Inspection on 18/07/07 for Norman Road (135)

This inspection was carried out on 18th 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norman Road (135) 24/06/08

Norman Road (135) 27/02/06

Norman Road (135) 12/01/05

Norman Road (135) 16/06/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Norman Road (135) 135 Norman Road Leytonstone London E11 4RJ Lead Inspector Anne Chamberlain Unannounced Inspection 18th July 2007 09:40 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 Norman Road (135) DS0000007313.V346481.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. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norman Road (135) Address 135 Norman Road Leytonstone London E11 4RJ 020 8539 0596 020 8989 5768 joomascarehome@gmail.com 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 Y. O. Jooma Mrs Rooksanah Jooma Mr Y. O. Jooma Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider to notify the National Care Standards Commission when the named client with associated mental health problems is admitted and when he/she is discharged 8th September 2006 Date of last inspection Brief Description of the Service: 135 Norman Road is a care home, which offers support, guidance and accommodation to a maximum of three service users with learning disabilities. The property is a terraced house situated in a residential area of Leytonstone in the London Borough of Waltham Forest. The home is a short distance from local shops and community amenities and is well served by local transport, including a nearby underground station. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service completed an Annual Quality Assessment Audit (AQAA) before the inspection and this useful information was studied by the inspector. The site visit took place over one day and lasted for six hours. The inspector exchanged greetings with all the residents and spoke with one at length. She interviewed the manager, and viewed two residents files and two staff files as well policies and various key documentation. The inspector viewed the arrangements for the administration of medication. She toured the premises including two residents bedrooms and the garden. The inspector would like to take this opportunity to thank the residents and manager of the home for their co-operation and assistance with the inspection. What the service does well: What has improved since the last inspection? The manager has met many of the requirements of the previous inspection and no requirements have been restated. The administration of medication has improved, as has staff supervision, a new mattress has been purchased for a resident and a number of improvements have been achieved throughout the premises. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Residents experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information is available for prospective residents. Assessment practice as described and evidenced in files is adequate. EVIDENCE: The inspector viewed the statement of purpose and service user guide. The statement of purpose states that the residents of the home are aged between twenty-five and sixty five years. This is the age range which the home can accept, but it is not the age range of the present residents. The document also states that there is a list posted in the office of the staff, with their qualifications and experience. This is not the case and the list must be posted or the statement deleted. The statement of purpose must be amended to ensure that there are no inaccurate statements in it (see requirements). Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 9 The inspector talked through the assessment process with the manager. she was confident that should he admit another resident in the future, the assessment process would be thorough and comprehensive, and the manager would consider issues of compatibility. The inspector noted assessment information on the two residents files she viewed. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Plans are individual and reflect needs. Service users are supported to make decisions for themselves and risk taking is assessed. EVIDENCE: The inspector viewed the residents support plans on their files. The first one had been updated on 4/4/07, the second on 6/4/07. The plans were comprehensive but fairly basic in the level of information they gave. The plans had been reviewed regularly. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 11 The inspector suggested to the manager that he should invite relatives and social workers to reviews, and should certainly have the two more able residents present at their reviews. She further suggested that reviews should look over the progress since the last review, and residents should be encouraged to set personal goals for the next period. This would avoid reviews becoming a paper exercise and make them more meaningful and productive (see recommendations). One resident at the home is quite dependent but the other two are very independent, with mild learning disabilities. It was obvious to the inspector that the two more able residents have many opportunities to exercise choice. They go out and about on public transport, join community activities of their choice, shop etc. At home they can express preferences and decide when they want to get up, retire, what they would like to eat etc. The inspector asked the manager how he encourages the more dependent resident to make choices. The resident in non-verbal and the inspector was told that various unsuccessful attempts have been made to support communication with a picture vocabulary. However the resident is able to understand simple language and has a few individual signs. He can choose between two alternatives and nods and shakes his head. The inspector was satisfied that the home is supporting this individual to be as independent as possible. The inspector viewed the risk assessments on the residents files. The risk assessments were relevant and had generally been regularly reviewed. One risk assessment for travel had not been updated since December 2005. This was pointed out to the manager who agreed to update it (see requirements). The inspector viewed the procedure for missing persons and noted that an action to advise social worker or CSCI. This should read advise social worker and CSCI and the manager agreed to amend it (see requirements). Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Residents experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users enjoy a variety of community activities to meet their leisure, recreational and cultural needs. Family contact is supported and rights and responsibilities emphasised. The service users enjoy their food but the range could be extended to include more healthy foods. EVIDENCE: The manager stated that a resident enrols himself for various adult education courses locally. Another resident had had college identified at a review, and set up, but has chosen not to attend. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 13 As previously mentioned the two very able residents access the community and derive much mental stimulation from this. Whilst the manager was at the service one resident went out to the bank and came back twice. The more dependent resident has retired from day services. The manager stated that he takes him out most days. He likes the park, shopping and markets, cafés and fun fairs. Two of the residents go horse riding once a week and the manager and inspector found they had mutual acquaintance among the staff at the riding school. The inspector noted that the group of residents and carers are ethnically diverse. She also noted Islamic symbols and information in the office, prayer calendar etc. The manager stated that the Islamic information is mainly for the benefit of staff. He stated that one resident is a Christian and attends a local church twice weekly. He said that this practice is supported by himself. One of the residents aspires to independent living. The inspector saw a letter from the local housing department regarding his eligibility for this. Waltham Forest runs a bidding system for available properly and the resident and manager get the property magazine to look for suitable accommodation. One resident has visits from his two cousins on two days each week. Another has regular telephone contact with a brother who lives in Australia. He also has friends in London and meets up with them from time to time. Two residents who can use them have keys to the house and to their bedrooms. If one of them arrives home when the manager is out with the other resident, they let themselves in and are quite safe until he returns. The manager stated that this practice was risk assessed when it started, some time ago, and there have never been any concerns or incidents. The other resident does not have a house key as he would not be safe unescorted in the community, but he has the option to lock his bedroom door if he chooses to. On the day of the inspection the two residents who were around at lunchtime agreed they would like a takeaway meal and one popped out to get it. The manager was careful to cut the meat for one resident who is at risk of choking, and needs this done for him. On looking through log books and recording of meals eaten, the inspector formed the impression that the residents eat a lot of take away foods. One of the residents spoken with confirmed this. The manager stated that a health professional has already advised this resident to cut his intake of fat, salt and sugar. The manager stated that proper meals are cooked in the house but the Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 14 inspector felt this was not often as the gas oven was extremely clean. She did not see any fresh vegetables or fresh fruit in evidence in the home. The inspector respects the choice of residents but strongly recommends that staff ensure that a nutritious meal is cooked each evening to include vegetables. Also that fresh fruit is available in the house at all times, providing there is no choking hazard or risk identified with this. Norman Road (135) DS0000007313.V346481.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. Residents experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who understand them and can meet their needs. Arrangements for the administration of medication are sound. EVIDENCE: The inspector found that support plans mainly stated needs full support or needs some support under headings like personal care. There was not detailed information on how to deliver that support. However the staff group have mainly known the residents over a number of years and the inspector felt that their preferences are well understood. There was a variety of evidence that health needs are well supported. The two files inspected had Health Action Plans and evidence of attendance at Chiropodist, Dentist, Optician. The inspector was told that one resident attends the local Psychology clinic. The manager is a registered mental health Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 16 nurse with many years experience of social care. The inspector felt that the health needs of the residents are well understood and supported. The manager was also aware of the emotional needs of residents. One resident demonstrates challenging behaviour but only when the manager is out of the service. He came to the service from the family home and has made a strong attachment to the manager. Another resident is quite emotionally fragile and needs constant reassurance, which the inspector noted he got from the manager. The manager told the inspector how he telephones the residents when he is on annual leave to reassure them he will be returning soon. The inspector viewed the arrangements for the administration of medication. There is a medication folder which contains the Medicine Administration Record (MAR) sheets. There is a list of the signatures of staff who will sign them. The sheets are not prefaced with a photograph of the resident and a requirement has been made. Medications are dispensed mainly in bubble packs. The inspector checked stocks and found no discrepancy between them and the MAR sheets. She saw a record of medicines received and returned to the pharmacist. The pharmacist signs for any medicines returned to him. The manager stated that all staff who administer medication have had medication training. Norman Road (135) DS0000007313.V346481.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. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and dealt with. Residents are protected from abuse but correct procedures must be clear for staff. EVIDENCE: The inspector viewed the complaints policy and the complaints file. The manager had recorded complaints and actions taken but not resolution. For example a neighbour had made a complaint about noise, and an apology had been made but not recorded in the complaints book. The manager must record the resolution of complaints and mark them in some way as completed, so he can tell at a glance whether a complaint is still outstanding (see requirements). The inspector viewed the adult protection procedure poster on the wall. It states that if a criminal act has been committed the police should be informed. This is misleading. In the event of any suspicion of abuse, criminal or otherwise social services must be informed first. They will decide whether or not the police should be involved and may have a strategy discussion with them or invite them to a meeting. The procedure should state that it must be Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 18 followed in conjunction with local authority policy (see requirements). The home has a copy of the Waltham Forest adult protection policy and procedure. There is a policy on whistleblowing for staff to follow. The inspector viewed, the accident and incident books. These raised concerns in her in relation to one resident. This resident has had several accidents. He has impaired mobility and the inspector heard the manager reminding him to take the stairs slowly and carefully. The tendency of this resident to fall is known and understood within the home and the inspector did not feel that any more precautions could be taken. The resident also has destructive behaviour and sometimes hurts his hands or sustains a bruise on his head through his destructive activities. Again the behaviour is well understood and the inspector could not recommend any measures in addition to those which are already in place. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Residents experience poor quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There are shortfalls in the appearance and cleanliness of the home environment. EVIDENCE: The service is reasonably homely, but is poorly decorated and the inspector felt not clean and hygienic. On entering the premises she noticed the house had an odour which was not fresh and clean. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 20 The inspector identified safety, décor and cleaning issues which must be addressed: Stairs There is a loose tread on the staircarpet which must be made safe. There are two hand safety rails on the stairs and one of them is loose and must be tightened. The stairs and landing had not been hoovered. They must be hoovered regularly. The plasterwork on the wall next to the stairs is broken and needs repair. Office The carpet is beyond cleaning and must be replaced. A box of rolls of wallpapers should be stored away. The gas fire is obsolete and the manager agreed to have it removed. If the hearth is removed too this will make useful additional room space. Ironing board and iron must be stored away, not on view in the office. Lounge The lounge has been decorated by putting one coat of lighter emulsion over purple painted walls. The walls need at least one more coat of paint probably two. Bathroom The door needs a coat of gloss paint. The ceiling needs a coat of emulsion paint. Kitchen The canisters in the kitchen need to be washed in soapy water. The cupboards need to be wiped over inside and out. The tiles need to be properly cleaned with an cream cleaner type of product. The door and doorway to the kitchen need to be painted with gloss paint. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 21 The inspector considered the chopping board a potential health hazard and the manager threw it away. The chopping board needs to be replaced with boards of different colours for different foods. The manager and staff will be aware of this from the food and hygiene courses they have undertaken. Conservatory The conservatory flooring is old and paint spattered. It must be replaced. Just outside of the back door there is a hole in the paved area. This is a hazard and must be filled in straightaway. The inspector saw the bedroom of one resident which was adequately decorated and furnished and clean. Another resident wanted to have a tidy up before she saw his room. When she did see the room she felt that it was adequately decorated and furnished and also personalised. However a castor was off his bed and this must be put back. General In many places (like skirting boards) the paintwork in the house is dirty and dusty and needs washing. The inspector was told that a set of net curtains had been washed recently. In that case they do not come up clean, and need to be replaced with new net curtains. Other similar net curtains purchased at the same time must also be replaced throughout the house (see requirements). The house has one bathroom which has a bath with a hand held shower, basin and toilet. This is shared by the residents. There is a staff toilet in the conservatory and a handbasin in there too. There are no specialist equipment needs in the house, apart from the above mentioned safety hand rails on the stairs. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 22 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, 35 and 36. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff are experienced, skilled and competent but training must not be allowed to become out of date. EVIDENCE: The staff consists of the manager and five carers one female and four male. The manager works on every weekday and comes in on Sunday mornings. He is relieved by another member of staff early each evening who provides sleeping night cover. The inspector viewed two staff files. One staff member had been with the home for nearly two years. Her recruitment appeared safe and she had undertaken training before joining the service. She had a certificate for a foundation course undertaken in May 2005, which covered a number of relevant care topics. She also had a certificate for medication training which Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 23 she had undertaken with a local pharmacy. She had also undertaken parts of an induction course with a local training provider. The second carer had joined the service in 2004. His recruitment appeared safe. He had undertaken food hygiene training in 2006 and protection of vulnerable adults training in 2006. He had repeated food hygiene in 2007 and also undertaken medication training. The inspector agreed with the provider that the following topics are core basics which need to be refreshed annually: Food Hygiene Health and Safety Fire Protection of Vulnerable Adults The manager has agreed to create a training matrix for his staff, so that he can see at a glance exactly what training they have done and when (see requirements). The manager stated that he has Registered Managers Award and that the carers have as follows; one has completed NVQ level 3, two have completed NVQ level 2, one does not have any NVQ qualifications. The inspector saw evidence in the files of staff, of regular and quite frequent supervision. The manager stated that supervision sessions last for between half and one hour. The National Minimum Standards require care staff to be supervised not less than six times per year and the manager would appear to be keeping up with this. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 24 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, 41 and 42. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. In many respects the home is well run and residents views are properly considered. Record keeping is good but an important health and safety issue has been identified. EVIDENCE: There are systems in place to support the efficient running of the home. However the inspector felt that the service would benefit if the manager spent some time tidying and organising his workspace, folders and files. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 25 he inspector saw evidence of a service user survey which was undertaken with residents and relatives this year. She viewed the annual development plans which span three documents. She was satisfied with them. She viewed the minutes of tenants meetings and house meetings and felt that residents and their relatives had good opportunities to state their views and voice requests. House meetings take place around every three months and another meeting is now due. The home has a large indexed policy and procedures manual which the inspector viewed. She noted that the policies are regularly reviewed with dates and signatures. The inspector viewed a wide range of record keeping in the home including daily log books. She found recording to be generally satisfactory. The inspector viewed the health and safety records and evidenced the following: The home has a fire safety policy and there are fire instructions. There are fire exit signs. The London fire brigade will be visiting the home on 29th July (entered in communication book). Portable appliance testing was undertaken in May 2005. The electrical system was checked in 2002 and is due to be checked again this year. The manager said that the company will contact him shortly. The boiler has needed several repairs over recent months. These have been recorded in a maintenance book. The fridge and freezer temperatures are taken regularly. The freezer temperatures were rather low and the inspector thought it looked a bit icy. She asked the manager to defrost it. The first aid box has a broken catch and needs to be replaced (see requirements). The inspector viewed the arrangements for the Control of Substances Hazardous to Health. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 26 The substances were stored in two different locked cupboards. The under the stairs cupboard was extremely untidy indeed with a miscellany of goods stored in there, among them COSHH products. The other cupboard was built in with shelves. Again a variety of goods were stored in there, old archived files, foodstuffs, COSHH products, Christmas decorations etc. The inspector has asked the manager to give both cupboards a good clear and tidy out and he has agreed. The under the stairs cupboard would benefit greatly from some shelving and hooks. COSHH products must be stored altogether in one locked cupboard. Food products must not be stored with COSHH products. This contravenes the homes own COSHH policy. The manager could produce no data sheets for the COSHH policy although he agreed staff need these to be readily available. The home must make available for inspection data sheets for all COSHH products kept. Requirements have been made. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 27 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x 3 2 x Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 28 NO 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 4 The statement of purpose must be amended to ensure that there are no inaccurate statements in it. A risk assessment for travel which was last updated in December 2005 must be updated to safeguard the resident. The missing persons procedure must be amended to read advise social worker and CSCI not advise social worker or CSCI. Photographs of the residents should be inserted in the medication folder in front of their MAR sheets. The manager must record resolution of complaints and mark them as completed when they are. The adult protection procedure must be amended to state that social services be advised in the first instance following the suspicion of abuse. The procedure should refer to the local authority policy and say Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 29 Requirement Timescale for action 01/09/08 2 YA9 13 (4) (c) 01/09/08 3. YA9 13 01/09/08 4. YA17 13(2) 01/09/07 5. YA22 13 01/09/07 6. YA23 13 01/09/07 7. YA24 23 it is to be followed in conjunction with the homes policy. The manager must attend to the following safety, décor and cleaning issues in the home.. Stairs Loose tread on the staircarpet which must be made safe. Loose safety handrail on the stairs must be tightened. The stairs and landing need to be hovered regularly. The plasterwork on the wall next to the stairs must be repaired. Office The carpet is beyond cleaning and must be replaced. A box of rolls of wallpapers should be stored away. The obsolete gas fire must be removed. Ironing board and iron must be stored away, not on view in the office. Lounge The walls need at least one more coat of paint probably two. Bathroom The door to be painted with a coat of gloss paint. The ceiling to be painted with a coat of emulsion paint. 01/10/07 Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 30 Kitchen The canisters in the kitchen must be washed in soapy water. The cupboards must be wiped over inside and out. The tiles need must be properly cleaned with an cream cleaner type of product. The door and doorway to the kitchen must be painted with gloss paint. The chopping board must be replaced and boards of different colours must be purchased in line with proper food hygiene practice. Conservatory The conservatory floori must be replaced. The hole in the paved area just outside the back door must be filled Bedroom A castor was off a residents bed and this must be put back. General Dirty and dusty paintwork in the house must be washed. Old net curtains which wont wash up clean must be replaced throughout the house. The manager must create a training matrix which shows at a glance what training staff have undertaken and when. 8. YA35 18 (1)(c)(i) 01/10/07 Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 31 9. 10. YA42 YA42 13 13 (4) (c) The first aid box has a broken catch and needs to be replaced. COSHH products must be stored altogether in one locked cupboard. Food products must not be stored with COSHH products. Data sheets must be made available for inspection for all COSHH products kept in the home. 01/10/07 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA17 Good Practice Recommendations Reviews should look over the progress since the last review, and residents should be encouraged to set personal goals for the next period. The inspector strongly recommends that staff ensure that a nutritious meal is cooked each evening to include vegetables. Also that fresh fruit is available in the house at all times, providing there is no choking hazard or risk identified with this. Norman Road (135) DS0000007313.V346481.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 - 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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