Inspection on 04/04/06 for Keats Way, 97

This inspection was carried out on 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Keats Way, 97 22/05/07

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 4th April 2006 08.50 Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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.V286800.R01.S.doc Version 5.1 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.V286800.R01.S.doc Version 5.1 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.V286800.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 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 an 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. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of just less than five hours, 8.50am-1.40pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service user plans, staff files and maintenance records. Two service users and one member of staff were spoken with as part of the inspection process. There were no visitors at the time of the inspection. There was one service user vacancy at the time of the inspection. It must be noted that it is sometimes difficult to ascertain the views of service users with mental health needs. The Registered Manager was present and assisted with the inspection process. An additional visit on the 7/12/05 was conducted for the purposes of following up the requirements from the previous inspection report and as part of the ongoing monitoring of the home. There has been one re-stated requirement and seven new requirements following from this inspection. The home has made some improvements and had met all of the previous requirements excluding the one re-stated. This is the first main inspection for 2006 and all of the key Standards were inspected. What the service does well: What has improved since the last inspection? The home has been making progress to address the requirements issued and to improve the standards within the home. The home has made some steps to improve the activities and evidence was seen that various activities have been offered to service users. This is an area that all staff must continue to pay particular attention to on a regular basis. Health records had improved and it is clearer as to what the service users health needs are and how these are to be met. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 6 Staff have now received training on safeguarding adults from abuse, which had previously been an ongoing requirement. Some environmental standards had improved, the dining room flooring had been replaced and the walls had been painted. Grab rails had now been provided leading from the dining room into the garden, which enables those service users with mobility difficulties to access the garden more safely. The Registered Manager had encouraged staff to study for an NVQ and this was now in place. The Registered Manager has also begun studying for the Registered Manager’s award. The induction programme highlights areas new members of staff work through with the Registered Manager when they join the home. Staff employment files contain all the necessary required documentation. Finally fire drills/practices are run on a regular basis and held at various times of the day. What they could do better: Daily records are a re-stated requirement and need to include relevant details regarding a service user, the personal care they received, activities they have taken part in and any mental health or other issues relevant for staff to know about. Although in place, risk assessments do not contain details regarding all the risks in a service users life. One service user now travels alone in a taxi, however there were no procedures or completed risk assessment regarding this new activity for the service user. Two service users also smoke in their bedrooms, although staff try and persuade service users to smoke in the dining room or garden, they continue to smoke in their rooms. Risk assessments had not been completed regarding smoking. Risk assessments must be constantly reviewed and updated in order to reflect the current potential risks to both service user and others. Once identified, risks can then be minimised and staff can work together to protect the health and safety of all those concerned. An overstock of medicines must not be stored in the home as this can lead to confusion and errors when administering medicines and signing for them. Although the previous requirements had been met regarding environmental standards, further requirements were made in relation to the décor, accessories, uneven flooring in a service users bedroom and the kitchen metal trim around the work top that had a large gap and could be unhygienic. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 7 The Registered Manager must carry out regular checks on each room of the home to ensure the home provides a clean, well maintained and pleasant environment for service users to live in. 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. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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.V286800.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Prospective service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training and supervision in order to meet the service users specialist needs. EVIDENCE: There have been no new admissions into the home since the last inspection. However the Inspector viewed the pre-admission documentation used. This document covers a range of areas necessary to establish if the home can meet the prospective service users needs, including details of the service users mental health needs. Once a prospective service user moves into the home the Registered Manager completes an initial assessment as they get to know the service user. The Inspector suggested to the Registered Manager that they use this detailed assessment, as it contains more detailed information, when initially meeting the prospective service user. The Registered Manager acknowledged this document might be a more appropriate tool to use from the start of the pre-admission assessment. There was one service user vacancy and the Registered Manager informed the Inspector they had received referrals, but many of these had been inappropriate. The Registered Manager is aware of the need to identify another service user whom they feel could establish positive relationships with the other service users and have their needs fully met by the members of staff. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 10 The staff team is small and the member of staff spoken with felt they had the skills and experience to meet the needs of service users with mental health needs. The Registered Manager, who is also the Registered Provider, works most days in the home and has the experience and knowledge to inform and lead the team to ensure they understand how to support the service users. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The health and personal care needs had been assessed and recorded on detailed care plans and were being met. Work is needed on improving the daily records so that they include sufficient information about the personal care support and encouragement some of the service users need on a daily basis. Where possible, service users are encouraged to make decisions about their lives. Although risk assessments were completed and show where service users can be independent, they did not include all the areas that are hazardous and could potentially pose a risk to the service user or others. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users’ identified health, personal and social care needs would be met. Services users had been consulted, where possible, when the care plans had been monthly reviewed, and their comments had been included in the reviews. The daily records viewed did not offer sufficient information about the personal care support and encouragement some of the service users need on a daily basis. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 12 This was discussed with the Registered Manager and a re-stated requirement was made to ensure all staff clearly record the care, activities and any other relevant information needed to support the service users appropriately. Service users spoken with stated they have some choices but at times would like more. Care plans indicate that choice and independence is respected and encouraged within the home. When limitations on independence are deemed to be necessary this had been recorded on care plans. The service users do not have advocates. Risk assessments were viewed. These did not include the risks service users pose when smoking in their bedrooms. The staff team have explored ways to discourage this, but as one of the service users is independent and goes out into the community without staff support and can purchase lighters/matches, the staff team have had difficulties in stopping this service user from smoking in their bedroom. The Inspector discussed with the Registered Manager the need to complete a detailed risk assessment on service users smoking in their bedrooms. One service user, spoken with on this subject, said, “…it is my choice I should be allowed to smoke where I like”. In addition, a service user who attends sessions at a local mental health centre now goes unaccompanied in the taxi to and from the centre. A risk assessment had not been completed for this particular activity. A requirement was made that risk assessments must include all potential risks and hazards to a service user and to others. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Service users are encouraged to take part in some activities throughout the week, although there are ongoing problems in motivating service users to engage in activities. Where possible, service users are encouraged to be a part of the community, through accessing local resources. Visiting is encouraged for service users to maintain contact with family and friends. Service users rights are respected within the home’s capabilities. Meal provision provides service users with a well balanced diet that caters for individual preferences whilst recognising the need to monitor service users health needs. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 14 EVIDENCE: The service users living in the home are not able to seek employment. There have been ongoing difficulties in identifying and encouraging service users to engage in activities. One service user attends a local centre for activities twice a week. Recently the Registered Manager attempted to increase this by referring the service user for art therapy however the centre did not offer the service user a place. The home continues to try and improve the activities offered to the service users, whilst recognising their abilities and interests in daily tasks. One service user is independent and when spoken with said they enjoyed going out alone, as they do not always like to be in the house. They stated they did not always get on with another service user. They also said they would like more freedom, although then went on to acknowledge that staff let them leave the house whenever they want to, apart from late at night. Service users visit the pub and local shops and are encouraged to assist with small household tasks with staff support. One service user confirmed they have regular contact with their family and they are able to see them in the home wherever they choose to meet with them. Daily records noted if service users had contact with family members. One service user also has friends near to where they used to live and have maintained some contact with them. Service users are encouraged to have keys to their bedrooms, although only one service user uses their key. Staff were seen and heard to interact with the service users in a sensitive and appropriate way. The one service user who is independent confirmed they could spend time alone or with others. They also felt they were respected by staff as they were able to make decisions about what they did with their day. The kitchen and menus were inspected. Fresh produce was seen in the kitchen and fresh fruit is freely available for the service users. One service user commented that the meals were good but small in portion size. This was highlighted to the Registered Manager who said the home was trying to reduce this service users food intake as they were overweight and staff had been concerned about their health. Individual meals are recorded to ensure the home can monitor each service users diet. The service users do not assist with the preparation or cooking of meals, as they do not show an interest in this task. Fridge and freezer temperatures were taken and were within the appropriate range. The kitchen was clean at the time of the inspection, although the metal strip around the worktops had a gap on one corner and did not look hygienic see Standard 24 regarding environment. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 & 20 Service users receive encouragement and support to ensure they maintain their personal care. Service users health needs are identified and are being met through the home and external health professionals. Overall medication systems are robust however there must not be an overstock stored in the home as this could jeopardise the health and safety of service users. EVIDENCE: Overall the service users are able to manage their own personal care without the assistance of staff. However at times all require prompting and reminding to manage their personal care on a daily basis. For some service users they need additional prompting and encouragement, as they might be reluctant to change their clothes or have a wash. Times are flexible for getting up/going to bed and service users spoken with stated they are able to choose what they do with their day. The home does not have a keyworker scheme in the home. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 16 Health needs are noted on care plans and those viewed demonstrated that service users see the Dentist and Optician. The local mental health team are also involved in supporting the service users. The home recognises that service users might refuse to have particular health needs addressed and this is documented on care plans if they refuse to attend appointments. However, the Registered Manager is aware of their duty of care to ensure service users are encouraged to maintain optimum health. Samples of the medication administration records were tracked. These had been completed although when the Inspector counted the medication there was found to be an excess amount of medication in the box, as the home does not have medication in a blister pack. The Registered Manager explained that sometimes the home keeps a small excess of medication to ensure they would never run out of stock. The Inspector made a requirement that there should be no excess stored in the home, as it cannot be proven, when checked, as to whether service users received the prescribed dose of medication. The Registered Manager acknowledged the need to carry out spot checks and be able to satisfactorily know if service users have received the medication prescribed for them. All medication was appropriately and securely stored. The service users do not self-medicate and there were no controlled drugs in the home at the time of the inspection. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 the following standard(s): 22 & 23 Service users knew how to make a complaint and felt their views would be taken seriously and would be acted on. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has not received any complaints and the CSCI had not received any complaints. The service users spoken with were aware of whom to complain to if they had any concerns or issues. They felt confident their opinions would be heard and addressed by the Registered Manager. Staff had received training on the protection of vulnerable adults, (POVA) and the staff member spoken with was aware of the different aspects of adult abuse and knew to report any POVA concerns to Management. Service users finances were not inspected at this inspection. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 the following standard(s): 24, 26 & 30 The home had made some improvements regarding the environment, however, there continues to be shortfalls regarding ensuring the home maintains a good standard in order for service users to live in a pleasant environment. Service users bedrooms were personalised and individual, offering them the space to spend time alone relaxing in their own private room. Overall the home maintains a satisfactory standard of cleanliness, the home was free from any malodours at the time of the inspection. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. There is now a grab rail leading from the dining room into the garden to assist those service users needing additional support and the toilet seat in the bathroom had been replaced. The dining room flooring had been replaced and this room had been decorated, although the woodwork had not been painted and looked marked and old. The kitchen was maintained satisfactorily however, as noted earlier, the metal strip surrounding the worktop had a gap on a corner, where dirt could gather and become unhygienic. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 19 A requirement was made that this must be replaced or made good. In addition a lampshade was missing from the first floor landing. This had been noted at an inspection earlier in 2005 and this shortfall must be addressed and a requirement was made. In one of the service users bedrooms it was noted that parts of the floor were uneven. This was pointed out to the Registered Manager and a requirement was made that this must be addressed. The Registered Manager, although has addressed some of the areas needing attention, the home continues to have requirements made regarding décor and/or furnishings. The home must be bright, clean and homely for the service users. Regular checks on the home must be carried out to ensure the maintenance of the home is monitored more closely. Samples of service users bedrooms were viewed. These were spacious and individual. It was noted on one care plan that one service user preferred a plain bedroom with no accessories for example pictures or photographs. Service users can lock their bedrooms if they want a key. Overall the home was clean and tidy at the time of the inspection. One service user prefers to wash some of their personal items in the bathroom, whilst the other service users have their laundry done by staff. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Service users are supported by competent staff who have the opportunity to study for an NVQ which enables them to reflect on their practice and acquire further knowledge and skills. The Recruitment procedures in place safeguard the service users. Training has improved and staff have received relevant information and training in order to meet the needs of the service users. Staff are supervised by the Registered Manager who offers staff regular one to one support. EVIDENCE: The staff team comprises of three members of staff, including the Registered Manager. Two members of staff are studying for an NVQ, level 2 and level 3. Members of staff recognise service users needs and are familiar with individual’s specific routines, likes and dislikes. The home had not employed any new members of staff since the last main inspection. Documentation was viewed regarding a member of staff’s visa and permission to work. They also had two references, photograph, Criminal Record Bureau check and completed application form. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 21 Training for staff had improved and evidence was seen that staff had received training on mental health issues and alcoholism. It was recommended the Registered Manager maintains a record of the details/qualifications of the trainer and the subjects covered on courses to ensure these meet the needs of the staff. The Inspector viewed a checklist new staff work through when they are receiving their induction. Staff discuss their training needs in supervision and these requests were viewed on supervision records. Staff receive regular one to one support from the Registered Manager and discussions are documented. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Overall service users benefit from a well run home and the Registered Manager has begun studying for a relevant qualification. Overall quality assurance systems are in place and incorporate service users views in order to ensure the home regularly monitors areas working well and areas needing attention. There were some shortfalls noted in the servicing and health and safety records. These must be addressed to protect the health and safety of the service users. EVIDENCE: The Registered Manager has been in post for many years and has recently enrolled to study for the Registered Manager’s Award. They aim to complete this course by Summer 2006. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 23 The home has begun to establish a quality assurance system in order to review the care and running of the home. Service user questionnaires are completed and the findings and work the home has done is transferred into a report. The Inspector recommended the Registered Manager considers increasing the areas the home reviews and incorporates this into a more detailed report, showing areas that need attention and areas where the home had sought to make improvements. Servicing records were viewed at random. Fire drills had increased and the Registered Manager had run these at varied times to ensure all staff and service users knew how to respond in the event of a fire. The Gas Safety Record, Portable Appliance Testing and fire equipment testing was up to date. There was no evidence that the testing for Legionella had been carried out in the last year and the Inspector made a requirement that there must be an annual test or a detailed risk assessment completed if the home was not to have an annual test. Water temperatures had been taken but not in all areas where service users had access, for example their washbasins. A requirement was made that this must be carried out. During the inspection the kitchen door had been propped open, this is a fire door. The Inspector reminded the Registered Manager that all fire doors must be closed or kept open with appropriate door releasing devices that respond in the event of the fire alarm being set off. The Registered Manager closed the door for the remaining part of the inspection; therefore a requirement was not made on this occasion. In addition, the cleaning cupboard in the kitchen, where cleaning products are stored had a latch to lock it but no padlock. The Registered Manager was reminded this cupboard must be kept locked too safeguard service users. A padlock was found and put on the cupboard whilst the inspection was still taking place; therefore a requirement was not made. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 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 3 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 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 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 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 25 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 17(1)(a) Requirement Timescale for action 04/04/06 2. YA9 13(4)(b) &(c) Daily records must record details of the care and any other relevant information regarding a service user. (Previous timescale 3/10/05 not met). There must be in place detailed 28/04/06 risk assessments with regard to a service user travelling alone in a taxi & service user’s smoking in their bedrooms. 05/04/06 3. YA20 13(2) 4. YA24 5. YA24 6. YA24 The Registered Person must ensure there is not an over stock of prescribed medicines stored within the home. 13(2)(d) The Registered Person must ensure the home maintains a reasonable standard of decoration and that accessories such as lampshades are in the home. 13(2)(b) The Registered Person must ensure the home is kept in good condition internally and uneven floors, eg. in the 1st floor bedroom is addressed. 13(2)(b)(d) The kitchen work top metal trim must be made good or replaced, with no gaps visible. DS0000027753.V286800.R01.S.doc 28/04/06 31/05/06 31/05/06 Keats Way, 97 Version 5.1 Page 26 7. YA42 13(4)(a)(c) &23(2)(c) 8. YA42 13(4)(a)(c) The testing for Legionella must be carried out on an annual basis. If not the home must produce a detailed risk assessment outlining why they are to test less often and what are the identified risks. Water temperatures must be taken & recorded on a regular basis in all areas where service users have access, eg, hand washbasins/baths. 31/05/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. 3. Refer to Standard YA35 YA39 Good Practice Recommendations The Registered Manager should outline details of the trainer offering courses to the members of staff and have evidence of the subjects covered on the training. The quality assurance systems should be expanded where necessary to incorporate an overall review of the home and demonstrate areas working well and areas needing to be addressed. Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Keats Way, 97 DS0000027753.V286800.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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