Inspection on 27/06/07 for Hatton Grove, 4

This inspection was carried out on 27th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hatton Grove, 4 12/12/05

Hatton Grove, 4 06/05/05

Hatton Grove, 4 08/11/04

Hatton Grove, 4 08/07/04

Hatton Grove, 4 10/12/03

Hatton Grove, 4 05/09/03

Similar services:

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Norbury Crescent (30)

Edenvale

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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 Hatton Grove, 4 West Drayton Middlesex UB7 7AU Lead Inspector Ms Pauline Griffin Key Unannounced Inspection 27 , 28 & 29th June 2007 14:00 th th Hatton Grove, 4 DS0000032589.V342402.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 Hatton Grove, 4 DS0000032589.V342402.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. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatton Grove, 4 Address West Drayton Middlesex UB7 7AU 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) 01895 441349 01895 444134 London Borough of Hillingdon Mrs June Christine Daniell Care Home 18 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (1) of places Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 12th December 2005 Brief Description of the Service: Hatton Grove is a purpose built home for seventeen adults with learning disabilities. It opened in the 1970s and is owned and managed by the London Borough of Hillingdon. The home is divided into three self-contained , one on the ground floor and two on the first floor. The ground floor unit accommodates service users who have physical disabilities as well as profound learning disabilities. A passenger lift provides access between the ground and first floor. Each of the residents has their own bedroom with wash hand basin and enough space to include an easy chair, table, cupboards and audio/visual equipment. The rooms are well decorated and comfortable. There are 2 bathrooms on each floor and each unit has 2 separate toilets. The ground floor accommodates shared space in the form of a spacious visitors lounge and a well equipped activities room. The rear gardens are secure and pleasantly laid to lawn with shrubs and seating on the patio area. There are currently 6 female and 11 male residents and their ages vary from 21 to 73 years of age. The majority of the residents are over 50 years of age. 15 of the 17 residents attend day centres and 2 (who are older) no longer attend. All of the 17 residents are white British. The Registered Manager is supported by a team of 4 Team Leaders (2 of the 4 positions vacant), 8 full time and 5 part time Residential Care Workers (3 full times posts vacant and the 5 part time posts vacant). There is a Team Leader on sleeping duty each night and a night Residential Care Worker on waking duty. All vacancies have been covered by regular agency workers including 3 domestic workers for cleaning and laundry. The home is in a residential area close to local shops and public transport links. The scale of fees was not available. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over three days for a total of approximately nine hours. The inspection was assisted by the Registered Manager and a Team Leader. The inspection took the form of a tour of the premises, meeting several residents, observing the evening meal being served, interviews with 2 Team Leaders, the examination of recording/logging systems, 2 staff files, 2 residents’ files and certificates for service to equipment/utilities for the building. Two residents’ representatives were spoken to on the telephone. Staff and residents files were chosen at random. The home has been heavily reliant on agency staff for the past 18 months due to a halt on recruitment for staff vacancies by the local authority. This situation has affected the running of the home and the service received by the residents. However, the local authority is currently having a recruitment drive and permanent staff members should be selected to fill the vacant positions and in place by the Autumn. The residents in the home, appeared well cared for and well groomed. Staff were observed to be interacting in a caring but respectful manner with the residents. Most of the 17 residents in the home are over 50 years of age. The home was decorated to a satisfactory standard throughout. What the service does well: What has improved since the last inspection? Staff files contained all the information outlined in Standard 34 Schedule 2 of the National Minimum Standards. Evidence of regular checks by accredited organisations of the utilities and safety equipment in the home are on file. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 6 Fridge and freezer temperatures are being monitored each day. 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. Hatton Grove, 4 DS0000032589.V342402.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 Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is good. 1,2,3 & 4 People who use the service or their representatives have all the information needed to choose a home that will meet their needs. Assessments made prior to admission ensure the home is able to meet the needs of the individual and take into account compatibility with others living in the home. People who use the service are able to make choices about their lifestyle and that their social, educational, cultural and recreational activities meet their individual expectations. This judgement has been made using available evidence including a visit to this service. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and Service User Guide should be reviewed to ensure they fulfil all the elements of Standard 1 of the National Minimum Standards. There are 17 residents in the home and the age range is between 21 and 73 years. The majority of the residents are over 50 years of age. The existing information does not include details of the age range of the residents and any limitations or arrangements associated with this. The home currently has 11 male and 6 female residents and the information does not include arrangements for choice of gender for personal care. The information does not describe the type of day t o day or weekend activities available to the residents. All the elements included in Standard 1.2 should be included in the Statement of Purpose/Service User Guide. Two residents’ files were chosen at random to examine. The details were stored in four separate files , a Primary File, Personal File, Individual Care Plan File and Working File. The home also keeps a personal planning book and a log book for day care communication for each residents. These arrangements made it difficult for the inspector to assess how up to date and relevant the information contained in them were. One Service User Plan appeared not to have been reviewed since 29/09/05. The Registered Manager of the home carries out a full core assessment to ensure that any prospective residents meets the eligibility criteria of the home. This assessment is carried out with the prospective resident and his/her family or representative. Arrangements are made for the prospective residents to visit the home for tea and to stay overnight and weekends prior to a decision being made. Hatton Grove, 4 DS0000032589.V342402.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 & 10 Quality in this outcome area is good. Residents are encouraged to participate in all aspects of life in the home. Personal goals, decisions and risk taking are supported to ensure that individuals achieve their potential. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents’ care plans were examined and were found to be comprehensive. However, the information was spread over four separate files and this made it difficult to assess the details contained in them were cohesive. The Registered Manager said that staff liaise with residents, their families and other professionals to obtain an holistic view of each individual’s needs. Each resident has a keyworker who is responsible for maintaining these documents. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 11 The Registered Manager said that she was planning to include the policy entitled ‘When I Die’ in the residents’ files to ascertain their wishes regarding wills, bequeaths and funeral arrangements. Person centred plans and activity plans are on file. The Registered Manager said that staff encourage residents to take manageable risks as part of an independent lifestyle. Individual risk assessments were seen on the files covering a range of activities from moving and handling, bathing, walking eating and using forms of transport. The home has a policy on confidentiality and staff are bound by the guidelines of the Local Authority to ensure that the written policies and procedures are adhered to. The policy on confidentiality is included in the Statement of Purpose in a shortened form. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is adequate. 12,13,14,15,16 & 17 People who use the service are able to make choices about their lifestyle. Social, educational, cultural and recreational activities must meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fifteen of the residents attend different day centres in the community where they participate in a programme of activities throughout the day. Two of the residents do not attend a day centre due to their age and poor health. None of the residents are able to take part in educational courses, training or employment. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 13 Residents’ representatives spoken to during the inspection said that the home was always welcoming when they visited. The Registered Manager said that some of the residents attend a local club one evening a week and residents enjoy trips to the shops and meals in pubs and restaurants. The Registered Manager said that the home arranges parties, theatre trips, sing songs and a garden party in the grounds in the summer. However, records on individual resident’s activity charts showed that there were no activities organised in the home at weekends. One resident’s representative said that there was ‘nothing going on’ at weekends. The Registered Manager said that although the home made efforts to organise outings for individuals and trips in groups - this has not been being carried out on a regular weekly or monthly basis. The Statement of Purpose and Service User Guide should describe details of what community links and leisure activities are facilitated by the home. The inspection included a tour of the home at different times over the course of three days. Staff were observed cooking and assisting people to eat their lunch and supper and interacting generally with the residents. Staff spoke to the residents in a friendly but respectful manner and took time to interpret what they wanted. There was a pleasant atmosphere in the home. Menus were examined and comprised suitable food designed to appeal to the culture and individual tastes of the residents. Details of the food eaten by each individual are kept. Many of the residents require their meals to be liquified and this is done with attention to the appearance and type of the food. On the evening of the inspection, residents were being served potatoes, cauliflower cheese and sausages. The Registered Manager said the there were standard desserts offered like, ice cream, yogurt and fruit but there were also choices of things like milk puddings, fruit purees and ‘smoothies’. On the day of the inspection it was a resident’s birthday and sponge birthday cake was being offered with the dessert. There is no evidence as to how the residents choose the meals they wish to eat when the majority of them have difficulties with communication. The Registered Manager said that plans for photographs of different meals and the use of picture boards and ‘board maker’ were being put into place. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is good. 18,19, 20 & 21 The health and personal care that people receive is based on their individual needs and wishes. Principles of dignity, privacy and respect are put into practice This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents in the home have a key worker who monitors the support provided for personal care and the way it is provided. Details of the daily routine are recorded in the personal files. During the course of the inspection, staff were observed interacting with the residents and taking time to ensure they understood what was being communicated to them. Each of the residents have a health action plan record that includes details of medication, medical conditions and medical appointments. The information included health care appointments like visits to the dentist, optician, chiropodist, physiotherapy, psychiatry, well women/man issues and hospital appointments. The files also contained a Hospital Assessment form for use Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 15 when residents are taken to hospital. These Assessments contained details of important information that the hospital would need to know either for emergency or routine admissions. The information would be particularly important for the hospital staff to know if the person were unable to communicate. Health files included records of the weight for some of the residents entered on a monthly basis. The Team Leader, assisting with the inspection, said that this was to ensure that changes in weight were monitored particularly where it had been identified that there were potential health issues. Medication storage and administration records were inspected in one of the three units. Boots pharmacy provides the home with a pre-dosed medication system but there was also liquids, creams and other preparations. The medication was stored in an appropriate manner and the records were maintained satisfactorily. Staff recorded the medication administered and signed each time. Receipt and disposal of unwanted medication was also recorded satisfactorily. None of the residents are able to manage their own medication. Medication is administered according to the London Borough of Hillingdon’s Medication Policy. Senior staff who administer medication in the home receive the Local Authority’s training in administration of medication. Boots Pharmacy makes regular visits to check that the home ensures that safe disposal, storage and recording is carried out in a satisfactory manner. The Registered Manager said that she was preparing to formalise the recording of the wishes of individual residents regarding ageing and dying. The Registered Manager said that the residents have full access to all health care professionals and changing needs and deteriorating conditions were fully assessed. The Registered Manager said that due to the fact that the majority of the residents were over 50 years of age, more attention will be paid to issues connected with the aging process, illness and death as detailed in Standard 21 of the NMS. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is good. 22 & 23 The home has a robust complaints procedure to ensure that people who use the service are protected from abuse. The home’s complaints procedure is included in the Statement of Purpose/Service User Guide to ensure that people who use the service and their representatives are familiar with it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is prominently displayed in the home and the procedure is also included in the Service User Guide/Statement of Purpose. The inspection process by the Commission for Social Care Inspection is also outlined and details provided as to where members of the public can obtain inspection reports. The complaints log kept in the home was examined and one complaint had been recorded since the last inspection and had been dealt with satisfactorily. The Registered Manager said that the complaints procedure would be produced using a ‘board maker’ package to ensure the residents have access to the process in pictorial form. Staff receive training provided by the London Borough of Hillingdon in the Protection of Vulnerable Adults and an up to date copy of the policy is maintained in the home. The Registered Manager said that staff would re-visit Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 17 the MacIntyre television documentary regarding adult abuse and the different forms it can take. The Registered Manager said that this would be shown on video during one of their full team meetings. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is good. 24, 27, 28 & 30. The physical design and layout of the home enable residents to live in a safe, well maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated in a quiet cul de sac close to local shops and public transport links. The general décor of the home is satisfactory and it is well furnished. The home is furnished in a way that creates a domestic setting that is bright and comfortable. There is an ongoing planned maintenance and renewal programme for the redecoration/refurbishment of the premises. The home occupies two floors of a purpose built property and there are three separate units, one on the ground floor and two on the first floor. The home has a passenger lift providing access the first floor. The home has purchased two new Oxford hoists, one of which includes body weighing scales and hand Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 19 rails have been installed in one of the units to enable the residents to remain as independent as possible. Each of the residents has a bedroom with room for a single bed, wash hand basin, cupboards and shelves. The rooms were well decorated and contained Personal possessions in the form of television, audio equipment, tapes, pictures and posters etc. Each of the bedrooms is lockable but staff said that the residents choose not to use the locks on the doors. There are two bathrooms on each of the two floors in the home and each of the three units have two toilets. The bathrooms are equipped with specialist equipment suitable for the residents’ needs. The toilet in unit B has a broken lock on one of the toilet doors. Each of the 3 units has a communal lounge and each contains comfortable furniture and audio/visual equipment. The first floor also has a visitor’s lounge and activities room. Staff have satisfactory arrangements for sleeping over and for storing their personal possessions. The decorative order of the home and quality of the furnishing is of a very good standard throughout. The home has a team of domestic staff to ensure that it is clean and free from odours. All staff have attended mandatory training in infection control, food hygiene, fire safety and health and safety legislation. The laundry is fitted with a sluice and the automatic washing machine includes a programme for laundering items at high temperatures (above 65 degrees) to ensure infection control. Procedures for infection control, hand washing and COSHH (Control of Substances Hazardous to Health 1988) are on display in the laundry room. Staff are provided with protective clothing. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is excellent. 31, 34 & 36 Staff are trained and skilled and in sufficient number to support the people who use the service, in line with their terms and conditions and to support the smooth running of the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff have clearly defined roles and each has a job description describing their roles and responsibilities. Job descriptions were seen on the individual staff files of the two examined as part of the inspection. The home has a very experienced and skilled staff team. The two Team Leaders interviewed as part of the inspection were able to demonstrate their knowledge and expertise and both had achieved qualifications above NVQ level 4. The Registered Manager said that over 75 of the staff team had achieve an NVQ at levels 2, 3 or 4. The Registered Manager said that the Local Authority is currently recruiting residential care staff and permanent staffing levels at the home should be reached within the next two months when selection procedures have been Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 21 completed. The home adheres to the robust recruitment policy and procedures of the Local Authority. All verifications and declarations are carried out and a probationary period of not less than 3 months is in place. The two staff files examined as part of the inspection were well maintained and confirmed that satisfactory recruitment practice had been carried out including enhanced Criminal Records Bureau clearance, references, health declarations, details of qualifications and work history. Each new member of staff receives a structured induction programme provided by the Local Authority. The Registered Manager said that staff receive induction in the home from the first day of employment and continues in line with the needs of the individual in their role and responsibilities. Staff receive individual performance and development agreements on an annual basis to identify training needs. All staff receive a minimum of five training days per annum and attend training and up date training courses in mandatory and specialist subjects provided by the Local Authority. Hatton Grove, 4 DS0000032589.V342402.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): Quality in this outcome area is good. The management and administration of the home is based on openness and respect. Quality monitoring systems must ensure the service provided to people who use it is of a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the course of the inspection of the home carried out at different times over three days, the staff performed at all levels of their roles with the residents in a professional and caring manner. The Registered Manager said that quality monitoring questionnaires were sent to a random group of the residents and these were returned to the Local Authority for examination. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 23 The home has a monthly monitoring system to ensure that health and safety issues are identified and addressed. Copies of these reports are forwarded to the CSCI. The home must develop the quality monitoring process it uses. Input from various stakeholders in the service should be obtained including the residents, their representative(s), staff, key workers at day centres, health professionals and visitors to the home etc (Standard 39.7) Feedback produced must be analysed and the results published and made available to the residents and their representative(s) (Standard 39.4). The home as a full set of policies and guidance produced by the Local Authority that are regularly reviewed to ensure good practice. Record keeping examined during the course of the inspection was satisfactory. Records seen were up to date and maintained securely in accordance with the Data Protection Act 1998. The Registered Manager said that the home adheres to the health and safety policies of the Local Authority. Staff receive regular training and support and receive moving and handling training annually. Staff also receive fire awareness training and records examined showed that fire drills are carried out three times per annum. Fire safety equipment is regularly tested and was last checked in June 2007. The home received a visit from the London Fire Brigade Department in July 2006. Staff have three fire drills per annum. The Registered Manager produced certificates by accredited organisations to prove that the gas, emergency lighting, electrical appliances, passenger lift and water had been checked within the past 12 months. Risk assessments examined were comprehensive but one completed by one of the Team Leaders in January 2007 had not indicated what measures were needed to be taken when a risk had been identified. The accident record book was examined and it was noted that 18 accidents had been reported since January 2007. The Registered Manager must monitor Accidents reported and identify any trends to ensure the safety of both staff and residents is protected. Hatton Grove, 4 DS0000032589.V342402.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 2 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 4 32 x 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 3 LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 x 3 2 3 3 3 x Hatton Grove, 4 DS0000032589.V342402.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 YA1 Regulation 4&5&6 Requirement Timescale for action 01/11/07 2. YA13 YA14 16 (2) (m) & (n) 3. YA21 12(2)(3) 4. YA39 24 The Statement of Purpose and Service User Guide must be reviewed to include all of the elements of Standard 1. A review of the arrangements for 24/08/07 individuals and/or groups of residents must be reviewed to ensure that they have access to and can choose from a range of appropriate leisure activities on a regular basis. The subject of aging, illness and 01/11/07 death must be approached with individual residents in accordance with the elements of Standard 21. A structure for the assessment of 01/11/07 quality monitoring must be produced. Information must be sought in accordance with the elements of Standard 39.6 & 39.7 and the outcomes published in accordance with Standard 39.4. Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA2 YA17 YA27 YA42 Good Practice Recommendations The files housing information concerning individual residents should be kept in a manner that is easy to refer and easy to maintain. Evidence should be available to confirm that residents have chosen meals from a selection of food that is in accordance with their dietary needs and individual choice. Locks on all bathroom and toilet doors should be checked to make sure that they work satisfactorily. Standard 27.6. Staff should receive training in fire prevention and attend fire drills at suitable intervals and night staff must attend. Residents should also be aware of the procedure in case of fire as far as is practicable. Standard 42.1 & 2. Regulation 23 (4). Records of accidents occurring in the home should be monitored to identify any trends that may prevent future incidents to improve the safety of both residents and staff. Standard 42.7. 5. YA42 Hatton Grove, 4 DS0000032589.V342402.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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