Inspection on 20/06/08 for Minford Gardens, 35

This inspection was carried out on 20th June 2008.

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

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

Other inspections for this house

Minford Gardens, 35 28/09/07

Minford Gardens, 35 08/02/07

Minford Gardens, 35 15/02/06

Minford Gardens, 35 16/08/05

Minford Gardens, 35 28/01/05

Minford Gardens, 35 08/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Minford Gardens, 35 Minford Gardens 35 Minford Gardens West Kensington London W14 0AP Lead Inspector Simon Smith Key Unannounced Inspection 20th June 2008 2:00 Minford Gardens, 35 DS0000019138.V362112.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 Minford Gardens, 35 DS0000019138.V362112.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. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Minford Gardens, 35 Address Minford Gardens 35 Minford Gardens West Kensington London W14 0AP 020 7603 8768 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) gill.ritchie@yarrowhousing.org.uk Yarrow Housing Post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only – Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 last key 28th September 2007 Date of inspection Brief Description of the Service: 35 Minford Gardens is a registered care home providing personal care and accommodation for four people with a learning disability. At the time of this inspection four men were living in the home and there were no vacancies. Notting Hill Housing Trust owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is close to the shops and transport links of Shepherds’ Bush and Hammersmith. The home is well staffed to support residents to take part in activities in the home and the community. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We used evidence from a number of sources to make this judgement about the home. These included visiting the home unannounced and speaking to all the residents and four staff. We also looked at some written records, including residents’ care plans. We received surveys from two residents, a relative, two members of staff and a healthcare professional who works with the home. Residents got help from their keyworkers to fill in their surveys. Residents’ surveys said they can decide what they do each day and that staff treat them well. One resident said, “I like it very much here. I can do what I like. I can play my DVD’s and listen to music”. The relative said that the home meets residents’ needs and gives them the right kind of support. When asked what the home does well, the relative said, “Generally [resident’s name] is well looked after. He is very happy there and is always able to do what he likes. The care home is very good at making sure that service users are looked after. Also the home is kept clean always”. When asked what the home could do better, the relative said, “I think the care home can improve communication between staff with each other. And also communication between staff and relatives of service users”. The healthcare professional who works with the home said the service ‘usually’ acts on advice given by them and “tries to cater for service users’ needs well”. Staff said that the team tries to meet residents’ needs and to promote choice but that sometimes they need more support from managers to do their jobs well. Staff also said that the sharing of information about residents could be better. The home met 24 of 31 National Minimum Standards assessed at this inspection. Five standards were almost met and two standards were not met. Two Requirements made at the last key inspection had not been met. What the service does well: Records good information about residents’ strengths, needs and preferences. Provides good support for residents to lead individual lives. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 6 Promotes residents’ involvement in their local community. Works hard to make information accessible to residents and to meet their individual communication needs. Seeks the views of residents and other relevant people about the service. Supports residents in making choices about their lives. Works well with other professionals where necessary to meet residents’ needs. What has improved since the last inspection? What they could do better: Ensure that residents’ medication is administered as prescribed. Appoint a service manager, who must apply for registration with the CSCI. Make sure that all areas of the home are safe for residents. Make sure that maintenance issues are addressed quickly. Improve the appearance of the home in some areas. Improve the appearance of the garden. Keep insurance, fire and health and safety records up to date. Improve the support provided to staff. Make sure that staff have opportunities to discuss and share important information about residents’ care. Please contact the provider for advice of actions taken in response to this Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 7 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. Minford Gardens, 35 DS0000019138.V362112.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 Minford Gardens, 35 DS0000019138.V362112.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): Standards 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available to prospective residents and those involved in their care. Residents’ needs are assessed to ensure the home can meet their needs. Prospective residents have the opportunity to visit the home before deciding to move in. EVIDENCE: The home has a Statement of Purpose, which provides information about the service residents can expect and sets out how to make a complaint. There is also a service user guide. Residents’ care plans contained a licence agreement, which outlined their rights and responsibilities. All the current residents have lived at the home for some time. Prospective residents’ needs are assessed before they move in and they are able to visit the home prior to making a decision to live there. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 10 Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain good information about residents’ strengths, needs and preferences. Residents receive good support to make choices about their lives. The home supports residents to take risks by carrying out risk assessments where necessary EVIDENCE: Each resident has a care plan. Those checked by the inspector contained good, individualised information about residents’ care and their needs, strengths and preferences. Care plans also contained guidelines for staff to enable them to work consistently with residents. All the risk assessments seen on file had been recently reviewed. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 12 There was evidence that the home has sought the advice of healthcare professionals to improve opportunities for residents to communicate their needs and wishes. For example a speech and language therapist has introduced objects of reference system for one resident, which is designed to enable him to express himself and make choices about his life. Observation and discussion with staff and residents demonstrated that the residents are supported to make decisions about their lives. Residents’ are able to choose the way in which they spend their time and have individual programmes that reflect their interests and preferences. The home seeks the input of other relevant people when discussing important issues about residents’ care. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in activities that reflect their needs and interests. Residents are involved in their local community. Residents are supported to maintain relationships with their families and friends. Residents’ rights and responsibilities are promoted. Residents are involved in choosing what they eat. EVIDENCE: Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 14 Residents have programmes of activities that reflect their needs and interests. Staff said that residents now have more opportunities to go out during the evenings and at weekends. Residents have opportunities to participate in a range of leisure activities. Two residents went bowling and had lunch out on the day of inspection. There was evidence that residents are involved in their local community and make regular use of local shops, restaurants, cafes and pubs. Two residents have regular contact with their families. One resident held his birthday party at the home in the week before inspection, to which he invited friends and members of his family. Residents were in the process of choosing their holidays at the time of inspection. Staff said that each resident has an individual holiday supported by two members of staff. Interaction between staff and residents was positive during the inspection. Residents are able to have privacy when they want it. There was evidence that residents are supported to express themselves and to participate in the civic process. There was also evidence that are residents supported to access benefits to which they are entitled. Residents are involved in food shopping and in choosing the home’s menu. Staff said that they aim to support residents in making informed choices about their diet and to promote healthy eating. Staff said that some residents have specific dietary needs that are considered when planning the menu. Residents are able to choose where they eat their meals. Minford Gardens, 35 DS0000019138.V362112.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): Standards 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare resources when they need them. The home works with healthcare professionals where necessary to meet residents’ needs. Residents’ medication is appropriately stored but there were gaps in the administration and recording of some medication. EVIDENCE: Individual care plans contained guidance about residents’ needs and preferences so that staff provide consistent care. There was evidence that residents have access to healthcare services when they need them and records demonstrated that the home consults appropriate professionals about residents’ care when necessary. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 16 All residents are registered with a local general practitioner and the home has access to the local community learning disability team, which provides services including speech and language therapy, occupational therapy, psychiatry and psychology. One resident has diabetes. This is well controlled by medication and regularly monitored through a general practitioner. Medication is stored securely and there is a written medication policy. The home uses a monitored dosage system for all prescribed medication. No residents control their own medication. The last inspection report identified some that should be made to the management of medication. The inspector found that these improvements had been made. The inspector checked medication records for all residents. There were no gaps or errors on medication administration records (MAR) for oral medication but one resident’s MAR chart states that emulsifying ointment should be applied twice a day. The MAR had one gap in the current week and three the week before. All medication must be applied as prescribed. Minford Gardens, 35 DS0000019138.V362112.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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaints policy. Training is provided for staff in the recognition, prevention and reporting of abuse. EVIDENCE: Yarrow has a written complaints policy, which has also been produced in an accessible version. The policy has been given to residents and their families. There is also an Abuse policy, which outlines the actions staff must take if they become aware of a potentially abusive situation. Staff on duty said they had attended training in the Protection of Vulnerable Adults and that new staff attend this training as part of their induction process. Staff said that there had been no complaints or safeguarding referrals since the last inspection. The complaints record contained no entries since the last inspection. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to the building since the last key inspection but there are still problems with maintenance that are affecting residents. Some areas of the home could be made safer for residents. The garden should be improved to make this area more appealing to residents. EVIDENCE: The home is situated on a residential street close to community facilities including shops, pubs, restaurants and public transport networks. Each resident has a single room. Residents’ bedrooms are personalised and provide evidence of interests and hobbies. There is a communal lounge and separate Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 19 dining room on the lower ground floor. All parts of the home were clean and hygienic at the time of inspection. The last key inspection report found that “the quality of life for people using the service is being made worse by the environment in which they are living” and identified a number of areas for improvement. This visit found that some improvements had been made. For example some parts of the building have been repainted since the last inspection and the shower room has been retiled. However there are still problems with building maintenance that are affecting residents adversely. There was no access to hot water on the first floor at the time of inspection. This meant that residents were not able to use the bath but instead had to use the shower on the floor above. It was also noted that the handrails have yet to be refitted to the bath following work to improve this area. Staff said that the lack of handrails makes the bath difficult for some residents to use. There was no seat on the toilet in the ground floor bathroom, which meant that people could not use the toilet properly. There were no hand towels in this bathroom, which meant that people could not wash and dry their hands properly. The carpets are heavily stained in some areas and need replacement. The flooring and tiling has been replaced in the shower room. Other areas of the room have been repainted, although the area above the basin needs attention. However some mould was present on the ceiling. There is an extractor fan in this room but it is currently not effective in removing sufficient moisture to prevent the presence of mould. This issue must be addressed. The shaving point above the mirror should be fixed or removed. There are some areas of the home that could be made safer for residents. These are outlined in the final section of this report. The rear garden is mostly lawn, with a flowerbed running down one side and there is some garden furniture. This could be a valuable resource but the garden’s condition does not encourage people to spend time there. At the time of inspection there were stacks of old timber and paving slabs in the garden as well as mops and buckets and full ashtrays. The relative who returned a survey identified the garden as an area that could be improved. There was evidence that the manager had tried hard to improve standards at the home and complained to the housing trust about the quality of repairs carried out on their behalf by contractors. Despite these efforts maintenance issues are not being resolved as quickly as they should be. This is partly because Yarrow has not carried out monthly monitoring visits as regularly as it should. This issue is addressed further in the final section of this report. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 20 Minford Gardens, 35 DS0000019138.V362112.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): Standards 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff know residents’ needs well. Staff confirmed that Yarrow carried out pre employment checks before they started work. Staff have access to appropriate training. The absence of a manager has affected the support provided to staff. EVIDENCE: There were enough staff on duty to meet residents’ needs. Staff working at the home knew residents’ strengths and needs well. Support at night is provided by a member of staff who sleeps in. Staff said that one of their colleagues left recently but a member of staff at another Yarrow service is to transfer to the home to keep the staff team at full Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 22 strength. Staff said that Yarrow employs bank staff to cover vacant shifts. One member of staff on duty said he was working through his induction. Another member of staff had just completed their induction. Staff records were not available but Criminal Records Bureau Disclosures were found to be in place at the last key inspection. Staff who returned surveys confirmed that they provided Criminal Records Bureau Disclosures and referees before they started work. Staff on duty said that they have regular training in mandatory areas such as health and safety, food hygiene, fire training and Safeguarding Vulnerable Adults. Most staff have achieved or are working towards National Vocational Qualifications. Staff said that Yarrow aims to ensure all staff have achieved a minimum of NVQ level 2 by 2010. The absence of a manager has affected the support provided to staff. Some staff have not had supervision as often as they should and there have been only four team meetings in the last year. When asked what the home could improve one member of staff identified “Better support of permanent staff” and “Improvement of team spirit”. One member of staff said that management support to the home has been “poor” at times and that the sharing of information could be improved, stating, “The communication is poor”. Minford Gardens, 35 DS0000019138.V362112.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): Standards 37, 39, 42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Yarrow must appoint a service manager, who should apply for registration with the CSCI. The home seeks the views of residents and other relevant people about the service. Some records were out of date. Yarrow must demonstrate that the home has appropriate insurance cover and that portable appliances have been tested for safety. The organisation must demonstrate that fire fighting equipment is serviced regularly and that fire drills are held at least once a year. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 24 Yarrow managers must carry out monthly monitoring visits to the home and record their findings in writing. EVIDENCE: Staff said that they had recently been informed that the manager will not be returning to the service. Yarrow must appoint a service manager, who should apply for registration with the CSCI. Residents’ care plans demonstrated that staff have worked with them to assess how well the home meets their needs and to identify how their quality of life might be improved. Residents’ relatives had completed questionnaires on all aspects of the service as part of this process. Some areas of the home pose a potential risk to residents. It was not clear whether the panels in the sliding door that separates the dining room from the kitchen were safety glass. If they are not, safety glass should be installed. The radiators in the home are not covered to prevent the risk of scalding. The home should either fit radiator covers or demonstrate through risk assessment that these are not necessary to ensure residents’ safety. Restrictors have been fitted to most windows but not the office window, although the last inspection report made a Requirement that a restrictor be installed here. The home should either fit a window restrictor or demonstrate through risk assessment that this is not necessary to ensure residents’ safety. Some records were out of date. The Certificate of Employers Liability Insurance displayed in the office expired at the end of March 2008. The health and safety file contains a sheet to evidence safety testing for portable appliances but this was blank. The fire alarm system was last serviced in February 2007 and the fire extinguishers in March 2007. Fire equipment should be serviced annually. The fire log has sheets to record fire drills and weekly in house checks, but these were blank. There was no evidence of a fire risk assessment. As highlighted earlier in this report, maintenance issues are not being resolved as quickly as they should be, partly because Yarrow has not carried out monthly monitoring visits as regularly as it should. Records showed that senior managers at Yarrow made these visits until April 2008 but there had been no visits since then. The organisation is required to make these visits by law and must use them to ensure that maintenance issues are resolved quickly. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 25 Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 3 5 3 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 1 25 3 26 X 27 1 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 2 Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA20 Regulation 13(2) Timescale for action Ensure that residents’ 30/07/08 medication is administered as prescribed. Provide access to hot throughout the home. Provide facilities needs. water 30/07/08 30/07/08 Requirement 2 3 YA24 YA27 23 23 bath and showier that meet residents’ 4 5 6 YA27 YA27 YA24 23 23 23 Repair the toilet seat in the ground floor bathroom. Make sure that hand towels are always available. In the shower room: • Remove the mould on the shower room ceiling and prevent this from returning. Repaint the area above the basin. Repair or remove the shaving point above the mirror. 30/07/08 30/07/08 30/08/08 • • Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 28 7 8 YA36 YA37 12(5) 8 Improve the support provided to staff. Appoint a service manager, who must apply for registration with the CSCI. Demonstrate that safety glass has been fitted in the sliding door that separates the dining room from the kitchen. Fit radiator covers or demonstrate through risk assessment that these are not necessary to ensure residents’ safety. Fit a window restrictor in the office or demonstrate through risk assessment that this is not necessary to ensure residents’ safety. This is a repeat Requirement. Original timescales not met. 30/08/08 30/08/08 9 YA42 13(4) 30/08/08 10 YA42 13(4) 30/08/08 11 YA42 13(4) 30/08/08 12 13 YA42 YA42 25 13(4) Provide evidence that the home has appropriate insurance cover. Provide evidence that portable appliances have been tested for safety. Provide evidence of: • • • Annual servicing of fighting equipment Annual fire drills A fire risk assessment of the premises. fire 30/07/08 30/08/08 14 YA42 23(4) 30/08/08 15 YA43 26 Yarrow managers must carry out monthly monitoring visits and DS0000019138.V362112.R01.S.doc 30/08/08 Minford Gardens, 35 Version 5.2 Page 29 send a written report to the home and the Commission after each visit. This is a repeat Requirement. Original timescales not met. 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 YA24 Good Practice Recommendations Improve the appearance of the garden so that people are encouraged to spend time there. Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Minford Gardens, 35 DS0000019138.V362112.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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