Inspection on 13/06/08 for Juliana Close 46

This inspection was carried out on 13th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Juliana Close 46 23/11/07

Juliana Close 46 11/04/07

Juliana Close 46 04/04/06

Juliana Close 46 12/12/05

Juliana Close 46 12/07/05

Juliana Close 46 12/08/04

Juliana Close 46 30/04/04

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Juliana Close 46 Off Thomas More Way East Finchley London N2 0TJ Lead Inspector Tom McKervey Key Unannounced Inspection 13th June 2008 09:45 Juliana Close 46 DS0000010456.V364608.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 Juliana Close 46 DS0000010456.V364608.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. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Juliana Close 46 Address Off Thomas More Way East Finchley London N2 0TJ 020 8343 0016 F/P 020 8343 0016 jaylott@adepta.org.uk www.pentahact.org.uk PentaHact Limited trading as Adepta 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) Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user. One specified service user who is over 65 years of age, may continue to be accommodated in the home for as long as the home continues to meet the service user`s needs. The home must advise the regulating authority at such times as the specified service user vacates the home. 23rd November 2007 2. Date of last inspection Brief Description of the Service: 46 Juliana Close is a purpose-built home designed to provide personal care and support for six adults of either gender, who have a learning and a physical disability. The home, which opened in November 1993, is leased from Servite Housing Association and is managed by Pentahact, trading as Adepta, which is a Barnet based organisation. Adepta also manage several other homes in the borough. The six places available, are funded by a block contract with the local authority. The home is a six-bedded bungalow in a quiet cul-de-sac in a housing estate. The communal areas comprise of a large lounge, a quiet room and a kitchen/diner. There are two assisted bathrooms, two toilets and a shower room, and there are gardens to the front, side and rear of the property. The home has its own vehicle, which can accommodate wheelchairs. The stated aims of the home are to provide twenty-four hour care and support for people with profound learning disabilities and to enable them to live as independently as possible in the community. The fees for the service are £1,429.26 per week. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes This unannounced inspection was carried out as part of the Commission’s inspection programme to check compliance with the key standards and also to assess how the requirements from the last inspection had been complied with. The inspection was completed in a period of five hours and twenty minutes. At the time of the visit, a new manager was in post having been the acting manager at the last inspection. The manager offered every assistance in the inspection process. In April 2008, an AQAA, (Annual Quality Assurance Audit), was sent to the Commission. This document is a self-assessment of how the home meets the National Minimum Standards. Against each standard, the manager is asked to provide evidence about what the home does well, what they could do better, how they have improved in the last 12 months and what their plans are for improvement. The content of the document was discussed with the manager who updated the information to reflect the current situation in the home. The Commission also sent out surveys to the people who live in the home, their relatives, and to staff. Four questionnaires in total were returned; one from a resident, which was completed by their relatives on their behalf, one from staff and three from other relatives. The majority of comments were favourable about the service, but some concerns were also expressed. Their views are included in various sections of this report. Six people were living at the home, all of whom have lived there for several years and there were no vacancies. The inspection process included visiting all areas of the home, observing the residents and speaking to the staff. We also looked at records and examined documents pertaining to the running of the home. It was not possible to interview the residents because of their limited verbal skills. However, through observation of how staff interacted and communicated with them, we concluded that the residents received a good quality of care. What the service does well: The home is purpose-built, which ensures that all areas of the home are fully accessible for those people who are wheelchair users. The residents’ bedrooms are individualised and decorated to reflect their personal tastes. The people who live in the home enjoy a good quality of life and they are supported with dignity and respect by a dedicated staff team. There is a good range of activities to keep the residents stimulated and they enjoy full access to facilities in the community. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 6 Care plans are person centred in a way that involves the resident and their relatives in deciding how their needs are best met and the residents’ health is maintained by regular check-ups and specialist appointments. The organisation provides a very good training and development programme for its staff and recruitment procedures are thorough in ensuring that new staff are properly screened before they start working in the home. A good system has been introduced to ensure proper accounting for residents’ personal monies, and the manager intends to promote residents having greater control over their finances by having personal safes in their rooms. 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. Juliana Close 46 DS0000010456.V364608.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 Juliana Close 46 DS0000010456.V364608.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): 2 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service to look at files. The people who live in the home and their representatives can be confident that the home continues to provide a service that meets their needs. EVIDENCE: There have been no new admissions to this home for several years. In March 2008, the local authority that commissions services for this group of residents, carried out a review of their placements in the home. This review involved some of the residents’ relatives and the manager of the home. The outcome of these reviews was that the reviewer was satisfied that the service was appropriate for the needs of the people who live in the home. However, the manager had concerns about some aspects of the reviews and a meeting has been arranged to address these in the near future. In our survey, a relative stated; “We can tell our son is happy living in the home.” In the AQAA, the manager states that Adepta carries out annual service reviews that includes questionnaires for people who use the service. There is a regional development group of service users who put forward their views about how they wish to be supported. One of the Juliana residents is a member of this. This group feeds back to a strategy group which reports to the Board of Trustees. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 9 One outcome from this forum was that “service users” preferred to be called “people”, and as a result all records in the home show that staff now refer to “people we support”. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including observation and looking at residents’ care plans. Each person living in the home can be confident that their care plan provides clear guidance for staff about how to support them in the way they prefer. Risk assessments are carried out to ensure that residents are able to partake in a wide range of activities to enable them to live as independently as possible. EVIDENCE: There is a person-centred approach to care planning and at the time of the inspection, three people had complete plans in this format. The acting manager told us that new care plans for the other three residents will be completed following a staff team event in September this year. We sampled three care plans. They were comprehensive and gave a good picture of each person. Peoples’ rituals and preferences were recorded, for example; “will usually have a lie-in”. The care plans showed that some people liked to be involved in some household tasks, for example cooking or shopping Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 11 for the home. It was evident that the person and their relatives were involved in putting the plan together as these were signed by the relatives. The plans provide good information and guidance about how to meet the person’s needs. This is important because none of the residents are fully articulate and this guidance ensures that staff have a consistent approach to them. Each person has an identified key-worker, who meets with the resident monthly to discuss the care plan and keep it up to date. These meetings are recorded. Detailed risk assessments are carried out for each resident regarding activities in the home and out in the community. For example, special precautions are documented for people who have epilepsy. There are three males and three females living in the home. In the AQAA document, the manager identified the residents as being British, two of whom are Christian and one is Jewish. One person attends religious services regularly. In accordance with the family’s wishes, the Jewish resident does not require specific meals. There is a letter to this effect from this person’s relatives. In our survey asking - “What do you feel the home does well?” A relative stated; “ They respond to my son’s individual needs”. However, a staff member responded, (anonymously); “The service is inconsistent in support of the basic needs of the people who live there”. The manager should explore this comment at the next staff meeting. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 & 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live in the home can be confident that they can enjoy lifestyles that reflect their individual needs and preferences. They are treated with courtesy and respect and they have a good programme of stimulating activities. People are supported to choose their own meals, which are well balanced and nutritious. EVIDENCE: Residents’ records show that five people who live in the home attend day centres or colleges during the week. One person is elderly and their care plan indicates that it is more appropriate to support them with daily outings in the local community. This person also has a programme that includes reflexology, attendance at church and visits to a friend who lives nearby. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 13 The daily records show a diverse and stimulating programme of activities is provided, including pub lunches and drives into the country. Shopping trips to London by train were also recorded. An outside entertainer visits the home on Sundays and plays for the residents. There is a computer for people to play games and there is sensory equipment in the lounge for stimulation and relaxation. In the AQAA, the manager has identified a need to develop more activities, particularly for people who have autism. There are good risk assessments and guidance for staff in place for when the residents spend time in the community. The home has an open visiting policy to ensure good contact is maintained between residents and their families. Several people go home at weekends. The AQAA states that residents are given privacy to express their sexuality appropriately. We observed that staff engaged with residents in frequent conversation and addressed them in a courteous and caring manner, by their preferred names. The people who live in the home appeared well cared for and were appropriately dressed in clean clothes. The menus showed a good variety of nutritious meals provided. The people who live in the home are supported in planning the menu at weekly house meetings. One resident has diabetes and another is overweight. Both residents are on appropriate diets as advised by the dietician. The manager told us that “special nights” are laid on for the residents, where staff cook special meals to celebrate various national holidays, for example; Scottish, Jamaican, Kenyan etc.. Juliana Close 46 DS0000010456.V364608.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence from residents’ health records and assessing medication standards. The people who live in the home can be confident that they will be supported in their personal care with dignity and appropriate appointments will be made for them if they become ill. They can feel assured that they will be given their medication safely, which helps to keep them well. They can also feel confident that their end of life wishes will be respected. EVIDENCE: The residents’ care plans that were examined, provide guidance about how each resident prefers their personal care to be supported and the staff rota confirmed that there was always male and female carers on duty to ensure that care was provided in an appropriate dignified manner with respect to the gender of the resident. Each person has a “Health Action Plan”, and all residents are registered with a G.P. Up to date records are kept of healthcare appointments. For example, one person had been assessed recently by an occupational therapist for an electric Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 15 wheelchair. Another had a recent review of their epilepsy medication by the consultant psychiatrist. The residents’ case files contained information about appointments with other healthcare professionals as appropriate, and their individual physical and emotional needs were well documented in their care plans. One resident has diabetes. The staff have been trained by the District Nurse to monitor their blood glucose and to administer insulin. None of the residents are able to self-medicate. The home has an appropriate medication procedure, including guidelines about covert administration of medicines and rectal Diazepam. The medication stock was stored safely and we noted that there has been an improvement in the administration records where there had been frequent discrepancies identified in previous inspections. The manager has introduced a system of checking the medication to ensure that mistakes are not made in recording. The manager acknowledges in the AQAA that the resident population is growing older and there is a need to prepare the staff to provide a service to respond to changing needs. In the last year, staff have undergone training in dysphasia and new guidelines have been produced regarding risks associated with eating. All staff have been trained in this by the speech and language therapist. The wishes of the people who live in the home and their representatives about arrangements at the time of their death are recorded in case files. Juliana Close 46 DS0000010456.V364608.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including observation, speaking to staff and examining records. People who live in the home and their representatives can be confident that any of their concerns will be taken seriously and acted upon appropriately. The residents can be confident that they are protected from potential abuse through staff training and their awareness about abuse issues. EVIDENCE: The residents appeared well cared for and they indicated to us that they were happy. There was a relaxed and friendly atmosphere and the interactions between the staff and residents were warm, friendly and respectful. The home has an appropriate complaints procedure and this is in pictorial format for residents to be able to understand it. We examined the complaints log, which showed that two complaints had been made by relatives in the past year. There was a record of how these complaints had been investigated, which was in a reasonable timescale. The complaints were upheld and an apology was offered. It was recorded that the complainants were satisfied with the response. The manager states in the AQAA, “We treat every complaint as a tool to improve the service”. In relation to how they could improve, they have identified a need to have more advocacy for the residents, but the manager said she had found this difficult to access locally. Nevertheless, she intends to pursue this matter. The staff records showed that they had attended training in adult protection procedures. In discussions with the staff, we were satisfied that they were Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 17 knowledgeable about the “whistle-blowing” procedure and their roles in relation to the protection of the residents from abuse. At the time of the inspection, an investigation was taking place into an incident whereby a member of staff may have compromised the health and safety of the residents. The manager immediately reported this incident to senior managers, social services and the Commission and appropriate action is being taken to address the matter. Juliana Close 46 DS0000010456.V364608.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): All these standards were assessed. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including observation, speaking to staff and examining records. Residents can be confident that they live in a home that is generally clean, safe and well maintained. People who live in the home need to be assured that they are not liable for the expense of replacing essential furniture. EVIDENCE: All internal and external areas of the home, including bedrooms were inspected. The kitchen, including the oven was clean and the lounge and dining areas were clean and tidy. We noted that communal areas had been redecorated and a new sofa had been purchased. The doors leading to the kitchen had been repaired to ensure they were fire-proof. In the AQAA, the manager states that funding has been provided to replace the flooring in the lounge and two bedrooms. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 19 The residents’ bedrooms were clean and tidy and were decorated in accordance with residents’ personal tastes. Each bedroom contained personal mementoes and family photographs. A drawer was missing from the chest of drawers of one resident. The manager believed that this might have to be replaced at the resident’s expense, but we asked the manger to seek advice from senior managers about this. In the meantime, a requirement is made for the furniture to be replaced and paid for by the home. In another bedroom, the carpet was very stained, but as noted above, funding has been made available to replace this. The general standard of cleanliness in the other areas of the home was good and there were no offensive odours. The area surrounding the building did not look very attractive. The grass was very long and there were several uneven paving stones, which could cause someone to trip. The manager said that the landlord has agreed to replace the paving and the work was due to start soon, but a requirement is made for the grass areas of the home to be maintained properly. The bathroom and toilet areas are well equipped with hoists and adaptations which are appropriate for the level of disability of the majority of the residents. There are records to show that the special baths and hoists are regularly serviced. There are sufficient fire extinguishers place in appropriate places around the home and staff records showed that they were trained in their use. Juliana Close 46 DS0000010456.V364608.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including examining staffs’ records. The people who live in the home can be confident that their needs are being met by sufficient numbers of staff being available who are appropriately trained and supervised. Residents’ welfare is protected by thorough staff recruitment procedures and checks. EVIDENCE: At the time of this inspection, there was one staff vacancy of 30 hours. The manager stated that someone had been recruited, but they were waiting for a Criminal Records Bureau clearance before they could start work. Vacancies are covered by regular bank/agency staff who know the residents well. We noted that the induction for agency staff emphasises that residents should be treated with dignity and respect. There are normally two staff on the am shift and three in the evenings, but on specific days, extra staff are on duty to support residents who go to clubs, or have one-to-one support. At night, one person is on waking duty and another sleeps-in. The manager or a senior carer, share an on-call rota. Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 21 The staff rota accurately identified the staff on duty. The manager stated that in her opinion, the staffing level was sufficient. However, two relatives and a member of staff commented in our surveys that staffing levels should be improved to provide more one-to-one activities with residents. A new member of staff’s records showed that they had a written induction programme, which covered all areas of care and the policies and procedures in the home. This person had a CRB check and references were obtained, before they started working in the home. The two staff who were spoken to, were knowledgeable about the people living in the home and their roles in providing care and support. A print-out of the staffs’ training programme was available for inspection. This was comprehensive and confirmed that staff had either already attended courses on the mandatory health and safety subjects, or if new, were booked to attend. Other training included epilepsy and medication. Four staff currently have a National Vocational Qualification level 2 and six others are currently on this course. There were records showing that all staff receive one-to-one supervision with their line manager each month. Juliana Close 46 DS0000010456.V364608.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, 38, 41 & 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live in the home can be confident that their home is being run efficiently by an experienced manager, and that they and their representatives are consulted about how the home is managed. There are good systems in place to ensure that residents’ money is properly accounted for, which safeguard their interests. Regular checks are being carried out on health and safety systems in the home, to protect residents and staff from harm. EVIDENCE: At the last inspection, there was an acting manager who had transferred from another Adepta home. Since then, she has been confirmed as the full time Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 23 manager for Juliana Close. She has applied to the Commission for her registration, and is currently training for the Registered Managers Award. The manager is supported by an experienced deputy manager, who also transferred from another Adepta home recently. In our survey, a relative expressed concern about the lack of consistent management in the home, which was reflected in our previous inspection reports. This is also reflected by the staff that were spoken to, who said they had been unsettled by having several changes of manager in the past few years. However, the staff now say they have confidence in the new manager’s ability and there is now a good team spirit in the home. The staff use a communication book to record important messages, which are passed on at shift handovers. There were minutes available of regular meetings between the staff and the people who live in the home and also relatives’ meetings, which showed that they had an input into the running of the service. We examined the personal finance records of two residents at random. We noted that receipts were kept for purchases and that two staff sign when they withdraw money from residents’ money pouches. These are then sealed until the next transaction. The sums of cash remaining, balanced with the records. The manager and deputy are authorised signatories with the bank to withdraw residents’ money on their behalf. In the AQAA, the manager stated that she was considering purchasing personal safes for the residents so they could keep their money in their rooms, which will give them more control over their finances. This is a laudable ambition and is commended. Accident forms were properly completed and the actions taken were recorded. The manager confirmed in the AQAA, that gas, electric and fire systems had all been serviced in the past year. COSHH materials were safely stored and the food in the fridge was properly sealed and labelled. Staff records showed they have been trained in health and safety issues and the fire log showed that fire alarms are checked weekly. Juliana Close 46 DS0000010456.V364608.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 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 X 23 X ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X X 3 3 X Juliana Close 46 DS0000010456.V364608.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 YA24 Regulation 23(2)(o) Requirement The grass areas of the property must be regularly cut to maintain the comfort of the residents. The chest of drawers in a specific resident’s bedroom must be replaced at the home’s expense. Timescale for action 31/07/08 2. YA25 16(2)(c) 31/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Juliana Close 46 DS0000010456.V364608.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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