Inspection on 16/11/06 for Hainault

This inspection was carried out on 16th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hainault 11/11/08

Hainault 18/12/07

Hainault 09/09/05

Hainault 04/05/05

Hainault 07/09/04

Hainault 11/05/04

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 Hainault 35 Lesney Park Road Erith Kent DA8 3DQ Lead Inspector Maria Kinson Key Unannounced Inspection 16th November 2006 09:15 Hainault DS0000038196.V307002.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 Hainault DS0000038196.V307002.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. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hainault Address 35 Lesney Park Road Erith Kent DA8 3DQ 01622769100 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) MCCH Society Limited Vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (14), registration, with number Sensory impairment (14) of places Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2005 Brief Description of the Service: Hainault is registered with the Commission for Social Care Inspection to provide personal care for fourteen adults with learning disabilities. The home has been open since October 1988 and is operated by Maidstone Community Care Housing Ltd (MCCH). Hainault is a large, old, detached building on two floors, with a large, rear garden. There is no lift. The house is divided into three flats. Flat 1 can accommodate two people, flat 2 five people and flat 3 six people. All service users have single bedrooms, apart from two service users who share a room in flat 2. All bedrooms have washbasins and three rooms have en-suite facilities. Each flat has a lounge, kitchen, bathroom and toilet(s). Flat 3 has very spacious communal rooms. There is also an office and a small sensory room on the ground floor. There were twelve service users staying in the home on the day of inspection and one vacancy in flat 1. The commission was not able to obtain information about the fees charged by this home. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days. The inspector visited all of the flats on day one and spent time assessing care records, medication and talking with service users and staff. On day two the inspector discussed care practices with the acting manager and examined staff recruitment and training records. Comment cards were sent to a random sample of relatives and health care professionals. Two cards were returned to the commission. What the service does well: Service users said they “liked” living at Hainault and had established positive relationships with staff. The arrangements for admitting new service users into the home were good with opportunities to visit and stay in the home before moving in. Although most of the service users living in the home were not able to maintain their own health care needs staff encouraged independence and promoted personal choice. Service users were supported to attend health care appointments and specialist advice was requested where necessary. The food provided in the home was varied and service users were able to help choose what they ate at most meals. Visiting arrangements were flexible and service users were supported to maintain contact with friends and family members. Relatives were invited to attend care review meetings and contribute ideas and suggestions that may improve their family members quality of life. Service users were supported to lead active and fulfilling lives in the home and community. The home was clean, tidy and warm. All of the communal areas and bedrooms seen were welcoming and comfortable. Staff provided personalised support with all activities of daily living. Specialist requirements and personal preferences were set out in the service user’s plan. A regular team of staff supported service users with assistance from temporary staff where necessary. Staff had a good understanding of service users’ needs and communicated effectively. Although there was some uncertainty about the future of the home staff were mostly positive and motivated. Access to training was good. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Individual contracts had been issued to service users outlining the care they could expect to receive in the home. Although contracts provided clear information about the terms and conditions of occupancy they did not include information about fees. Some of the records maintained in the home did not include adequate information or were blank in parts. Records of activities did not always state the type of activity that the service user had taken part in and staff recruitment records did not show if thorough checks were undertaken when appointing new staff. Service users and their representatives were asked to contribute to care plan and life plan reviews but service users did not have an opportunity to comment about the running of the home and tell staff what they liked and disliked. Health and safety issues were good overall but staff had not received fire safety training updates and the mains electricity installation was “unsatisfactory”. The work undertaken to repair the damaged worktops in the kitchens did not provide a suitable surface for cleaning. Medication was administered in a manner that suited the service user. Staff did not always maintain adequate records about medication. In particular it was not always clear when and how much medication was received in the home. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 7 The support provided for staff was variable. Some staff received regular supervision whilst others did not have a regular opportunity to discuss their work and training needs. The home did not have adequate systems in place for reviewing the quality of care provided in the home. Feedback about the service was not obtained and used to improve the service. The manager has been in post for several months but had not submitted an application to register. All registered care homes must be managed by a person that has been assessed by the commission to have suitable qualifications and experience to manage the service. 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. Hainault DS0000038196.V307002.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 Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The contracts provided for service users and their representatives did not include adequate information about fees and charges. This information will assist service users and their representatives to decide if the service offers value for money. Staff obtained information about individual needs and preferences before making arrangements for new service users to move into the home. EVIDENCE: The manager had received an individual contract for each service user. The contact did not include information about fees and were not agreed or signed by the service user or their representative. See recommendation 1. Prior to new service users being admitted to the home staff attended various meetings and obtained a copy of the service users care needs assessment. One of the assessments seen was rather basic in parts but the service user was not known to social services and had difficulties communicating. The previous manager of the service had carried out her own assessment and recorded that the service user’s needs could be met in the home. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs and personal preferences were outlined in the records and plans held in the home. Service users were able to decide how they spent their time in the home and community but did not meet on a regular basis to discuss what they liked and disliked about the home. Staff identified potential risks but some additional work is required to keep service users safe. EVIDENCE: The care records for two service users were examined. Both of the files included a list of service users strengths and needs, a pen portrait, which provided information about health and continence issues, communication, personal preferences and dietary needs and a care plan. Service users and relatives were invited to attend individual plan meetings where previous goals were reviewed. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 11 When the inspector arrived in the home some of the service users were still in bed having chosen to have a ‘lie in’ on their day off. When the service users in flat two got up they were asked what they wanted for breakfast and supported to prepare cereals or toast. During breakfast a discussion took place about what individual service users wanted to do for the rest of the day. MCCH is currently carrying out a consultation exercise regarding the future of the home. A staff meeting took place during the inspection to discuss possible options for the home and to advise staff about how they could make their views known. A meeting was also planned for service users relatives and the manager said that consideration would be given to involving some service users in the consultation process. There was no evidence that service user meetings were taking place regularly. Staff said that service users were able to raise concerns or suggestions about the service at any time and were asked if they had any concerns during care plan review meetings. To ensure that service users are involved in key decisions affecting the service regular meetings should be established. See recommendation 2. Risk assessments were seen in the files examined and additional assessments were kept in the manager’s office. Staff had identified potential risks such as road safety issues, difficulty using the stairs and a tendency to wander but had not always developed strategies to minimise the risk of injury to the service user or others. See recommendation 3. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were supported to take part in individual and group activities in the home and community. Service users were able to maintain contact with friends and family and were supported to develop new friendships. Service users received a varied and appetising diet. EVIDENCE: A number of service users attended local day centres and educational classes. During weekends and days off service users were supported to pursue personal interests and undertake activities of their choice in the home and community. Discussions with service users and staff and examination of service users diaries indicated that in recent weeks some service users had been bowling and swimming, had visited the library, local parks and cafes and had enjoyed aromatherapy or massage sessions. Some trips included using public transport and service users also had access to the homes own transport. An individual activity programme was developed for each service user. One of the programmes seen included practising news skills such as making lunch, Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 13 shopping and managing money. It was difficult to establish if activities programmes were followed and how often the sensory room was used from the records seen. Some of the entries in service users diaries stated, “went out”, “out with social pursuits” and “helpful around the flat. See recommendation 4. A social pursuits file provided ideas and suggestions about activities that staff could staff could facilitate in an evening and at weekends. The home had a sensory room that provides a quiet area for service users to relax and various light and sound displays. A visiting professional expressed concern that the room was not used regularly. During the summer months service users were supported to take an annual holiday or weekend break. Relatives were able to visit at anytime and staff confirmed that there were no restrictions. Records indicated that some service users received regular visitors and maintained telephone contact with family members and friends. Staff developed a weekly menu with input from service users where possible. During the day the inspector observed breakfast, lunch and supper being served in some of the flats. Service users were asked what they wanted to eat and were encouraged to assist staff to purchase food, prepare meals and hot drinks and lay and clear away the table where possible. The service users in flat three ate their evening meal together in the dining area. Staff provided assistance and encouragement where necessary. The meal was well presented and looked appetising. Although the food provided on the day of the inspection looked nutritious it was not clear what service users in flat two had eaten during the previous week, as there was no menu. See requirement 1. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff followed service users personal preferences and guidelines when undertaking personal care. Service users received support to maintain good physical and mental health. The arrangements for the administration and disposal of medication were good but staff did not always maintain adequate records when medication was received in the home. EVIDENCE: Service users were supported to have a wash or bath depending on their preference. Staff were aware of service users likes and dislikes and tried to accommodate personal preferences where possible. Staff maintained service users privacy and discreetly reminded one of the service users to ensure that she had adequate clothing on when she was in the lounge or communal areas. Attached to every medication chart in flat two were individual guidelines about how each service user preferred to take their medication. Records indicated that staff had arranged for service users to see the GP when they were unwell or when new issues were identified. One service user was not feeling well on the day of the inspection so had remained in bed rather Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 15 than attend the day centre. Other professionals from the community learning disability team were also called on for advice and guidance when necessary. Ten comment cards were sent to health care professionals that were in regular contact with the home. Two comment cards were returned to the commission. Although respondents said they were usually satisfied with the overall standard of care provided in the home some concerns were expressed about a lack of understanding of service users’ needs and the lack of response to concerns raised about the service. See standard 22 and 39. The arrangements for managing medicines were assessed in flat two. There were no records of receipt of medicines but running totals were kept for medicines that were not supplied in specialist containers. Records of administration and disposal of medication was good. One service user was prescribed a variable dose of medication. It was not always clear from the records how many tablets the service user had received. See requirement 2. One of the service users ate very little lunch. The records indicated that the service user was assessed to be underweight when he was admitted to the home and was referred to a GP and Dietician. The care plan indicated that the service user was weighed every Sunday. Some weights were recorded but not as frequently as indicated in the care plan. The service user had gained a little weight. Staff should ensure that care plans are followed. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home had a comprehensive complaints and adult protection procedure in place for responding to complaints or allegations of abuse. EVIDENCE: The home had a comprehensive complaints procedure, which included a timescale for responding to concerns and contact details for the commission. There was some evidence that concerns may have been raised about some aspects of the service in the past but the acting manager was not aware of these issues. See standard 19. The acting manager said the home had not received any complaints since she came into post in July 2006. See standard 39. Staff had a good understanding of abuse and were clear about reporting allegations to senior staff promptly. Some members of staff had attended Protection of Vulnerable Adults training or covered this topic whilst undertaking vocational qualifications. The manager said that the adult protection procedure was currently being reviewed and updated and further training sessions were planned for staff. Since the last inspection the home had referred one adult protection issue to the local authority for investigation and a previous investigation was closed. No evidence was found to support any of the allegations. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was spacious, comfortable and well maintained. Work had been undertaken to cover the damaged work surfaces in the kitchens in flat one and two but this did not provide a suitable surface for cleaning. EVIDENCE: All parts of the home were clean, tidy and odour free. One bedroom looked rather sparse but had been identified for redecoration. All of the other bedrooms and communal areas seen were spacious and comfortable. Bedrooms were personalised with photographs and pictures and depending on service users interests there were various items such as sensory equipment, films or CD’s stored in the rooms. Since the last inspection a new carpet was fitted in the lounge in flat two and a new sofa had been purchased. This made the room look welcoming and homely for service users and their visitors. Glass boards had been stuck over the damaged work surfaces in the kitchens in flat two and three. Kitchen surfaces should be smooth to make it easier for staff to keep them clean and to avoid dirt getting trapped under any joints. See recommendation 5. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 18 There is a huge mature garden at the rear of the property. The patio and lawn area were well maintained but the sensory garden looked rather neglected. The manager had identified volunteers to help clear and maintain this area in the warmer weather. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff carried out their work in a professional and caring manner. Staff recruitment procedures were thorough but records maintained in the home did not always provide adequate evidence of this. Training opportunities were good. The appointment of a new team leader and completion of supervision training should provide better support for staff. EVIDENCE: The manager said that 33 of care staff had attained a NVQ qualification in care and four staff were currently undertaking this training. The home continues to work towards meeting the standard set by the Department of Health for 50 of care staff to achieve a vocational qualification in care. Since the last inspection six members of staff had resigned. Staff stated that the uncertainty surrounding the future of the home had prompted some staff to leave. Although a new senior member of staff and three support workers had been appointed, the home was still reliant on bank and agency staff. It is acknowledged however that under the current manager the use of agency staff had reduced. Where possible the manager used temporary staff that were familiar with the home and service users to ensure continuity of care. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 20 Staff communicated effectively with service users and advised the inspector about service users preferred means of communicating. One service user communicated in part by writing on a note pad, which was kept by his side. Staff had a good knowledge of service users current needs, including ongoing health issues. All of the interactions observed between staff and service users were professional and caring. The commission had agreed that staff records could be held centrally and a form outlining all of the information and checks that had been undertaken for staff would be kept in the home for inspection. Two recruitment forms were examined. The agreed form was in use but parts of the form were blank. There was no evidence that a criminal record bureau disclosure and proof of identity was requested or that references and a statement about the applicants physical and mental health was obtained for one member of staff. It was not clear whether one employee had completed an application form or if either staff had attended an interview. The acting manager acknowledged that the records did not meet the required standard and said she was planning to arrange for a member of staff from the company’s human resources department to visit the home with staff files so that she could complete all of the forms. See requirement 3. A provider relationship manager from the commission was undertaking additional checks at the company’s head office twice a year. The most recent audit was undertaken in January 2007 when all of the files examined were found to comply with regulations. Staff said they were able to attend relevant training sessions and the records seen reflected this. During the past year some members of staff had attended NVQ, moving and handling, supervision, food hygiene, first aid, fire safety, medication and COSHH training. The home received a copy of the training programme which listed all of sessions that were planned and staff were encouraged to attend. The acting manager was responsible for providing formal supervision for staff until senior staff had received training and could take over this task. The frequency of supervision was variable with some staff receiving supervision every two months and others not receiving any. See recommendation 6. Hainault DS0000038196.V307002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager was committed to improving standards of care and support for staff. There was little evidence of quality assurance work taking place. It was not always possible to establish exactly what service users had eaten or what activities they had taken part in from the records maintained in the home. Health and safety issues were well managed overall but staff did not receive regular fire safety training updates and the report about the mains electricity system stated that the installation was “unsatisfactory”. EVIDENCE: Two acting managers had managed the service since the Registered Manager resigned in April 2006. The current manager was asked to manage the service for six months until a permanent manager could be appointed. This period was extended due to lack of response to the internal advert for the manager’s Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 22 post. This is welcomed, as it will provide a further period of stability for staff and service users. The acting manager had managed a registered care home and a supported living scheme for people with a learning disability in the past and had completed the Registered Managers Award. The current manager of the service had been in post for over six months but has not submitted an application for registration. The manager must submit an application to the commission as soon as possible. Staff were concerned about frequent changes in management stating that they found this a bit “unsettling”. Staff said there had been difficulties due to different styles of management “but things had settled down now”. Staff said the current manager was approachable and kept everyone informed at staff meetings about changes in the company or issues in the home. There was little evidence of quality assurance work taking place. The frequency of regulation 26 visits had improved but there were no formal arrangements in place for obtaining feedback from relatives and other professionals. See standard 19. See requirement 4. The manager had good systems in place for storing information and records. Good records were maintained about service users strengths, needs and preferences but activity and food records were sometimes vague or incomplete. See requirement 1 The home has a part time maintenance employee who undertakes health and safety checks and carries out minor repairs. There was an up to date fire risk assessment and the fire alarm system and equipment was serviced at regular intervals. Fire drills were recorded and new staff received fire safety training during induction. It was not clear from the records whether other members of staff received regular fire safety updates. See requirement 5. A random check of health and safety records was undertaken. Records relating to water chlorination, hoists, assisted baths and gas safety inspections were examined. These records were found to be satisfactory. The mains electricity installation was inspected in 2004. The report indicated that the installation was found to be “unsatisfactory”. See requirement 6. The local environmental health department inspected the home in October 2006. A number of requirements were made about the standard of cleanliness in the kitchens, food hygiene training and repairs. Some of the work outlined in the report had been addressed and cleaning schedules were now in place. Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 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 3 2 X 2 X 2 X 2 2 X Hainault DS0000038196.V307002.R01.S.doc Version 5.2 Page 24 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 YA41 Regulation 17 Requirement The Registered Person must ensure that staff maintain accurate and up to date records about the food provided in the home. The Registered Person must ensure that adequate records are maintained for all medicines received in the home. When a service user is prescribed a variable dose of medication staff must record the amount of medication that was given to the service user. The Registered Person must ensure that the agreed form for recording recruitment checks is completed in full for all members of staff. The Registered Person must establish a system for reviewing and improving the quality of care provided in the home. This must include consultation with service users and their representatives. The Registered Person must ensure that all staff receive regular fire safety training updates. The Registered Person must DS0000038196.V307002.R01.S.doc Timescale for action 14/03/07 2. YA20 13 14/03/07 3. YA34 19 14/03/07 4. YA39 24 09/05/07 5. YA42 23 11/04/07 6. Hainault YA42 23 11/04/07 Page 25 Version 5.2 advise the commission in writing about the action that was taken to address the concerns identified in the mains electricity installation report. 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 YA5 Good Practice Recommendations The Registered Person should ensure that contracts: • Include information about the fees charged by the service • Are agreed and signed by the service user or their representative The Registered Person should ensure that service users have regular opportunities to comment about the running of the home. The Registered Person should ensure that strategies are in place to minimise risks identified by staff. The Registered Person should ensure that staff maintain adequate records about activities that service users have taken part in. The Registered Person should replace the damaged work surfaces in the kitchen in flats two and three. The Registered Person should ensure that care staff receive regular supervision. 2. 3. 4. 5. 6. 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