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

This inspection was carried out on 9th 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

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

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

Similar services:

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Harrow Road, Flat C, 291 Flat C 291 Harrow Road London W9 3NF Lead Inspector Ffion Simmons Unannounced Inspection 9th November 2006 10:00 Harrow Road, Flat C, 291 DS0000010875.V314541.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, Flat C, 291 DS0000010875.V314541.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, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harrow Road, Flat C, 291 Address Flat 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) The Westminster Society for People with Learning Disabilities Miss Nikky Ajiboye Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2006 Brief Description of the Service: The home is located on the Harrow Road with access to transport links, local shops and amenities. It is registered for up to five people with learning disabilities with each resident having their own bedroom and access to shared amenities. The home is fully equipped with aids required to enable the residents to pursue a full and active life. The Westminster Society for People with Learning Disabilities is the registered provider. There is currently a full occupancy. The home also has access to a minibus that increases residents opportunities to develop interests outside the home and much time is spent attending activities at day centres and on trips out. Current fees as outlined in the pre-inspection information is £1,714.88 per week. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key unannounced inspection took place on the 9th November 2006 between 10:00 and 15:30. This was the home’s second key inspection for this inspection year. The inspector spent time talking to staff, service users and observing care practices. A range of documentation was checked including service users’ personal files, medication records, financial records, health and safety documentation and complaints and incidents. Three comment cards were received about the service. Service users were at home during the inspection as they had a break in their day services. Staff were observed to be very attentive to service users’ needs and demonstrated a good understanding of their individual needs. The staff team were very helpful and friendly during the inspection process. What the service does well: What has improved since the last inspection? Sixteen requirements were set following the home’s last key unannounced inspection in May 2006. The following improvements have been made: The home has met the two immediate requirement set at the last inspection. The first immediate requirement was to ensure that manual handling risk assessments are on file for all service users. The second was to ensure that wedges are removed from the fire doors and that fire doors are not obstructed. Individual risk assessments have also been updated. A new care planning format is being introduced, which is person centred making good use of pictures and symbols. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 6 Service users’ health records have improved and service users are receiving appropriate health checks. A picture of each service user has been made available on the medication files and details of any allergies are noted on the MAR sheets. The information within the society’s complaint policy has been updated to include pictures of relevant personnel to contact. A copy of the home’s valid insurance certificate has been obtained and displayed. 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. Harrow Road, Flat C, 291 DS0000010875.V314541.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, Flat C, 291 DS0000010875.V314541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Full information is sought on the needs of service users prior to them moving in. Service users have the opportunity to visit the home prior to moving in. EVIDENCE: There has been no change to this standard as there have been no admissions to the home since 1995. The Society has an admissions policy in place. The admission policy specifies that service users’ needs would be assessed prior to them being admitted. This is to ensure that the placement is suitable for meeting their needs. Prospective service users would have the opportunity to visit the home prior to moving in. This provides service users with the opportunity to get to know the staff and feel familiar with the environment. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment of risk to service users had been completed and updated. Service users are supported to make their own decisions about their lives. Steps have been taken to introduce a new system for recording the needs of service users using a person centred approach. Further work is needed in this area to ensure that information relating to the support needs of service users is fully documented. EVIDENCE: Since the last inspection, staff have been working with service users to introduce a new system for recording their needs. The documentation that has been introduced is person centred and the inspector noted that some very good work has been undertaken to outline service users’ history/biography; likes and dislikes. The care records of three service users were checked during the inspection. One of the service users’ person centred plan has been completed to a high standard making the plan accessible to service users using a good range of pictures and symbols. The plan contains a good level of information relating to the support needs of this service user. The person centred plans for the other two service users need to be completed to include information relating to their support needs. It is possible that staff vacancies Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 10 have contributed to the delay in completing the person centred plans, but steps are being taken to fill vacant posts. Since the last inspection, service users’ risk taking policies have been updated and were on file. The risk taking policies highlight potential risks and strategies for minimising risks. Manual handling risk assessments were on file for the service users case tracked. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have a full programme of activities, and are supported to access services and facilities in the local community. Service users are offered a healthy and varied diet. EVIDENCE: On the day of the inspection all service users were at home as there was a break in their programme of activities at their day services. All service users attend day service where they are encouraged to take part in structured group sessions classes and activities. The inspector case tracked three service users during the day. When the inspector arrived, one of the service users was being supported in the well-equipped sensory room, which contains various lights and musical instruments including drums and a piano. Another service user was painting pictures and watching the television before being supported to look at their photographs on their laptop using specialist equipment. Service users are encouraged to be part of the local community and some of the activities accessed within the wider community includes trips to the cinema, concerts, shopping, going to local parks, going to pubs and Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 12 restaurants, swimming, local walks and bike rides. Service users’ preferences with regards to social and leisure activities are outlined in their personal files. Some service users enjoy music and have access to a music system, video and DVD player. The home has a small garden, which is accessible via the living area. One of the service users was observed to be enjoying being outside briefly with staff. Routines in the home were seen to be flexible with service users being supported to go back to/stay in their room as they preferred. Service users enjoyed fish and chips for lunch, and staff were attentive and offering service users choice of food and drink throughout the day. The staff team have been discussing at team meetings how they can offer and promote a healthy diet to service users. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in private. Further work is needed to ensure that the support needs of service users are fully documented to ensure that their needs are known and that they receive the support in the way they prefer. The home’s policies and procedures relating to medication were being followed at the time of the inspection but steps must be taken to ensure that the date of opening is clearly recorded on containers of liquid medication. EVIDENCE: Further work is needed to ensure that service users’ support needs are fully documented with regards to physical and emotional needs. Individual needs, preferences and wishes with regards to personal care should be outlined in the new care plan format (see section individual needs and choices). Service users were observed to be receiving personal care in private. The health care files of three service users were checked during the inspection. The inspector noted that steps have been taken to improve and update the health care records of service users since the last inspection. The records reflected that service users were receiving appropriate and timely health checks and have access to support from the multi-disciplinary team. All three service users case tracked had been invited for an annual health check with their GP. A comment card was received by a health care practitioner, who Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 14 commented that they are satisfied with the overall care provided to service users within the home. Service users’ medication is securely stored in a metal cabinet, which is located within a locked store cupboard. The medication is received mainly in blister packs. A list of signatures of staff who have been trained in the administration of medication is kept on the file. The medication records of all five service users were checked during the inspection. The records were well maintained with no errors noted. Since the last inspection, steps have been taken to ensure that a picture of each service is kept on the medication file. Service users do not have any known allergies; this was clearly documented on their medication administration records. Staff must ensure that they record the date of opening on all liquid medication. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an upto-date complaints policy, a copy of which is made available to service users. Policies are in place for the protection of service users from abuse. Training records need to reflect that all staff have received training in the protection of vulnerable adult. Steps must be taken to improve the recording and handling of service users’ finances. EVIDENCE: The home has a complaints policy which is available to service users within the service user’s guide. The policy has been updated since the last inspection to include pictures of the relevant individuals to contact. The policy makes good use of symbols and pictures. Staff members confirmed that service users are supported to make complaints in residents meetings. Two complaints have been documented since the last inspection. The records demonstrated that staff have supported service users to make complaints about a transport service. The Westminster Society has an Adult Protection policy available for staff reference. One Adult Protection investigation is currently ongoing. The Adult Protection procedures were followed and the CSCI were notified. The Manager is asked to forward the outcome of the investigation to the CSCI once known. The staff training records still indicated that not all staff have received training in the Protection of Vulnerable Adults from abuse. It was noted however that the protection of vulnerable adults has been discussed at a recent team meeting. Steps must be taken to ensure that this is reflected in the training records and that any gaps in training are identified and steps taken to fill any identified gaps. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 16 Service users’ money is kept in the office for safe keeping. The financial records of three service users were checked during the inspection. The balance of two of the three service users’ money was accurate. There was an error noted in the balance of one of the service users’ records. The Assistant Team Manager was aware of the error and is dealing with the situation. The Team Manager was asked to forward the findings of the investigation to the CSCI. Harrow Road, Flat C, 291 DS0000010875.V314541.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, 25, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are accommodated in a homely, safe and comfortable home. The home is clean and hygienic. Service users have access to the public transport and local amenities, which are located nearby. Service users’ bedrooms are personalised but one of the service users is still waiting for a new bed. EVIDENCE: A tour of the building was undertaken. The home is suitable for its purpose, homely, safe and comfortable. The home is fully accessible to wheelchair users and there are overhead hoists fitted in every room. The home is well located, close to public transport and local amenities. New seating has been purchased for the living area since the last inspection. The staff team confirmed that the service user has been assessed by the Occupational Therapist for a new bed, but the service user is still waiting for the new bed to arrive. This requirement is being repeated for the second time. The home was clean and hygienic and odour free at the time of the inspection. Staff are responsible for the cleaning of the home and all cleaning materials are locked away and COSHH assessments available. A separate laundry and sluice room is available, equipped with a washing machine and dryer. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff vacancies has reduced but vacancies still exists, which has an impact on the service. The home’s recruitment policy is robust. The staff training records have improved but further work is needed in this area to ensure that they are kept up-to-date and that the records reflect the actual training undertaken. A training needs analysis would also be beneficial. EVIDENCE: On the morning of the inspection there were two Assistant Team Managers on duty and one support worker supporting the service users. Currently there are two full-time posts vacant and another part-time post vacant. Staff confirmed that these vacant posts are either covered by internal staff or care bank staff. The recruitment of new staff remains ongoing and since the last inspection, new staff have been recruited/seconded to reduce the vacancies from six posts. The home is continuing its attempts to recruit suitable staff with interviews currently taking place. There has been no change to the Westminster Society’s recruitment procedure. The Westminster Society’s Human Resources department is responsible for recruiting new staff and for completing the necessary pre-employment checks. The checks include three reference checks and a CRB and POVA check. Information was available outlining the date of CRB disclosure for each staff member. Each applicant is required to attend an interview by a panel of Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 19 Managers and service users. Staff confirmed that two of the service users at the home have attended the interviewing training and regularly take part in the interview process. Staff confirmed that service users have direct influence over the decisions for which candidates are recruited. The staff training records were seen during the inspection. Improvements were noted in the way that staff training is being recorded. Minutes of team meetings illustrated that some of the staff team have received updates in manual handling but this has not been reflected in individual training records. Steps must be taken to ensure that the staff training records are kept up-todate and reflect the actual training undertaken. A training needs analysis should also be in place for the staff team to identify training needs and to identify when training updates are needed. It remains a requirement that steps are taken to ensure that staff receive refresher training in safe working practices. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 20 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, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from a qualified and experienced Manager. The home’s Quality Assurance systems are not sufficiently robust but steps are being taken to obtain the views of service users. Some improvements were noted in the promotion and protection of service users’ health and safety, but there were still identified areas for improvement. EVIDENCE: The Registered Manager is experienced in working with the client group and has been working at Flat C for the last six years. She is qualified with NVQ Level 4 in care and also holds the NVQ assessors qualification. Since the last inspection, an Assistant Team Manager (ATM) has been recruited and another ATM seconded from another Westminster Society home. This has enabled the manager to delegate some of her duties such as health and safety, support worker supervision and dealing with finances. Two full-time and 1 part-time posts remain vacant, which does impact on the service. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 21 The standards of care in the home have not been formally assessed since April 2004. A tool is available for assessing the quality of the care, which must be implemented immediately. The staff team confirmed that since the last inspection, a staff member of the Westminster Society had visited the home to involve service users in satisfaction questionnaires. The results of the satisfaction surveys were not available at the time of the inspection. It remains a requirement that the quality of care is regularly reviewed and that a report must be produced, which includes service users’ views and must be made available for service users, their representatives and the CSCI. This is a repeat requirement. Monthly visits on behalf of the registered provider are undertaken and the reports are forwarded to the CSCI as per the regulations. Health and safety documentation was checked during the inspection. Health and safety policies are available on file in the home. Fire and building risk assessments were seen in place and weekly fire alarm tests and monthly fire drills are performed. There was evidence on file that the fire equipment has recently been tested. A list of used substances that are hazardous to health is kept and COSHH assessments are maintained for these substances. The home’s electricity certificate is valid, and portable electrical appliances have been recently tested. The Gas certificate however, expired in August and urgent steps must be taken to ensure that the home obtains a valid Gas safety certificate. The documentation indicates that the thermostatic mixer valves were last serviced in 2003. It remains a requirement that the thermostatic mixer valves are serviced to ensure that they are working and delivering water at safe temperatures. The home has met the two immediate requirement set at the last inspection. The first immediate requirement was to ensure that manual handling risk assessments are on file for all service users. The second was to ensure that wedges are removed from the fire doors and that fire doors are not obstructed. The home has also obtained a valid service insurance certificate, which was displayed at the time of the inspection. Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 22 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 3 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 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 X 2 X X 2 X Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 1 & 2 Timescale for action The person centred plans for 01/01/07 service users must be completed to include information relating to their support needs. Staff must ensure that the date 01/12/06 of opening of all liquid medication is recorded. The Manager must ensure that 15/12/06 the recording and handling of service users’ finances is improved. An investigatory report relating to the incorrect balance must be forwarded to the CSCI. The Manager must ensure that 01/02/07 all staff receive training in the protection of vulnerable adults from abuse. Original timescale of 01/09/06 not fully met and is being repeated. The bed in the red bedroom must be replaced. Original timescale of 01/02/06 not met. This requirement is repeated for the second time 01/01/07 Requirement 2. 3 YA20 YA23 13 [2] 13 17 4 YA23 13 6 5 YA25 16 1 (c) Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 24 6 YA33 18 1(a) (b) 7 YA35 13 4 18 1 (c) Vacant posts must be recruited 01/02/07 to. Original timescales not met. This requirement is repeated for the third time. Staff must receive refresher 01/02/07 training in safe working practices. Original timescale of 01/09/06 not fully met and is being repeated. A training needs analysis must be in place for the staff team. Original timescale of 01/09/06 not met. This requirement is being repeated. Steps must be taken to ensure that the staff training records are kept up-to-date and reflect the actual training undertaken. The Quality Assurance system must include service users and their representatives and the quality of care must be regularly and formally reviewed. A report must be produced and be made available for service users, their representatives and the CSCI. Original timescale of 01/09/06 not fully met. This requirement is being repeated. The thermostatic mixer valves must be serviced to ensure that they are working and delivering water at safe temperatures. Original timescale of 10/07/06 not met, this is a repeat requirement. Urgent steps must be taken to ensure that the home obtains a valid Gas safety certificate. 01/02/07 8 YA35 17 18 1 (c) 9 YA35 17 18 24 01/02/07 10 YA39 01/02/07 11 YA42 13 4 10/12/06 12 YA42 13 23 01/12/06 Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Harrow Road, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 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, Flat C, 291 DS0000010875.V314541.R01.S.doc Version 5.2 Page 27 - 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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