Inspection on 26/07/05 for Kitchener Road 83

This inspection was carried out on 26th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kitchener Road 83 16/01/07

Kitchener Road 83 07/02/06

Kitchener Road 83 08/11/04

Kitchener Road 83 19/07/04

Kitchener Road 83 23/02/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 83 KITCHENER ROAD London N17 6DU Lead Inspector Caroline Mitchell Announced 26 JULY 2005 @ 09:30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 83 Kitchener Rooad Address 83 Kitchener Road, London, N17 6DU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8808 6931 Mr Edward William Marcus Beverley Delano Willis PC Care Home 3 beds Category(ies) of LE Learning Disability registration, with number of places 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08 November 2004 Brief Description of the Service: 83 Kitchener Road is a privately run home for adults (aged 18-65) who have a learning disability. The home is an ordinary house, simillar to its neighbours in a residential area of Tottenham north London. The stated aims of the home is to provide care to people who have a learning disability (usually mild to moderate) or service users with an autistic spectrum disorder including some users who may have complex behavioural problems. Priority is given to maintaining privacy, dignity, independence, security, civil rights, choice and fulfilment. Accommodation in the home is provided in three single rooms, one on the ground floor (with an ensuite shower and toilet facility) and two on the first floor (each equipped with a hand basin and sharing a bathroom and two toilets nearby). A sleeping in room and office are also provided on the first floor. Service users also have access to a lounge area, diner/conservatory, and rear garden area. Service users resident in the home are supported to use nearby community facilities to meet education and recreational needs including local transport networks, leisure facilities and shops in close proximity to the home. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an announced basis and the lead inspector was accompanied by a second inspector, Wendy Heal. The inspection took one day to complete and took into account the written information supplied by the registered person in the pre-inspection questionnaire. The inspectors toured the building and reviewed a number of the records kept in the home. The inspectors spoke with the registered person, the acting manager and also had the opportunity to speak with several staff members and to spend some time with the service users. Due to the nature of their disability, and their communication difficulties it is difficult to gain the opinions about life in the home from two of the service users. However, the inspectors observed that they were relaxed and comfortable, in each other’s company and in the company of the staff. The third service user was very forthcoming, and was kind enough to spend some time describing life in the home to the inspectors. What the service does well: What has improved since the last inspection? What they could do better: Unfortunately, the registered manager of the home is unable to work at present. The registered person has put in place an acting up arrangement to manage the home on a day-to-day basis and it was evident that the team are working to minimise the affects of the absence of the manager. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 6 A number of areas were identified as needing improvement in the records kept regarding staff recruitment. Service users money needs to be kept in individual accounts and the outside paintwork on the house still needs to be re-painted. 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. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 & 5 Prospective users have the information they need to make an informed choice about where they live, as both a statement of purpose and a service user guide are available. Each service user has a contract in place, which makes clear the service on offer to them. The service users can be confident that the home can meet their needs and aspirations. EVIDENCE: 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 9 It was noted that a statement of purpose and service users guide including all the matters as set out in the regulations and this Standard was available and a copy had been provided to the Commission for Social Care Inspection. Examination of the three service users’ files indicated that comprehensive assessments had been undertaken that covered all of the matters as set out in the national minimum standards. The home accepts referrals from Haringey social services, and appropriate assessments were also available from a specialist assessment and treatment team. However, it is acknowledged that, whilst the home was managing to meet the needs of one, relatively new service user, who had been admitted as an emergency admission to the home, the needs of this user did not fit in well with the needs of the other two service users resident in the home. Whilst the three service users’ needs were not entirely compatible, observation and inspection of records maintained within the home indicated that the home continued to work hard to ensure that each individual person’s needs were met appropriately. The three service users are from ethnic minority communities. Their needs were noted as part of their plans, understood and addressed by the management and staff team in the home. The registered person has been careful to employ staff from the same ethnic backgrounds as the service users, who speak the service users’ first language. Service users are admitted under the terms of a contract drawn up by Haringey social services department. At the previous inspection the registered person was required to ensure that each service user’s statement of terms and conditions with the home is maintained up to date, with amended copies given to the individual service users as appropriate. The inspectors were able to confirm that this requirement had been satisfactorily addressed. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 Service user plans and risk assessments are detailed and informative. Service users are generally encouraged to make decisions about their lives and supported to take risks as part of an independent lifestyle. In order to protect service users’ best interests, their money must be kept in properly named accounts. EVIDENCE: The records for the three service users resident in the home were examined during this inspection and were found to be reasonably comprehensive. Service user plans are being further developed. There was also very good schedule of activities for each service user. One service user has a “communication passport” which is a book kept by the service user that sets out the ways in which he communicates, his likes and dislikes, interests, activities, and other information that is helpful in understanding his life. It is pictorial and of a particularly high standard, being service user focussed and service user led. The registered person explained that this passport is to be developed for all service users. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 11 The service users and staff were observed interacting in a relaxed manner. One of the primary aims of the home is to empower and support service users to make decisions for themselves. One service user receives support from two Greek-speaking support workers in the home, and there are also two Turkishspeaking support workers for the two service users whose first language is Turkish. The registered provider is the appointee for the service users within the home, and details of monies maintained for the service users were made available, including the current financial records, their bank statements and correspondence with regard to benefits. Some of the service users’ money is currently kept in the business account for the home and a requirement is made for a separate account to be established for this purpose. The registered person explained that two service users need support outside of the home, and do not go out unaccompanied. Staff accompany service users on shopping trips and in other activities outside of the home. All require assistance with budgeting their money. One service user was able to go out independently and time limits are agreed and in place for these trips out, as was recommended in the assessments completed prior to his admission. Service users are also involved in the weekly shopping trips for the home, assisting and choosing items to be bought. Risk assessments have been undertaken for all service users. Detailed risk assessments were also available as part of the assessments undertaken by the specialist teams prior to service users’ admission. A requirement is made to expand each service users’ risk assessment to include individual support needs in respect of evacuating the building in the event of a fire. (This is discussed further under standard 42 of this report). 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, & 16 The daily routines in the house do generally promote independence, individual choice and freedom of movement. There are some restrictions placed on service users, and these are for their own safety, and are documented appropriately. The service users are provided with a rich and varied social life by the home with range of, appropriate leisure activities being offered. Staff support service users to participate in activities, the local community and service users do maintain family links and friendships. EVIDENCE: Service users are encouraged to be involved in the tasks of daily living e.g. making their own breakfasts and tidying their rooms. The service user plan for each service user details support to be provided in order to maintain and develop social, emotional, communication and independent living skills as part of weekly timetables. The same provider also provides community based day activities for the service users. Comprehensive weekly plans of activities were available for each of them including trips out to the centre of London, cultural meals at local 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 13 cafes/restaurants, cinema trips, bus rides, swimming, walking, playing pool, football and daily language skills. Local leisure facilities such as the cinema, swimming pool, snooker halls and pubs are also visited frequently. One service user attends a local church another visits a number of Turkish cafes in the local area on a regular basis, and all service users enjoy visiting their family members regularly. Records reflected that service users went out for meals, for long walks, swimming, bowling, and shopping and to the cinema. Within the home, Greek and Turkish TV channels are installed on the televisions. One service user goes out independently, visiting arcades, cafes and shopping areas, whilst the service user most recently admitted is encouraged to draw, chat and watch television programmes of his choice within the home, as well as going out for walks and to pubs, cafes and bowling with close support and supervision from the staff team. All service users have contact with family members, and visit them regularly, in addition to occasional phone contact. One service user is escorted on weekly visits to his father, often following the Sunday church service, another has regular supervised family visits and the other service user is able to visit family members independently. The service users have unrestricted access to their rooms and communal areas in the home. Observation of practice in the home showed that the service users chose when they wanted to be alone or in the company of others. As previously stated under standard 9 of this report, there are some restrictions placed on service users, and these are for their own safety, and are documented appropriately. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 21 The healthcare needs of service users are assessed and recognised and that procedures are in place to address them. The service users are protected by the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. Service users can be confident that the home would deal with the ageing, illness and death of a service user with sensitivity and respect. EVIDENCE: Service users are registered with different local GPs and examination of service users’ records showed that they were supported to access medical practitioners including the optician and dentist as required. The home is also able to access specialist medical support from the learning disabilities team based at the nearby St. Anne’s hospital. One service user is also receiving support from a psychologist in working on his behaviour within and outside of the home, and with family members. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 15 The home uses the Boots medication system. There was evidence that staff members had attended appropriate training courses in the administration of medication. A video on the correct administration of medication is available in the home. Inspection of the medical administration records indicated that medication was being administered and recorded accurately. There was evidence that the temperature at which medication is stored was being recorded on a daily basis. Service users wishes in the event of their death or dying had been recorded as required, and the home has sought advice from service users’ family members, where appropriate. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 That there are clear and effective complaints, adult protection and whistle blowing procedures and service users are safeguarded from abuse and neglect. EVIDENCE: The complaints procedure is clearly written, included clear time scales for the process, and informs complainants that they may contact the Commission for Social Care Inspection at any stage of the process should they wish, as required. The complaints procedure is available in Greek for one service user currently accommodated. Three complaints had been recorded since the previous inspection. These were of a very minor nature and had been dealt with appropriately. The registered person has produced an adult protection procedure (including whistle blowing), and had obtained a copy of the local authority’s adult protection policy. There was evidence that staff members had attended training in adult protection and the prevention of abuse. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28 & 30 The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; and meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedrooms are furnished nicely and meet individual needs and lifestyles. The home provides service users with toilet and bathroom facilities. The premises are kept clean, hygienic and free from offensive odours throughout. EVIDENCE: The home is an ordinary house in keeping with the local community. The premises are comfortable, bright, and cheerful and there is sufficient and suitable light in each room. Furnishings and fittings in the home are of good quality, and domestic in character. The communal space in the lounge and dining room comfortably exceeds the national minimum standards in terms of space. The front and rear gardens are well maintained. At the previous inspection the registered provider was required to ensure that a carpet was replaced in a downstairs room and this had been done. It was also required that the paintwork on the exterior of the home be attended to in 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 18 places where it is beginning to wear, particularly on the outside of the upstairs room (occupied by a service user). This requirement is restated. Each service user has their own, private single bedroom. All bedrooms have sufficient and comfortable furniture and were decorated and equipped to reflect the backgrounds and interests of their occupants. The service users told the inspectors that they are happy with their rooms. The home provides a total of two toilets, a bathroom and a shower in addition to the en suite facilities located in the ground floor bedroom. The toilet and bathroom areas are clean, well maintained and provide facilities appropriate for the needs of the service users currently resident in the home. An inspection of the building showed that it was well maintained and cleaned to a good standard. Laundry facilities are sited in the conservatory area and do not affect the operation of the kitchen. The home has a policy and procedures to prevent the spread of infection, and documentation indicated that staff were aware of their responsibilities in carrying it out. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 The home operates quite a robust recruitment procedure. However, there is a need for some further work to ensure that service users are more fully protected. Staff receive a good quality induction, are generally well supervised and have access to training of a good quality. The home has an effective staff team with sufficient numbers and complementary skills to meet service users’ needs. EVIDENCE: All staff had had a CRB check. However, records indicate that two staff members had started work in the home prior to a CRB check being obtained. The registered person explained that the home operates a very thorough staff induction system that allows each new staff member to shadow members of the staff team on a supernumerary basis, for a number of weeks, whilst learning about the service users’ needs and the core skills. He added that new staff are genuinely not allowed access to service users without supervision during this induction programme. In discussion with staff members it was evident that the induction process is very thorough and of a high standard. There was evidence throughout the inspection of good practice that indicates that the approach taken to recruitment and induction by the registered person does work well in the home. The registered person explained to the inspector that he prefers to recruit staff who have some transferable knowledge of the service user group, but who have not necessarily worked in a residential setting. He looks for an active 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 20 mind and sensitivity in applicants and avoids anyone who seems to have an institutionalised approach. The inspector explored this issue in some detail and in this particular setting, it in the inspector’s opinion this approach is working well. There is a diversity of background and a varied skills mix in the team, and this leads to lively debate. The inspector was able to meet and talk with several members of staff and all came across as very thoughtful about the practice in the home and particularly committed, creative and sensitive to the needs and rights of the service users. They told the inspector that they are well supported and supervised and have received good quality training since working in the home. Again, whilst the records held in the home regarding staff members were of reasonable quality, there were some areas identified as needing further work. The application form for staff, whilst of a good quality, does not currently provide as full an employment history of applicants as is necessary. Applicants must provide an explanation of why they left any previous posts where working with children or vulnerable adults, and provide a written account of any gaps in their service. The start date of their employment was not clear for some staff members, some files did not include a recent photograph of the staff member and some, for workers from overseas, did not include sufficient evidence of their right to work in this country. A number of requirements are made in respect of these issues. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41 & 42 The home does not have real consistency in terms of managers at present. However, the staff team are working hard to ensure that this does not adversely affect the service users. Effective quality assurance and quality monitoring systems, based on seeking the views of service users and staff, are in place. The home’s written policies and procedures comply with current legislation and recognised professional standards and cover all of the necessary topics. Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. The health, safety and welfare of service users and staff are generally very well maintained. However, in order to better protect service users, work remains to be done regarding evacuating the home in the event of a fire. EVIDENCE: 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 22 The registered provider explained that the registered manager of the home is unable to work due to ill health. The registered person has put in place an acting up arrangement to manage the home on a day-to-day basis, until the issue is resolved. A requirement is made that the registered person put in writing to the Commission the details of the management arrangements that are to be put in place to manage the home in the absence of the registered manager. All feedback indicated that the home has a positive and inclusive character, with issues being discussed openly, or at relevant meetings/supervision sessions. Staff spoke positively about the support provided to them. A quality assurance policy and procedure was available and an audit of service users views of the home had been carried out. At the previous inspection it was required that regulation 26 inspections of the home be carried out at least monthly with copies of the report sent to the home and the CSCI after each inspection. The inspectors found that this issue has been satisfactorily addressed. Policies and procedures in the home are kept in the office which is accessible to all staff. All policies had been reviewed to ensure that they are fully applicable to the home. A current employers’ insurance liability certificate was available. Records examined showed that there had been regular servicing of equipment in the home, testing of emergency lighting and fire alarms, fire drills and servicing of fire extinguishers. A current landlord’s gas safety certificate, electrical installation certificate and a portable appliance testing certificate were available. All COSHH materials were stored in a locked cupboard. Records indicated that fire alarm testing was occurring weekly. The temperature of hot water within the home (from all outlets other than the kitchen sink) was also being monitored and recorded on a weekly basis to ensure that it does not exceed 43°C. The inspectors noted that the records kept in the home relating to fire prevention indicated that some of the service users do not react well to fire drills and require a lot of support from staff. Although good records are kept of regular fire drills, this area of risk is not reflected in service users’ individual risk assessments and a requirement is made in respect of this. 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 83 KITCHENER ROAD Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 3 2 x 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 24 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 24 Regulation 23(2) Requirement The registered persons must ensure that the paintwork on the exterior of the home is painted in places where it is beginning to wear. (previous timescale of 01/10/04 not met). The registered person must ensure that individual service users risk assessments address the issue of their safe removal from the home in the event of a fire. The registered person must ensure that where staff are employed from overseas, evidence is included in their personel records of their right to work in this country. The registered person must ensure that all applicants provide an explanation of why they left each post, where previously employed with children or vulnerable adults. It is also necessary to ensure that applicants provide a written explanation of any gaps in their service. The registered person must ensure that a recent photograph of each staff member is included Timescale for action 30/11/05 2. 9, 42 13 (4) 23 (4) 30/09/05 3. 34 4. 34 Asylum & Immigrati on Act 1996 Amended May 2004 19, 17 Schedule 2&4 30/09/05 30/11/05 5. 34 19, 17 Schedule 2&4 30/09/05 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 25 6. 34 19, 17 Schedule 2&4 38, 39 7. 37 8. 7 20 in their individual personel records. The registered person must ensure that the date each staff member started work in the home is included in their individual personnel records. The registered provider must put in writing to the Commission the details management arrangements that are to be put in place to manage the home. The registered provider must ensure that service users money is paid into an account in the name of the service user to which the money belongs. 30/09/05 30/10/05 30/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 26 Commission for Social Care Inspection North London Area Office Solar House, 1st Floor 282 Chase Road London N14 6HA 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 83 KITCHENER ROAD 20050726 Kitchener Road X00023 AN Stage 4 S31156 V232088 G59.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!