Inspection on 23/07/07 for Newburgh Road, 13

This inspection was carried out on 23rd July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newburgh Road, 13 19/10/06

Newburgh Road, 13 04/07/06

Newburgh Road, 13 21/02/06

Newburgh Road, 13 25/11/04

Newburgh Road, 13 21/07/04

Newburgh Road, 13 23/01/04

Newburgh Road, 13 26/06/03

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 09/07/2008.

CARE HOME ADULTS 18-65 Newburgh Road, 13 13 Newburgh Road Acton London W3 6DQ Lead Inspector Robert Bond Key Unannounced Inspection 17th July 2007 10:00 Newburgh Road, 13 DS0000027736.V345942.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 Newburgh Road, 13 DS0000027736.V345942.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. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newburgh Road, 13 Address 13 Newburgh Road Acton London W3 6DQ 0208 993-5992 0208 993 5992 hm13newburgh@ealing.org.uk www.ealing.org.uk Ealing Consortium Limited 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) Mr Dominic Shingleton Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental disorder, excluding of places learning disability or dementia (0), Physical disability (0) Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include Learning Disability Users who are Elderly or have a Physical Disability or have a Mental Health Illness 19th October 2006 Date of last inspection Brief Description of the Service: Newburgh Road is currently registered for seven adults with learning disabilities, that may be associated with a physical disability and/or mental health needs. Those service users with physical disabilities are accommodated on the ground floor. The registered provider is Ealing Consortium Limited and the building is owned by Acton Housing Association who have responsibility for its maintenance. The home is located on a quiet residential street, close to Acton town centre, its shops, facilities and bus links. The building has three floors, linked by an elevator, but access to certain upstairs rooms involves negotiating stairs. On the ground floor there are two en-suite bedrooms that are suitable for service users who use a wheelchair, a large communal kitchenette/diner, an office and staff sleeping in room, a laundry, and a large garden and wheelchair friendly patio area to the rear. On the first floor there is the non-smokers lounge, bedrooms, adapted bathroom, and the managers office. On the top floor are further bedrooms, a bathroom, and the smokers lounge. The staff team comprises a manager, two senior support workers, eight support workers and domestic staff. Fees are not quoted as the home has a block contract with London Borough of Ealing. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection that considered mainly only the ‘key’ National Minimum Standards (NMS) for care homes for younger adults. The performance of the home was assessed in terms of achieving anticipated outcomes for 24 of the NMS. 11 outcomes were exceeded, 7 outcomes were fully met, whereas 6 outcomes were only partly met. This led to the Inspector making 8 requirements and 1 recommendation. The previous CSCI inspection report contained 5 requirements, four of which have been fully met, and one requirement has been restated in this report. The Registered Manager submitted a detail Annual Quality Assurance Assessment (AQAA) to the CSCI in advance of the inspection. The Inspector also made use of Regulation 26 and Regulation 37 reports that the home had submitted to the CSCI during the period since the previous inspection report. Other surveys were sent out by the CSCI to residents (previously known as service users), their relatives, staff members, and to professionals connected with the home. Questionnaire feedback has not been included within this inspection report as regrettably no questionnaires were received back within the timeframe allowed. However the feedback received when the previous CSCI inspection was undertaken was very positive. On the day of the inspection, the Inspector interviewed the Registered Manager, met staff members and residents, tour the premises, and examined a range of records and files. Residents told the Inspector of their satisfaction with the home. The home remains fully occupied and no new resident has moved in since before the previous CSCI inspection report. The age range of residents is 56 to 81 years. The home now has two instead of three senior support workers, but there is only one support worker vacancy. The home makes use of relief staff and agency staff to a small extent. All the residents are white British or Irish. Equality and diversity issues are appropriately addressed. What the service does well: The home is reasonably domestic and homely despite its relatively large size. There is a relaxed atmosphere within the home. Residents are treated very much as individuals and their individual care needs are well assessed and are generally being met. Care plans are very thorough and are well presented, providing clear direction to staff on how to undertake personal care tasks. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 6 Regular reviews take place. There is a strong emphasis on empowerment and promoting independence. Individual interests are strongly promoted. Record keeping is of a high standard. The home and residents make good use of the complaints procedure. All staff are trained in the Protection of Vulnerable Adults (POVA), now known as Safeguarding Adults. Recruitment processes and induction training are good. A thorough Regulation 26 quality assurance system is in place, and the home has its own quality assurance processes. What has improved since the last inspection? What they could do better: A complete Service User Guide is required in a format that residents can understand and that fully meets Standard 1 and Regulation 5. The medication records of each resident (if the resident agrees) must include a recent photograph of the resident in order to aid correct identification when medication is administered. The top-floor smokers’ lounge must be improved by repainting, replacing chairs, and installing curtains. All light bulbs in areas used by residents must be covered by shades. The means of eradicating the very noticeable malodour in and around one particular bedroom must be investigated. Both offices contain damaged furniture and the desk in the downstairs office in particular should be replaced. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 7 Ealing Consortium must find ways of increasing the percentage of support workers in the care home who have NVQ awards in care so as to achieve at least 50 . The trip hazard of a missing thresh-hold strip when entering the kitchen must be eliminated. First aid boxes must be properly maintained and when items are found to missing, they must be replaced or ordered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Newburgh Road, 13 DS0000027736.V345942.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 Newburgh Road, 13 DS0000027736.V345942.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): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Existing residents do not yet have a Service User Guide that is in an accessible format and that is complete. Existing residents individual aspirations and needs have been fully assessed. Each resident has a well produced individual written contract or statement of terms and conditions concerning their stay in the care home. EVIDENCE: The Inspector examined the home’s current Service Users’ Guide. The document is going to be produced in a resident friendly easy to understand format, which is commended. The document however is not yet complete as for example staff qualifications have not yet been added in. The Registered Manager reported that the Service User Guide would ultimately be personalised for each resident, and a copy would be kept in residents’ bedrooms, together with their support plan. No new residents have moved into the care home, or have been assessed as prospective residents, since before the previous CSCI inspection report. Existing residents have been fully and appropriately assessed, and assessments are kept under review. The Inspector examined a sample contract issued by the home to a resident. The document was clear and contained relevant details. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 10 Newburgh Road, 13 DS0000027736.V345942.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): 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. Residents know their assessed and changing needs and personal goals are well reflected in their support plans. Residents are very well supported in making decisions about their lives. Residents are very well supported in taking risks as part of an independent lifestyle. EVIDENCE: The Inspector examined in detail (case-tracked) the contents of a care file on one resident. The file was seen to contain a recent, well produced, and detailed support plan. This plan is supplemented by excellent further written guidance for support staff concerning how to implement specific aspects of the support plan. The resident is able to choose their key worker, which is commended, and the key worker amongst other things is responsible for producing a monthly report. Formal reviews of support plans are scheduled to take place next month (August). Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 12 The Registered Manager reported that support staff have been trained in aspects of person centred planning, and that following the support plan reviews, a pilot project would be undertaken to introduce a form of person centred planning known as ‘essential lifestyle planning’. Residents and their relatives are involved in drawing up and reviewing support plans. The Inspector examined the notes of regular meetings of the residents with staff at which topics such as holidays and menu choice were discussed. Residents are encouraged to manage their own finances were possible, and the Inspector noted the records that evidence this aspect of empowerment, which is commended. The Registered Manager discussed with the Inspector the extent to which residents assist in operating the home by helping with laundry and food preparation, and the challenges associated with this approach. A volunteer has recently been encouraging residents to undertake gardening, and the back garden is looking particularly attractive this year. The Inspector observed that appropriate risk assessments on residents had been undertaken, were on file, and were regularly reviewed. It was clear that therapeutic risk taking was encouraged as a means of promoting independence. The Registered Manager reported that he intended to assess residents’ ability to keep a front door key for the property. This approach is commended. Newburgh Road, 13 DS0000027736.V345942.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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to take part in a wide range of appropriate activities, in the local community, and with friends. The home has excellent procedures for discovering residents interests and promoting them. Residents are provided with a healthy diet, in pleasant surroundings and at appropriate times. EVIDENCE: The Inspector noted evidence that all residents have been consulted about their interests, and activities and outings have been set up specifically to cater for those interests. Individual activity timetables have been tried out, but the residents prefer flexibility. The two residents who tried out Age Concern’s day centre have chosen not to continue attending. Residents however choose to visit local pubs and cafes, and some residents go further afield to Ealing and Shepherd’s Bush. All residents have Transport for London travel cards, some have TFL taxi cards, and the home also has its own adapted vehicle to take residents out in. This year there have been day trips to Brighton and Woburn Safari Park. Holidays have also taken place in Blackpool and in Bognor. The Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 14 range and extent of holidays and outings is commended. One resident is going by train to the railway museum at York, and the home has enabled him to maintain a garden summer-house that contains model trains. This is commended. Two residents have employment within other Ealing Consortium homes. All residents hold a key for their bedroom. Relationships and family contacts are encouraged. The Inspector examined the current food menu, and saw a meal being prepared by a member of staff. Residents are encouraged to assist. The Registered Manager reported that weekly meetings are held where residents can express their food choices and that each support plan includes a list of food likes and dislikes. The time of serving Sunday lunch has recently been changed following resident consultation. This empowering approach is commended. Dietary needs are discussed in staff meetings, and one resident sees a dietician. The home keeps a record of who has eaten what. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive excellent personal support in the ways they prefer and require. Residents’ physical and emotional health needs are fully and appropriately met. Residents are not quiet fully protected by the home’s policies and procedures for dealing with medicines as residents’ photographs are not kept with their medication records. EVIDENCE: The Inspector examined in detail the support plan for one resident and found that it, and its associated documents, contained substantial and excellent detail concerning the resident’s wishes about how personal care needs should be met. The Inspector observed that special equipment was available to be used to assist residents whilst their personal care needs were being met. The Registered Manager reported that one GP practice provides a service to all the residents, and that four residents receive depot injections at the home from a community psychiatric nurse. The Inspector examined the health records for the resident he case-tracked and found that the resident’s health needs were very well documented. The Inspector noted that residents are Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 16 encouraged to eat healthily, OK Health Checks are undertaken annually, and most residents are weighed monthly. Good records are kept of dentist, chiropodist, optician and dietician appointments. The Registered Manager reported that in future Health Action Plans would be completed by the Community Team for People with Learning Disabilities. The Inspector checked the home’s medication storage arrangements, the administration of medication records, and the returns to pharmacist record. The Inspector found these to be in order. The Inspector had received a Regulation 37 report concerning a misadministration of a medicine to a resident. As the medicine records do not include a photograph of each resident to assist with correct identification, this is made a requirement. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ views are listened to and acted upon in an excellent manner. Residents are excellently protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaint record and found that there were two informal complaints noted since the previous CSCI inspection. Both of these were from a resident who had complained about the behaviour of another resident. Both complaints had been appropriately investigated and recorded. The fact that residents know they may complain in this way, and that appropriate action is then taken, is commended. The home has in place an excellent procedure for reporting incidents of suspected abuse. The Registered Manager reported that all current staff at the home have undertaken POVA training. The Inspector examined the home’s training records. Newburgh Road, 13 DS0000027736.V345942.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): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is reasonably homely and comfortable but that is not sufficiently safe due to a trip hazard in the kitchen. Residents live in a home that is sufficiently clean but because of malodours is not sufficiently pleasant and hygienic. EVIDENCE: The Inspector toured the premises in the company of the Registered Manager. Overall, the home’s environment is adequate, with some good areas, but also with some poor areas. At the top of the house, is a smokers’ lounge. Some new furniture has been provided, but the chairs are dirty and must be replaced, paint on the walls is dirty and missing in places, and the window is not curtained. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 19 The stairways and landings have been recently repainted, but the lampshades have been removed and not put back. The premises will become more homely and domestic as required if all light-bulbs are covered by shades. A trip hazard was found in the kitchen but this is reported in more detail under health and safety. In the downstairs office, the desk is substantially damaged and it is recommended that it is replaced. Communal areas (other than the smokers’ lounge) were acceptably furnished and decorated. Smokers are no longer allowed by the home to smoke in the kitchen/diner. They do however smoke on the patio, and the back garden was seen to be an attractive area to spend time. The Inspector was invited into a resident’s bedroom that was beautifully furnished and decorated according to the resident’s own taste and choice. Another resident’s bedroom, whose door was left open, was not entered but the Inspector noticed a strong malodour of urine had permeated the corridor outside. The reasons for this were discussed in detail with the Registered Manager and will not be reported here. However as there are hygiene implications, and quality of life implications for other residents, this situation must be further addressed by the management of the home. Improved ventilation for this bedroom is one option that could be investigated. The home overall was seen to be sufficiently clean. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported by competent staff but the staff are not sufficiently well trained in terms of having NVQ’s in care. Residents are well protected by the home’s recruitment policy and practices. Residents’ individual and joint needs are well met by staff who have received good induction and mandatory training. EVIDENCE: The Inspector examined the current staff rota for the home. He found that sufficient staff were on duty, and that relief bank staff and agency staff are used on a frequent weekly basis. The Registered Manager reported that the same agency staff are used where possible to maintain continuity for residents. The Inspector observed that the induction training for new agency employees had been improved and now included whistleblowing. A new employee has recently been appointed but is yet to start. One almost whole time equivalent support worker post remains vacant. The Inspector checked the recruitment file of a new employee who had already started work and found that according to the records kept, all appropriate Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 21 recruitment checks and processes had been applied. This included a thorough induction programme. The Inspector checked other training records and found that all mandatory training was up to date. In terms of NVQ awards, of a staff group of nine, one support worker only has an NVQ in care, although two more are undertaking the award. The National Minimum Standard is for all care homes to have at least 50 of the care/support staff with an NVQ level 2 or 3 in care. A requirement has therefore been made. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a generally well run and well managed care home. The internal quality monitoring system has been improved but is still not totally adequate. The health, safety and welfare of residents are still not fully safeguarded but improvements have taken place. EVIDENCE: The Registered Manager reported that he is still undertaking the A1 NVQ Assessor’s Award, and that he is still to undertake the Registered Manager’s Award, due to commence in Autumn 2007. The home is well managed overall as evidenced for example by the number of previous CSCI requirements that have been fully met. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 23 Thorough Regulation 26 reports are undertaken on the operation of the care home by a rota of visiting managers from Ealing Consortium. The internal quality monitoring has improved, and new health and safety monitoring procedures have been introduced. Unfortunately these are only partially successful. The Inspector noticed a trip hazard upon entering the kitchen as the threshhold strip that should hold down the edge of the vinyl floor had been removed without anyone noticing and reporting it. The Inspector examined the contents of the home’s first aid box and found that the number of boxes had been rationalised, the contents were listed, and the contents were checked monthly, but that when a large dressing was found to have been used, it had not been replaced. This was because the home did not have any more of this item in stock, but no order had been placed for more dressings. This situation had persisted for four months. The requirement about first aid boxes made at the previous CSCI inspection is therefore restated. Other checks made by the Inspector included hot water temperatures, fridge and freezer temperatures, the home’s elevator, and the home’s call bell system. All were found to be in order. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 x 2 x x 2 x Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 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 YA1 Regulation 5 Requirement A complete Service User Guide, in accessible format, is required that meets Standard 1 and Regulation 5. The medication records of each resident (if the resident agrees) must include a recent photograph of the resident in order to aid correct identification when medication is administered. The top-floor smokers’ lounge must be improved by repainting, replacing chairs, and installing curtains. All light bulbs in areas used by residents must be covered by shades. The means of eradicating the very noticeable malodour in and around one particular bedroom must be investigated. Ealing Consortium must find ways of increasing the percentage of support workers in the care home who have NVQ awards in care so as to achieve at least 50 . The trip hazard in the kitchen must be eliminated. DS0000027736.V345942.R01.S.doc Timescale for action 01/10/07 2. YA20 13(2) 01/09/07 3. YA24 23(2)(d) 01/10/07 4. 5. YA24 YA30 23(2)(p) 23(2)(p) 01/09/07 01/10/07 6. YA32 18(1)© 01/08/09 7. YA42 13(4)© 01/09/07 Newburgh Road, 13 Version 5.2 Page 26 8. YA42 23(2) First aid boxes must be properly 01/09/07 maintained. This is restated as the requirement has not been fully met within the timescale for action of 01/12/06. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations Both offices contain damaged furniture and the desk in the downstairs office in particular should be replaced. Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Newburgh Road, 13 DS0000027736.V345942.R01.S.doc Version 5.2 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. 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!