training had yet been booked on these topics. The fire safety measures were inspected. The fire appliances and fire alarm had been serviced. Weekly fire alarm and emergency light checks and monthly drills are recorded as taking place. A fire safety risk assessment is available and is in the process of being reviewed. The fire safety emergency plan needs to be completed and the manager explained that she had the format available to complete this work. The self-assessment (AQAA) confirmed that current certificates were available to confirm the maintenance for the gas system, electrical installations and portable electrical appliances. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 4 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x x 2 x H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 The registered person must record medication entering the home and being sent to the day centre on the medication administration record. The registered person must upgrade the upstairs bathroom and shower room. The registered person must ensure that all staff have a CRB arranged by the company and that copies of all their employment details are available in the file in the home. The registered person must ensure all staff have completed epilepsy training. The registered person must ensure all staff are supported to have regular supervisions. The registered person must prepare a fire safety emergency plan and update the risk assessment. The registered person must ensure staff have completed training on fire safety and first aid to protect the residents, especially at night. Timescale for action 31/12/07 2. YA24 23(2)(b) 30/04/08 3. YA34 19(1)-(5) 31/12/07 4. 5. 6. YA35 YA36 YA42 18(1)(c) 18(2) 23(4) 31/01/08 31/01/08 31/01/08 7. YA42 13(4) 28/02/08 H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA11 Good Practice Recommendations The registered person should ensure the resident files in their bedrooms, contains up to date information. The registered person should ensure personal care takes place in people’s bedrooms to preserve their privacy. H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI H.C.S. (Enfield) Ltd (Holtwhites Hill) DS0000010576.V350832.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!