Inspection on 23/05/05 for Integrated Care Services Limited

This inspection was carried out on 23rd May 2005.

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

Other inspections for this house

Integrated Care Services Limited 01/05/07

Integrated Care Services Limited 11/04/06

Integrated Care Services Limited 14/11/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 09/07/2008.

CARE HOME ADULTS 18-65 2A Tudor Gardens 2A Tudor Gardens Kingsbury London NW9 8RN Lead Inspector Andreas Schwarz Announced 23 May 2005 9.00am 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 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 Stationary 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. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 2A Tudor Gardens Address 2A Tudor Gardens Kingsbury London NW9 8RN 020 8959 3965 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Goodwin Percy Bamunuwatte Mrs Moline Bamunuwatte Care Home 3 Category(ies) of LD 3 registration, with number of places 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Variation of registration to 4 service users. Date of last inspection N/A Brief Description of the Service: 2A Tudor Gardens is a newly registered home. The registered person is Mr Percy Bamunuwate and the manager is Mrs Moline Bamunuwate. The home is located in a residential area of Kingsbury. The property is detached, there are two bedrooms, bathroom, lounge/diner and kitchen on the ground floor. Two more bedrooms, office/sleep-in room and bathroom/WC can be found on the first floor. There is parking space for two cars in the homes own drive and free kerbside parking on a road around the home. There are a few shops in walking distance. More shopping facilities are in Wembley or Harrow, which can be reached through public transport. The home is registered for four residents and is currently occupied by two residents living on ground floor level. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over a whole day in May 2005. The manager was available throughout the inspection. The inspector was able to talk to two members of staff and both residents currently living at the home, additionally records and documents were viewed. Jane Shaw CSCI Pharmacy Inspector visited the home during this inspection and assessed Medication standards, a separate report will be send to the home, which can be made available from the CSCI on request. Mr Bamunuwatte (Responsible Individual) joined the inspector for the last hour of this inspection. The inspector assessed the majority of National Minimum Standards. The inspector would like to take the opportunity thanking residents, staff, manager and responsible individual of being welcoming and forthcoming throughout this announced inspection. What the service does well: What has improved since the last inspection? What they could do better: 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 6 Overall the home was judged providing good services to the residents. There is however a lack of recording and the inspector discussed this with the manager. There are a number of requirements made during this inspection, which is due to being inspected for the first time. The compliance of these requirements will improve the overall services provided to residents. 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. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 The home has a Statement of Purpose (SoP) and Service Users Guide (SUG) available, this allows residents making an in-formed decision of where they want to live prior of moving in. The manager or proprietor assess residents needs, before offering a place in the home. All new residents are offered trial visits before moving in. The home is offering contracts to residents stating the terms and conditions, however further work is needed for full compliance. The inspector judged that the home is meeting the needs of residents living in the home. EVIDENCE: The inspector viewed the homes SoP and SUG, which were found to be of good standards. The home is providing both documents in written and pictorial form enabling residents with less reading skills to have a better understanding of what is offered in the home. It is required to forward a copy of both SUG and SoP to the inspector and the manager must include the CSCI address in the SUG. Residents confirmed to have seen both documents and staff having explained the contents of the documents to them. The manager informed the inspector that she is carrying out assessments of new residents. The viewed assessment forms confirmed this. One of the residents living at the home is self-funding; the assessment viewed by the inspector has been judged as comprehensive and compliant with National 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 9 Minimum Standards. All care plans viewed take the initial assessment in consideration and risk assessments have been put in place. The home has a needs assessment policy, which has been made available for inspection. The policy was judged as being detailed and helped the inspector’s understanding of the assessment process more clearly. Both residents have mobility problems and the home offered ground floor accommodation, which suits their needs more appropriately. The manager informed the inspector of having good relationships with clinicians at the Brent Learning Disabilities Team and is contacting the team if needs change or specialist input is required. The manager informed the inspector that the home can offer respite placements, but is planning admitting residents for long term placements. A third resident is said to be moving in around mid June. The manager informed the inspector, that prospective residents are offered a trial visit and overnight stay before moving into the home. The resident the inspector has spoken to did not have a trial visit on this occasion. The manager explained that the resident’s brother and placement officer visited the home prior to admission. After this initial visit and assessment the home offered a place to the resident. The inspector discussed this with the resident and the resident confirmed to have chosen the colour in his room and being happy with the home. Only one resident was given a contract, which was compliant with the National Minimum Standards. The inspector informed the manager of the importance for all residents having a contract and that he must provide contracts for all residents living in the home. The contract viewed by the inspector was not available in a user-friendly format, this is required. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 standard(s) 6; 7; 9; 10 Care plans are of high standards and residents are involved in the review processes. Residents are encouraged to state their wishes and choices about what they want to do, where to go and staff are supporting residents in these processes. Residents are encouraged to take part in aspects of decisionmaking, the home offers residents’ meetings and questionnaires to find out what residents want. Manager and staff assess risks to ensure residents live in a safe and as far as possible risk free environment. Storage and record keeping is secure and confidential. EVIDENCE: Care plans viewed by the inspector were detailed and of good standards. It was evident, that regular reviews of the care plan are taking place and residents are involved in the review process. The residents the inspector has spoken to confirmed this. Care plans include the management of challenging behaviour, goals and objective. Important events such as death of a close relative are discussed in reviews and residents are encouraged and helped to deal with the loss. One care plan was incomplete, however this resident has only moved in recently and the manager informed the inspector that the home is currently in the process of drawing up his plan. All residents have a key worker allocated. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 11 Staff was observed respecting residents wishes, i.e. one resident was provided lunch, but decided to eat later due to being occupied. Residents informed the inspector of being listened to and having regular meetings with staff and peers. Unfortunately none of these meeting have been documented and the inspector informed the manager that this is required in the future. Residents informed the inspector that staff and manager are assisting them with finances and explained that they are happy with this arrangement. The responsible individual is acting as appointee for one resident and finance records viewed were in order. Risk assessments viewed by the inspector are judged to be present and up-todate. One resident has clearly written guidelines of challenging behaviour management in place, explaining to staff to respond consistently to the resident when having episodes of challenging behaviour. The risk assessments were found to be reviewed regularly and up dated if needs or risks are changing. The home has a missing person procedure in place. Records are stored safely in the office and only authorised people have access to the records. The home has a detailed storage of records policy in place. The policy should be up dated including the Freedom of Information Act 2005 to be in line with new legislations. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 standard(s) 11 - 17 Residents are encouraged to gain more independence and are supported in learning new skills. Residents are supported in attending college and in-house training for example literacy, computer, etc. Residents access the community individually and as a group. Meals were judged as healthy and of good standards and residents are encouraged to choose and prepare their meals with staff assistance. EVIDENCE: Residents informed the inspector to be encouraged by staff in learning new skills such as preparing tea/coffee, washing up, etc. One resident said that he is happy with this and staff doesn’t force him if he is not in the mood. The home has involved psychologists in the past supporting one resident in dealing with the loss of a close family member. The inspector noted a similar need with a different resident and recommends to explore counselling or psychology services for this individual. Residents are offered to go to church, but choose not to do so. One resident said, “ I used to go to church, but I read the bible now when I feel like it.” 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 13 One resident informed the inspector of attending North West London College in September to attend computer and literacy classes. He informed the inspector that he is looking forward to this and his key worker helped him in choosing the appropriate course. Records showed that the college has assessed the resident and the manager informed the inspector that the resident will visit the college for lunch to get familiarised to the new environment. The resident informed the inspector that the new skills could help him in finding employment once completed. Residents are encouraged accessing community facilities; one resident went to the local hairdresser during this inspection. The manager informed the inspector that residents go to the local pub, restaurant, café, library, cinema, etc. All the residents the inspector has spoken to confirmed this. Residents are not registered with the electoral register and the home must give service users the opportunity to vote. The home uses a car to facilitate transport for residents. All residents have their own television and music system. There is cable television available in the lounge. One resident has his own computer and was so kind to show the inspector his work. Residents informed the inspector of having been away on numerous trips to Lords Cricket Club, holidays, playing pool, etc. The home has planned a holiday to Blackpool this year and residents confirmed to be involved in the planning process. Resident’s relatives are involved and welcomed in the home. Regular visits were recorded in the visitor’s book. Families and friends are invited and encouraged to take part in care planning reviews. Both residents spoken to said they are able to invite friends to the home. The home has a relationship policy in place confirming visitors and friends having access to the home at a reasonable time. Staff were observed assisting residents with respect and privacy. All residents have been issued with their own key. Residents can choose to be alone or in company of others. Residents have access to all areas in the home. Residents are encouraged doing their own laundry, cleaning, etc. One resident said staff help me with cleaning my room and that he is happy with support received in domestic tasks. The home has a smoking and alcohol policy in place. Residents are able to smoke in designated areas, however none of the residents currently living in the home does smoke. The inspector viewed the menu; the home provides a healthy, well-balanced traditional british diet. One resident likes vegetable and salads and confirmed being happy with the meals provided. Residents confirmed of being asked what they want to eat and menu planning is done in a group. Meal choices are recorded separately. The manager informed the inspector that residents are encouraged eating together, but can choose not to do so if they wish. Fruits, 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 14 snacks and drinks were made available during this inspection. The inspector was not able to observe mealtimes during this inspection. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 18-21 Residents are treated with respect and dignity and receive personal care support in privacy. Residents are judged to be supported appropriately by the professional involved in their care. Medication was assessed by Jane Shaw CSCI Pharmacy inspector and was overall judged of being satisfactory, however requirements were made. A separate report can be obtained from the CSCI on request. Death and dying is discussed with residents, but more work will be required for full compliance. EVIDENCE: The home has two bathrooms, which can be locked, and residents are supported by staff in personal care. No personal care guidelines were available and the inspector discussed this with the manager. Residents confirmed being able to choose their own clothes and were observed of being nicely and appropriately dressed. The physiotherapist is involved with one resident and has drawn up an exercise programme for him and staff to follow. The inspector received very positive feedback from the physio praising the home for the care provided and staff being friendly and approachable. The managers informed the inspector having good relationships with professionals at Brent Learning Disabilities Team and access their services when there is a need in the home. All residents are registered with a local GP 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 16 and visits to dentist, podiatrist, and optician are recorded. Residents confirmed being able to see clinicians in their room if they wish. Jane Shaw CSCI Pharmacy Inspector has assessed the homes medication and a separate report is made available to the home. The manager must comply with requirements made by the pharmacy inspector. The home has an up-to-date policy on Death and Dying in place, but no records have been made available of residents wishes in death, dying and funeral arrangements were discussed in their care plans. This has been discussed with the manager and arrangements must be made to incorporate this in care planning processes. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 17 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 standard(s) 22;23 Residents have a good understanding who to complain to and explained to the inspector that they feel being listened to at the home. Polices and procedures are in place and residents are protected from abuse or neglect. EVIDENCE: The inspector viewed the homes Complaints Policy, which was openly available on the notice board in the kitchen. Residents informed the inspector having seen the policy and staff having explained the policy to them. The home has not received any complaints since registration with the CSCI. Documents to record complaints are in place. The home adopted Brent Protection of Vulnerable Adult Guidelines and has service guidelines in place. In addition to this the home has a whistle blowing policy and other procedures such as residents finances, violence and aggression in place. Staff have received POVA training through Brent Social Services and showed a good understanding of procedures in place. The responsible individual is acting as appointee for one of the residents and a family member manages the finances of the second resident. Finances of one resident have been assessed and were found to be correct and of good standards. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The home has recently been registered with the CSCI and therefore none of the environment standards have been assessed on this occasion. EVIDENCE: 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Staff roles and responsibilities are clearly defined and residents are aware of whom to approach if they need to. The home provides training for new and existing staff and staff are competent supporting residents. The home is providing adequate staffing levels to meet the needs of residents. However the inspector raised concern of staff working in both homes managed by Integrated Services Ltd. The home has a robust recruitment procedures in place and residents are protected through these procedures. Staff have been regularly supervised since opening the home. EVIDENCE: The homes job descriptions gives clear indication of the roles and responsibilities that care workers have in the home. Staff the inspector has spoken to confirm this. Staff receive induction before working with residents to get a clear understanding of their needs. Staff was not aware of the Code of Conduct set by General Social Care Council and the manager must ensure and raise awareness of this within the staff team. The home does not employ any volunteers. The inspector assessed Standard 33 through sampling of staff files, observing staff, talking to manager and service user. Staff was observed interacting with service users sensitively and appropriately. The inspector found staff and manager listening and responding to service users in a respectful manner. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 20 Staff-members the inspector has spoken to showed enthusiasm and great interest in improving the lives of service users. All staff have experience in working with people with learning disabilities. The inspector was able to talk to two staff-members during this announced inspection and found them knowledgeable and having good understanding of service users needs. The inspector judged both staff having a professional relationship with the residents. The home does not employ staff less than 18 years of age. Three of the seven staff currently employed by the home hold NVQ2 qualification or above and four staff are working towards achieving this qualification. The home has seven staff employed, which was judged as being appropriate for the current number of residents. Staff have appropriate breaks and days off. The inspector was however concerned of one staff member working in both services and explained to the manager that this must be reviewed. Currently there is a very low sickness and turnover noticeable. The home can access Brent Learning Disabilities Team for clinical support and a physiotherapist is currently involved in one resident’s care. The home has regular staff meeting and minutes were made available for inspection. Staff was observed communicating appropriately with residents. The home does not employ any staff below the age of 18. The inspector viewed staff records and found them all in order, staff have submitted two references, CRB checks and other relevant documents. The home is providing Learning Disabilities Award Framework (LDAF) Inductions to new staff. Residents are currently not involved in the selection of new staff and the inspector discussed this with the manager, suggesting in finding ways of involving residents in the future. Staff attended a wide range of training and certificates were made available for inspection. The training and development plan looks at current and future development needs and was judged as being appropriate by the inspector. The home has a separate training file and the manager informed the inspector having a training budget available to provide training in the future. The responsible individual attended a training course with the fire brigade enabling him to give fire training to the staff team. Staff the inspector has spoken to confirmed of receiving training, e.g. NVQ2 in Care, First Aid, Food Hygiene, etc. New staff working in the home undertake LDAF induction, which can be used towards achieving their NVQ 2 in Care. Staff informed the inspector receiving regular supervisions, which was evident in some personal files and the manager must ensure all staff receive regular supervisions. The manager is very involved in the home and is available during the week for help, guidance and supervision. Staff spoke very highly of the support received by the manager and responsible individual. Staff confirmed of being aware of the homes Grievance and Disciplinary policy and a Violence and Aggression policy was found to be in place. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41; 42 The home has relevant policies and procedures in place. Residents live in a healthy and well-maintained home. EVIDENCE: Relevant policies and procedures were assessed and judged to be satisfactory by the inspector. The home has an access to records policy in place, enabling residents, and families to see their personal records on request. The inspector recommends including the Freedom of Information Act in this policy. Records are kept locked within the office/sleep in room of the home. The inspector viewed relevant certificates such as Gas Installation, electrical wiring, water temperature checks, Legionella compliance, fire checks, etc. All certificates were found to be current and in order. The home is having weekly fire alarm tests, regular fire drills and the most recent fire lecture was done by the responsible individual. Relevant Health and Safety policies are in place and staff confirmed to be aware of their Health and Safety responsibilities. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 22 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 2 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2A Tudor Gardens Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 24 N/A 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. 2. Standard YA1 YA1 Regulation 5(1)(f) 5(2) & (4)(2) 5(1)c 5(1)c 15(2)(a) 17 16(1) 13(2) Requirement The CSCI address must be included in the Service Users Guide. The manager must forward a copy of Service Users Guide and Statement of Purpose to the inspector. The manager is required providing a written and signed contract to all residents. The contract must be provided in a user-friendly format. All residents must have an upto-date plan of care. Resident meeting minutes must be provided. All residents must be enroled with electoral register The manager must comply with requirements made by CSCI Pharmacy Inspector in the given time scales. Wishes of dying and death must be discused with residents as appropriate. The manager must review arrangements of staff working in both homes owned by the same company. All staff must receive regular supervisions. Timescale for action 30/06/05 30/06/05 3. 4. 5. 6. 7. 8. YA5 YA5 YA6 YA7 YA13 YA20 30/06/05 31/07/05 30/06/05 30/06/05 31/07/05 see time scales given in report 31/07/05 30/06/05 9. 10. YA21 YA33 12(3) 18c(ii) 11. YA36 18(2) 30/06/05 Page 25 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 12. YA31 The manager must ensure that staff is aware of the Code of Conduct. 31/07/05 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 YA10 YA11 YA34 Good Practice Recommendations It is recomended to include the Freedom of Information Act in the homes records policy. The inspector recomends exploring opportunities for bereavement counselling. The home should involve service users in the reruitment process of new staff. 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 2A Tudor Gardens G62 - G11 S56792 2A Tudor Gdns v218328 230505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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