Inspection on 26/06/08 for Harrow Road, Flats A, B and C

This inspection was carried out on 26th June 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Harrow Road, Flats A, B and C 11/06/07

Harrow Road, Flats A, B and C 09/11/06

Harrow Road, Flats A, B and C 01/06/06

Harrow Road, Flats A, B and C 15/12/05

Harrow Road, Flats A, B and C 19/11/04

Harrow Road, Flats A, B and C 27/05/04

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Chatsworth Care - Dawson House

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Harrow Road, Flats A, B and C Flats A, B and C 291 Harrow Road London W9 3NF Lead Inspector Ffion Simmons Key Unannounced Inspection 26th June 2008 11:00 Harrow Road, Flats A, B and C DS0000010875.V364540.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 Harrow Road, Flats A, B and C DS0000010875.V364540.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. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harrow Road, Flats A, B and C Address Flats A, B and C 291 Harrow Road London W9 3NF 020 7266 3072 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) najiboye@wspld.org The Westminster Society for People with Learning Disabilities Miss Nikky Ajiboye Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (excluding nursing) and accommodation to service users of both sexes whose primary needs on admission to the home are within the following category:Learning Disability (Category LD). The maximum number of service users who may be accommodated is 13. 11th June 2007 2. Date of last inspection Brief Description of the Service: 291 Harrow Road is located close to the transport links, shops and amenities of Paddington and Westbourne Park. The home is registered to provide accommodation and care for 13 men and women with learning and physical disabilities. Flats A and B were registered by the Commission in March 2007 to provide care for 8 people. Flat C provides care for 5 people and has been registered for a number of years. Each person living in the home has his / her own bedroom and access to shared amenities. The home is wheelchair accessible and is fully equipped to enable people to pursue a full and active life. The care is provided by the Westminster Society for People with Learning Disabilities, a local voluntary organisation. The property is owned by Kensington and Chelsea Primary Care Trust. The current fee for the service is £1,736.17 per week. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection took place on the 26th June 2008 and lasted a total of 7 hours and 20 minutes. We spent time with residents during this inspection and observed their care. Residents living at the home have specialist communication needs. We spent time talking to the Team Managers, Assistant team managers and staff. We tracked the care of three residents, and in doing so we checked their personal records. A number of other records and documentation were also checked during the inspection, including the care plans and risk assessment, medication records, staff files, health and safety documentation, the home’s complaint records and incident records and quality assurance documentation. We received surveys as part of the inspection and comments from these have been included in the body of the report. The Registered Manager took time to complete and return the Annual Quality Assurance Assessment (AQAA), and has been used as evidence to inform this report. What the service does well: What has improved since the last inspection? We noted improvements of the safe storage of medication. Medication is now stored safely at all times to make sure that residents are safe. Staff are now clearly recording the expenditure of each person’s money, including details of what the money is used to pay for. Receipts are obtained each time residents’ money is spent. This ensures that residents’ financial interests are safeguarded. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 6 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. Harrow Road, Flats A, B and C DS0000010875.V364540.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 Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. People using the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and prospective residents have access to the comprehensive statement of purpose and service user’s guide, which are in an accessible format. This enables them as far as possible to make an informed choice about moving into the home. All new residents receive a comprehensive needs assessment carried out before admission to ensure that the home is suitable for meeting their needs. EVIDENCE: During the inspection, we looked at the home’s statement of purpose and service user’s guide. Each flat have their own guide, made available to residents and other interested parties by the main entrance of the flats. The quality of the documentation is excellent, providing prospective residents and/or their representatives with the information they need in accessible formats. The documentation makes excellent use of photographs and is written in Plain English. Residents in flat C have lived together for a period of more than ten years. Residents in flats A and B have moved in more recently as these flats opened in March 2007. A completed full assessment of their care needs was on file for the three residents case tracked during the inspection. The Manager confirmed within the AQAA that, “we have a moving in pack which involves a thorough assessment re individuals needs and wants. This is matched with services available and is done with a multi agency approach to ensure professionals Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 9 such as care management, OT’s and health professionals agree. All transitions have met legal requirements including the Mental Capacity Act with the involvement of Independent Mental Capacity Advocates in assessment and independent advocacy where required.” Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ care needs are well documented within comprehensive and personcentred care plans. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. EVIDENCE: During the inspection, we tracked the care of three residents currently living at the home. As part of this process, we checked their personal files. During this inspection we noted that the team have worked hard to compile support profiles and care plans for each resident case tracked. This has resulted in residents’ current care needs, goals and preferences being well documented. The care records seen were person-centred written in the resident’s voice and included a range of needs, including personal care needs, social and leisure activities, communication and healthcare. Some of the residents’ favourite pictures appear in the documentation in an attempt to make the content more accessible to each individual. Staff commented that “support profiles are updated when changes occur, do not wait until the review is due.” Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 11 Communication plans were also on file outlining the best ways to communicate with residents living in the home. The Manager confirmed within the AQAA that “we have spent a great deal of time recently reviewing communication methods. Where possible systems have been developed with assistance from professionals such as speech and language therapists.” During the inspection, staff were observed to be respecting the privacy and dignity of residents living in the home and facilitating choice. Individual risk assessments were on the files of all three residents case tracked. These risk assessments assessed the risks associated with personal care, communication, chosen activities and manual handling. We noted that the risk assessments were recently reviewed and updated where needed. Harrow Road, Flats A, B and C DS0000010875.V364540.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): 12, 13, 15, 16 & 17. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are involved in meaningful activities in the home and the local community. Visitors are welcomed into the home and residents are The supported to maintain important personal and family relationships. service is committed to the principle of inclusion. The meals offered cater for the varying cultural and dietary needs of individuals. EVIDENCE: Residents’ “All about me” and “My history/life story” documentation provides very good background information on the interests and social, cultural and religious needs of residents. The documentation includes information about their families and significant people in their lives and how to maintain contact. Most of the residents have some family involvement in their lives. The Manager confirmed within the AQAA that, “we support people to maintain these contacts by facilitating visits in the service, inviting them for parties and to dinner, phone calls, letters and review meetings”. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 13 Each resident whose care was tracked had a weekly programme of activities, which included a range of activities both inside and outside the home. Some of these included using the sensory room, which is available in the home and therapy sessions such as reflexology and massage. The communal areas enable residents to watch television/videos and DVD’s and listen to their favourite music. Art and crafts and cookery sessions take place in the home and house meetings are arranged. The Manager confirmed within the AQAA that external activities include “trips to the cinema, concerts, shopping, pub, restaurants, zoo, local walks, swimming, bike ride, theatres, day trips to the sea side, local parks, visiting football grounds, bowling, disco and night clubs, day services, museums, hairdressers, local cafes, family homes, markets and visiting friends.” We observed during the inspection that some of the residents were attending the day service and other residents were supported to go out for lunch. Mealtimes in the home are flexible to accommodate the residents’ chosen programme of activities. In discussion with staff, we found that residents have the option of eating foods that they associate with their culture. The Manager confirmed within the AQAA that “people are offered three health meals a day” and “we work closely with dieticians and other health professionals to ensure we offer people a varied and wholesome diet.” Harrow Road, Flats A, B and C DS0000010875.V364540.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): 18, 19 & 20. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each resident’s personal and healthcare needs are well recorded as part of their care plan. People are referred appropriately to specialist services. Residents are protected by the home’s policies and procedures for managing medication. EVIDENCE: The care plans checked during the inspection outlined the residents’ needs and preferences in relation to attending to their personal care needs. The care plans had been recently reviewed and updated where necessary. The Manager confirmed within the AQAA that “choices of showering, bathing or bed washes are offered as needed and requested.” Residents’ have a “My health” section within their personal files, which outline their health care needs. A Health Action Plan (HAP) was in place for the three people whose care was tracked during the inspection. The residents care tracked were up-to-date with their health checks, which included hearing tests, eye tests, dental checks and podiatrist treatment. We could see evidence that residents have access to members of the multi-disciplinary team including the GP, Speech and Language Therapists and dieticians. The Manager confirmed within the AQAA that “we have built good relationships with health professionals especially specialists such as psychologists, dialysis nurses and Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 15 speech and language therapists”. A staff member had been out supporting a resident to a chiropody appointment during the morning of the inspection. The management of medication was assessed in two of the three flats during this inspection. The medication is received into the home mainly in blister packs. Regular audits are undertaken to check that the quantity of medication is correct against the Medication Administration Records (MAR). There was secure storage for prescribed medication in each of the flats. The MAR charts were checked in two of the three flats and found to be well completed. Any known allergies were noted on the MAR charts. Where medication had not been administered, the appropriate code was used and an explanation on the back of the MAR chart outlining the reason why the medication was not administered. It is a good practice recommendation that the date of opening is recorded on all liquid medication to ensure medication is not used passed its shelf-life and to aid the auditing process. The Manager confirmed within the AQAA that “the team has received training from Boots as well as Westminster Society training in effectively administering medication”. We noted that residents have a medication profile on their individual files outlining the medication they are taking. The home has a policy for the safe management of medication. Harrow Road, Flats A, B and C DS0000010875.V364540.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): 22 & 23. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is accessible to residents. Residents are supported to make a complaint. There is a lack of consistency in staff’s understanding of when they should report incidents and allegations of abuse. Improvements are needed in this area to ensure residents are protected. EVIDENCE: The home has a clear complaints procedure that is produced using pictures and drawings to make the information more accessible to some residents. The complaints policy is made available to each of the residents. We noted during the inspection that staff were supporting residents to voice their concerns and to log these. The Manager confirmed within the AQAA that residents are supported to discuss complaints in house meetings and are supported to make complaints either regarding the service they are receiving or regarding any external issue. During the inspection, we checked the finance records for three people living in the home and discussed procedures with one of the team managers. Staff clearly record the expenditure of each person’s money, including details of what the money is used to pay for. Receipts are obtained each time residents’ money is spent and the balances we checked were correct. We observed a residents being involved in the checking of their financial balance. The Manager confirmed within the AQAA that “financial records are checked on a daily basis to ensure accuracy”. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 17 During the inspection we were told that staff have received training in the protection of vulnerable adults from abuse and the topic is discussed regularly at team meetings. Policies and procedures are in place for the protection of vulnerable adults from abuse and the whistle blowing procedure is available. Staff commented that “whistle blowing procedure is part of the induction and has been refreshed”. We noticed in the incident book in Flat C that there were five incidents where staff had documented that they had noticed unexplained bruising/injury to two residents. We discussed these cases with staff in charge of Flat C on the day of the inspection, who confirmed that they had not reported these to the safeguarding adults team. They confirmed also that Regulation 37 forms had not been completed and that the CSCI had not been made aware of these unexplained injuries. We were concerned to note that the safeguarding procedures had not been followed, especially as the need to follow safeguarding procedures had been highlighted as an area for improvement during the home’s key inspection in June 2007. Action must be taken to make sure that all staff working in all three flats are clear of their responsibilities for following the local multi-agency safeguarding policies and procedures and report incidents to the local safeguarding team and the Commission. During the inspection we were also told of an incident involving a member of staff, which is currently under investigation. We were not informed of this incident prior to the inspection as this incident had not been reported to us under regulation 37. Action must be taken to make sure that all staff are aware of their responsibilities for reporting incidents which adversely affect the well-being of residents to the Commission without delay. Harrow Road, Flats A, B and C DS0000010875.V364540.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): 24 27, 29 & 30. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable and well maintained and is fully accessible and meets the specific needs of the people who live there. EVIDENCE: The home is located on the Harrow Road, close to shops, cafes, restaurants and library and transport links in Paddington and Westbourne Park. Flats A and B share one building, whereas Flat C is separate. We spent time in flat A, B and C during the inspection. All three flats have level access and are fully accessible for people using a wheelchair. Fixed hoists are provided in communal areas and bathrooms in all three flats, including the sensory room. The home provides spacious communal areas and an enclosed garden where residents can spent time. There are two sensory rooms in the home, which include specialist equipment. A music room has also been developed and the Manager confirmed within the AQAA that “we have purchased a musical optibeam system for the music room and provided training to the team in its use”. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 19 A separate room is available for use aromatherapists and massage therapists. by visiting physiotherapists, Each flat has an accessible bathroom and shower room. Two of the bathrooms have assisted baths, with spa facilities and three kitchens have adjustable work tops. We saw the two laundry rooms in the home, which include a sluicing facility, these rooms are located away from where food is being prepared. The home was found to be clean and hygienic during the inspection. The Manager confirmed within the AQAA “we have cleaning rotas in place morning/afternoon and night staff to complete”. The cleaning products used in the home were found to be securely stored. Harrow Road, Flats A, B and C DS0000010875.V364540.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): 32, 34 & 35. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staffing levels are sufficient for meeting the needs of people living in each flat. There are good recruitment procedures in place, which involve and protect the residents. EVIDENCE: The staffing levels were discussed with a Team Manager and the rotas were checked. There is a minimum of two staff on duty in each flat during the day, increasing to three between 10am and 6pm. During the hand over period there are up to five staff on duty. Staffing levels were considered adequate for meeting the needs and supporting the residents living at the flats and staff confirmed that “the service is well staffed”. We spent time at each flat during the inspection observing the staff supporting residents. We saw that staff were treating residents with respect and facilitating choice. Staff interactions were very positive. The Society has clear recruitment procedures, which involve residents. Staff arrange for interviews to take place at the home to enable residents to be part of the interviewing process. The Manager confirmed within the AQAA “we have held 2 days of interviews and involved each individual in different parts of the Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 21 process”. One of the assistant team managers confirmed that staff do not start work in the home until an Enhanced Disclosure has been obtained from the Criminal Records Bureau (CRB). Staff confirmed that the society carried out pre-employment checks and told us “the society is realistic about how long these checks will take i.e. they say at the interview it is likely to be 2-3 months before you can actually start working.” Staff commented that they receive good training opportunities. A staff commented “the internal training offered by the society is of an excellent standard and highly relevant to the work in services. It also gives opportunities to work with teams in other services which helps in terms of problem solving. Also have access to external training.” Harrow Road, Flats A, B and C DS0000010875.V364540.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): 37, 39, 42. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required experience and qualifications to run the home. The home’s quality assurance systems, which are based on seeking the views of residents living in the home. Not all staff have had training in fire safety, first aid and food hygiene practices, which could impact negatively on the health and safety of residents. EVIDENCE: There is a Registered Manager in post, who has the overall responsibility for all three flats. The Registered Manager is experienced and has worked at flat C for a number of years and so is aware of residents’ needs. There are team managers in post, to support the Registered Manager, who work at flats A and B. There are also Assistant Team Managers in post to support the Team Managers. The AQAA completed by the Registered Manager confirmed that, “all team managers have their National Vocational Qualification (NVQ) 4 qualification and 2 of the managers have their registered managers award.” Staff commented that they felt well supported and commented that they had a “very open and easy relationship with management”. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 23 The home has quality assurance systems in place, which are base on seeking the views of residents. The residents were supported to complete the 2007/2008 Housing Survey. The report from these surveys was seen during the inspection and the results were generally positive. The Manager confirmed within the AQAA “we are taking on board individual views from the service user survey and incorporating their wishes where possible into the homes where they live.” Residents are supported to attend house meetings and the Manager confirmed within the AQAA that “people also attend the News and Stuff group (monthly service user meetings for the organisation).” In addition to the quality assurance work mentioned above, monitoring visits are made to the home. Written reports are sent to the home and the latest report on file was dated April 2008. Steps must be taken to ensure that these visits are undertaken on a monthly basis and a report forwarded to the home promptly. Health and safety documentation was checked during the inspection. Health and safety policies are available on file in the home. The fire records demonstrated that weekly fire alarm tests and monthly fire drills are performed. The training needs analysis of staff at Flat C highlighted that some staff have not received fire training, first aid training and food hygiene training and is a requirement. Information within the AQAA confirmed that the fire equipment and portable electrical appliances have been recently tested. Records showed that the thermostatic mixer valves are checked on a weekly basis to ensure that they are working and delivering water at safe temperatures. Substances hazardous to health were securely stored at the time of the inspection and written assessments on hazardous substances are in place. The accident and incident book was seen during the inspection. We noted that some unexplained bruising had gone unreported. Harrow Road, Flats A, B and C DS0000010875.V364540.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 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 Timescale for action To ensure residents are safe, 08/07/08 action must be taken to make sure that all staff are clear of their responsibilities for reporting incidents of unexplained bruising under the safeguarding adults policies. All incidents which adversely 08/07/08 affect the safety or well-being of residents in the home must be reported to the Commission for Social Care Inspection without delay. Steps must be taken to ensure 01/08/08 that visits on behalf of the registered provider are undertaken on a monthly basis and a report forwarded to the home promptly. This is important so that any action necessary following these visits can be taken promptly. Action must be taken to ensure 01/09/08 staff receive all training in safe working practices so that they are clear on how best to support residents safely. Requirement 2. YA23 37 3. YA39 26 4. YA42 18 Harrow Road, Flats A, B and C DS0000010875.V364540.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 Refer to Standard YA20 Good Practice Recommendations The date of opening should be written on all liquid medicines to ensure they are not used past their expiry date and to aid with the medication audit process. Harrow Road, Flats A, B and C DS0000010875.V364540.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Harrow Road, Flats A, B and C DS0000010875.V364540.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. 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