Inspection on 03/01/06 for Norwood 60 Carlton Avenue

This inspection was carried out on 3rd January 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 60 Carlton Avenue 27/09/07

Norwood 60 Carlton Avenue 27/09/06

Norwood 60 Carlton Avenue 05/09/05

Norwood 60 Carlton Avenue 25/01/05

Norwood 60 Carlton Avenue 13/07/04

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 60 Carlton Avenue 60 Carlton Avenue Kenton Middlesex HA3 8AY Lead Inspector Judith Brindle Unannounced Inspection 3rd January 2006 08:30 60 Carlton Avenue DS0000017520.V270874.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 60 Carlton Avenue DS0000017520.V270874.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. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 60 Carlton Avenue Address 60 Carlton Avenue Kenton Middlesex HA3 8AY 020 8907 0239 020 8907 3711 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 Ms Amy Vickers Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 Brief Description of the Service: 60 Carlton Avenue is a care home providing personal care, and accommodation for up to 8 adults with learning disabilities. The care home is owned by Norwood, which is a Jewish organisation that provides care for children and adults with learning disabilities. The care home is located in a residential street in Kenton, close to Harrow. The home is situated very close to a park. There are local shops, a large supermarket, pubs, a post office, building societies, restaurants, and other amenities within a few minutes walk from the home. The home was opened in 1997, and consists of a purpose built detached building. There is a small garden area, and parking for 2-3 vehicles at the front of the house. The home includes a flat attached to the main house, where accommodation and support is provided for up to two service users, to enable them to have the opportunity to develop independent living skills. All the homes bedrooms are single; one bedroom has a shower facility. The home has a passenger lift. There is an enclosed, accessible, maintained garden at the rear of the property 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 4.5 hours during the day in January 2006. The inspector was pleased to meet all the residents during the inspection. Two residents kindly showed the inspector their rooms. The residents in the main house have varied verbal communication skills and needs. Several residents do not speak, and use signs, gestures, sounds, and physical contact to make their needs known. There were six residents in the main part of the house and two residents accommodated in the flat, which is attached to the main house. The focus of the inspection was to spend a significant part of the inspection with residents, observe and to obtain the views from residents (if able to communicate them) of the service provided, talk to staff, and assess as to whether 19 National Minimum Standards for adults had been met, and whether a previous inspection requirement had been met. A tour of the care home took place. There were 4 care staff on duty during the inspection. These staff were very helpful, and were able to provide all the documentation and information asked for by the inspection. The registered manger was present for part of the unannounced inspection. The documentation inspected included residents’ care plans, some policies, and procedures and health and safety documentation. All the National Minimum Standards for adults that were inspected had been met or almost met. A requirement from a previous inspection had been met. What the service does well: The care home has a very warm and welcoming atmosphere. Staff are very approachable and helpful. The environment is homely. There are numerous photographs of recent activities that residents have participated in displayed within the care home. Furnishings and fittings are of quality, comfortable. Activities for residents are varied, and meet individual needs. Staff have a good understanding of residents varied and sometimes complex needs, and are competent in meeting those needs. There is an atmosphere of ‘empowerment’. Residents are supported by staff to develop their varied skills, to make choices, and to be as independent as they are able to be. The culture and religious needs of residents are understood and facilitated. Staff are supported to develop their knowledge and skills and to gain qualifications appropriate to their role and responsibilities. Resident’s care plans are clear, accessible, and regularly reviewed. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. 60 Carlton Avenue DS0000017520.V270874.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 60 Carlton Avenue DS0000017520.V270874.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): Standard 2 and 4 Arrangements are in place to ensure that residents are admitted to the care home following a comprehensive assessment of their needs, so that the service is clear that it could meet the prospective resident’s needs. Arrangements are in place to ensure that residents have the opportunity to visit the care home several times prior to making a decision in regards to their admission. EVIDENCE: The care home has an admission procedure. The inspector was informed during a previous inspection that prospective residents receive assessment from Norwood’s admissions coordinator, and the registered manager/deputy manager. Residents (generally with support from relatives) participate in this process. The relevant Local Authority funding authority care manager also assesses their needs. Documentation recorded in a care plan confirmed this. The three care plans, which included the care plans of the most recent admissions to the care home, inspected all recorded evidence of comprehensive assessment of individual resident’s needs, which included personal care needs, health needs, mobility needs, and cultural/religious needs. This assessment information had been regularly reviewed. There was also evidence of recorded assessment from healthcare professionals. A resident kindly spoke to the inspector of the varied, and numerous visits that he had made to the home prior to moving in to the home. There was evidence that during the ‘settling in’ period, there was a review meeting attended by the resident, his relative, care manager, and staff including the key worker and 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 9 registered manager. This was a comprehensive review of the residents needs, and of action to be taken by the service to meet those needs. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6 and 9 Arrangements are in place to ensure that all the residents have a plan of care that records their individual needs, and the action to be taken by staff to meet those identified care and support needs. Arrangements are in place to ensure that risks are assessed, and that residents are supported to take risks as part of an independent lifestyle. EVIDENCE: All the residents have a care plan. The three care plans inspected included comprehensive information, and documentation in regard to the assessment of individual residents ‘ needs, such as personal care needs, cultural needs and mobility needs. There was clear recorded staff guidance in regard to meeting those needs. This guidance included resident’s assessed current, and anticipated specialist requirements. The care plan format has continued to be developed and improved. Information in regard to the resident’s assessed needs is accessible and clearly documented. Staff demonstrated an awareness of how to access information from the care plans. Some of the care plan information was in pictorial format, to aid accessibility. Resident’s preferred morning, and evening routines of residents were recorded. Records inspected informed the inspector that care plan documentation is reviewed monthly. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 11 All the residents have a key worker. Two residents spoke very positively of their key workers, and had an understanding of their role. There was evidence that risk assessments had continued to be developed. Bathing/showering risk, financial risk assessments, risk of falls, and other health and safety risk assessments were recorded in care plans. These included information in regard to action to be taken by staff, and residents to minimise any identified risk. General health and safety risk assessments relevant to staff and residents were also recorded, and were available for inspection. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 14 and 16 Arrangements are in place to ensure that residents have access to a wide range of leisure activities. Resident’s rights and responsibilities are respected and understood by staff. EVIDENCE: Records, residents, and staff confirmed that residents each have an individual activity programme that is linked to their needs and preferences. Two residents spoke of the numerous and varied activities that they enjoyed. Records and observation confirmed that residents were supported in participating in several activities a day. Residents spoke very positively of a recent holiday abroad, and of day trips. Records and staff confirmed that other residents had also been on holiday. The manager spoke of a resident who participated in day trips rather than holidays due to their preference. Residents were observed clearing their plates from the table to the kitchen, and of pouring themselves cups of tea. Other residents spoke of varied household chores that they participated in with support from staff, which included food shopping and tidying their bedrooms. Two residents were observed to participate in the laundering of their clothes during the inspection. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 13 Staff were observed to interact with residents in a respectful manner, and spoke to them in a friendly and supportive manner. Staff knocked on resident’s doors. Records confirmed that residents (following assessment) have their own house key. A resident was observed to choose to be on his own when he wished. Staff who kindly spoke with the inspector had knowledge and understanding of resident’s varied and individual needs. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18 and 20 Arrangements are in place to ensure that resident’s personal care, and support needs are met. Medication is stored and administered safely. EVIDENCE: The care plans inspected all recorded evidence that resident’s preferred personal care needs are assessed, and that there is clear accessible staff guidance in place to ensure that staff meet those identified needs. This includes clear recorded (in written and pictorial format) individual resident’s morning and evening routines. These needs are very varied, and complex in regard to several residents. Records and staff confirmed that staff had understanding of how to meet resident’s personal care needs. Staff respected resident’s privacy needs during the inspection. Two residents spoke of the support that they had from their key workers, and that their times for getting up and going to bed were flexible, and that they chose their own clothes, and participated in their personal shopping needs. Records informed the inspector that residents had received assessment, advice and support from specialist healthcare professionals, this included in regards to meeting individual resident’s mobility needs, and specialist medical needs. Specialist equipment to meet resident’s individual needs was accessible; there was a specialist light facility in the communal area to meet the particular needs of a resident. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 15 Records and staff confirmed that there was consistency and continuity of support for residents. Staff who spoke to the inspector knew the residents well. Staff, records and residents confirmed that the general approach within the care home is very much to support all the resident’s (with there wide range of needs) to maximise their independence, and choice. This is commendable. The care home has a medication policy. Medication is stored securely. Staff administered medication during the inspection and were observed to administer it safely, and in a sensitive manner. Two staff participate in the administration of medication. Medication records recorded no gaps in recording. ‘Homely remedies’ were recorded and signed by a GP. Records confirmed that there was recorded staff guidance in regard to meeting the administration of medication needs of resident’s with specialist medical needs. Staff who spoke with the inspector were aware of this guidance. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and 23 Arrangements are in place to ensure that residents, and others can communicate their views, and any complaints, and those these are listened to and acted upon. Arrangements are in place, which include robust policies and procedures to ensure that the residents are protected from abuse. EVIDENCE: The care home has a complaints policy/procedure. This is in written and pictorial format. It includes timescales for staff action of seven working days from the complaint referral. There have been no complaints for fourteen months. There is a comprehensive recording procedure, which includes action taken to investigate complaints. Two residents spoke of speaking to the registered manager or their key worker if they had a ‘concern’ or complaint. Residents who kindly spoke with the inspector reported that they had no concerns or complaints, and were very happy with the service provided by the care home. The care home has an abuse policy. This had been reviewed in January 2004. There were also accessible policies and procedures in regard to whistle blowing, protection of client’s monies, racial awareness, counter bullying, and physical intervention. Records informed the inspector that staff signed when they had read policies. The registered manager was unable to locate the appropriate Local Authority protection of vulnerable adults procedure. This needs to be accessible. A copy of this documentation and information in regards to protection of vulnerable adults training for care staff was supplied to the manager by the inspector following the unannounced inspection. It is recommended that the registered person obtain copies of the protection of 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 17 vulnerable adults procedures and guidance from the other funding authorities. The manager informed the inspector that all staff complete abuse awareness training in their induction programme. It is recommended that the registered manager (and other staff) complete further protection of vulnerable adults training. This was discussed with the registered manager. The care home has financial procedures, and policies in regard to resident’s monies, and valuables. Records concerned with resident’s monies were well documented, and receipts from purchases were in good order. Three residents monies were inspected, and the cash amounts balanced with the records. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24, 26 and 30 Arrangements are in place to ensure that resident’s live in a homely and safe environment. Resident’s bedrooms are personalised and meet their individual needs and lifestyles. The care home is clean. EVIDENCE: The care home is located within walking distance of a variety of shops and amenities. There is a public park a few metres from the home, and local bus and train services are close to the home. A resident spoke of having used public transport, and of accessing community facilities and amenities. The care home also has its own passenger vehicle. A tour of the care home and adjoining flat took place during the unannounced inspection. The care home is generally well maintained. There was considerable evidence that the registered manager, and the staff team have worked hard over several months to provide a more homely, comfortable and generally pleasing environment for residents. Throughout the care home there are personalised items, which contribute to more welcoming atmosphere and warm environment. This is commendable. The registered manager reported that there were plans to renew the flooring in the sitting room/dining room communal areas. The furnishings and fittings of the care home were judged to be of quality. The residents living in the flat 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 19 kindly showed the inspector around their home. They spoke of being involved in choosing the décor. The carpet in the communal sitting room of the flat was very stained. The registered manager spoke of this carpet having recently been renewed, and of having been cleaned, but that this did not remove the stains. It is recommended that the carpet be ‘deep cleaned’ by a specialist in carpet cleaning. The registered manager reported that a specialist bath was not in working order, and that quotes had been obtained to replace/or repair the facility. The manager informed the inspector that residents who generally used the specialist bath were presently using a shower facility. Action by the registered person needs be taken to ensure that this bath facility is in working order to ensure that residents preferred bathing facility is accessible. A shower facility in a resident’s bedroom had caused maintenance issues within the room due to a recent leak. The registered manager reported that there were plans to repair the facility. This needs to be actioned by the registered person promptly so that the resident can access the bedroom. The manager informed the inspector that there was the possibility of including a toilet ensuite facility to meet the resident’s needs more comprehensively. This is recommended, if it meets all building and registration requirements. The registered person should ensure that the relevant statutory bodies (including the CSCI) are consulted prior to installing a toilet facility, and/or changing the shower facility within the resident’s bedroom. All the residents have a single room. Resident’s bedrooms that were inspected were all individually personalised. Bedrooms included televisions, specialist chairs (i.e. massage chair), music systems, and pictures. Staff have gained knowledge and understanding of resident’s particular needs and preferences in regard to the layout and décor of their bedrooms. An example from the manager informed the inspector that a resident who had due to their particular needs had not had any personalised items in their room, has now several homely features which included their own variety of possessions, due to staff working closely with the resident. This is positive. The residents living in the flat kindly showed the inspector their bedrooms. They reported that they were very happy with their rooms. The care home is very clean. A part time domestic staff member was on duty during the unannounced inspection. Laundry facilities are located away from food storage and food preparation areas. The home has industrial laundering facilities, which were in working order. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32 and 34 Arrangements are in place to ensure that the staff team in the care home are competent and have qualities needed to meet the residents varied needs. Robust staff recruitment and selection procedures are in place to ensure the protection of residents within the care home. EVIDENCE: Staff were observed to have knowledge and understanding of the resident’s individual needs (and changing needs), and interacted with residents in a respectful and approachable manner. Two residents spoke very positively about the staff within the care home. Records confirmed that staff received varied and appropriate training in regard to carrying out their job role. Staff are supported in completing appropriate qualifications in care. The registered manager informed the inspector that all staff except for two new staff had completed or were in the process of completing NVQ level 2 or 3 care training courses. She reported that staff commence NVQ training following six months employment, and following having completed a comprehensive induction programme. The care home has a recruitment and selection policy/procedure, and an equal opportunities policy. Three staff personnel records were inspected. These included required information and documentation, including Criminal Record Bureau checks. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 21 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): Standard 37, 39, 41 and 42 Residents benefit from a very well run home. Systems are in place to ensure that the quality of some aspects of the service is monitored, but there needs to be further development in the monitoring and review of the service provided. Required records are in place and secure. Resident’s rights and best interests are safeguarded by the care home’s record keeping policies and procedures. The health and safety and welfare of residents are promoted and protected. EVIDENCE: The manager has several years working with the service user group, and had two years supervisory experience and work as a management staff member in the care home prior to taking up the position of registered manager. She has managed the care home for over two years. The registered manager has completed an NVQ assessor’s course (D32/33) and registered managers award. She recently completed NVQ level 4 in care course. The manager reported that she regularly updates her knowledge and skills, and that she had 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 22 completed refresher training in regards to statutory health and safety training courses. Records and observation confirmed that she has been and is proactive in regard to improving the service and works hard to meet the National Minimum Standards for adults, and inspection requirements. There was not an accessible quality assurance policy/procedure. This should be in place. There was evidence that some quality assurance monitoring systems were in place within the care home. Records confirmed that care plan documentation, and maintenance and health and safety needs in the care home are regularly reviewed, and that views of residents had been sought. Records confirmed evidence of a Norwood quality monitoring scheme, which had included service user participation. The registered manager reported that a business plan, which includes evidence of quality monitoring systems in regard to 60 Carlton Avenue, was in the process of being developed. This needs to be completed, and the registered person shall supply to the Commission a report in respect of monitoring and improving the quality of the service provided in the care home. This report needs to include evidence of consultation with residents (dependent on the assessed needs of the resident) and/or their representatives. Records informed the inspector as to the reason why a resident wanted only one chair in their bedroom. This documentation should be signed by the resident (if able). Another resident had signed few of their personal money transactions and records. Residents (in regard to assessment of their ability and need) should have the opportunity to maintain their personal records. This was discussed with the registered manager. Required records were in place, and are secure, well maintained, and staff had awareness of how to access them. Certificates of worthiness in regard to the electrical and gas systems within the care home were accessible and up to date. Fridge/freezer temperatures and water temperatures are monitored. Food stored in the fridge was covered and dated. Records informed the inspector that required fire safety checks and staff fire training take place. COSHH (Control of Substances Hazardous to Health 1999) items were stored securely at the time of the inspection, and there was an accessible COSHH risk assessment. Records confirmed that staff had completed training to ensure that they have knowledge and understanding of health and safety. This training included food and hygiene training, manual handling training, health and safety training, and medication training. The employer’s liability insurance certificate was displayed, and up to date. 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 23 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 X 2 3 3 X 4 3 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 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 X 2 X 3 3 X 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 24 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 YA24 Regulation 23(2)(c) Requirement Timescale for action 01/03/06 2 YA24 3 YA39 Action by the registered person needs be taken to ensure that the specialist bath facility is in working order to ensure that residents preferred bathing facility is accessible. 23(2)(c) The shower facility in a resident’s bedroom needs to be repaired promptly so that the resident can access the bedroom. 24(1)(2)(3) The registered person shall supply to the Commission a report in respect of monitoring and improving the quality of the service provided in the care home. This report needs to include evidence of consultation with residents (dependent on the assessed needs of the resident) and their representatives. 16/03/06 01/04/06 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 25 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 YA23 Good Practice Recommendations It is recommended that the registered person obtain copies of the protection of vulnerable adults procedures and guidance from all purchasing authorities. • It is recommended that the registered manager (and other staff) complete further protection of vulnerable adults training. It is recommended that the carpet be ‘deep cleaned’ by a specialist in carpet cleaning. The registered person should ensure that the relevant statutory bodies (including the CSCI) are consulted prior to installing a toilet facility, and/or changing the shower facility within the resident’s bedroom. There should be an accessible quality assurance policy/procedure in regard to the service provided. Residents (in regard to assessment of their ability and need) should have the opportunity to maintain their personal records. • 2 3 YA24 YA24 4 5 YA39 YA41 60 Carlton Avenue DS0000017520.V270874.R01.S.doc Version 5.1 Page 26 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. 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