Inspection on 01/08/06 for Park Avenue 4

This inspection was carried out on 1st August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park Avenue 4 01/05/07

Park Avenue 4 25/10/05

Park Avenue 4 27/06/05

Park Avenue 4 25/10/04

Park Avenue 4 21/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Park Avenue 4 Wood Green London N22 7EX Lead Inspector Susan Shamash Key Unannounced Inspection 1st August 2006 3:45 Park Avenue 4 DS0000010748.V298924.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 Park Avenue 4 DS0000010748.V298924.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. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Avenue 4 Address Wood Green London N22 7EX 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) 020 8888 5055 020 8888 5055 Hoffmann Foundation for Autism Ms Sharon Diana Martin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: 4 Park Avenue is a registered care home owned by the Hoffman Foundation for Autism, a voluntary organisation that provides services to meet the needs of people with learning difficulties who may also have autistic spectrum disorders. The home is a large converted house with six bedrooms on the first and second floors and the main communal areas on the ground floor. The premises are not suited to meet the needs of residents with significant mobility disabilities. 4 Park Avenue is walking distance to Wood Green shopping centre and a range of public transport links. Hoffman Foundation for autism also provides a separate day service provision in the adjoining premises. The stated aim of the home is to provide high quality residential service for up to six people with learning disabilities and characteristics that may fall within the autistic spectrum. The range of fees for the home, as at August 2006, is £1153.85 - £2057.69 depending on level of need. Copies of the most recent CSCI inspection reports can be obtained from the office at the home or from www.csci.org.uk (the CSCI website). Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted approximately five and a half hours. The registered manager was present for the majority of the inspection and the inspector was also assisted by a senior support worker and other members of the staff team. On arrival at the home, the staff were just commencing an urgent team meeting and the inspector agreed to return to the home two hours later at the end of the meeting. On the inspector’s arrival back at the home, residents were arriving back from day activities. The inspector was able to speak to one resident in detail and spent time with the five other residents in the presence of staff members in the kitchen and dining area. The inspector also had the opportunity to speak with three staff members briefly during the inspection. The visit was undertaken as a routinely scheduled inspection of the home and to monitor compliance with matters identified at the previous inspection. A tour of the building was conducted, and four care plans, four staff files in addition to a range of other records maintained at the home, were inspected. What the service does well: Park Avenue is a comfortable and well-managed home that provides a good standard of care for residents with a range of complex needs. The home makes a concerted effort to ensure compliance with requirements issued by the CSCI. Residents generally appear happy and well cared for and at ease with staff members supporting them. The majority of staff at the home have been employed there for over 3 years. Even the majority of bank staff have been working at the home for many years. The low staff turnover helps to give residents a sense of stability and reassurance as their routines are not constantly disrupted by new staff. The living environment is decorated and furnished appropriately, and residents are able to choose the décor of their own rooms and personalise them according to their tastes. Comprehensive care plans and risk assessments are available for all residents, and a range of appropriate activities are available both inside and outside of the home. Residents are also supported to go on holiday at least once a year and to maintain contacts with their family and friends. Pictorial aids are used effectively to meet the communication needs of individual residents. A varied menu is available for residents, with choices to meet their individual and cultural preferences. The home is flexible at supporting residents to assist Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 6 in tasks of daily living including setting the table, cooking and clearing up. One resident, who has more advanced independent living skills, is supported to cook independently. Staff undertake a variety of relevant training courses as appropriate. There is a good rapport between residents, management and staff. The manager at the home has been in post since the home first opened five years ago and it remains the inspector’s opinion that the home has benefited from her management. What has improved since the last inspection? What they could do better: Monitoring of medication records is needed to ensure that there are no gaps in the medication administration records and that the reason for administration of PRN (as and when) medication is recorded on each occasion. The cupboards in the two identified bedrooms and the wall in the identified bedroom are in need of repair. New linoleum flooring (or an alternative) must be provided in the top bathroom and the cracked glass pane on the front door must be repaired. Staff must receive individual supervision sessions at least six times a year. It remains required from the previous inspection that the provider organisation must conduct unannounced visits to the home every month. Reports of these visits must be kept in the home and a copy sent to the CSCI. Hot water temperature in the home must be monitored on a regular basis and this should be recorded, and an annual legionella test must be carried out for the home. Fire drills must be arranged at the home on a regular basis and recorded including the date, time, staff and residents involved and any issues arising. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 7 It is recommended that the recording system for care plans, risk assessments and guidelines for support of residents, be reviewed to create a simpler system. It is also recommended that different options for an alternative reclining chair be offered to the resident who does not like to use a bed when sleeping in their bedroom. Finally it is recommended that the chart of staff training needs be updated. 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. Park Avenue 4 DS0000010748.V298924.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 Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Detailed pre-admission information is available for residents to ensure that their needs are fully assessed and can be met effectively. EVIDENCE: The home is registered for six residents all of whom have lived at the home for several years. The most recent resident moved into the home in 2003. Detailed assessments were available for each resident, from which care plans had been developed. The manager was very aware of the need to obtain pre-admission information before any new resident was admitted to the home, and confirmed that appropriate admission procedures were in place. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s care plans have been reviewed recently to ensure that they reflect residents’ current needs. Residents’ wishes regarding their care are sought consistently, and they are involved as far as possible in all aspects relating to life at the home. Following assessments, residents are supported to take appropriately safeguarded risks and to develop independent living skills. EVIDENCE: Four resident files were examined in detail. All contained detailed care plans with evidence that they had been reviewed within the last six months. Files also contained “guidelines” including detailed care plan and risk assessment information on particular areas of need or concern e.g. dealing with challenging behaviour. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 11 Files contained a person centred plan including useful information about the resident’s needs and wishes obtained through close consultation with them. Information in these plans indicated that residents’ wishes and decisions relating to all aspects of their care had been taken into account as far as possible. The majority of residents have limited levels of verbal communication and some were reluctant to speak to the inspector. However the inspector was able to have a chat with one resident who went on holiday the morning after the previous inspection. They told the inspector that they had enjoyed the holiday and that they were well looked after by staff at the home. They also said that they were encouraged to be independent in areas that they were able to e.g. in cooking. Observation of staff interacting with residents indicated that they continued to have a good rapport with residents, and were very knowledgeable about their individual needs. Risk assessment information was specific to each resident and their needs, including risks within the home and outside. Picture boards were being used for each resident to plan their day ahead and communicate choices to staff. Although care planning documentation for residents is very comprehensive, the large number of different formats in use can make it difficult to find the relevant information required, and results in a certain amount of repetition. It is recommended that the recording system for care plans, risk assessments and guidelines for support of residents, be reviewed to create a simpler system. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home supports residents to engage in a variety of educational, leisure and daily living activities of their preferences both within the home and in the community. They are encouraged to maintain positive relationships with their family members and friends, and their rights and responsibilities are respected. Residents’ dietary needs and tastes are well catered for by the home and menu options are presented in a pictorial format that encourages them to make informed choices on what they would like to eat. EVIDENCE: Daily notes recorded for residents included details of a wide range of activities that they are involved in. The inspector saw daily shift plans that list the names of all the staff on duty and the work or activities that they are to undertake with individual residents. If the activity does not take place, staff record the reasons why and any alternatives offered. The information in the Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 13 daily shift plans are linked to the information contained in each resident’s weekly activities programme tailored to individual tastes and reviewed when there are changes. Activities recorded included computer work, art, cooking, visits to the local park, arcades, the library, day centres and discos, car boot sales, family visits, eating out, shopping, pub visits, cinema trips and drives in the home’s van. The inspector arrived at the home as residents were returning home from day services and other activities organised outside of the home. Residents spoken to and with whom the inspector spent time indicated that they had enjoyed their daytime activities and were able to engage in activities of their choices within the home. Residents go on at least one holiday each year, there also trips arranged to the seaside and other places of interest during the year. One resident had been on an additional holiday abroad with staff support in the last year. Care plans indicated that residents are encouraged to be involved in household tasks such as preparing meals and cleaning and tidying the house and observation of activities in the home confirmed that this was the case. The home uses communication boards where pictures are used to show the activities that residents will be involved in, on a daily basis. The home has a 4-week set menu (with picture aids) and staff advised that individual residents have the opportunity to take it in turns to make meal choices for everyone. Residents who do not like the meal selected still have the option to make their own choices. The inspector observed residents eating their evening meal and noted that staff were very aware of their preferences and all appeared to eat well and enjoy the meal. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported with both physical and emotional health needs according to their preferences. The home has stringent medication practices and safeguards as appropriate to minimise potential risks to residents. However gaps in the medication administration records may place residents at risk of not having medication needs met appropriately. EVIDENCE: Care plans include information about residents’ physical, emotional and social needs as appropriate. Daily records, discussion with staff and residents and observation of interactions within the home indicated that these needs are being addressed appropriately. Information is maintained regarding all GP, hospital and health care appointments as appropriate, indicating that regular contact is maintained with health care professionals. There are no residents self-administering medication at present. All staff working in the home have received training in the appropriate administration of medication. Medication received at the home is checked and signed in by staff to ensure that the medication is correct. There is also a weekly check Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 15 carried out by a member of staff to ensure that medication practices are being followed appropriately. Temperatures are maintained within the required range in the area where medication is stored. Medication administration records inspected were generally completed appropriately by staff but there were a small number of gaps in the records. Use of PRN (as and when) medicines appeared to be appropriate, however the reason for administration is not always recorded on the medication administration records (MAR sheets). Although this information is generally available elsewhere e.g. recorded on incident records, this should be recorded on MAR sheets to facilitate monitoring of the correct usage of such medicines. A requirement is made accordingly. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Regular residents’ forums ensure that residents have a formal channel through which their concerns can be expressed and resolved. Appropriate procedures are in place and all staff have been trained in adult protection to ensure that residents are protected from abuse. EVIDENCE: Where complaints are recorded, evidence is available that appropriate action has been taken to address the concerns raised. An appropriate record of complaints is maintained indicating action taken within appropriate timescales. At the previous inspection the manager explained that the home holds user forum meetings periodically in addition to six-monthly meetings at the Hoffman Foundation for Autism head office. These meetings encourage resident participation in addition to advocacy from family members and friends and provide a forum where issues of concern can be discussed and addressed. The manager noted that it had been difficult to arrange user forums within the home due to the different needs and abilities of each resident, but informal arrangements were in place for seeking their views on a regular basis. Staff spoken to confirmed this as did entries recorded within residents’ care plans and daily notes. Certificates were available evidencing that staff members had received adult protection training as required. The inspector also spoke to a number of staff members who confirmed that this training had been relevant and useful. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home environment is comfortable, clean and safe and is generally in a good state of repair and decoration. Residents have personalised their bedrooms and have adequate toilets and bathrooms to meet their individual needs. A small number of repairs are required to ensure that residents continue to live in a safe and comfortable environment. EVIDENCE: The home is comfortable and safe but it is generally sparsely decorated. This is primarily due to a resident who becomes agitated and destroys decorations such as pictures, placing other residents at risk of injury. Despite the constraints of decorating communal areas, residents are able to decorate their rooms according to their tastes. The inspector was able to view the majority of residents’ rooms, and was told that all residents had chosen the colour schemes for their rooms. One resident spoken to advised that they liked their room, it was comfortable and decorated in their colour of choice. The home was clean with no unpleasant odours despite some residents being incontinent. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 18 The home has a large garden at the rear, which was maintained appropriately. As required at the previous inspection the rear garden fence had been repaired. Staff and residents confirmed that they used the garden frequently with risk assessments in place for the level of supervision each resident needed when using this area. Given the nature of some residents’ disabilities the inspector noted that there were relatively few repairs required within the home. The cupboards in the bedrooms belonging to LB and DS need to be repaired and the damaged wall in LB’s is also in need of repair. New linoleum flooring (or an alternative) should be provided in the top bathroom and the cracked glass pane on the front door must be repaired. The exterior of the home was in a reasonable state of decoration but some of the paint around the entrance area was slightly cracked. Following the inspection a schedule was presented to the CSCI for the redecoration of the external areas of the home. It is recommended that different options for an alternative reclining chair be offered to the resident who does not like to use a bed when sleeping in their bedroom. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Appropriately experienced and trained staff support residents effectively according to their individual needs, but the frequency of supervision must be increased to ensure that residents’ needs are met in line with best practice at all times. The home has a rigorous recruitment procedure for new staff members, in order to protect residents from harm. EVIDENCE: Four staff files were inspected and these were found to include satisfactory enhanced CRB disclosures, references, identity documents and all the other required information as specified under Schedule 4 of the Care Homes Regulations 2001. In the case of one file that was missing a copy of a second written reference, this was provided to the local CSCI area office shortly after the inspection (having been held at the provider’s head office). Inspection of staff supervision records indicated that whilst some supervision has been occurring, there had been a recent reduction in the frequency of oneto-one supervision meetings. This was confirmed by staff members, who noted that this was largely due to the departure of the deputy manager, who had not as yet been replaced. A requirement is made regarding the need for Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 20 an increase in the frequency of supervision to at least two-monthly. The manager noted that the home’s policy is for staff to have individual supervision sessions on a monthly basis. Staff files included certificates of all relevant training courses undertaken by staff including adult protection, health and safety, food and hygiene, autism awareness, first aid, working with challenging behaviour, fire safety and breakaway techniques. Staff spoken to advised that training provided was useful and relevant. A chart recording training undertaken by each staff member was available for the home so that training needs could be targeted easily, however it was not current, as it included staff members who had left and did not include all new staff members. It is recommended that the chart of training of needs for staff members be updated. Staff members spoken to confirmed that a high standard of training was provided to them including mandatory courses and training in skills relevant to the client group. These included training in Makaton, epilepsy, autism and challenging behaviour. New staff members advised that they had induction training at head office prior to commencing work at the home. Park Avenue 4 DS0000010748.V298924.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed effectively to ensure that residents’ needs are appropriately met. There are effective quality assurance procedures to ensure that service users’ preferences are taken into account and that the standard of care and support remains high. However this could be improved by more regular visits from the responsible individual appointed by the provider organisation. There is a need for more frequent fire drills and hot water temperature monitoring to ensure the safety of staff and residents in the home. EVIDENCE: The registered manager was in the process of completing the Registered Manager’s Award at NVQ level 4. Discussion with the manager, individual staff members and one resident indicated that the manager is very knowledgeable about the needs of residents at the home, and supports staff effectively to meet these needs. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 22 The home has effective recording and checking procedures to safeguard residents’ finances as appropriate, with all amounts checked at the end of each shift. The finances of one resident were checked during the inspection and appeared to be in order. Staff meetings are held regularly and minutes indicated that staff are encouraged to express their views about the running of the home. A detailed quality assurance audit had been undertaken for the home as appropriate, however the inspector had not been receiving reports of unannounced visits by the provider organisation to the home on a monthly basis. No reports had been received at the CSCI office since February 2006, although a requirement was made about this at the previous inspection. It is required that the provider organisation must conduct monthly unannounced visits to the home. Reports of these visits must be kept in the home with a copy sent to the CSCI. Staff files indicated that they have received training in health and safety, first aid and food hygiene. Each week a different member of staff is assigned the responsibility of completing a health and safety check list. The frequency of testing fire alarms had increased to weekly as appropriate, however there was no evidence that a fire drill had been undertaken in the last few months previous to the inspection. A requirement is made accordingly. Appropriate gas, electrical and portable appliances testing certificates were available for the home. Although appropriate thermostatic valves had been fitted to hot water outlets, it is also required that the temperature of hot water from all outlets in the home be monitored on a regular basis and that this be recorded. An annual legionella test must also be carried out for the home. Park Avenue 4 DS0000010748.V298924.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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 2 2 X Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The registered persons must ensure that there are no gaps in the medication administration records and that the reason for administration of PRN (as and when) medication is recorded on each occasion. The registered persons must ensure that the cupboards in the two identified bedrooms and the wall in the identified bedroom are repaired. New linoleum flooring (or an alternative) must be provided in the top bathroom. The cracked glass pane on the front door must be repaired. The registered person must ensure that staff receive individual supervision sessions at least six times a year. The registered persons must ensure that the provider organisation conducts unannounced visits to the home every month. Reports of these visits must be kept in the home and a copy sent to the CSCI. DS0000010748.V298924.R01.S.doc Timescale for action 01/09/06 2. YA24 23(2bcd) 06/10/06 3. YA36 18(2) 20/10/06 4. YA41 26 22/09/06 Park Avenue 4 Version 5.2 Page 25 5. YA42 13(4)(a) 6. YA42 23(4e) (Previous timescale of 02/12/05 not met). The registered persons must ensure that hot water temperature in the home is monitored on a regular basis and this is recorded and an annual legionella test must be carried out for the home. The registered persons must ensure that fire drills are arranged on a regular basis and recorded including the date, time, staff and service users involved and any issues arising. 06/10/06 22/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA24 YA35 Good Practice Recommendations It is recommended that the recording system for care plans, risk assessments and guidelines for support of service users, be reviewed to create a simpler system. It is recommended that different options for an alternative reclining chair be offered to the service user who does not like to use a bed when sleeping in their bedroom. It is recommended that the chart of training of needs be updated for existing staff members. Park Avenue 4 DS0000010748.V298924.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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