Inspection on 14/09/06 for Huntley Close (7)

This inspection was carried out on 14th September 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Huntley Close (7) 13/10/05

Huntley Close (7) 06/05/05

Huntley Close (7) 12/01/05

Huntley Close (7) 06/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Huntley Close (7) 7 Huntley Close Stanwell Middlesex TW19 7DD Lead Inspector Helen Dickens Key Unannounced Inspection 14th September 2006 09:30 Huntley Close (7) DS0000013531.V312028.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 Huntley Close (7) DS0000013531.V312028.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. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Huntley Close (7) Address 7 Huntley Close Stanwell Middlesex TW19 7DD 01784 254322 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) Owl Housing Limited Anita Mundra Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 35-65 YEARS. ONE MAY BE OVER THE AGE OF 65. Date of last inspection 13th October 2005 Brief Description of the Service: 7, Huntley Close is a purpose built house, providing accommodation for up to 6 residents with a learning disability. All resident’s bedrooms are single occupancy and located on the ground floor. The office and staff facilities are on the first floor of the house. The resident’s communal areas consist of a large lounge, a quiet room and a large kitchen/dining room. There is an enclosed garden, accessible from the lounge. The home is located on the edge of a residential housing estate and has its own vehicle to provide transport for residents and staff. Owl Housing are the registered provider for this service. The current charges range from £1,128.95 to £1,178.82 per person per week. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over eight hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The home was inspected using the National Minimum Standards for Younger Adults only. Helen Dickens, Lead Inspector for the service, carried out this inspection. Josephine Garlick, Acting Manager, represented the establishment. A tour of the premises took place. The inspector met and spoke with four of the six residents (two others were out) and interviewed one member of staff. All residents have difficulties with communication so other means of ascertaining their views, such as observation of body language and staff/resident interaction, were also used. A number of documents and files were also examined as part of this inspection. This was a very positive inspection. The inspector would like to thank the residents, staff and deputy manager for their time, assistance and hospitality. What the service does well: Huntley Close provides a safe and very homely environment for its residents. The atmosphere in the home was friendly and relaxed and residents and staff interacted well. Standards in this home, especially the administration and decoration of the home, continue to improve and this is detailed in the next section. The key worker system works well to the benefit of residents. The format of the Essential Life Plans and care plans used is exceptionally user-friendly; this means residents are fully included in planning their own care. Resident’s meetings are also arranged and reported on in a way which is inclusive for residents. Positive feedback was received from a number of professionals who work with this home, and from relatives. One family wrote on their comment card; ‘We have always felt this is a well run and happy home….and have always been very satisfied with the care our relative receives.’ The manager is currently on maternity leave and the team is being led by the Acting Manager, Josephine Garlick who was very positive and receptive towards the inspection process. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The recruitment files sampled during the inspection were incomplete and arrangements must be made to ensure evidence of all pre-employment checks, and the information listed in Schedule 2 of the Care Homes Regulations (2001) (as amended) is available to be inspected. The legionella safety certificate and the current Employers Liability Insurance certificate were also not available to be inspected and a request was made for them to be faxed from head office to CSCI. Some decorative matters, including the awaited refurbishment of one bathroom and the outstanding gardening, detract somewhat from the Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 7 otherwise homely appearance of 7 Huntley Close. A risk assessment needs to be carried out on the toiletries which were to be found in some bathrooms and bedrooms. 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. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective resident’s individual aspirations and needs are assessed prior to admission. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six residents files were sampled and all had a good record of assessments both initially and throughout each resident’s stay at the home. Some of the original assessments have now been archived though relevant information that would not have changed, e.g. on specific health conditions, has been carried forward in each residents file. All clients are funded by social services and therefore all have community care assessments and reviews. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Residents know their assessed and changing needs and personal goals are reflected in their care plans, and they are encouraged to make decisions about their lives and participate in all aspects of life in the home. Residents are supported to take risks as part of an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care planning is good at this home and the systems for keeping plans updated has improved since the previous inspection year. These documents (called essential life plans) are reviewed 6 monthly and all residents have a named key worker. Of those sampled, there was information on daily routines, sensory equipment used, how staff were to offer support with personal care, help with mealtimes, out in the community, looking good, transport, and long and short term goals. They were in picture as well as word format which made them very resident-friendly. Two residents have chosen to keep their own care plans in their rooms. One resident’s essential life plan needed to be up-dated in line with their recent reviews and to change the date to 2006. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 11 Resident’s rights are respected at this home and there were many examples both on the day of the inspection, and from examining resident’s files, that residents were encouraged to be independent. One resident answered the door when the inspector arrived and later in the day another resident was seen to admit a staff member coming on duty by using the door entry system in the kitchen. These arrangements were supervised by staff who were available in the background to provide support where necessary. Records of choices made by residents are kept, for example in the Minutes of the residents meetings. Communication support is provided to residents, and staff were observed to have a good understanding of resident’s communication needs; communication passports were used for those residents who were assessed as needing them. Residents are assisted to do their own banking and the monthly Regulation 26 visits include sampling the financial records of at least one resident on each visit. Residents are consulted and given opportunities to participate in the day to day life in the home. Policies (e.g. complaints policy) and documents (e.g. their care plans) relevant to them are translated into resident friendly formats to aid their participation. One improvement since the last inspection has been the introduction of a large menu board in the kitchen with the menus for the coming week in words and pictures so that residents can see what they will be having at mealtimes. Residents are involved in menu planning and in shopping for the home. Comment forms are produced by the home to get feedback from residents and these are in a friendly format. Residents are also involved in compiling the service plan for Huntley Close. Risk assessments are carried out on a variety of aspects of each resident’s lives including moving and handling, going out into the community, and on particular health issues, for example nutrition and help at mealtimes. There are also risk assessments covering potential hazards which could affect all residents for example the use of hot water in the kitchen. The deputy manager was asked to review whether a written risk assessment was necessary relating to the toiletries which are in the bathrooms and resident’s bedrooms throughout the home; the potential hazards have been considered but not documented. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Residents are assisted to take part in appropriate and enjoyable activities and to be part of the local community. Family relationships are encouraged and residents are treated respectfully. Residents are offered a healthy diet in pleasant surroundings. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are assisted to take part in valued and fulfilling activities and had a list of their weekly activities on their care plans. There was evidence throughout the home of their activities for example photographs on the walls, in their essential life plans, and in the Minutes of residents meetings. One resident was pleased to show posters which had been given to them at a visit to a famous racing car dealer. Residents are encouraged to follow their own particular interests but there are also a number of activities where they join with other residents such as Saturday visits to the cinema and annual holidays where two or three residents go together. One resident has had a Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 13 wheelchair modified to suit their special mobility needs and this has increased their opportunities for participation. One key worker interviewed said the resident he worked with was well known in the local area as he liked to like to chat to people locally, have breakfast in the local Tescos, and use local pubs. Residents also liked to feed the ducks at Bedfont lakes, and on Saturday afternoons two or three residents go to the local cinema in Staines. Residents also went to local shops with staff for example to buy small food items such as milk, and also assisted with the main shop at the local supermarket. Family links are encouraged by staff at the home and at previous inspections staff had been closely involved in arranging visits to resident’s elderly parents. Staff are knowledgeable on resident’s family and friends and try to involve them where this is the wish of relevant family members. One resident had recently had a special birthday party and family members joined staff and residents at a local pub for the celebrations. The resident showed the inspector photographs of this event on the day of the inspection. Residents were observed to be treated respectfully by staff and staff were seen to knock on resident’s bedroom doors, and on toilet doors before entering. There were no instances of staff speaking exclusively with each other and ignoring residents. There was documented evidence of residents making choices about whether to join in or not, for example with residents meetings, where records showed that some residents chose not to attend, whilst others sometimes left during the meeting. Residents are offered an appetising range of food and they help to choose the weekly menu. This is now displayed on a whiteboard on the wall in the kitchen in large writing with pictures/photographs to aid understanding. The dining area in the kitchen is very pleasant with bright and tasteful decoration. Regarding the menu, the key worker interviewed said that the resident he worked with, and some of the other residents, particularly enjoyed the full English breakfast on Saturday mornings. Specialist advice is taken as necessary and dieticians are involved with several residents at the moment. Care plans clearly documented the help resident’s needed at mealtimes, and special diets were also noted in the kitchen as an aid for staff. Mealtimes are flexible to suit resident’s needs and residents are encouraged to help with shopping and to be involved in food preparation within their abilities. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Residents receive personal care in the way they prefer and their health needs are met. The administration of medication is well organised at this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s personal care needs were well documented on their care plans including how they are guided to move around, what their daily routines are, and how they like to be supported with these. Residents were observed to be dressed individually and additional specialist advice (e.g. occupational and physiotherapy advice) had been sought and was documented on resident’s files. All residents have a designated key worker. New health information packs have been created for each resident. Each pack contains a photo of the resident and where they live, photographs/and or pictures of the different health needs including communication, hearing, sight, diet and exercise, oral health, sleeping, skin and hair, and feet. There is also a section on mental health needs. There are pictures throughout, and some sections have larger writing with easier to understand words. There are details of health professionals involved with each client and any medication they are Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 15 taking. There is also a record of treatments, including complementary therapies. The home has changed their community pharmacist since the last inspection and a pharmacy inspection was carried out following the transition. Some advice was given to the home and this has been actioned. One person is in charge of the overall administration of medication but all staff are involved in administering medication on a day to day basis. Staff who administer medication are trained to do so. There was a list of staff sample signatures, guidelines for ‘as required’ medications for individual residents, and no unexplained gaps on the medication administration records sampled. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Resident’s views are listened to, and they are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints since the last inspection and a central log has now been created should they receive any. A resident-friendly complaints procedure is available which is a shortened version of the main policy but using easy words and pictures to make it more accessible to residents. This is available in the entrance to the home, together with comment cards for use by relatives and other visitors. There have been no protection of vulnerable adult matters raised since the last inspection with regard to the staff at this home. There is an in-house protection of vulnerable adults policy which works alongside the Surrey multiagency procedures for the protection of vulnerable adults. Staff are aware of their responsibilities for reporting suspected abuse. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Residents live in a homely, safe and comfortable environment. The home is clean and hygienic throughout. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents live in a homely and generally well kept environment and there have been a number of improvements since the last inspection including some bedrooms being redecorated and two bathrooms having new flooring. The premises are bright and cheerful with suitable light, heat and ventilation. The premises are in keeping with others in the local environment and furnishings and fittings are of good quality and domestic in nature. The environmental health officer’s visit found few issues needing to be remedied and made positive comments on a number of areas. However, the third bathroom needs refurbishment as some paint is peeling from the wall and the flooring is worn and unsightly in places. A toilet roll holder in another bathroom was not functioning and had a serrated edge which could have been dangerous. The gardening arrangements are not really satisfactory as care staff are expected to do the gardening – on the day of the Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 18 inspection this task was overdue and the front garden had large weeds and looked unattractive. The metal fence is unpainted and offers neither an attractive border nor any privacy for the garden. These arrangements should be reviewed. The premises are clean, hygienic and free from offensive odours throughout. Here is individually dispensed anti-bacterial hand soap in all hand-washing areas and paper as opposed to cotton hand towels. All the toilet areas were inspected and found to be clean and tidy. The previous recommendation to highlight the correct hot washing temperatures in the laundry has been met. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Residents are supported by competent and qualified staff team though recruitment policies and practices need to be reviewed in order to fully protect residents. Resident’s needs are met by appropriately trained staff. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff have the competencies and qualities required to meet residents needs. There is a friendly, open and positive atmosphere within the home which emanates from the acting manager and the staff team. Communication between staff and residents was good and residents were seen to turn to staff for assistance. 50 of staff (including agency staff) have either NVQ2 or above or a nursing qualification. This target will be exceeded when three more staff complete their training courses next month. Residents are supported by an effective staff team – on the day of the inspection there were sufficient staff to meet resident’s needs and many examples of good one-to-one working with individual residents. There is low use of agency and bank staff and where agency staff are used, the same staff are used regularly and well-known to residents. Rotas were sampled. The deputy manager was asked to either locate the previous staff to resident ratio Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 20 calculation or to use the Residential Forum matrix as recommended by the Department of Health and set down in Standard 33.3. Recruitment at Owl Housing is a shared responsibility with the HR department and therefore not all the relevant records are kept at the home. Following the inspection, the relevant missing information was faxed to CSCI. An arrangement has been made that from now on a pro-forma of all recruitment records will be kept at each Owl service in Surrey and inspectors will retain the right to ask for specific records to be brought from Owl head office if necessary. Requirements will be made regarding the accessibility of records and the necessity to take up a full employment history, not just the current request which is for only 10 years. Also, the service should seek advice from the CRB website on the correct storage and timely destruction of CRB records. A skills audit has been carried out and all staff have had a training and development needs assessment. There is a dedicated budget and a training officer at head office deals with the organisation of the training programme. Both internal and external trainers are used. There is also the Owl Housing learning and development opportunities booklet for all staff. The team meetings and staff supervision sessions are opportunities for staff to raise training issues. Staff have recently gone on an epilepsy training course as a result of the developing health need of one resident. The new business plan also contains information on the training and development arrangements for the home. A recommendation will be made that these elements be brought together to make a training and development plan for the home as per Standard 35.2 and Standard 35.7. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Resident’s benefit from a well run home and can be confident their views are taken into account in the development of this service. Health and safety arrangements are good. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Josphine Garlick, previously the deputy manager, has been acting manager at Huntley close whilst the registered manager is on maternity leave. She has been deputy manager at this home since 2004. Her background is in working with people with learning disabilities. The home is running smoothly and the atmosphere is pleasant and relaxed for residents. This home does well on monitoring the quality of their service and there is a service plan for the home which takes into account views of all stakeholders including residents, their families, and staff at the home. Staff involvement included a specific and dedicated meeting to discuss relevant issues. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 22 Monitoring of the plan was through team meetings, and from internal and external feedback; action plans were drawn up as necessary. The home gathers resident feedback in a number of ways. For example, residents have regular meetings which are documented in pictorial and word format – these represent a real improvement and the format is excellent. There is also a simple laminated complaints procedure in the entrance area of the home (with pictures and large writing) with comment cards for visitors, staff and residents to give feedback. One resident from this home attended the community inclusion conference in London organised by Owl Housing earlier in the year. Regulation 26 monthly inspection reports are completed and sent to CSCI. There are also monthly visits from a service user (from supported living) who comes and speaks with residents and does a more straightforward and shorter report. A ‘Service Report’ is also done quarterly and reports progress on residents ELPs, including goals achieved and those still outstanding. The quality assurance policy was updated 2006 and there is a 5 year business plan. There is also a policy on the internal quality management system and a service user involvement policy. A number of health and safety documents were sampled including the last environmental health officer’s report which was satisfactory, and a number of risk assessments relating both to the home generally and to individual residents. The hazardous substances cupboard was securely locked. Water temperatures tested in bedrooms were all within acceptable limits. The Legionella testing certificate and Insurance Certificate were still at head office and these were faxed to CSCI. The deputy manager was also asked to carry out a risk assessment on the availability of toiletries within the home, for example in bathrooms and bedrooms, and take any appropriate action. Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 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 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23(2)(b) Requirement Timescale for action 14/10/06 2. YA34 3. YA42 The registered person must review and set a timescale for remedying the following shortfalls which were highlighted during this inspection: • the third bathroom which is overdue for refurbishment • the use of the toilet roll holder which has a serrated edge • the gardening arrangements which are not satisfactory 19 Evidence that the records 14/10/06 and Schedule required by regulation (and as 2 set out in Schedule 2) have been acquired must be available to be inspected in the home. The application form needs to be reviewed to request a full employment history. 13(4)(a)(b)(c) A written risk assessment 16/09/06 must be carried out relating to the toiletries which are in the bathrooms and resident’s bedrooms throughout the home. DS0000013531.V312028.R01.S.doc Version 5.2 Huntley Close (7) 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. 1. Refer to Standard YA33 Good Practice Recommendations The registered person should use the Residential Forum matrix, as recommended by the Department of Health and set down in Standard 33.3, to calculate staff to resident ratios. The registered provider should consult the CRB website for advice on the correct storage and destruction of CRB certificates. The registered person should bring together the recent work on staff training and development, and any other information necessary, to produce a training and development plan as per Standard 35.2 and Standard 35.7. The registered person should review the equal opportunities policy to include ‘age’. 2. YA34 3. YA35 4. YA40 Huntley Close (7) DS0000013531.V312028.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Huntley Close (7) DS0000013531.V312028.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!