Inspection on 20/08/08 for Old Oak Road, 20

This inspection was carried out on 20th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Oak Road, 20 09/07/09

Old Oak Road, 20 31/01/08

Old Oak Road, 20 16/07/07

Old Oak Road, 20 04/05/06

Old Oak Road, 20 28/09/05

Old Oak Road, 20 06/01/05

Old Oak Road, 20 11/08/04

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 08/11/2008.

CARE HOME ADULTS 18-65 Old Oak Road, 20 Old Oak Road 20 Old Oak Road Acton London W3 7HL Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 20th August 2008 10:00 Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Oak Road, 20 Address Old Oak Road 20 Old Oak Road Acton London W3 7HL 020 8740 1296 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) info@yarrowhousing.org.uk Yarrow Housing Ms Martyne Rosaria O Reilly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 31st January 2008 Date of last inspection Brief Description of the Service: 20 Old Oak Road is a registered care home providing accommodation and personal care for six men and women with a learning disability. At the time of this inspection, one male and five women were living in the home. The home is located in a residential area of Acton and there are good transport links with the community facilities in Hammersmith and Shepherds Bush. Shepherd’s Bush Housing Association owns the property and the care are provided by Yarrow Housing Limited, a voluntary organisation. The home provides an adequate standard of accommodation. It was fully accessible to people with a physical disability and people with limited mobility, including those who use a wheelchair with lift access to the top floor. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Wednesday 20th August 2008; we spent 3.30 hours visiting the home. The Inspector spent time talking to the deputy manager three people living at Old Oak Road and a member of staff. We checked the care records of two of the residents; all medication records were looked at and were well recorded. The finance records of two residents were looked at and all were well recorded with receipts in place for any financial transactions, the balance of cash for both residents was correct. All of the bedrooms were looked at and all communal parts of the home. The home is in need of a cyclical programme for the redecoration of the whole house internally including the bathrooms and toilets. The home was seen to be clean and tidy on the day of this inspection. We received five residents’ surveys, seven staff surveys and two professional surveys; comments from the surveys will be included throughout this report. One requirement that were set 31/01/08 has been met; six new requirements have been made from this visit. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly fee for Old Oak Road is £1042.37. What the service does well: We looked at two residents files and care plans and PCP Person Centred Plans were looked at. Both residents information was very informative with a lot of information about the individual’s health and social care need and how staff at Old Oak Road was meeting their needs. We spoke to a resident that was very positive about living at the home saying they like the staff, the food was very good and they enjoyed helping in the kitchen and assisting to cook at times. We went with the resident to their bedroom that was very individualised with pictures and lots of personal property including DVD’s a new flat screen TV and a music centre. The resident told us that they liked their bedroom. We looked at Passport books on residents that are excellent with a lot of information telling their life story of who they are, what are their likes and dislikes. These books have photographs and picture details also. We looked at the NVQ qualifications gained by staff and all staff have an NVQ in level 2 or 3, one staff member has a diploma in health and social care. The registered manager has registered to do the Registered Mangers Award. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: We looked at the Statement of Purpose that needs to be updated with all relevant information in place as written in Schedule 1 of the Care Homes Regulations. We looked at the staff rota and also discussed staffing with the deputy manager. There are two full time vacancies and one part time vacancy; there is also a member of staff on maternity leave and a member of staff that is not working at the home at this present time. Surveys sent to the CSCI mention staffing levels as being low and the impact that it has on staff and residents. We were told that bank staff and agency staff are used but still the staffing is low. A member of staff called in sick the day of this inspection that meant there was three staff on duty, on day centre worker escorted a resident to their scheduled activity, leaving two staff with residents. The impact was that no one else could participate in activities in the community and staff were extremely busy looking after the five residents in the house. The organisation must look at the staffing levels at Old Oak Road as the low number is impacting on the social life of the residents. The house had subsidence and representatives from Shepherds Bush Housing (the landlords) visited the house 17/07/07. The works were then completed and a letter was sent to the organisation to state the house needs 12 months to settle before the house should be decorated, this time is now lapsed. We had a full tour of the home and the house is in need of a cyclical programme for the redecoration of the whole house internally as the home is now looking unkempt. The remedial works of filling in cracks throughout the house has happened but no plan to paint the house has been given. We looked at all residents bedrooms and the curtains and net curtains are now looking old and do not fit windows anymore due to shrinkage when cleaned. All communal areas including the bathrooms and toilets also need decorating. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 7 We looked at healthcare plans that state that a residents weight should be monitored, this was not happening and in discussion with the deputy manager we were told that this was something that she would make sure starts again straight away and is recorded on a weekly basis. We looked at the supervision records of some staff and also discussed supervision with the deputy manager. Supervision meetings are taking place however the impact of staffing makes it difficult to keep to the schedule for some staff. We discussed supervision with a member of staff who told us that they have regular structured supervision and were happy that any issues raised were dealt with. We looked at the health and safety records kept at the home, one entry showed that one residents bedroom fire door was faulty. In discussion with the deputy manager she told us that this had been reported numerous times but the works had not been carried out. We requested it be reported straight away, as this was a high-risk area; the deputy manager did this the day of the inspection. We also received a mail from the registered manager later on that day to show that the works had been acknowledged and the fire safety representative form the landlords was going to the home. There is a big garden at the back of the house that has so much potential for residents to enjoy, however the garden was overgrown and not being utilised. The organisation should look at completing work to make it an accessible place for residents to go and spend some quality time. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 8 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 Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager completes a needs assessment on all individuals that move into the home. The needs assessment is directly linked into the local authority referral showing how the home can meet the needs of the individual. EVIDENCE: We looked at the Statement of Purpose and the Service User Guide both documents are very condensed with adequate information about Old Oak Road. We discussed that the documents had to be up dated and suggested the organisation make sure all documents are standardised with other Yarrow homes. We looked at the assessment records of two resident’s the information in place was very informative and directly linked into the local authority referral. The care plans and risk assessment records were informative showing the residents social and healthcare needs, looking at their aims and aspirations and showing how the staff at Old Oak Road was going to support the residents. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care which affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. EVIDENCE: Comments made by people who use the service and their relatives. ‘I like living here, the staff look after me’. ‘The staff look after my daughter very well’. ‘I am touched by the care given to my daughter. I am grateful to all of the staff my daughter is so well cared for’. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 11 We looked at two residents files that had a comprehensive care plan that was fully completed had a lot of information linking into the daily routine of the individual. There were also support plans with up to date relevant information showing what care needs each resident has throughout a twenty-four hour period. We looked at life path showing all of the information from when a resident was younger up until the present time; these books were very informative and interesting with pictures and lots of other relative information. Reviews were looked at in each residents file showing that the residents care needs are closely monitored and care plans are up dated to reflect any change. There was a Person Centred Plan (PCP) in both of the residents files that was very informative showing the individuals likes, dislikes their family and what activities they enjoyed doing. The Person Centred Planning (PCP) is in pictorial formats and is used as an ongoing record. One residents PCP was taking place the next day and the deputy manager told us that the information was ready to go through with the resident as PCP are working documents. In discussion with two residents we were told they liked the home and the staff were really friendly. All of the residents in Old Oak Road have to be supported to be more with all of their personal care needs. Residents are encouraged to choose what they wear and we heard a member of staff discussing clothing with a resident who was able to make that decision. We spent time with two residents that told us they are happy with the support given to them by staff and that they like living at Old Oak Road. We looked at the risk assessment records for the two residents; all risk assessment records had been reviewed in January 2008. The risk assessments linked into the care plans for any risk areas with action plans in place to show how the staff were eliminating or minimising the risk. We were told by the deputy manager that risk assessments are reviewed on a regular basis and amended when necessary linking into a change of the residents care needs. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are given the opportunity to take part in a variety of activities in the home and the community this could be improved with the arrangement for adequate staffing to be in place. EVIDENCE: Comments made by people who use the service and their relatives. ‘I go out most days and do the things I enjoy doing with the staff’. I visit my friend in her house and she comes to see me here we have a nice time’. ‘Its birthday soon and I am having a party here and I am inviting all my friends and the staff’. ‘I am always made welcome when I visit my daughter’. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 13 All of the residents have an activity plan that was written in their files and also on the notice board in the office and on the wall next to the kitchen. Three residents attend different venue’s in the local community where they participate in activities, the other three residents have activities provided in the home. One of the residents is taken out daily to lots of different venues and we were told that they enjoy doing lots of different activities. One of the residents had been taken out on the day of the Inspection to go to a sports day at the centre they regulary attend with his day care worker. The other residents were unable to be taken out into the community, as the staffing levels were not sufficient on the shift. In discussion with the deputy manager we were told that there are staff vacancies and other staff members are not rostered to be on duty and some shifts are short of staff. We looked at two files that contained a lot of information about the resident’s likes, dislikes, hobbies and leisure interests. We looked at daily records for the people staying at the home and there was information written daily about what activities an individual had done including shopping, eating out, and going for walks and attending any community centres. Information including photographs was seen in the two residents files showing their holidays. One resident discussed their holiday arrangements; we were told that he was going to Cornwall with his girlfriend in a few days time and that he was really looking forward to it. We looked at the care records of two residents, included was information about attending relationship classes with Hammersmith and Fulham local authority. The groups meet on a regular basis to discuss their personal relationships and are given the support to spend time with the people who are important to them. Two residents told us about visiting their partners that live in other Yarrow homes; we were also told that their partners visit Old Oak Road for meals on a regular basis. We looked at photographs of the resident’s partners visiting the home and enjoying outings together. Surveys from relatives inform us that they are always made welcome by staff at Old Oak Road. We were told that the home does a big weekly shopping for food but shop regularly for the food requested by the residents as they have different dietary needs, one of the residents also requires a special diet. In discussion with two residents we were told that they liked the food provided and always had a choice of what they wanted to eat. Records of what residents had eaten were looked at and discussed with the deputy manager. The Annual Quality Assurance Assessment (AQQA) form completed informs us about the different diverse cultural differences of the residents and how residents are offered at times meals from their different cultures. Birthday parties are held for all residents at Old Oak Road photographs were looked at showing birthday celebrations that were attended by family, friends and residents partners. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan. EVIDENCE: We looked at two of the residents files that had information in place including support care plans showing what the residents health and social care needs were on a daily basis. (PCP) Person Centred Plans also go into detail about what assistance the residents require in attending to their personal care. We spent time with two residents that told us they always choose what clothes they are going to wear, records also show when the residents have their hair done by a local hairdresser that visits the home. We saw records from and reports from social workers, psychologists, occupational therapists and speech and language therapists. The reports each contained useful information and guidance for staff. In discussion with the deputy manager it was clear that different levels of support are required from monitoring to assistance of care support. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 15 All of the people living at Old Oak Road are registered with their own GP. We saw records in the two residents files that show visits and home visits to the GP for different health checks. We looked at the medication records kept at the home that were well recorded and accurate, there are always two staff that check the medication when it is administered and sign the record kept in the medication file. There are residents that have PRN medication this was recorded appropriately, the information regarding all medication was written in the care plans looked at. The two files also contained Health Action Plans that had all information regarding health checks including optical, podiatry, dental and other regular health checks. The records show that the residents have had regular check ups when required. We looked at the staff training records that show all staff have had medication training and are fully aware of the medication policy and procedure. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in different formats for anyone living at the home. EVIDENCE: We looked at the complaints procedure that is available in different formats; a copy of the pictorial complaint procedure was in a residents file. There have been no complaints recorded in the home for the last 12 months. The CSCI was sent five surveys from residents that state they know the home’s complaint procedure and who they would speak to if they had a complaint. Two of the resident’s told the Inspector they are happy living at the home and have no problems. The Inspector looked at the home’s policy on protection that had been up dated in 2007, all of the relevant information was seen to be in place including (POVA) Protection of vulnerable adult procedures. All staff has attended safeguarding training. We looked at Person In Control (PIC) records that show visits are taking place on a monthly basis with recommendations recorded for the registered manager or the organisation to meet. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 28 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment does not reflect the standard that is written in the statement of purpose. EVIDENCE: We had a full tour of the home and all areas were seen. There is a need for Old Oak Road to have a full cyclical programme in place as all areas are in great need of redecoration. The house had subsidence and representatives from Shepherds Bush Housing (the landlords) visited the house 17/07/07. The works were then completed and a letter was sent to the organisation to state the house needs 12 months to settle before the house should be decorated, this time is now lapsed. The communal areas and resident’s bedrooms look unkempt, walls are badly stained in some areas and the woodwork needs to be painted. The bathrooms and toilets that are communal areas and are used by all residents also need to be included in the programme. The organisation must provide a homely environment for residents to live in as written in the Statement of Purpose. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 18 We went into all of the resident’s bedrooms all of the bedrooms are adequately furnished. One of the residents bedrooms had curtains in that had clearly shrunk when cleaned and did not fit the windows correctly any longer, other curtains and net curtains however clean throughout the home are now looking old. We looked at the garden that is at the back of the home; the garden is in need of works and not being benefited by resident’s as it is overgrown. The home was clean and tidy on the day of this inspection. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are generally satisfied with the care they receive to meet their needs, but there are times when they will have to wait due to the shortage of staff on some shifts. EVIDENCE: On the day of the Inspection there were three staff on duty including the deputy manager. We looked at rotas and insufficient staff was scheduled to be on duty on some shifts. There are eleven full time staff including the managers, there are three vacancies in the home. Two of the staff surveys stated that the staffing needs to improve stating staffing as being low and the impact that it has on staff and residents. We were told that bank staff and agency staff are used but still the staffing is low. A member of staff called in sick the day of this inspection that meant there was three staff on duty, on day centre worker escorted a resident to their scheduled activity, leaving two staff with residents. The impact was that no one else could participate in activities in the community and staff were extremely busy looking after the five residents in the house. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 20 We were given a copy of information showing that all staff including agency staff has a full Criminal Records Bureau (CRB) Disclosure. We looked at the training programme that all staff has completed; this has been updated by the deputy manager. The deputy manager told us that all staff are up to date in mandatory training and have all completed first aid training. We looked at the training records of two staff that show they are up to date with training. We met with a member of staff that told us that they enjoyed working at the home and were happy with the teamwork and had a good working relationship with all staff at the home. All recruitment is completed by the Human Resources team at Yarrow head office. There is an induction/information pack in place for any bank or agency staff that was very informative. The registered manager is at present registered to complete an NVQ level 4, the manager keeps a training and development schedule for herself and the Annual Quality Assurance Assessment (AQQA) states that the manager undertakes regular training courses to update her knowledge. There is a currently nine staff member who has an NVQ level 2 or 3. We looked at the supervision records of three staff and also discussed supervision with the deputy manager. Supervision meetings are taking place however the impact of staffing makes it difficult to keep to the schedule for some staff. We discussed supervision with a member of staff who told us that they have regular structured supervision and were happy that any issues raised were dealt with. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the home. They are aware of and work to the basic processes set out in the NMS. EVIDENCE: In discussion with the deputy manger we was told that registered manager is registered to complete an NVQ level 4 in Management. The registered manager has worked in social and healthcare for many years and has lots of experience; the Manager is also a qualified Nurse. The Manager is also a training Coordinator for Yarrow. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 22 We looked at two residents files and each had quality assurance questionnaires in place. The residents had both been assisted by other people to complete the questionnaires, one of the residents was assisted by a member of their family and another resident was assisted by a support worker at Options day centre. The residents had no issues and stated they were happy living at Old Oak Road. Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. We looked at residents files and included was a summary of the Quality Assessment for the organisation from 2007, that showed how the organisation was working at improving their service provision where there are issues and also lots of positive information from residents living in Yarrow homes. We spent time talking to two residents living at Old Oak Road that were able to express their feelings about the staff and the home, and stated they were happy. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 2 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 X 3 X X 2 X Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation Schedule 1 Requirement The organisation to make sure all that the Statement of Purpose contains all of the relevant up to date information on Old Oak Road to inform residents and prospective residents and stakeholders about the home. The registered manager must make sure that a resident is weighed on a regular basis as written in their health care plan to make sure they are sustaining a healthy weight. The organisation must action a cyclical programme for the redecoration of all residents’ bedrooms so that the environment is homely and comfortable for the people living there. The organisation must replace all curtains throughout the house that do not fit the windows correctly and are old now due to wear and tear so that the environment is homely and comfortable for the people living there. The organisation must action a cyclical programme for the DS0000019140.V367942.R01.S.doc Timescale for action 20/10/08 2 YA19 12 20/09/08 3 YA25 23 20/11/08 4 YA26 23 20/11/08 5 YA28 23 20/11/08 Old Oak Road, 20 Version 5.2 Page 25 6 YA42 23 redecoration of all communal areas so that the environment is homely and comfortable for the people living there. The organisation must make sure that the bedroom fire door has the works completed, as this is a risk for the resident. A risk assessment must be completed immediately. 27/08/08 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 YA24 Good Practice Recommendations The organisation to look at completing work in the garden to make it accessible for residents and improving the environment to make it an area where residents can go safely and spend some quality time. Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Oak Road, 20 DS0000019140.V367942.R01.S.doc Version 5.2 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!