Inspection on 22/10/07 for H.C.S. (Enfield) Ltd (Southbury Road)

This inspection was carried out on 22nd October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

H.C.S. (Enfield) Ltd (Southbury... 18/11/08

H.C.S. (Enfield) Ltd (Southbury... 05/06/08

H.C.S. (Enfield) Ltd (Southbury... 19/04/07

H.C.S. (Enfield) Ltd (Southbury... 25/04/06

H.C.S. (Enfield) Ltd (Southbury... 06/09/05

H.C.S. (Enfield) Ltd (Southbury... 24/05/05

H.C.S. (Enfield) Ltd (Southbury... 16/06/04

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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 (Southbury Road) 20-24 Southbury Road Enfield Middlesex EN1 1SA Lead Inspector Jane Ray Key Unannounced Inspection 22nd October 2007 9:30 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 (Southbury Road) DS0000010582.V346356.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 (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service H.C.S. (Enfield) Ltd (Southbury Road) Address 20-24 Southbury Road Enfield Middlesex EN1 1SA 020 8364 6923 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 ** Post Vacant *** Care Home 12 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five specific service users who are currently resident in the home and are over 65 years of age may remain accommodated in the home. This condition must be reviewed at such times as any of the specified service users vacate the home. 19th April 2007 Date of last inspection Brief Description of the Service: Southbury Road is a care home managed by HCS (Enfield) Ltd and the registered provider is Mr Crausaz. The service is registered to provide 12 places to younger adults with a learning disability. The home was originally established to provide support to older people with a learning disability but over the years the service has been extended to younger adults with a learning disability and high physical care needs. The home currently has 5 residents who are over the age of 65. The home consists of a group of terraced houses, which were combined into one dwelling. Each resident has a large single bedroom. The home has a lift to the first floor. The people with higher physical care needs have bedrooms on the ground floor. There is one assisted bathroom on the ground floor. There are two dining areas. People can either eat at a table in the large kitchen area or alternatively in a small separate dining area, where a few of the more independent residents choose to eat. There are two lounges on the ground floor. Most of the residents also have a TV and a music system in their own rooms. There is a conservatory at the rear of the house, which acts as a sitting area and as a smoking area. There is a very pleasant garden with some sensory features. Staffing consists of a manager, deputy and team of care staff working on a morning and afternoon shift. The night shift is covered by two waking night staff. The home also has a domestic and cook who work on weekdays. The weekly fees of the home range between £883.00 and £1380.00. The level of the fees depends on the support and services provided. The provider must make information available about the service, including inspection reports to service users and other stakeholders. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 22 October 2007 and was unannounced. The inspection took four and a half hours to complete. The inspector was able to spend time with nine of the current residents. The manager and four care staff who were on duty assisted the inspector. The inspector did a full tour of the premises and also looked at all the relevant records including service user records, staff files and health and safety information. The is the second key inspection since April 2007. This was arranged in response to the significant number of requirements made at the previous inspection. The aim is to look at how well the service is meeting the key National Minimum Standards for Younger Adults. The inspector also assessed the progress made by the service in meeting the requirements from the previous inspection. The home also prepared a self–assessment (AQAA) and this was submitted to the Commission for Social Care Inspection prior to the inspection. The inspector would like to thank the residents and staff for their assistance with the inspection process. What the service does well: The home provides a reasonable standard of care and support to a group of people with a range of complex needs. Two of the people who live in the home were able to tell the inspector how much they enjoy living in the home and how much they value their friendships with each other and their positive relationships with the staff. One person said “its alright here”. The home is supporting the residents to access healthcare professionals as required. The staff demonstrated a good knowledge of the people who live in the home and were able to recognise their individual needs and how to respond appropriately to them. The residents are supported to have their individual needs met by a comprehensive person centred care planning system. There is also a keyH.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 6 working system in place and residents are aware of the support they receive from their key-worker. The people who live in the home all feel able to express their views on the running of the home and their daily lives. Residents say they are happy with the food they are offered. One person said “I like the food although I don’t want to eat too much”. The home is very clean, comfortable and homely and the service users each have an attractive single bedroom. What has improved since the last inspection? What they could do better: H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 7 There are a few areas for improvement identified at this inspection. Staff need to have their epilepsy training updated. The resident care plans need to have individual goals for each person. The residents need to be supported to access more community based leisure activities. A record of the food eaten for supper needs to be recorded to ensure that residents who have sandwiches during the day are offered a cooked meal in the evening. The home needs an ongoing maintenance and decoration programme. Staff need to be supported to have regular supervision. The manager needs to complete the registration process. Staff need to complete fire safety training with an appropriately qualified trainer. Medication being received in the home needs to be recorded. It is also recommended that residents are supported to be an independent as possible such as carrying their own money when they go shopping. It is also suggested that the manager finds ways of informally consulting with the residents to get their views on the operation of the home. The home should also keep a record of each residents weight in their records in the home. The staff need ongoing support to communicate effectively with the residents. 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 (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 8 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 (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 9 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 and 3 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 who live in this service can be assured their needs will be assessed as part of their admission process. Staff have benefited from additional training to meet the specific needs of the people living in the home such as training on diabetes and mental illness. EVIDENCE: We looked at the new statement of purpose and this was comprehensive and provided all the necessary information in a clear manner that would be understood by relatives and care professionals. We looked at the case notes for four people who live in the home including the person who moved most recently to the service. The residents all had comprehensive assessments prepared by the home. These assessments form the basis for the care plans. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 10 We discussed the current needs of the people who live in the home with the manager and inspected the staff training records. This indicated that the residents have a number of very specific individual needs including one person who has diabetes and another person who has mental health issues. The manager explained that a local community nurse has provided training sessions on dementia, diabetes and mental health. These sessions were also reflected in the staff training records. The training records do however also indicate that twelve of the staff now need their epilepsy training updated. The manager said she has contacted the local learning disability team to arrange this training but is still waiting for a date. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 11 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. The people living in the home can be confident that they will be supported to have an individual person centred care plan and risk assessments. They would however benefit from having individual goals with the progress being monitored on a regular basis. EVIDENCE: We inspected care plans for four people currently living in the home. We also spoke to the staff about the care plans. All four of the people whose records were inspected had new person centred comprehensive care plans in place. These were clearly laid out and covered all aspects of each persons needs in a user-friendly language. The care plans had all been prepared in the last six months. The people living in the home had all been supported to have a review H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 12 meeting with their care manager and relatives in the last couple of months apart from one person where they are waiting for social services to provide a date. The minutes of these reviews were not all available yet. It was noted that the new care plans did not have individual goals or a review process. The manager explained that for some of the residents the aim was to maintain their quality of life rather than developing new skills. We spoke to three of the people living in the home about their key workers and they knew who they were and said they had a good relationship with them. The staff were asked about their key working role and were able to describe the support they gave especially with shopping and healthcare appointments. We read the risk assessments for the same four people who live in the home. It was possible to see that an effort had been made to identify areas of personal risk and look at how this can be managed without place unnecessary restrictions on people. Where restrictions are needed, for example the staff hold one persons cigarettes on her behalf, the reasons for this are clearly recorded. The risk assessments also reflected each persons health care needs such as diabetes or epilepsy. The arrangements to support the people living in the home to manage their own finances were recorded in all of the care plans that were viewed. On the day of the inspection one of the residents was being visited by an advocate. One of the other residents explained that unfortunately her befriender has moved out of the area and is no longer able to visit. The manager explained that she arranged one resident meeting but this was not enjoyed by a number of people living in the home. We recommended that consultation takes place more informally such as chats during meals. It was however observed that the people living in the home felt able to express their wishes and the staff responded to them appropriately. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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): Standards 11,12,13,14,15,16 and 17 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 supported to develop their daily living skills and are also enabled to follow their own routine. It is however evident that there are still not enough community based activities available to enable the residents to enjoy interesting and active lifestyles. EVIDENCE: We spoke to the people living in the home and the staff about the activities. The manager explained that out of the ten people currently living in the home, three go to a day service four or five days a week. One person goes to a day service one day a week and one person is funded to have one hour of 1:1 staffing a day. The residents were able to tell me that they were occasionally going out and said this included going shopping, eating in restaurants and H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 14 visiting the cinema. The staff also explained that they now have access to a minibus and driver one day at the weekend and this means more people can go out. The activity records were inspected for five people living in the home and there was limited evidence of people going out other than to day care and healthcare appointments. One resident said, “I would like to do more activities”. Where they are able to do so, residents were observed making themselves a drink and a snack. One person told me how she cleans her bedroom with the support of her key-worker. One resident said that when she goes shopping the staff look after her money for her, but she wondered if she could hold her own money. In terms of holidays the manager and staff explained that two of the residents are going to Eurodisney and one resident is going on a swimming holiday in Tenerife in the next few weeks. We were able to observe during the inspection that the people living in the home were able to follow a routine of their choice. People were getting up at different times and one resident said how she liked to stay up in the evening and watch the television in her bedroom. We saw the four-week menu and spoke to the staff member who was preparing the food. The lunch was healthy and nutritious and there was adequate fresh food available. The record of the food eaten was inspected but this had not been fully completed. Where the suppers were recorded these showed the residents as all having a sandwich and sometimes soup. We were still concerned that people who do not have a cooked lunch at the day centre were not having a cooked meal in the evening. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 15 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 and 20 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. The people living in the home are supported in a manner that protects their privacy and dignity. The resident’s healthcare needs are promoted. Some improvements to the medication administration system are identified. EVIDENCE: We observed during the inspection that the staff were supporting the people living in the home to receive personal care in a manner that preserved their privacy and dignity. It was however observed that one member of staff spoke to a resident from behind her, rather than sitting at her level which would have enhanced the communication. Another member of staff was also observed using very little verbal communication during her interaction with the residents. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 16 The residents were observed to be wearing nice clothes and to have had haircuts. Some of them were able to talk about how they had been out shopping. We looked at the healthcare records for four of the people living in the home. They had all been supported to access a range of healthcare professionals including the GP, dentist, optician and other outpatient appointments according to their individual needs. One resident has been in hospital since the last inspection linked to his epilepsy and this input had been recorded. The manager explained that she has arranged for all the residents to attend a monthly health promotion clinic where they will be weighed and have their blood pressure checked. They have attended one clinic so far. It is recommended that the home also keeps a record of each persons weight in addition to the records held at the clinic. I looked at the medication, administration records and staff training records. The home uses the Lloyds pharmacy medication administration system. The medication is stored in a locked cupboard in the office and the temperature of the cupboard is checked daily. The home is not recording on the administration record the medication received when it is in the blister packs, but this record should still be completed to ensure there is an audit trail for each medication available. The administration records were correctly completed. There was no out of date or no longer used medication in the cupboard. The training records show that medication training is up to date. There is no record of the staff signatures for the staff who administer the medication. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 17 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. The people living in the home have access to an appropriate complaints procedure and are protected by staff having received up to date training on safeguarding vulnerable adults. EVIDENCE: The home has an appropriate complaints procedure. The complaints record was inspected and there have been no complaints recorded since the previous inspection. Since the last inspection most of the staff have received training on safeguarding vulnerable adults and one staff member said that this had been useful. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 can know that they are living in an environment that is clean and comfortable. Ongoing maintenance is required as parts of the home are becoming shabby. EVIDENCE: We did a tour of the home with the manager. The building consists of three terraced houses that have been joined together. The building is located on a main road within easy reach of Enfield Town and local shops. The building is on two levels and a lift is available. The layout of the building means that there is a long corridor particularly on the upper floor. Each person living in the home has an individual bedroom. These are gradually being redecorated. The bedrooms are comfortable and individually personalized. Since the last inspection a number of residents have bought H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 19 themselves new televisions for their rooms and all the televisions are safely installed. Toilets and bathrooms are found throughout the house, but the disabled accessible bathroom on the ground floor is the bath used by most of the people living in the house. Since the last inspection the flooring in the bathroom and toilets has been replaced. The home has a large kitchen / dining area. There is a large and a small lounge. Three of the people who live in the home, also eat in the small lounge. A small conservatory area at the rear of the house is the smoking area. Since the last inspection residents have purchased their own individual armchairs and these are very comfortable. We observed that the home was clean throughout and there were no unpleasant odours. The utility room had a washing machine and tumble drier and these were both working. The office is located on the first floor and now has a working fax machine. The manager explained that access to the internet is being implemented. It was observed that parts of the house were starting to appear worn and in need of minor repairs or redecoration. This includes the external decoration. An ongoing maintenance and decoration programme needs to be in place. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 stable staff team working in adequate numbers to meet their needs and maintain their safety. Staff need to be supported to work effectively through regular individual supervision. EVIDENCE: The rota showed that there are 21 staff working at Southbury Road of which there is one manager, one deputy, 17 care staff, 1 cook and 1 cleaner. The staff turnover is low and since the last inspection a deputy manager has been appointed. The staffing levels are four care staff on the day shifts and two waking night staff. The manager explained that twelve staff have completed an NVQ in care at level 2 or 3. An additional three staff are currently studying for the qualification. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 21 We looked at the recruitment records for two staff recruited in the last 12 months and three staff who have worked in the home for a longer period. It was found that all the staff had two references and a CRB disclosure. One member of staff did not have ID available. All the staff had a contract of employment. We inspected the training records. The home has a training matrix and this was up to date and so it was possible to accurately tell who had received training and when this had taken place. An ongoing training programme is in place including all the mandatory training. We spoke to one new member of staff and he was able to describe his induction and arrangements for shadowing until he was able to work independently. We looked at the supervision records for the three staff. They had all received individual supervision but this had not taken place on a regular basis. The manager acknowledged that she had not managed to complete regular supervisions for all the staff. The deputy manager has supervision skill training booked so she will be able to assist with the staff supervisions. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 and 42 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 home has a manager with the appropriate skills and experience but she needs to complete the registration process. Progress has been made to improve fire safety in the home but staff still need to receive training in this area. EVIDENCE: We were able to spend part of the inspection with the manager and could see she has considerable skills and experience which means she is managing the home very effectively. The manager still needs to complete the registration process. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 23 Since the last inspection the home has been inspected by a fire officer from the LFEPA and this has resulted in them carrying out urgent work to improve fire safety in the home. Most of this work is complete although the lift shaft still needs to be fitted with a seal to prevent smoke travelling around the building in the event of a fire. I looked at the staff training records and these showed that the staff team still need fire safety training. The manager said she was proposing to use some internal training using a computer programme but a trainer is needed so staff know how to implement the training within the service. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.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 2 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 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 1 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x x x x 1 x H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard YA3 YA6 Regulation 12(1) 15(2)(b) Requirement The registered person must arrange for the staff to have their epilepsy training updated. The registered person must ensure the care plans include individual goals and are reviewed on an ongoing basis. The registered person must support the service users to have regular access to ongoing community based leisure activities. This requirement is restated from the previous inspection. Timescale of 31/5/07 is unmet. The registered person must keep a record of food consumed in the evening to ensure the residents are eating a healthy and nutritious diet. This requirement is restated from the previous inspection. Timescale of 15/5/07 is unmet. The registered person must ensure the medication received is recorded on the medication administration record. A record of staff signatures for staff who administer medication must be DS0000010582.V346356.R01.S.doc Timescale for action 31/01/08 31/12/07 3. YA13 16(2)(n) 31/12/07 4. YA17 16(2)(i) 15/11/07 5. YA20 13(2) 30/11/07 H.C.S. (Enfield) Ltd (Southbury Road) Version 5.2 Page 26 6. YA24 23(2)(b) 7. YA34 19(1)-(5) 8. YA36 18(2) 9. YA37 9(1) 10. YA42 23(4) kept with the medication administration records. The registered person must ensure an ongoing maintenance and decoration programme is implemented in the home. The registered person must ensure all staff have a copy of their ID in their staff records. This requirement is restated from the previous inspection. Timescale of 31/5/07 is unmet. The registered person must ensure each member of staff receives regular supervision to ensure their work is an appropriate standard. This requirement is restated from the previous inspection. Timescale of 31/5/07 is unmet. The registered person must ensure the manager completes the registration process. This requirement is restated from the previous inspection. Timescale of 30/6/07 is unmet. The registered person must ensure all the staff have undertaken fire training. This requirement is amended and restated from the previous inspection. Timescale of 30/6/07 is unmet. 31/01/08 15/11/07 30/11/07 31/01/08 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 27 No. 1. 2. Refer to Standard YA8 YA16 Good Practice Recommendations The registered person should continue to develop systems for consulting with the residents about issues relating to the operation of the home. The registered person should continue to explore ways to support the residents to further develop their independence such as holding their own money when out shopping. The registered person should continue to encourage the staff to communicate effectively with the residents. The registered person should keep a record of the residents weights in the home. 3. 4. YA18 YA19 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V346356.R01.S.doc Version 5.2 Page 28 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. 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