Inspection on 09/08/05 for Oaklands Road, 82

This inspection was carried out on 9th August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Oaklands Road, 82 05/09/07

Oaklands Road, 82 10/01/07

Oaklands Road, 82 04/01/06

Oaklands Road, 82 01/02/05

Oaklands Road, 82 09/09/04

Oaklands Road, 82 24/02/04

Oaklands Road, 82 15/07/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Oaklands Road, 82 Hanwell London W7 2DU Lead Inspector Sarah Middleton 9 TH Unannounced August 2005 10.15pm 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 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 Stationary 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. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oaklands Road, 82 Address Hanwell, London W7 2DU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 840 5996 acomaskey@hotmail.com Ealing Consortium Limited Allyson Comaskey Care Home 3 Category(ies) of Learning Disability (0), Learning Disability - over registration, with number 65 years of age (0), Mental Disorder - excluding of places learning disability or dementia (0), Mental Disorder - excluding learning disability or dementia - over 65 years of age (0) Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 1/2/05 Brief Description of the Service: 82 Oaklands Road is a registered home for three people with learning disabilities and/or mental health needs. The home is registered to take service users over sixty-five years old if their needs can be met. There is currently one service user over sixty five years old. The home is managed by Ealing Consortium and owned by Ealing Family Housing Association. It is located in a terraced house in a quiet residential road. It is close to local amenities, including shops in Boston Manor Road. There are transport links on the Uxbridge Road in Hanwell which lead to larger towns such as Ealing Broadway. There are leisure facilities available in the local area. There are three single bedrooms, one on the ground floor and two on the first floor. There is one lounge, a dining room with adjacent kitchen and a small laundry area on the ground floor. The first floor has a bathroom/toilet and separate toilet with an office/sleeping in room. There is a garden to the rear, where there is decking leading off from the kitchen and a patio area with gravel, plants and shrubs. There is a small garden to the front and parking is on the street. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of almost four and half hours, 10.15am-2.40pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service users plans, staff files and maintenance records. Three staff were spoken to as part of the inspection process. Two of the service users were out during the inspection and the other service user was not able to discuss any thoughts or feelings about the home. Most of the previous requirements set at the last inspection were met and three new requirements were set at this inspection. The Registered Manager was present for this inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must seek ways to implement training on the protection of vulnerable adults and ensure it is a topic that is discussed with all staff on a regular basis. Service users eat out several times a week, usually with staff from the house, when this occurs this must be accurately recorded to ensure service users are not eating the same thing or unhealthy food on a regular basis. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 6 The floor in the kitchen has posed several problems, as it was not safe to walk on when wet, the flooring is due to be changed. The Registered Manager must ensure they have evidenced consultations and dialogue with the housing association when seeking maintenance work on the home. Recording the time it takes for action to be taken and work to be carried out when requested can evidence any problems that might be occurring with the housing association. Staff employments files must contain details set out in current legislation. This must be available to view during an inspection. Staff must declare they are fit to work prior to starting employment with the organisation. This was not evident in one file viewed. Although questionnaires were completed for service users views, a full quality assurance review of the quality of care offered in the home has not been available at this or the previous inspection. This must be carried out to ensure the home is constantly gathering opinions, acting upon suggestions and raising standards of care. A report must be available for the CSCI and service users once the review has been carried out. 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. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 standard(s) 1, 2 & 5 Service users and their representatives are provided with information about the home and all service users receive written terms and conditions. Any prospective service user would be assessed prior to them entering the home. Existing service users were assessed to ensure the home could meet their individual needs. EVIDENCE: Service users and their representatives are provided with information regarding the home in the form of a Service Users Guide and Statement of Purpose, which are informative and freely available. The Statement of Purpose has been shortened to summarise information about the home and organisation. The Registered Manager has added pictures to the Service Users Guide to be more accessible for the service users living in the home. There have been no recent admissions into the home. A pre-admission assessment form was viewed that had been completed on one of the service users living in the home. This provided a clear picture of the service users needs, including mobility, health needs and communication needs. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 9 Terms and conditions were seen on service users files. The information provided various details, for example the services the service user could expect and any additional costs. The home is aware of the need to review how information is given to service users as they each have various ways of communicating and ways of understanding information. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 standard(s) 6, 7 & 9 The health and personal care needs of service users had been identified and were being met. All staff were aware of individual needs and how to meet those needs. Staff aimed to encourage service users to make decisions about every day life. This was done through offering choices and respecting decisions service users made. The home aimed to balance the opportunity service users should have against recognising each individual’s abilities and understanding. Detailed and current risk assessments were in place and safeguarded service users. EVIDENCE: Individual service user plans were available and samples were viewed. These had improved since the last inspection and were easy to read and offered relevant information on the service user. Overall they were comprehensive and detailed how the service users health, personal and social care needs would be met. They were up to date and had been reviewed on a monthly basis by the named keyworker. Daily records were available and detailed the care provided. Assessments for eating/drinking and moving and handling were in place. Reviews are held for the whole care plan every six months and service users and their representatives are a part of the review process. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 11 It is noted on care plans service users abilities and guidelines on how to work with each individual taking into account how they communicate and what they appear to understand. Staff described ways they enable service users to make decisions about every day life. One service had an advocate but currently no service users receive this additional support. The Registered Manager is exploring the possibility of all service users having their own advocate. It is clearly recorded where service users cannot make decisions about their lives. This is mainly highlighted in the risk assessments that are completed. Risk assessments were available, up to date and detailed how to manage the noted risks for each service user. These were comprehensive and aimed to minimise the risk whilst balancing service users rights to make decisions. These are reviewed on a regular basis to ensure service users needs have not altered. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16 & 17 Social activities are in place and offer service users a range of activities to take part in on a daily basis. These are mainly outside of the home, which offers the opportunity for integration with the community. Visiting is encouraged for service users to maintain contact with family and friends. The meal provision provides choice whilst considering service users health needs. All recordings of meals must be noted when service users have eaten with staff in the community to enable staff to review the diet service users have on a regular basis. EVIDENCE: Service users have the opportunity to attend church or any religious place they choose to. One service user attends the local church weekly and is supported by staff. Each service user has an individual plan where different daily activities are planned with the service user. None of the three service users living in the home can seek employment due to their individual needs. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 13 There are some fixed activities for part of the week, for example, attending the local day centre or massage/drama session. Other days are opportunities for service users to have one to one support with a member of staff. Service users choose with staff what activities they want to do. During the inspection, one service user was at the day centre and one was out on a day trip with two members of staff. The home has access to transport, as there are drivers within the staff team. In addition there is a transport co-ordinator who can be booked to take service users either to specific appointments or out for the day. Where possible the home uses local community resources such as the cinema and public transport. As noted earlier there is sufficient staff working throughout the week to provide service users time with one member of staff to support them in activities. In the past a service users went on holiday but had not appeared to enjoy it, therefore after consultation with them and their family this has now altered. This service user now goes on day trips with staff. Where service users enjoy going away for a break, this continues to be a part of their care plan. Families are encouraged to visit the home and staff will support the service users to visit their family members. Service users have locks to their bedrooms but they do not use them. Staff interacted with the service user, who was present during the inspection, in a sensitive and positive manner. Service users can access any part of the home and one service user spent some time sitting in the office whilst the inspection was taking place. Service users can choose when they take part in an activity and when they want to be alone. On the day of the inspection one service user appeared agitated and staff responded appropriately with this service user, recognising the service users feelings. They had opportunities to be alone or with staff whenever they wanted to throughout the inspection. Where possible service users are assisted in household tasks, should they choose to take part or are able to take part in them. Menus were available and reflected choices. Staff devise the menus with service users and they consider what service users like or dislike to eat. Alternatives are recorded, although when service users go out to eat in the community it was not noted what they had eaten. The kitchen was clean at the time of the inspection and food was stored satisfactorily and the date of opening/preparing was clearly labelled on the food in the fridge. Fridge temperatures were recorded daily and were within the appropriate range. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 standard(s) 18, 19 & 20 Service users were treated with respect and their preferences acknowledged by the staff team. Service users health needs are met and recorded to indicate when service users have received input from a healthcare professional. Medication systems are in place and are robust. The home must ensure all medications have a date of opening on them to ensure the health and safety of service users is monitored at all times. EVIDENCE: Staff support service users in a sensitive and appropriate manner. Staff described how they knew when a service user wanted something and when they were unhappy. Meal times and getting up/going to bed is flexible and staff review individual’s routines to ensure they are fit and healthy. Guidelines were noted on one service users care plan as to their particular routine and how staff should support this service user throughout the morning and evening. Service users choose their clothes and add additional accessories, as they desire. Keyworkers ensure routines are consistent amongst the whole team and work closely with the service user they key work to review any changes service users want to their lives. Staff spoken with stated the communication about service users needs is good within the home. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 15 Individual care plans noted health appointments and service users receive health checks from Chiropodists, GP’s and Dentists. All medication was stored appropriately and securely. The medication administration records viewed were correctly completed. Liquid medications had dates of opening on them, except for one bottle that had been used for a while. All staff receive training on administering medication. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 standard(s) 22 & 23 The home has a clear complaints procedure to ensure service users and their representatives could have their complaints acknowledged and acted upon. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has recently updated its complaints policy and procedure. This is detailed and a more accessible format has been produced for service users. This is freely available. There have been no complaints since the last inspection and the CSCI have not received any directly. There were no service users to speak with to ensure they were aware of how to complain and whom they felt able to complain to. The home has a clear procedure for the protection of vulnerable adults (POVA). It was recommended that the home also obtain the Local Authority’s POVA documentation. New staff receive POVA training, but as required at the last inspection existing staff are still waiting for training in this area. It has been acknowledged that this is an area that needs to be addressed. The Registered Manager had given a presentation to the staff team in May 2005 on POVA issues. Staff spoken with were aware of how to respond if they had any POVA concerns. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 17 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 standard(s) 24, 26, 28, 29 & 30 Overall service users live in a comfortable and pleasant home. Action must be taken to replace the kitchen floor with a more suitable flooring that is not hazardous to service users when washed. Service users bedrooms are suitable for their individual needs and provide privacy and offer the opportunity to have their own personal belongings with them. The home was clean and tidy and systems are in place to prevent infections in the home. EVIDENCE: A full tour of the home was carried and rooms were viewed. The kitchen floor could only be washed at night as it was identified as hazardous to service users and staff. Risk assessments had been completed for service users using the kitchen but as the floor was now bubbling in places the housing association had agreed and measured for new flooring to be fitted. An up to date fire risk assessment of the home had been completed. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 18 Furnishings and fittings throughout the home were of good quality and provided a homely environment for service users. Service users bedrooms were personalised and provided service users the opportunity to relax in a room, which is private for them with all their belongings around them. All bedrooms are single and have a small hand basin in each of the rooms. The Registered Manager is hoping the bedrooms can be decorated in the near future. There is a communal lounge and the dining area is linked to the kitchen. During the summer months all service users use the garden. Preferences are respected if a service user wishes to eat elsewhere in the home, often one service user will eat in the garden, weather permitting. The home has installed handrails alongside the banister, in the bath and leading into the kitchen to support those service users who need additional assistance. The Registered Manager is conscious of the ages and mobility of the service users living in the home and has obtained adaptations to meet their changing needs. Procedures are available for the control of infection. Protective clothing was seen in a bathroom for staff to use. The laundry facilities are located in a small room near to the dining area to minimise the spread of infection. The home was clean and tidy at the time of the inspection. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 Staff are aware of their roles and work together as a team to provide continuity of care to service users. Staff receive training in appropriate areas and have the opportunity to study the NVQ courses. The training provided ensures staff are competent to meet the different needs of the service users. There are systems in place for recruitment of staff, medical declarations from new staff must be evident for inspection to ensure the staff member has stated they are fit to work. Documentation must be in place to safeguard service users. EVIDENCE: The Registered Manager stated staff have received the General Social Care Council codes of practice, job descriptions and terms and conditions of service. All members of staff have the NVQ qualification, level 2 or 3 apart from the new member of staff. One staff member is also a person centred planning facilitator. Staff receive information and training to ensure they are competent to carry out the work that is required of them. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 20 Staff were seen to be aware of the service user who was in the home during the inspection and how they were feeling that particular day. They worked to support this service user in a caring and understanding way. There are no staff vacancies at the home and staff spoken with felt there were sufficient staff working within the home on a daily basis. The Registered Manager stated the sickness record within the home was low. Staff confirmed they met regularly as a team and could talk through any issues that needed addressing. The staff employment files viewed contained details of the applicants completed application form, Criminal Record Bureau numbers, (the certificate is held at the organisations Head Office) and references. There was no information from one of the applicants regarding their fitness to work in the home. The Registered Manager understood this information might be held at the Head Office. Individual staff have a training profile to ensure records are kept of the courses staff have attended and areas where staff have an interest or require specialist courses to meet the needs of the service users. Recently all staff attended training on learning disability and mental health issues. Some staff have attended equal opportunities training and found this to be a useful course. Staff have studied the Learning disability Award as part of their induction to the home. Staff confirmed they receive one to one supervision from the Registered Manager on a regular basis and that this is a useful meeting to discuss any issues they might have. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41 & 42 The home is well managed and the Registered Manager has an open style of management. A review of quality assurance and the care provided in the home has begun. However there was no report available of the overall findings of the review of care. This must be carried out, as requested in previous inspections, to ensure the home is aware of service users and their representatives views and that the care provided is reviewed on a regular basis. The new policies and procedures in place should provide staff with up to date knowledge and information. This will guide them to work with and provide care for the service users in line with current documentation and legislation. Servicing records are up to date and safeguard service users welfare. As noted earlier, the kitchen floor has proved hazardous to service users and must be replaced to ensure the home has minimised any risks to the vulnerable people living in the home. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 22 EVIDENCE: The Registered Manager is planning to study the NVQ level 4 before the end of 2005. They are an NVQ assessor. Staff spoken with stated the Registered Manager was approachable and available to discuss issues and ideas with and where possible act on those suggestions staff might talk to them about. The Registered Manager has a visible presence in the home and works shifts and sleeps in the home once a fortnight. The home has recently carried out surveys with service users and their relatives. A summary of these findings, along with a general review of the care offered in the home has not been made available. Regular Regulation 26 visits occur to monitor the home but there is no overall quality assurance system in place to review the running of the home and respond to any comments made by service users or their representatives. The organisation has updated all their policies and procedures and these are to be checked with staff to ensure they have read and understood them. This process will occur during supervision so that the Registered Manager is confident that all staff have up to date information. The record keeping is now in order in the home and records were easily located during the inspection. Care plans have been streamlined and fire records are now up to date. Servicing records were viewed at random. Legionella testing and portable appliance testing is now up to date. Fire tests and checks of the call points are carried out on a regular basis. Water temperatures for all areas where service users have access to are tested regularly. Bedroom windows have restrictors fitted to them to ensure no accidents occur. Risk assessments have been carried out on the radiators and service users, as they are not covered. The Registered Manager feels as the home is small covers would not be suitable. The risk assessments were detailed and will be reviewed on a regular basis. The radiators in service user’s bedrooms are far from their beds and the Registered Manager is confident there are no risks at present with the current environment. As noted earlier in the report, the kitchen floor must be replace due to the hazards it poses to service users and staff. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oaklands Road, 82 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 x G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 17 Regulation 17 (2) Schedule 4 Requirement Timescale for action 10/8/05 2. 3. 20 23 4. 24 & 42 5. 34 6. 39 Meals must be recorded, when eaten out in the community to ensure service users receive a balanced diet. 13 (2) Liquid medications must have the date of opening written on them. 13 (6) It must be demonstrated that all staff have been made aware, by training or other methods, of the procedures in respect of the Protection of Vulnerable Adults. (Previous timescale 30/4/05 not met) 13 (4) (a) The Registered Provider must (c ) ensure the kitchen floor is replaced to minimise hazards in the home. (Previous timescale 28/2/05 not met). 19 (1) (a) The Registered Provider must (4) (a) (b) ensure all records, for example medical declaration/fit to work, as noted in Schedule 2 have been obtained and are available for inspection. 24 Quality assurance and monitoring systems must be in place to provide a review of the quality of care. (Previous timescale 30/4/05 not G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc 10/8/05 30/11/05 30/9/05 30/9/05 31/10/05 Oaklands Road, 82 Version 1.30 Page 25 met) 7. 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 23 Good Practice Recommendations A copy of the Local Authoritys Protection of Vulnerable Adults policy & procedure should be available within the home. Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 Oaklands Road, 82 G61-G10 s27737 Oaklands Rd v214846 090805 Stage 4 .doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!