Inspection on 01/02/06 for Norwood 54 Old Church Lane

This inspection was carried out on 1st February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 54 Old Church Lane 02/10/08

Norwood 54 Old Church Lane 22/09/06

Norwood 54 Old Church Lane 18/10/05

Norwood 54 Old Church Lane 02/03/05

Norwood 54 Old Church Lane 10/09/04

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 54 Old Church Lane 54 Old Church Lane Stanmore Middlesex HA7 2RP Lead Inspector Clive Heidrich Unannounced Inspection 1st February 2006 09:30 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 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 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 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. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 54 Old Church Lane Address 54 Old Church Lane Stanmore Middlesex HA7 2RP 020 8954 6498 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) Norwood Mr Peter Behan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user may have additional physical disabilities Date of last inspection 18th October 2005 Brief Description of the Service: 54 Old Church Lane is located in a residential area of Stanmore. It is a registered care home that offers personal care to a maximum of six service users who have learning disabilities. The organisation has voluntarily reduced this number to five so that the double-room need not be shared. The registered provider is Norwood, a national care organisation that specialises in providing services to people of a Jewish culture. The home is situated within a residential area of Stanmore. It is in keeping with other homes in the area. There is parking available in the forecourt for up to three cars, and on surrounding roads. Local transport links and shops are within 10 to 15 minutes walk. The building includes a lounge, a dining room, a ground-floor bedroom, a ground-floor shower room, four upstairs bedrooms, and a separate upstairs bathroom and shower room. Access to the first floor is by passenger lift or stairs. The home had a secluded and fair-sized garden. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across a cool day in early February. It finished at 2:50p.m. Its focus was mainly on compliance with previous requirements. There was additionally one core standard remaining for consideration relative to the first inspection of the year. All of the service users were present at the start of the inspection. The inspector met with them individually to discuss the services provided in the home, although feedback was not always possible verbally. The service users then went out on planned activities. The inspector also discussed aspects of the service with staff working during of the visit, and with the manager. Additionally, care practices were observed across the day, most of the environment was checked on, and a number of records were sampled. Concurrent to the inspection, the manager was requested to send out comment cards to involved people, and to complete an inspection questionnaire. He promptly undertook this, and consequently information from five service users’, one visitor’s, and two health professionals’ comment cards, along with the inspection questionnaire, have been included in this report. Feedback overall has been positive. The inspector thanks all involved in the home for the patience and helpfulness during and after the inspection. What the service does well: What has improved since the last inspection? 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 6 The manager has successfully been registered with the CSCI in respect of managing the home. Work on the kitchen and the lounge has been completed, and both are now both more presentable and easier for service users to use. The manager reported that additional staff funding has been agreed in respect of increased service user needs. The increased staffing levels were about to be implemented at the time of drafting this report. There have been good developments to ensure that service users’, and other involved people’s, views better influence how the home operates. Processes must now be completed and formalised. Appraisals are reported by management to have been completed for all staff for the first time. This followed specific training for all on the purpose of appraisals. 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. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 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 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective service users can be supplied with detailed information about how the home and the organisation operate. EVIDENCE: The manager updated the home’s Statement of Purpose and Service User Guide in December 2005. These documents provide detailed information about the home and the organisation in line with the National Minimum Standards. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users are supported by the provision of detailed care plans. Their care needs are reviewed and updated, although the frequency of undertaking this formally must be improved on. EVIDENCE: Detailed care plans were seen to be in place for the two service users checked on. Formal review meetings were found to have generally taken place almost a year ago. The manager reported that the next set of meetings were being organised with social workers. Goals from previous meetings were generally found to have been completed according to general evidence found during the inspection. There were however no obvious records of progress and completion of these goals. This is recommended, for reasons of focus and evidence. The manager must additionally ensure that a formal review meeting takes place every six months, with social worker and other representatives’ attendance if possible if the service user wishes for them to attend, to help ensure that appropriate focus on the individual service user’s needs take place. It is however positively noted that internal reviews of plans generally take place three-monthly. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Service users are part of the local community. They take part in some appropriate leisure and occupational activities, both in and out of the home. There are shortfalls in this respect however, in terms of sufficient staffing levels and suitable records of activity. EVIDENCE: The home has a large car that service users use. The home had one driver at the time of the inspection. Feedback from staff and service users found that overall, the car is not ideal to service users’ gradually reducing mobility needs, and that taxis are also used regularly. It is strongly recommended that a more appropriate vehicle be acquired, and that more staff are encouraged to be approved of by the organisation to drive the vehicle. An audit of three service user’s daily records across the ten days prior to the inspection found that they had been out between four and five days each, for such things as a group music session, the circus, and for lunch out. There was no evidence here of internal activities such as therapies or staff-supported activities, or of cultural input such as synagogue attendance or visitors in this respect. The inspector is concerned that this does not provide evidence of 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 11 sufficient occupation of service users, in that there appears to have been no occupation of each service user every other day. At the previous inspection, it was noted that it is difficult for service users to participate in outside activities in the evening because the staffing ratio is not adequate. This also applies to weekends when it is difficult to take service users to the synagogue due to lack of staffing. This is discussed further under standard 33, and is noted by the manager to be in the process of being rectified. The manager supplied a chart of the planned weekly occupation of each service user. This showed appropriate occupation for every weekday, with the option of additional Sunday outings. The manager stated that a lot is being done in terms of activities for service users, and felt that the recording of activities is the shortfall. Feedback from service users found no concern about activities or of being bored. The manager must ensure that there is proper evidence of activities undertaken by service users in and out of the home. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of them. EVIDENCE: All of these standards were considered at the previous inspection. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of them. EVIDENCE: All of these standards were considered at the previous inspection. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30. Service users live in what is overall a homely and comfortable environment whose bedrooms and shared spaces meet needs. Improvements to the design and décor of the home, particularly in the dining area, have been recently made. There are however a number of shortfalls with upholding the environment as homely, comfortable, and safe. These are listed below, and within the requirements list. One issue, about a lack of hot water from taps in some areas of the home, was put to the organisation by urgent-action letter. The manager consequently reported the issue to have been addressed. EVIDENCE: The home is situated in a quite residential area. The house is in keeping with the other residences along the road. The interior of the home is domestic in nature as are the furniture and fittings. One service user complimented the furnishings. The ambiance is homely and comfortable. The home was seen to have completed refurbishment in the lounge and the kitchen across the last year. The kitchen now has a useful breakfast bar that additionally allows service users to view the kitchen area from the dining table. The whole area was additionally tastefully refurbished. The lounge now has a 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 15 more suitable flooring, and new furniture that that co-ordinates well. This includes sofas, a table and chair set, and a computer. Both areas now additionally allow service users greater independence, which is encouraging. The home has a reasonable sized back garden. A shed has recently been resited to improve access and views. The garden has a lot of stone-slab paving that is not fully level. The manager noted that a risk assessment of the area has meant that service users are not to go out alone there due to risks of tripping and falling. A request has been put to the organisation’s maintenance department to have the area levelled. Due to risks and consequent limitations on service users’ independent freedom in the garden, the levelling is judged as necessary and is listed as a requirement at the end of this report. There remain problems with the provision of hot water from the upstairs bathroom and some sinks. There was no hot water available to these areas during the inspection. Feedback from staff and one service user found that service users seldom use that bathroom for baths due to the inconsistency in supply of hot water. Service users are reported not to have a bath or shower preference, and no service users raised the lack of hot water as an issue. However, it was consequently found, according to staff feedback and records, that the large ensuite shower facility downstairs in one service user’s bedroom is commonly used by other service users for showering. Management explained that this had been a short-term solution a number of months ago, but that the upstairs shower room, that is communal but smaller, should have been being used. This room however has a small entry door and a change in level on entry of about 3cm. An urgent action form was left with the manager to ensure that the larger problem, of consistently supplying hot water from the bath and sink taps, is promptly addressed. The manager must re-clarify to staff as to which shower room service users may use, based on written risk assessments, and ensure that this practice is followed. Staff should not ordinarily support service users, other than the occupant, to use the en-suite shower room. The bath additionally needs a new bath panel, as the current panel is showing signs of wear and tear. The hallway was seen to be in a worn state of repair. The carpet had a number of small holes in it, and so must be replaced. The walls could not be fully cleaned according to feedback, and so presented as somewhat grubby. They should be repainted. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 16 The manager showed evidence of reporting, and re-reporting, maintenance issues to the organisation’s maintenance department. The downstairs toilet was found to be effective for use. There were many unused yellow disposal bags openly stored there, which for homeliness purposes must be stored discreetly. It was also found that the staff-call alarm system next to the toilet did not work. This was rectified when management found that it had been switched off at the switch outside of the toilet, an issue that may be related to a service user. Consideration of whether this switch puts service users at risk is recommended. On this occasion, the laundry room was seen to lack a significant amount of plasterboard, approximately 1m² on its lower left-hand side, so exposing the structure underneath. This was previously required to be addressed in respect of it being just a crack in the wall at that time. The issue is a health and safety hazard, and is poor décor. It must be rectified promptly. Additionally, there is an outstanding requirement about the laundry flooring. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 34. Service users are supported by an established staff team. The team are overall suitably competent and qualified. A shortfall in staffing numbers, with respect to service users’ needs, was about to be addressed at the time of drafting this report. Service users are protected by the standard of the organisation’s recruitment checks. EVIDENCE: Feedback from service users about staff was positive. One person said that staff are alright, another that the carers try their best and that the carers know their needs and understand them. Health professional comment cards found that there are always senior staff available, that staff work in partnership with them, and that advice made by them is incorporated into the service user’ plan. It was noted, from the inspection process, that staff sometimes undertake tasks on behalf of service users, without the service user being present. For example there was feedback that some staff may sometimes undertake community tasks such as shopping without involving the relevant service user. The inspector observed a staff member in a service user’s room undertaking cleaning. The service user was not present. It is recommended, for the reasons 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 18 of inclusion and appropriateness, that service users be involved whenever possible with tasks that involve them. There is good commitment to relevant NVQ training, according to records and feedback. The home is close to achieving the National Minimum Standard of 50 of staff having this NVQ, and ongoing efforts of individual staff should see this figure exceeded shortly. Management noted that they have acquired training in dementia care, as per the needs of a service user in the home. This training was due shortly to take place. They will feed this training back to the team. This is good practice. Rosters for the home showed that there has been no change to the staffing levels. The manager ensures that three staff work in the mornings, two in the late afternoons and evenings, and two at all times of the weekend. The home has a waking night and a sleep-over staff member across each night. There is a senior staff presence across every weekend. No agency staff are used, and where gaps occur, these are filled by ‘cluster’ staff who work as needed in local Norwood homes. This enables a better continuity of staff for the service users. The manager stated that there is one staffing vacancy in the home. Recruitment for this post is ongoing. There will additionally be further hours available from March for staffing, following successful negotiations with funding authorities in terms of the increased support needs of some service users. The manager explained that this will enable a third staff member to work the late afternoon shifts and on Sundays in support of providing service users with community activities at these times (see also standards 11-17). This was a requirement from the previous inspection that is now considered partly addressed. An audit of two newer staff members’ recruitment records was made. It was established that appropriate checks of identification, work permits, references, and Criminal Record Bureau disclosures, were made. Both staff members had signed contracts on file. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 39. Service users benefit from a home that is overall suitably managed and led. There have been good developments to ensure that service users’ views influence how the home operates. Processes must now be completed and formalised. EVIDENCE: The registered manager has completed NVQ level 3 in care. He is currently undertaking NVQ level 4. He is also studying towards the registered managers’ award and the NVQ assessors’ award. The manager previously worked as a senior staff member in another home run by the same organisation, and has about ten years of experience working with people who have learning disabilities. He has been successfully registered with the CSCI, since the last inspection, as the manager of the home. The manager informed the inspector, just prior to this inspection, that he is additionally overseeing another local care home within the organisation now for half of the week, pending the organisation recruiting a permanent manager for 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 20 that home. It is recommended, so as to uphold sufficient support and leadership at 54 Old Church Lane, that this arrangement be kept to a minimum length of time. Staff feedback indicated that they feel supported by management in the home. The manager noted that there are ongoing supervisions for staff, and that all staff have recently received appraisals for the first time. This is encouraging. Records of staff meetings found them to take place approximately every six weeks. They include discussions about the needs of specific service users, and about management expectations in terms of the care provided. It is recommended that these meetings be held more frequently, so as to support effective communication between employees of the home in the care of service users, particularly in light of the manager temporarily covering an extra home. The manager stated that the home’s business plan was set up recently. It involved the informal auditing of service users and staff members’ views. It was seen to be broad, detailed, and target-led, and so should benefit service users greatly. There is an overall strategic plan for residential services that spans 2004-7. The manager also noted that the home has had a recent internal audit through the organisation, and that lay visitors audit regularly. Proprietor visit reports had just restarted taking place on the required monthly basis, with the last report held in the home being from mid-December. However, the inspector has not received any reports since that of November, which must be addressed, to show that appropriate organisational checks on the standards within the home continue to take place. There were records of monthly service-user meetings available for viewing. Recent meetings included explanations of upcoming changes in the home, standard checks of such things as menus and activities, and included appropriate views of service users. It was previously discussed with the manager about the home, or the organisation, having a policy in respect of establishing and maintaining a system of periodic review and improvement of the quality of care and support provided in the care home. Whilst there is clear evidence of this commencing in practice, a policy remains to be completed. This is required, to clarify expectations around quality auditing and improvements. The processes must include formal and proactive feedback channels for service users, their representatives, and involved professionals. As per the summary of this report, CSCI comment cards were received from a number of people following the inspection, including from all five service users, which was appreciated. It appears that a member of the staff team supported 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 21 service users to fill out their comment cards, which is a reasonable response, as all service users would need some degree of support with the cards. It is recommended for future surveys, that a person independent of the organisation, such as an advocate, be asked to support service users with filling out quality audit questionnaires, so as to more transparently ensure that service users’ opinions are reflected. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 22 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 1 28 3 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 3 2 X X X X 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 23 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 YA14 Regulation 17(1)(a) sch 3 pt 3 Requirement The manager must ensure that the records of activities undertaken by each service user in and out of the home accurately reflect what the service user has been involved in. The garden has a lot of stoneslab paving that is not fully level. The paving must be levelled and made safe to use independently by ambulant service users. The hallway carpet has a number of small holes in it, and so must be replaced, to uphold a homely appearance. The bath needs a new bath panel, as the current panel is showing signs of wear and tear. Hot water must be permanently available from the bath and the identified hand-wash basins. Previous timescale of 20/12/05 not met. This issue put to the organisation as an urgent requirement, and is consequently reported to have been addressed. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 24 Timescale for action 01/05/06 2 YA24 13(4), 23(2)(o) 15/05/06 3 YA24 23(2)(b, d) 23(2)(b, d) 23(2)(j) 01/07/06 4 5 YA27 YA27 01/07/06 08/02/05 6 YA27 12(4), 13(4), 23(2j) 7 YA30 12(4)(a), 13(3) 8 YA30 16 (2) The manager must re-clarify to 01/05/06 staff as to which shower room service users may use, based on written risk assessments, and ensure that this practice is followed. There were many unused yellow 01/04/06 disposal bags openly stored within the downstairs toilet area, which for homeliness purposes must instead be stored discreetly. The laundry flooring requires 20/12/05 replacement in the area where it is missing (a small section on the right-hand side on entry into the room). Previous timescales of 19/4/05, 1/8/05, and 20/12/05 not met. The small but significant crack to the left-hand wall of the laundry room must be rectified, for appearance and hygiene issue. Previous timescales of 1/10/05 and 20/12/05 not met. On this occasion, the crack was seen to have developed into an area lacking approximately 1m² of plasterboard, so exposing the structure underneath. Afternoon and weekend shifts need one more support worker to allow the service users the opportunity to pursue activities outside of the home. 9 YA30 23(2)(b) 20/12/05 10 YA33 18(1)(a) 20/03/06 11 YA39 26(5)(a) Previous timescale of 20/12/05 partially met. Proprietor visit reports must be 15/04/06 promptly supplied to the CSCI on a monthly basis. A policy, in respect of DS0000017551.V281383.R01.S.doc 12 YA39 24 01/07/06 Version 5.1 Page 25 54 Old Church Lane establishing and maintaining a system of periodic review and improvement of the quality of care and support provided in the care home, is required. The policy must include about formal and proactive feedback channels for service users, their representatives, and involved professionals. 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 26 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 3 4 Refer to Standard YA6 YA13 YA24 YA24 Good Practice Recommendations It is recommended that there be records of progress and completion of goals within service users’ care files, for reasons of focus and evidence. It is strongly recommended that a more appropriate vehicle be acquired, and that more staff are encouraged to be approved of by the organisation to drive the vehicle. The hallway walls could not be fully cleaned according to feedback, and so presented as somewhat grubby. They should be repainted. The switch outside the downstairs toilet partially controls the staff-call alarm inside the toilet. It can be turned off. Consideration of whether this puts service users at risk, and of any consequent actions, is recommended. Staff should not ordinarily support service users, other than the occupant, to use the en-suite shower room. It is recommended, for the reasons of inclusion and appropriateness, that service users be involved whenever possible with tasks that involve them. It is recommended, so as to uphold sufficient support and leadership at 54 Old Church Lane, that the arrangement of the manager additionally overseeing another home temporarily, be kept to a minimum length of time. It is recommended that staff meetings be held more frequently than six-weekly, so as to support effective communication between employees of the home with the care of service users. It is recommended for future CSCI surveys received at the home, that a person independent of the organisation, such as an advocate, be asked to support service users with filling out quality audit questionnaires, so as to more transparently ensure that service users’ opinions are reflected. 5 6 7 YA27 YA32 YA37 8 YA38 9 YA39 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 54 Old Church Lane DS0000017551.V281383.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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