Inspection on 22/05/07 for Keats Way, 97

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Keats Way, 97 04/04/06

Keats Way, 97 06/09/05

Keats Way, 97 12/04/05

Keats Way, 97 05/07/04

Keats Way, 97 25/06/04

Keats Way, 97 18/06/03

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

CARE HOME ADULTS 18-65 Keats Way, 97 Greenford Middlesex UB6 9HF Lead Inspector Sarah Middleton Unannounced Inspection 22nd May 2007 09:35 Keats Way, 97 DS0000027753.V334426.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 Keats Way, 97 DS0000027753.V334426.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. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keats Way, 97 Address Greenford Middlesex UB6 9HF 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) 0208 575 3986 0208 575 8632 Mr Rajgopal Ramanah Mrs Premila Ramanah Mr Rajgopal Ramanah Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th April 2006 Brief Description of the Service: Keats Way is a large end of terrace house on a corner plot in a residential area. The property is situated on the borders of Greenford and Southall. It is near to small local shops and a short distance by transport to a larger town. A bus route runs nearby providing transport to mainline railway and underground services, which are only a few miles away. There is a small front paved front garden and an enclosed back garden with a small patio and grass area. The home is registered for four people, with an age range between 18 years old to above 65 years old, with a mental disorder. There is one bedroom situated on the ground floor, which has en-suite facilities. The other three bedrooms are located on the first floor, along with a sleeping in bedroom for staff. This means that primarily the home caters for service users who can manage the stairs. The communal rooms are located on the ground floor, where there is a separate dining room and lounge. The home is staffed twenty-four hours a day and can provide personal care or assistance with personal care and supervision for people with mental health needs. Fees range from £550-£650 per resident per week. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Resident replaces the previously used term “service user” and refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.35am-4.30pm. The Inspector viewed a sample of resident’s files, staff employment file and maintenance records. Two resident’s and one member of staff were spoken with as part of the inspection process and one family member had completed a postal survey. The Registered Manager assisted with the inspection process. The Registered Manager has plans in the near future to extend the home to include an additional two bedrooms available for prospective residents. Equality and diversity issues are considered by the home and where identified are commented on in this inspection report. One of the previous two requirements had been met and twelve new requirements were made at this inspection. All of the Key Standards were assessed during this inspection. What the service does well: What has improved since the last inspection? A fire risk assessment had been completed in relation to fire doors being propped open. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 6 What they could do better: Care plans need to consider other areas relating to a resident’s life, such as cultural and social needs. Risk assessments must be updated and reflect the current risks in resident’s lives. Activities need to be offered on a regular basis and provide residents’ with opportunities to develop interests and engage with the community. Food that is opened must be dated when opened or prepared to ensure out of date food is not used. Resident’s individual preferences for meals must be acknowledged and provided. Religious beliefs must be considered, but this must be balanced with recognising resident’s rights to choose the meals they would like to eat. Any changes in health needs must be recorded along with information as to how to support the resident with their specific health needs. The home must continuously review and update the environment. Areas needing updating must be planned for and the maintenance of the home must be pro-active not reactive. Staffing levels need to be reviewed and where appropriate increased so that residents have the more opportunities to go out into the community. Staffing levels in general will need to be considered if the home is to increase in size. Staff employment files must contain all the required information, such as completed application and signed health declaration forms. The training programme must be available and detailed in order to meet the needs of the staff team. Training needs to be provided on a continuous basis. Evidence must be available to demonstrate how the home is reviewed, highlighting the areas that have been updated and areas that still need attention. Resident’s views regarding the home must also be obtained in order for the home to consider their views and work to address the resident’s comments. Evidence must be available that a percentage of the fire drills held throughout the year take place during the evening and night. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 7 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. Keats Way, 97 DS0000027753.V334426.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 Keats Way, 97 DS0000027753.V334426.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home to ensure the home can meet their needs. EVIDENCE: The home had a new resident who had moved in just before Christmas. An assessment procedure is in place and is used to assess a prospective resident. The Registered Manager would meet the prospective resident and begin the initial assessment. Visits to the home are also planned. The home also seeks as much information from the referrer, such as reports and their assessments in order to make a decision regarding whether the home can meet the resident’s needs. Once a new resident moves in on a trial basis, the home begins a more detailed assessment. The Inspector viewed the initial preadmission assessment and this covered areas such as presenting issues, social circumstances and mental health needs. The Inspector viewed the assessment documents used and was satisfied that every attempt is made to obtain detailed information about the new resident. As all new residents move in for a short trial period, no final decision is made to offer a permanent home until staff have fully considered the resident’s needs. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not take into account a resident’s cultural or social needs, these areas need to be assessed to ensure all needs are considered. Residents are encouraged to make decisions about their every day lives. Risk assessments were incomplete and did not reflect the current potential risks for one resident. EVIDENCE: The Inspector was informed that residents are involved in the development of the care plans. The Inspector viewed a sample of care plans and found that residents had signed each part of the care plan. The Inspector suggested additional ways the home might wish to consider and evidence how residents view their needs and how they might contribute in more detail to their own care plan. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 11 Overall care plans considered different areas such as personal appearance, budgeting and some health needs, (See standard 19 for further information regarding identifying health needs). Each month the Registered Manager records an update on each section of the care plan and adjustments are made accordingly. The Registered Manager mainly completes the care plans and risk assessments, although there was evidence that one of the support workers had also completed part of a care plan. The Inspector noted that cultural, religious or social needs and relationships were not included in the care plans viewed. The Inspector brought this to the attention of the Registered Manager and a requirement was made for staff to assess and record these areas of a resident’s life. Daily records were viewed and these indicated if a resident had engaged in an activity and their general mood. A survey completed by a family member commented positively on the home meeting their relative’s needs. None of the residents have advocates but the most have some form of contact with family members. Residents are encouraged to make decisions and those asked stated they could make daily decisions regarding what they did each day. One resident is able to withdraw and manage some of his own personal money. Staff support all residents with their personal finances. The Inspector viewed minutes from resident’s meetings. These meetings are held on a regular basis and enable residents to contribute their views on the home, (See Standard 39 for further information on residents’ contributing their views). The current risk assessment tool used is a checklist with scope to write further information if the assessor considers the need to expand on potential risks. This document was discussed with the Registered Manager, as the Inspector noted there was room for improvement and expansion. The Inspector viewed on a sample of daily records that one resident had left the home on at least two occasions and had stayed out overnight. The Registered Manager stated that he knew where the resident was going each time this occurred and that he had picked the resident up the next day. Upon viewing this resident’s risk assessment this behaviour and potential risk was not documented. The Inspector made a requirement that risk assessments must reflect all identified potential risks posed to a resident and/or towards others. Keats Way, 97 DS0000027753.V334426.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, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities and opportunities for social inclusion did not always occur for the residents who need support in these areas of their lives. Residents are encouraged to maintain social contact with family and friends. Resident’s rights are listened to and respected by staff. Some food opened had no dates of opening written on them, placing potential risks to the residents. The home had had not taken into account the balance between acknowledging religious beliefs and the resident’s right to choose alternative meals. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home has struggled for some time to identify local places and resources for resident’s to access. The interests and abilities of the residents varies and although there have been some attempts to provide activities, such as visiting the local pub or shops, there are still times when residents are in the home and not engaged in any meaningful occupation. One new resident told the Inspector that often they were bored. The Inspector had read the referrer’s letter, regarding this new resident, and this had clearly stated he needs structure and regular occupation. The Inspector saw little evidence to suggest this resident had any daily meaningful activity to take part in. A requirement was made for staff to make every attempt to identify the activities residents are interested in and seek to provide as much stimulation and variation to each resident’s life. The Inspector discussed with the Registered Manager holidays and day trips, as these have not been offered within the home. It was strongly recommended for the home to offer and where appropriate provide day trips for the resident’s and to consider the possibility in the future of offering short-break holidays away from the home. Family contact and maintaining social relationships is encouraged and most of the residents have some form of contact with family. One resident confirmed they were supported to use public transport to occasionally visit a family member. The Registered Manager explained to the Inspector that staff had spent time with this resident outlining the buses and route the resident would need to take to visit their family. The home respects resident’s independence and where possible residents are encouraged to develop daily skills. One resident informed the Inspector that they did not do chores in the home, as they were not getting paid for it. Motivating some residents to take an active role in the home is an ongoing issue. Residents have keys to their bedrooms and one resident has a key to the front door. Those residents able to read receive their own personal mail. Staff were seen to interact with residents’ throughout the inspection. The Registered Manager informed the Inspector that one resident has specific religious needs that inform the home of the foods this resident can and cannot eat. The home purchases halal meat and cooks the food in a separate dish. The Inspector suggested the home also considers purchasing separate utensils, such as knife, fork and cooking equipment. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 14 The Registered Manager also described how this resident occasionally asks for food that does not follow his religious beliefs. The home has mainly refused this resident’s request and the Inspector discussed with the Registered Manager the need to respect resident’s right to choose. A requirement was made for all residents, regardless of their religious and cultural beliefs, to be able to choose the meals they eat. The home is making attempts to monitor the diet of the residents and has made a referral to the Dietician to support those residents needing this form of professional support and advice. The meals and menus are chosen by the residents, with staff making minor adjustments to incorporate fresh healthy produce. One resident spoke about the changes in the meal provision and stated they were not happy with the changes in meals. The Registered Manager is aware that some residents are finding it hard to adapt to healthier meals and so every attempt is made to provide a balance of the meals residents want and healthier options. The Inspector viewed the kitchen and found that food opened had been covered but had no dates of opening written on them. A requirement was made for this to be addressed. If the home is extended there will be a new kitchen, which would be beneficial for the residents as the current kitchen will need updating in the near future. Fridge and freezer temperatures are taken on a daily basis and were within an appropriate range. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer. Current health needs were not recorded on one care plan. In order to meet resident’s needs detailed records need to be kept. Robust medication systems were in place. EVIDENCE: The Inspector was informed that all of the residents need encouragement to bathe, change their clothes and to maintain their personal appearance. One resident needs full support with personal care. Personal care support is provided in private. Residents wear their own clothes and a resident confirmed to the Inspector that they are able to get up and go to bed when they so choose. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 16 All residents have access to a range of health professionals, such as GP’s, Dietician, Dentist’s and Optician’s. Appointments are recorded onto a medical form in order for staff to monitor when a resident has seen a health professional. One resident has recently been diagnosed with specific health needs and so far his family usually support and accompany him to these health appointments. Following on from these appointments, staff are informed of any outcome. The Inspector noted that this resident’s care plan did not comment on or reflect the changes in his health needs. This shortfall was discussed with the Registered Manager and a requirement was made for care plans to reflect resident’s current health needs. The Inspector briefly spoke with this resident who was fully aware of the changes in his health needs. The Inspector viewed a sample of medication. Medication is stored in a small, secure metal cabinet in the main kitchen. The home had no controlled drugs and no residents self medicate. Staff carry out a weekly audit and count all of the medication, as it is not in blistered packs. The Inspector counted two resident’s medication and found it all to be correct. The Medication Administration Records had been completed correctly. Staff receive medication training and the Inspector suggested for the Registered Manager to liaise with the local Pharmacist to ascertain if they could provide training to staff. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make a complaint and would feel listened to. Systems are in place to safeguard residents’ from abuse. EVIDENCE: The Inspector viewed the complaints procedure that was freely available and located in the communal main hall. The home had not received any complaints and the CSCI had not received any complaints. The Inspector viewed the complaints file to ensure documentation was in place to record investigating a complaint. Those residents asked stated they would talk to the Registered Manager if they were unhappy. There have been no adult abuse allegations or investigations. The Registered Manager has a copy of the Local Authority’s adult abuse policies and procedures. All staff attended a recent training and information day regarding legislation and adult abuse. The Inspector counted a sample of resident’s personal monies and these were found to be correct. One resident can withdraw money with the support from staff and one resident’s family manages their finances. The home manages the other resident’s financial transactions and receipts are kept and any money withdrawn or spent is recorded. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 18 The Inspector made a recommendation for regular audits to be carried out on each resident’s personal money in order to monitor and identify any errors. Evidence should be available of any monitoring checks that have been carried out. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are ongoing maintenance shortfalls needing to be addressed that do not provide residents with a homely place to live in. Overall the home was clean and free from odours. EVIDENCE: The home has had previous requirements regarding the environmental standards of the home. Certain areas of the home are neglected and work is often carried out to a minimum standard. The following areas were noted during this inspection: •The bathroom had no light shade. •The bath seal was mouldy and in need of replacing. •The paint on the office window frame was also on the windows. •The dining room flooring was lifting and in corners looked marked and dirty. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 20 The Inspector discussed the ongoing maintenance issues with the Registered Manager, as improvements are often reactive rather than proactive. There continues to be a lack of attention paid to the physical environment. The Inspector is aware that if plans to extend go ahead then many rooms will be updated, such as the office, kitchen, lounge and dining room. The home is in need of being modern, welcoming and well maintained. The Inspector made a requirement for the home to be maintained to a good standard. The Inspector spoke with the Registered Manager, in light of the imminent changes in the law regarding smoking. All of the residents smoke and the Registered Manager will need to consider how this affects the new layout of the home. The Registered Manager acknowledged the need to carefully consider the design of the rooms and the needs of the residents. Overall the home is kept to a reasonably clean standard. Staff keep the home clean and tidy, with some input from residents. The laundry facilities are kept in a separate cupboard in the dining room. Each resident does their own personal laundry with assistance from staff. On the day of the inspection the home was free from any malodours. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent staff team support the residents. Residents would benefit and be able to go out more if staffing levels increase. A completed application form and health declaration form was missing from a staff file. Robust recruitment systems would protect residents’. Gaps in the training programme were identified. Residents would benefit from being supported by a well -trained staff team. EVIDENCE: The staff team is small with the Registered Manager supporting staff to obtain an up to date qualification such as an NVQ. One member of staff has yet to study for an NVQ and it is expected that they will be encouraged to do so in the near future. The Inspector met with a member of staff who was committed and motivated to meet the needs of the residents. Staff receive information on mental health issues mainly from the Registered Manager and have an awareness of the specific needs of the residents living in the home. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 22 Initially, the Inspector was informed there were always two members of staff working in the home at any one time. The rota did not reflect this information, as it was clear that at certain times during the week there is only one member of staff working at any one time. The Inspector raised this issue with the Registered Manager and discussed the impact this would have on residents, who rely on staff to take them out of the home to access community resources. A requirement was made for sufficient numbers of staff to be working in the home to ensure the residents have opportunities to go out and take part in activities away from the home. The Inspector was informed by the Registered Manager that recently all members of staff attended a training day and a member of staff from another registered care home worked in the home to support and care for the residents. The home did not obtain employment details regarding this member of staff. The Registered Manager explained this member of staff would have had all necessary recruitment checks carried out by the Registered Manager of the other care home. The Inspector discussed the implications of accepting staff from other care homes, where no employment details, such as Criminal Record Bureau checks are checked. It is the Registered Manager’s, who is also the Registered Provider, responsibility to ensure the resident’s welfare is protected at all times. In addition, a staff employment file was viewed and this contained a photograph and Criminal Record Bureau check. A completed application form and signed health declaration form were not available for inspection. A joint requirement was made relating to the above findings. The lack of robust recruitment procedures in place must be addressed. The Inspector discussed the home’s induction programme for new members of staff. The current system used provides information about various areas such as general information about the home, health and safety issues and mental health information. The Inspector advised the Registered Manager to view the TOPSS induction programme as this could provide additional information the home could use. The Inspector viewed a sample of staff training files and found there to be shortfalls in the training programme. A requirement was made for staff to receive all the training they need to support and care for the residents effectively. The Inspector spoke with the Registered Manager about the importance to ensure the trainers used are suitably qualified and experienced to provide appropriate training to the staff team. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced Registered Manager manages the home. There was a lack of systems in place to review the care and running of the home. Fire drills had not been held at various times of the day and night, thus placing residents potentially at risk. EVIDENCE: The Registered Manager is studying for the Registered Managers Award and hopes to complete this in 2007. He has owned and managed the home for many years and has plans to develop the home and increase its size by an additional two beds. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 24 The Inspector spoke with the Registered Manager regarding needing to carefully consider the needs of the residents and the layout of the home, in order to provide a comfortable home. The home continues to need attention in particular areas and the Inspector stressed the importance of meeting requirements and National Minimum Standards. The Inspector was informed that resident’s views on the home, through the use of questionnaires, had not been obtained for some time. A requirement was made for this to be addressed, as involving residents and considering their comments is an important aspect of running a care home. Furthermore the Registered Manager needs to develop a robust system for reviewing the home in order to demonstrate the improvements made and shortfalls still to be addressed. There was no report available for inspection or for the residents to evidence how the home monitors the care being provided and the outcomes for residents. A requirement was made for this to be addressed. As outlined in the report, there continues to be shortfalls identified and if the home were to implement regular checks and monitoring areas, then these issues could be identified and rectified. Maintenance records were viewed. Portable Appliance Testing, Gas Safety Record and fire equipment checks were all up to date. The Registered Manager queried as to the frequency of testing for Legionella. The Inspector explained that if the home were to test for Legionella on a less frequent basis, then safeguards would need to be put in place. Providing a detailed risk assessment and regular maintenance checks could minimise the opportunity for Legionella to be present in the home’s water systems. The fire officer had visited the home in October 2006 and no recommendations were made. The home’s fire risk assessment did not record each resident’s capability to respond to a fire drill or real fire. A strong recommendation was made for this to be completed. It was noted that fire drills had not been held in the evening or at night. A requirement was made for this to occur several times throughout the year. The home had completed a brief fire risk assessment for those bedroom doors propped open without door releasing equipment being fitted to them. The home was advised to keep all fire doors closed or to have appropriate door releasing equipment fitted. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 25 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 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 2 x Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 26 YES 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 YA6 Regulation 15(1) Requirement Timescale for action 30/06/07 2. YA9 3. YA12 YA13 4. 5. YA17 YA17 Care plans need to consider the health and welfare of a resident. This includes considering his/her cultural and social needs. 13(4)(b)(c) In order to safeguard the resident, risk assessments need to reflect all possible risks, such as staying out overnight. 16(2)(m)(n) Regular activities need to be provided in order to provide residents’ with stimulation, occupation and social inclusion. 12(2) Residents need the opportunity to make decisions and choices about the food they eat. 13(4(c) Food opened or prepared must be suitably covered with dates of opening or expiry dates to ensure residents health and welfare is protected. 15(1) Care plans need to reflect current health needs and how these needs are to be met. 30/06/07 31/08/07 23/05/07 22/05/07 6. YA19 31/05/07 Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 27 7. YA24 23(2)(b)(d) The Registered Person must ensure the home maintains a reasonable physical standard in order to provide a welcoming home for the residents’. (Previous timescale 31/01/07 not met). Staffing levels need to be reviewed to ensure there are sufficient numbers of staff working in the home at any one time. Appropriate numbers would encourage social inclusion. In order to protect residents, details on persons working in the home, as outlined in Schedule 2, must be available for inspection. Residents need to be supported by staff who have received the training appropriate for the work they are to perform. Residents would benefit from the Registered Person establishing a system for reviewing and improving the quality of care provided in the home. A report of such a review must be available for inspection and for residents. In order to provide the type of care and service the residents want, residents’ views need to be sought, considered and acted upon. In order to safeguard residents fire drills/practices need to, on occasion, occur during the evening and night. 31/07/07 8. YA33 18(1)(a) 31/07/07 9. YA34 Schedule 2 23/05/07 10. YA35 18(1)(c)(i) 31/08/07 11. YA39 24(1)(2) 31/08/07 12. YA39 24(3) 31/08/07 13 YA42 23(4)(e) 30/06/07 Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA14 YA23 YA42 Good Practice Recommendations Holidays or group trips should be offered and provided for those residents interested. It is strongly advised that regular checks and audits are carried out on resident’s personal monies. It is strongly recommended that individual fire capability risk assessments be completed on each resident. Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Keats Way, 97 DS0000027753.V334426.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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