Inspection on 05/02/07 for Hoffmann Foundation for Autism 11 Pear Close

This inspection was carried out on 5th February 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hoffmann Foundation for Autism... 21/08/07

Hoffmann Foundation for Autism... 10/10/05

Hoffmann Foundation for Autism... 20/10/04

Hoffmann Foundation for Autism... 20/05/04

Hoffmann Foundation for Autism... 28/01/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hoffmann Foundation for Autism 11 Pear Close Hoffman De Visme Foundation 11 Pear Close Kingsbury London NW9 0LJ Lead Inspector Julie Schofield Key Unannounced Inspection 5th February 2007 08:00 DS0000017476.V325293.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 DS0000017476.V325293.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. DS0000017476.V325293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hoffmann Foundation for Autism 11 Pear Close Address Hoffman De Visme Foundation 11 Pear Close Kingsbury London NW9 0LJ 020 8200 8667 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) Hoffmann Foundation for Autism Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000017476.V325293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: The home is one of a number of care homes operated by the Hoffmann Foundation for Autism, a private care service provider. It provides accommodation and personal care for 6 adults with learning disabilities. The home is located within a residential area of Kingsbury, within the London Borough of Brent. It is close to local shops and bus routes and there is parking outside the home and in the nearby streets. There are two bedrooms on the second floor and a shower room with a toilet. Four bedrooms, 2 offices and a bathroom with toilet are situated on the first floor. On the ground floor there is a lounge, a large kitchen/dining room, a laundry room, a toilet and an activity day care room/staff sleeping in room. Leading from the day care room is a bathroom, with a toilet. Access to the garden is through patio doors leading from the lounge and from the dining area. Since the last inspection a new manager has taken over the running of the home although they have not been registered by the Commission for Social Care Inspection. Information regarding the fees charged may be obtained, on request, from the manager of the home. DS0000017476.V325293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Monday in February. It consisted of 2 visits. The first visit began at 8 am and finished at 11 am. The second visit started at 3 pm and finished at 6 pm. The Inspector met each of the 6 residents although most of the residents are unable to communicate verbally. During the inspection a site visit took place, records were examined, the preparation of a meal was observed, discussions took place with the deputy manager and with members of staff and care practices were observed. The Inspector would like to thank everyone for their assistance. What the service does well: The home is responsible for organising a day care programme for each resident ranging from 1 day per week to 5 days per week. For this purpose the home has a separate day care room, which is spacious and which contains the equipment necessary for art or music sessions and for games, puzzles and exercise. The daily programme includes activities taking place inside and outside the home. Each resident’s daily programme is “posted” on the communications board by placing a picture of the activity next to a photograph of the resident. A member of staff supports one of the residents to place the pictures next to the appropriate photograph. Staff said that they have access to a comprehensive training programme. A newer member of staff commented on a positive team spirit in the home and that staff worked together and supported each other. Guidelines are in place for when staff support residents with personal care tasks and also for a range of other activities. The importance of residents maintaining contact with their families is recognised and carers support residents to visit family members who are unable to visit the home due to increasing frailty or ill health. DS0000017476.V325293.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. DS0000017476.V325293.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 DS0000017476.V325293.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 The prospective resident, and those acting on their behalf, are helped to make an informed choice about the suitability of a placement by the provision of information about the care home. Standard 2 was not inspected at this inspection as no new residents have been admitted to the home for several years. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement was identified during the previous inspection that information regarding the room sizes and the development of a designated day care room need to be added to the Statement of Purpose and Service users guide. It was noted that changes have been made to the documents that were available for inspection. DS0000017476.V325293.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The resident’s needs are fully assessed on a regular basis and care plans are in place, which reflect their individual needs and choices. Residents are supported in managing their finances to enable them to budget wisely. Responsible risk taking contributes towards the resident becoming more independent and this is reviewed on a regular basis. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. Each contained guidelines for supporting the resident and for providing assistance with personal care. There were also guidelines tailored to the individual needs of the resident e.g. supporting a resident when the resident was visiting a relative. Files contained a personal development plan, a personal planning book and a “My Life Now” book. Person centred plans were reviewed. DS0000017476.V325293.R01.S.doc Version 5.2 Page 10 Three of the residents receive assistance with managing their financial affairs. Records were inspected and were up to date and complete. Day to day records included information about expenditure and receipts are kept. For each resident there was a running total of the balance held and the company has a system of carrying out regular audits. Information about their savings accounts was available. Referrals for advocacy services have been made on behalf of 2 residents. Each of the 3 case files examined contained risk assessments, which had been reviewed on an annual basis. The date of the last review was within the previous 6-month period. The format of the risk assessment included the setting, the frequency, the anticipated positive and negative outcomes, measures to minimise the risk, views of all interested parties, action to be taken and the date of review. Risk assessments were tailored to the individual needs of residents. There were risk assessments in respect of going swimming, going out for a walk, travelling on public transport, travelling on the home’s transport, going shopping etc. DS0000017476.V325293.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Taking part in activities, developing skills and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. By maintaining contact with their family the resident’s need for company and fellowship is met. Residents are encouraged to become more independent by exercising their right to choose. Residents are offered a balanced diet to promote their well being and the diet respects their cultural needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the residents has a day care programme and a copy of their weekly activities is kept on file. Three residents’ programmes include attendance at a day centre although they also have days at home during the week. On the day of the inspection these residents were attending a day centre in Wembley. Each of the remaining 3 residents that have day care activities arranged by the DS0000017476.V325293.R01.S.doc Version 5.2 Page 12 home was going out for part of the day as their day care programmes included activities both inside and outside the home. Weekly activities arranged by the home include exercise, free time and personal interests e.g. hair and beauty care, music sessions, cooking or going to the pub for a drink. There was a communication board in the kitchen/dining area, which had a photograph of each resident and space to place a picture of the planned activity next to the photograph. A resident selected and placed the pictures on the board, with support from a member of staff. There is a designated day care room, which is used to provide in house activities, and it contained musical instruments, an exercise bike, games etc. The home has its own transport, which is used regularly as well as public transport for activities taking part in the community. The rota is drawn up so that staff are on duty to support residents in the community including time in the evenings and at weekends. A carer described some of the leisure activities that residents took part in and these included visits to restaurants, pubs, parks, the shops, the bowling alley and the sports centre. Some of the residents also attend clubs and discos, which take place in the evenings. Each of the residents enjoyed an annual holiday in 2006 and the deputy manager said that 2 residents went on holiday to Spain, 3 residents went to Norfolk and 1 resident went to West Sussex. Some of the residents enjoy regular contact with their families. Family members may visit the home to see a resident or call to collect the resident to take them out. The home supports two residents by providing carers to accompany them when the resident visits their elderly parent. When a relative of a resident visits the home the resident can choose whether they want the visit to take place in the lounge or in the resident’s room. A member of staff said that the key worker takes responsibility for keeping in contact with the resident’s family. As most of the residents are not able to communicate verbally a discussion took place with a carer regarding daily routines and residents being able to exercise choice. The carer described how residents were encouraged to choose their breakfast cereal in the morning and how carers interpreted the residents’ facial expressions and body language. It was observed that residents had the freedom to enjoy the communal areas of the home and to socialise with other residents. They were able to use their rooms, when they wished, without unnecessary interruption by members of staff. The carer spoke of the need to respect the privacy of the resident and the importance of knocking on the door before entering a room. Residents are encouraged to take part in domestic tasks so that they can become more independent During the inspection the preparation of the evening meal was observed. The member of staff preparing the meal confirmed that they had undertaken food hygiene training. The meal consisted of savoury mince, rice and vegetables DS0000017476.V325293.R01.S.doc Version 5.2 Page 13 with yoghurt for a dessert. There is a 4-week menu cycle and each day a hot meal is available at lunchtime and in the evenings. The weekly menu was examined and it was noted that the menu was varied and wholesome and included fresh fruit and fresh vegetables. Alternatives are offered if the resident doesn’t like the meal and a carer said that residents were able to make this known by pushing the plate away or by not eating the food. Foods that meet the cultural needs of African Caribbean residents are incorporated into the menu. One of the residents is diabetic and guidelines regarding suitable food items and recommended quantities are on display in the kitchen/dining area. DS0000017476.V325293.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 Residents receive assistance with or prompting with personal care in a manner, which respects their dignity. However privacy must be promoted by residents wearing appropriate clothing when using communal areas. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Guidelines in respect of assisting with personal care were included in resident’s case files. A carer said that there is always a female member of staff on duty to assist female residents with personal care. Male residents’ wishes in respect of whether they are assisted with personal care tasks by male or by female staff members are respected. It was noted during the inspection that assistance with personal care was offered discreetly and in a manner that DS0000017476.V325293.R01.S.doc Version 5.2 Page 15 promoted the dignity of the resident. However during the morning inspection visit one of the female residents was sitting in the lounge in her nightdress, but did not have a dressing gown. After getting dressed in the morning residents were observed to be wearing clothing appropriate for the time of year and were clean and tidy. Staff support the female residents in the care of their hair, nails and make up as part of the day care activities. A system of key working is in operation in the care home. Records were kept of the residents’ health care appointments. These demonstrated that residents had access to the support of the GP, the dentist and the optician. There was a record of medication reviews taking place. Where appropriate, referrals have been made to the speech and language therapist. There was a health assessment form on each of the 3 case files examined. Medication is kept in a locked facility. The home uses a monthly monitored dosage system. The blisters had been opened appropriately prior to the inspection. Records were up to date and complete. Two members of staff are responsible for the administration of medication. One member of staff acts as a witness and both members of staff are obliged to initial the record sheets. The administration of medication was observed and it was noted that sufficient liquids were offered with tablets to aid swallowing. Staff confirmed that they had undertaken medication training. DS0000017476.V325293.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 A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place, which has timescales for each stage of the process. If a complaint cannot be resolved locally a senior manager within the company deals with the complaint. The policy advises the complainant of their right to contact other agencies who are involved in the process e.g. the CSCI, the local authority and the Ombudsman. The deputy manager said that no complaints involving residents have been recorded since the last inspection, although a complaint from a neighbour regarding a member of staff had been logged in November 2006. Records were complete and included details of the investigation carried out. The residents are unable to make complaints due to the level of their learning disabilities and the manager confirmed that referrals for advocacy services have been made on behalf of those residents without family support. The home has an adult protection procedure in place and has a copy of the local authority’s interagency guidelines. Induction training held at head office DS0000017476.V325293.R01.S.doc Version 5.2 Page 17 includes protection of vulnerable adults training. The deputy manager said that no incidents or allegations have been recorded since the last inspection. Staff on duty confirmed that they had received training in protection of vulnerable adults procedures. DS0000017476.V325293.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, 30 Residents enjoy a comfortable and “homely” environment with pleasant communal facilities although some redecoration of the bedrooms is needed. Residents live in a home where standards of cleanliness are good although not all members of staff have received training in infection control procedures. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A site visit took place. It was noted that communal areas were comfortably furnished and decorated and that there was a “homely” atmosphere in the house. Levels of lighting and heating were appropriate for the time of day and for the season. Two bedrooms on the first floor were in need of redecorating. The sealant around the wash hand basin in one of the second floor bedrooms was perished and needed replacing. The Inspector was informed that there DS0000017476.V325293.R01.S.doc Version 5.2 Page 19 were still problems with the toilet on the second floor, although an appointment for a plumber to call to carry out repairs had been made. The laundry room is situated on the ground floor and although small in size contains a commercial washing machine and a commercial drier. Using this room does not involve carrying soiled linen through any area where food is stored, prepared or eaten. It was noted that all parts of the home were clean and tidy and free from offensive odours. The manager confirmed that some members of staff have received training in infection control procedures. DS0000017476.V325293.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, 33, 34, 35 NVQ training enhances the general skills and knowledge of carers and the home has met the target of at least 50 of carers achieving an NVQ level 2 or 3 qualification. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents and the home needs to ensure that evidence of all of these is kept on the staff file. Residents benefit by being supported by staff who have access to both induction training and training to meet the needs of the particular client group. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four members of staff discussed NVQ training with the Inspector. One person said that they were studying for Level 2, one person had completed Level 2 and was currently studying Level 3 and one person had completed level 3. The fourth member of staff said that they planned to retire and so had not put themselves forward. A discussion regarding NVQ training took place with the DS0000017476.V325293.R01.S.doc Version 5.2 Page 21 deputy manager. Six of the 12 members of staff on the rota have completed their NVQ level 2 or 3 studies and a further 3 staff have enrolled for NVQ level 2 training. The home has met the target of 50 of carers achieving an NVQ level 2 or 3 qualification. The rota was examined. Staffing levels varied, according to the day of the week, and there were additional staff on duty during the week on days when most or all of the residents were at home i.e. a Friday. The deputy manager confirmed that the number of staff on duty on the rota was sufficient to support residents with their activities both inside and outside the home and that the need for a member of staff on duty that was also a driver was taken into account when planning the rota. During the inspection staffing levels supported residents going out on activities on a one to one basis. Three staff files were examined and each member of staff had started working in the home in 2006. Each file contained an enhanced CRB disclosure, although a previous employer had obtained one disclosure. All files contained passport details as proof of identity and right to work, where required. One of the files contained only 1 reference. An induction checklist and pack were available for inspection. The pack contained a reference to the LDAF units and referred to the GSCC Code of Practice. Attending mandatory training i.e. fire safety, food hygiene, manual handling, first aid and infection control is monitored by Head Office and the home is notified when staff are to attend. Training specific to supporting the client group is also arranged e.g. understanding autism. A programme of training courses available is sent to the home although the home does not have its own training plan. There is a training needs assessment for the team but individual training profiles need to be developed. The new manager has taken over responsibility for carrying out staff appraisals and is setting up a programme for those due in 2007. DS0000017476.V325293.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 The manager is continuing to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Completion of the NVQ level 4 training will assist this process. Service satisfaction questionnaires, forums and meetings help to monitor the quality of the service provided to residents and contribute towards the development of the service. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Servicing and testing equipment and systems within the home demonstrates that they are safe to use. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000017476.V325293.R01.S.doc Version 5.2 Page 23 The previous manager, Blessing Oloke, informed the Commission for Social Care Inspection (CSCI) that he was taking up a senior management post at Head Office, effective from the 10th October 2006. Although Frances Caiquo has been appointed manager of Pear Close the CSCI has not received an application for registering a new manager. A discussion took place with her regarding her previous experience and qualifications. Ms Caiquo has worked as a manager in the private sector, for Housing Associations, for approximately 10 years. She has previous experience of working with young adults with learning disabilities. She holds an NVQ level 3 in care and has commenced the RMA training. The company has a number of ways in which feedback on the quality of the service is obtained. Feedback from relatives may be given during their visits to the home. The company organises a forum (which is held on a quarterly basis) for relatives and residents and a parent of a relative attends. Comments can also be given during the review meetings, to which relatives are invited, if the resident wishes. In addition, on a quarterly basis a sample of relatives are sent a quality assurance feedback form. In respect of the placing authority a sample are sent a quality assurance feedback form and comments can be given during review meetings. The manager said that she is drafting a customer satisfaction survey form, which can be kept in the home and distributed to relatives or professional visitors. She will also install a suggestion box which relatives, visitors and staff will be welcome to use. The company forwards a copy of the monthly Regulation 26 reports. A statutory requirement was identified in a previous inspection that the home has a valid certificate for the testing of the portable electrical appliances. Although this had been addressed after the last inspection the certificate dated the 22nd November 2005 has since expired. The deputy manager said that the appliances had been tested in 2006 and that they were waiting for the certificate to be forwarded to the home. There were valid certificates for the testing and servicing of the fire precautionary systems and equipment in the home. There was a valid Landlords Gas Safety Record and a valid certificate for the electrical installation. Testing of the fire alarm system, the emergency lighting, water temperatures and holding fire drills were recorded in the monthly health and safety inspection of the home. The home had a health and safety risk assessment and a fire risk assessment. A carer on duty confirmed that they had received training in safe working practice topics and listed manual handling, fire safety, first aid, food handling and infection control. DS0000017476.V325293.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 3 X DS0000017476.V325293.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 YA18 Regulation 12.4 Requirement That service users wear a dressing gown over their nightclothes when seated in communal areas. That the bedrooms on the first floor are redecorated. That the sealant is replaced around the wash hand basin in the second floor bedroom. That all members of staff receive training in infection control procedures. That each staff file contains an enhanced CRB disclosure that has been obtained by the company and 2 satisfactory references. That the manager completes and forwards an application for registration to the CSCI. Timescale for action 12/03/07 2 3 4 5 YA24 YA24 YA30 YA34 23.2 23.2 13.3 19.1 01/07/07 01/04/07 01/07/07 01/05/07 6 YA37 8.1 01/04/07 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 Good Practice Recommendations DS0000017476.V325293.R01.S.doc Version 5.2 Page 26 1 2 3 Standard YA35 YA35 YA42 That the home develops a training plan, which is in accordance with the aims and objectives of the home and is designed to meet the collective needs of service users. That each member of staff has an individual training profile. That the home requests a copy of the certificate for the testing of the portable electrical appliances from the company responsible for carrying out this task. DS0000017476.V325293.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000017476.V325293.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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