Inspection on 26/02/07 for Northampton Road (65)

This inspection was carried out on 26th February 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

Northampton Road (65) 17/02/09

Northampton Road (65) 07/12/07

Northampton Road (65) 04/01/06

Northampton Road (65) 09/09/05

Northampton Road (65) 11/11/04

Northampton Road (65) 28/06/04

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 Northampton Road (65) 65 Northampton Road Croydon Surrey CR0 7HD Lead Inspector David Pennells Key Unannounced Inspection 26th February 2007 11:30 Northampton Road (65) DS0000028184.V331385.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 Northampton Road (65) DS0000028184.V331385.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. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northampton Road (65) Address 65 Northampton Road Croydon Surrey CR0 7HD 020 8655 1929 020 8655 1929 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) Mrs Nandhinee Dabadeen Mr Ravesh Dadabeen Mrs Nandhinee Dabadeen Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last key inspection 4th January 2006 Brief Description of the Service: Northampton Lodge is registered to provide care for up to three younger adults with learning disabilities, though currently the community operates happily with just two people using the service living with the Dabadeens. The home is a semi-detached house situated in a residential area not that far from East Croydon; it is well situated to access local transport links (trams & busses), shops and other community facilities. The accommodation available for service users comprises: three single bedrooms, two reception rooms, kitchen, two bathrooms and two toilets. Upstairs, service users have the benefit of their own kitchenette to prepare drinks and snacks as well as a lounge / dining area to entertain guests. There is a large garden area to the rear of the property and parking to the front - and on street (free of charge). Two service users currently live at the home. The home is also the private residence of the registered owners, Mr and Mrs Dabadeen, and their children. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was conducted from lunchtime throughout an afternoon, allowing the inspector to meet those people who used the service, the proprietors, and their children. During this time the lifestyle of those living there was described, with these people offering their own opinions about the service - and the proprietors were amenable to all enquiries and comments offered by the inspector. All parts of the care home premises were seen. The inspector was grateful to be able to share lunch with the ‘extended family’ and thanks them all for their welcome, hospitality and cooperation during the visit. What the service does well: What has improved since the last inspection? Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 6 Individual risk assessments for those using the service have improved, and the process of person-centred planning is being introduced to the home. The house continues to be upgraded, premises-wise, and a recent fire Risk Assessment has led to improved fire safety provision. 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. Northampton Road (65) DS0000028184.V331385.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 Northampton Road (65) DS0000028184.V331385.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 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose, and Service User Guide provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. The home has created an assessment of each individual residing at the home ensuring that aspirations & needs are recognised and will be responded to. EVIDENCE: There have been no significant changes in home’s service provision or category since the last inspection visit, and no new service user has been admitted since the last CSCI inspection. In response to the last key inspection, the home’s Statement of Purpose has been reviewed to include the sizes of the rooms and details about the experience and qualifications of the staff employed there. The views of the two service users who live there have also been added with positive feedback such as “My room is like a princess room. I went to Ikea to choose the pictures.” and: “ I like going out shopping with Priya.” Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 9 East Sussex CC and London Borough of Croydon currently fund placements at the home. The current scale of charges is set at £750 per person per week though both people are covered by ‘added-value’ care rates above this level. The cost of toiletries / magazines / holidays are paid by the individual. The two current service users have been at the home since 2001 and 2004. When potential newcomers first move to the home, care managers from their client’s placing authorities completed informative needs assessments. These are the basis of the home’s care plans and clearly describe each individual’s social, physical, emotional and cultural needs. The resultant service user plans were well organised, had been reviewed at regular intervals and up dated accordingly to reflect any changes, also containing detailed guidelines to follow in order to meet the individual’s identified personal, social and healthcare needs. Northampton Road (65) DS0000028184.V331385.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, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment and care planning process leads to the service users plan which supports them to meet their assessed needs and personal goals. Choice and decision making for users of the service is encouraged and promoted to a good standard, enabling their involvement and opportunities to contribute to the culture and operation of the home. Individuals are supported to take risks as part of an independent, preferred lifestyle, through risk plans being formulated and reviewed, fully safeguarding individuals from potential harm. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 11 EVIDENCE: As previously required, the manager had developed a care plan for the newer of the two persons who use the service. Each now has a written plan of care that describes their needs, strengths and wants and states when they require support from staff. As a small home, the manager/proprietor retains the main keyworker role - this ensuring a generally constant overview of their cases. Staff members do maintain progress records for the service users which highlight progress, achievements and any activities participated in, but some gaps / deficits were noted; it is recommended that these progress notes be regularised to a daily entry. It is also recommended that documentation is monitored / checked that it is dated - without such ‘markers’ (alongside clear signatures) documents have little significance / relevance. The manager reported that both she and her husband have undertaken training in ‘person centred planning’, and will be introducing the process at the home. This will make the care plans even more accessible and meaningful to each individual, though they do currently sign their agreement to their plans. From discussion and questionnaire responses, service users consider that they are sufficiently consulted about the running of the home, and do not wish to be more involved in decision-making. One service user chooses to go out shopping and buy her toiletries and other requisites, whilst the second prefers to be more ‘organised’. Risk plans cover a variety of situations from accessing community activities, travelling independently, and learning skills within the home. Risk assessments have also been put in place to safe guard service users when the home is occasionally left un-staffed (part of a specific developing plan moving towards independence). Records evidenced that those who use the service are supported to take risks as part of an independent lifestyle. The risk plans recognise the rights of the service users to take responsible risks - and also to be supported where necessary. Northampton Road (65) DS0000028184.V331385.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Users of the service access activities inside and outside the home in the local community regularly, and are supported to continue education and appropriate activities, so that they can maximise fulfilment and achievement in their lives. The friends and relatives of service users can expect to be welcomed and encouraged to keep in touch with those who live at Northampton Road. Meal provision reflects a wide variety and provides choices, whilst seeking to maintain a healthy lifestyle for those resident at the home. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 13 EVIDENCE: The general domestic life at the home is clearly enjoyed by both who live there with Mr & Mrs Dabadeen; videos, letter writing, books, TV, DVDs. Due to the small scale nature of the home there is a lot of flexibility in the daily routines and service users are very much involved in the day–to–day decisionmaking process. Both service users were consulted about their social lifestyle and commented positively about the activities provided. The homeowners support the service users to continue and develop social networks and they regularly access community activities such as pub visits, meals out and shopping. Service users confirmed that they often go out with the proprietors and the one staff employed at the home. Social needs are clearly described within the care plans that take account of individual preferences. Both service users discussed their social lifestyle and commented positively about the opportunities provided. Family involvement is encouraged as appropriate and friends are welcome at the house. One person at the home is more independent outside the home and is well known in the local community; the second needs company though swimming (and possibly yoga) are the sort of activities enjoyed, once out. Pubs, clubs, restaurants and bars are popular and frequented, the library, post office and beauty treatments such as manicures, facials and waxing at a local beautician’s are also popular. The work experience opportunity at a local charity shop has recently stopped due to the culture of the place being unsuitable for these young people. Day care opportunities have also been rejected on the basis of inappropriate activities. No specific cultural or religious needs have been identified by either of those living with the Dabadeens. One service user accompanied the Dabadeens with their family to Dubai; both went to Jersey for a holiday not long ago last year. Mrs Dabadeen had booked a ‘lastminute.com’ trip for herself and the two service users to Edinburgh in the New Year. Due to the smaller size of the home, meals tend to be planned on a daily basis. In response to the last key inspection, record keeping has improved concerning food provided. Those resident have been consulted about their preferred meals - and menus revised to include their preferred choice. Service users said they like the meals and enjoy going out shopping to the supermarket if they want. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident they will be supported in personal care issues according to their own preferences and/or assessed needs. Those who use the service may be assured that their welfare is closely monitored to ensure that their physical and emotional needs are met - and will receive such care support through the timely intervention of allied professionals (including any prescribed medication) in an appropriate way. The home manages the administration of medication well, within the supportive context of policy and good record keeping. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 15 EVIDENCE: Care and support provided by the home was observed to be appropriate and sensitive to the needs of the two individual service users. Routines are flexible, and guidance and support is ‘second nature’ to the proprietor, ‘living alongside’ service users as they do, whilst integrating support and assistance. Service users clearly choose their own clothes and initiate their own activities of choice; they are supported in activities and day-to-day routines by staff. Dental and GP input is available at local surgeries and visits by psychologists / counsellors are arranged as appropriate. The right of the individual to refuse treatment is also acknowledged. Medication storage and records were examined and found generally well kept. It is required that medication profiles be kept up to date - and that the proprietors map changes to the profile carefully. It was also recommended that people who use the service who self-medicate are encouraged to ‘sign for’ receipt of their medication - this emphasising their responsibility for the meds and also providing a fully written audit trail for the drugs administered by the home. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescale. The home provides adequate support to service users to ensure that they are protected from harm, neglect and any form of abuse. Recruitment practices have improved meaning that service users are more fully protected - and staff members have a better understanding of preventing abuse. EVIDENCE: The home has a clear Complaints policy and procedure that is also available in picture format - and a log sheet for recording any complaints. Those using the service have been provided with a list of emergency telephone numbers, including relevant care managers, and the Commission. Both service users are aware of who they should contact should they wish to complain. No complaints had been made about the home since the last inspection. Procedures for alleged abuse is in place at the home, alongside the London Borough of Croydon adult protection / safeguarding procedure. Previous inspection requirements concerning these safeguarding standards had been addressed; at the last random inspection visit, completed CRB and PoVA Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 17 checks were seen for the two part time staff currently working in the home. In addition, both had completed in-house training on abuse awareness - this organised by Mr Dabadeen. As good / best practice, all staff should attend the Croydon Local Authority training on ‘Adult Protection / Safeguarding’. Northampton Road (65) DS0000028184.V331385.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, 26, 27 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally decorated and furnished to a good standard and provides service users with safe, comfortable surroundings in which to live. Improvements continue to be made to the fabric of the premises meaning that service users are provided with a more welcoming, homely and pleasing environment in which to live. EVIDENCE: The house is also in a good location - in the middle of an ordinary street in Addiscombe, close to shops, trams, busses and local civic amenities. The centre of Croydon with the attraction of bars and clubs is a short drive / bus journey away. Both service users hold keys. The home clearly suits the needs and lifestyles of the two service users who currently live there. With the benefit of a separate kitchenette and lounge, the Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 19 service users are supported to develop their independent daily living skills and progress towards a more independent lifestyle. An amount of refurbishment has been undertaken over the past year; those who use the service are positive about living in the house - reporting their active involvement in the decoration of their rooms. One individual said she was very pleased with her new room that had been repainted and furnished with items of her choice, including a new dressing table. The service user said she went shopping to choose pictures for her wall and selected the paint colour. The other service user had chosen some new bed linen and carpet for her room. There is a planned maintenance book, recording the bathroom improvements and the recently newly installed water tank. A new carpet has been fitted in one bedroom, and a smart, wooden floor introduced to the lounge. The users of the service are supported to do their own housework and arrange their rooms as they wish. Good general hygiene practices are observed - and the home appeared clean and tidy and odour-free. Northampton Road (65) DS0000028184.V331385.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): 31, 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training for staff members has improved since the last inspection resulting in a more skilled workforce to meet the service users’ needs and home’s aims and objectives. Overall, recruitment practices are now managed more securely although some improvements are needed to maximise protection for service users. EVIDENCE: Due to the home’s small size, the two service users are supported within a family type environment. The owners, Mr and Mrs Dabadeen and just one part time care worker currently staff the home - with the occasional recent use of an agency worker. Service users were complimentary about this small staff team and gave the impression that they are treated as part of the family. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 21 The home has developed an induction pack that covers key learning objectives and an orientation process. Files included a completed induction for both current and previous staff and records of achieved training. Training opportunities are now more widely available and courses are accessed through an independent training consultant used by the home. Staff members had undergone in-house training on Food Hygiene and Abuse Awareness, and the current staff member is studying for their Level 2 NVQ in Care qualification. The two homeowners quite recently attended a course on understanding mental illness. A further deficit noted was the lack of First Aid training - which is essential, being required by Regulation and is raised alongside other statutory training under Standard 42 - focusing on Health & Safety. Staff files seen contained most of the necessary documentation as required in the Care Homes Regulations 2001 including a completed CRB and PoVA First check. The staff member still did not have a contract of employment, however; the manager must put such a document in place - for the home’s protection, as much as for the security of the employee. Aside from these abovementioned issues, record keeping for staff had clearly much improved and the manager has worked hard to ensure that recruitment practices will be adhered to more carefully. Sadly, one clear deficit identified was the absence of the February staffing rota. Such a document is required to be in place and kept as a record of staffing input within the requirements of the Care Homes Regulations (Schedule 4.7). Staff supervision must be afforded to all staff members - even one. It is suggested that such an input could be provided ‘pro-rata’ as the staff member is not a full-time practitioner (working about 15 hours per week). The inspector suggests that perhaps a 1:1 session each quarter - or four months - would be sufficient. The opportunity to encourage the staff member’s development and to monitor performance must not be neglected. Northampton Road (65) DS0000028184.V331385.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 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements made to the quality assurance system mean that the quality of care is more regularly appraised. Overall, health and safety practices are well observed to ensure that service users live in a safe environment although staff must be provided with training in all key areas. EVIDENCE: The Manager, Mrs Dabadeen, has a nursing background and has experience of working with people with learning disabilities. She is currently undertaking the CMS at Croydon College and already currently holds the NVQ in Care, Level 3. Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 23 Throughout the inspection, Mrs Dabadeen demonstrated a good knowledge about both service users’ needs and showed a general competency in managing the home. The manager’s husband provides extra support for those who use the service - to go on outings or other activities in the community. As a small home, the input to Quality Assurance is at a micro-level when compared to larger organisations - and current provision ensures that those who use the service are involved in day-to-day decisions - their views being sought regularly through discussion with the homeowners. Further systems still need to be put in place, however - such as satisfaction questionnaires. At the previous inspection, the home was required to implement a quality assurance system and put in place an annual development plan, both involving service users. This was achieved as a Quality Plan developed for 2006 - this needs to be kept ‘up to speed’ - by review and supplementary progress in using the questionnaires, etc. The individual people who use the service handle their finances - they have their own benefit books, and manage their own financial affairs. A full and comprehensive Fire Risk Assessment has been completed for the home - with fully illustrated documentation. The inspector recommends that fire drills be reduced from the monthly activity to approximately three-monthly events within the life of the home - this sufficient and avoids the development of complacency in all those resident inn the home. It is also required that Fire point activation checks must indicate the specific point used -to ensure that all points are checked by strict rotation. All accidents and incidents are appropriately recorded and safety notices are displayed appropriately. Other servicing and maintenance records for the home were checked on this occasion - it being noted that the Portable Appliance Testing was overdue / required. Gas and electrical safety checks had been completed as well as regular fire equipment and fire system checks. The manager completes a health and safety check on the environment every month. Up-to-date risk assessments covering safe working practices for the premises are in place. Since the previous key inspection, some progress has been made with training staff in key health and safety issues, such as in-house training completed on food hygiene practices. The manager must now ensure that all staff member / proprietors attend other relevant courses - such as First Aid - to ensure that they have the necessary knowledge and skills concerning health and safety practices. Northampton Road (65) DS0000028184.V331385.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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 25 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) Requirement Medication profiles must be kept up to date, and map changes to a person’s profile accurately. Staffing rotas must be used, maintained and kept as a statutory record - as required by regulation. All staff must be provided with a job contract that outlines the terms and conditions of their employment. All staff members - even if parttime - must be afforded personal supervision to encourage their development and monitor performance. Questionnaires must be offered to people who use the service, their family / representatives and any other interested parties - to assess whether the home is meeting its aims, objectives and stated purpose. A copy of the survey assessment document to be sent to the Commission. Timescale for action 01/03/07 2. YA33 17(2) Sch 4.7 01/03/07 3. YA34 18(4) & Sch 4.6 (e) (f) 18(2) 30/05/07 4. YA36 30/05/07 5. YA39 24 30/06/07 Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 26 6. YA42 9(2)(b), 13, 18 & 19 All staff must attend training on 30/06/07 health and safety topics i.e. First Aid, Infection Control and Fire Safety - and records must be kept to evidence this. Fire alarm checks must indicate the specific activation point used - to ensure that progressively all points are checked on a rotating basis. Small electrical appliances both belonging to the home and the people using the service must be PAT tested on an annual basis. 30/05/07 7. YA42 23(4) 8. YA42 13(4) 30/05/07 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. Refer to Standard YA6 Good Practice Recommendations That all documentation is monitored / checked that it is dated - and that progress notes for those that use the service be regularised to a daily entry. That people who use the service are encouraged to ‘sign for’ receipt of their medication - this emphasising their responsibility for the drugs, and also providing a fully written audit trail for the drugs handled by the home. That all staff members attend formal training on Adult Protection organised by the ‘host’ local authority (London Borough of Croydon). That the monthly fire drills be reduced to approximately three-monthly events within the life of the home. 2. YA20 3. YA23 4. YA42 Northampton Road (65) DS0000028184.V331385.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Northampton Road (65) DS0000028184.V331385.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. 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