Inspection on 01/05/07 for Park Avenue 4

This inspection was carried out on 1st May 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park Avenue 4 01/08/06

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

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 Park Avenue 4 Wood Green London N22 7EX Lead Inspector Susan Shamash Unannounced Inspection 1st May 2007 12:30 Park Avenue 4 DS0000010748.V333419.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.V333419.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.V333419.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 6785 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.V333419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 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 people 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.V333419.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 hours. The registered manager was present throughout the inspection and I was also assisted by other members of the staff team. During the inspection, people living at the home arrived back from day activities. I was able to speak to one person in detail and spent time with the five other people living at the home in the presence of staff members in the kitchen and dining area. I also had the opportunity to speak with two 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 two care plans, three 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 people with a range of complex needs. The home makes a concerted effort to ensure compliance with requirements issued by the CSCI. People 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 four years. Even the majority of bank (as and when) staff have been working at the home for many years. The low staff turnover helps to give people living at the home 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 people living at the home 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 people living at the home, and a range of appropriate activities are available both inside and outside of the home. People are also supported to go on holiday at least once a year and to maintain contacts with their family and friends. Staff have detailed guidelines, drawn up with the support of psychologists provided by the provider organisation, for dealing with challenging behaviours expressed by people living at the home. Pictorial aids are used effectively to meet the communication needs of individual people living at the home. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 6 A varied menu is available for people living at the home, with choices to meet their individual and cultural preferences. The home is flexible at supporting people to assist in tasks of daily living including setting the table, cooking and clearing up. One person, 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 people living at the home, management and staff. The manager at the home has been in post since the home first opened and the home has benefited from her management. What has improved since the last inspection? What they could do better: A number of minor repairs are required in the toilets and bathrooms in the home. Staff training certificates must be available for all training completed and all staff members must complete training in first aid, manual handling and fire safety. An annual legionella test is carried out for the home, and the fire risk assessment is reviewed. It is recommended that a simplified care planning system be put in place, so that important information can be found easily, guidelines for the Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 7 administration of ‘as and when’ medication be kept in the medication administration file and fire alarm system test certificates be kept in the maintenance file. 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. Park Avenue 4 DS0000010748.V333419.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.V333419.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre-admission information is available for people to ensure that their needs are fully assessed and can be met effectively. EVIDENCE: The home is registered for six people all of whom have lived at the home for several years. The most recent person moved into the home in 2003. Detailed assessments were available for each person from which care plans had been developed. The manager remains very aware of the need to obtain pre-admission information before any new person was admitted to the home, and confirmed that appropriate admission procedures were in place. Park Avenue 4 DS0000010748.V333419.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): 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home’s care plans have been reviewed recently to ensure that they reflect peoples’ current needs. Peoples’ wishes regarding their care are sought consistently, and they are involved as far as possible in all aspects relating to life at the home, for which the home is commended. Following assessments, people are supported to take appropriately safeguarded risks and to develop independent living skills. EVIDENCE: Two people’s files were examined in detail. Each 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.V333419.R01.S.doc Version 5.2 Page 11 Files also contained person centred plans including useful information about the people’s needs and wishes obtained through close consultation with them. Information in these plans indicated that peoples’ wishes and decisions relating to all aspects of their care had been taken into account as far as possible. The majority of people living at the home have limited levels of verbal communication and some were reluctant to speak to me. However I was able to have a chat with one person and to spend some time with the other people. One person told me that they were well looked after by staff at the home and they were encouraged to be independent in areas that they were able to e.g. in cooking. Observation of staff interacting with people living at the home indicated that they continued to have a good rapport with people living at the home, and were very knowledgeable about their individual needs. Risk assessment information was specific to each person and their needs, including risks within the home and outside. Picture boards were being used for each person to plan their day ahead and communicate choices to staff. I witnessed people using the picture boards successfully, and the home is commended for the effective use of such communication tools. Although care planning documentation for people living at the home is very comprehensive, the large number of different formats can still make it difficult to find the relevant information required, and results in a certain amount of repetition. The manager advised that two further formats for care planning had been tried out since the previous inspection. It remains recommended that the recording system for care plans, risk assessments and guidelines for support of people living at the home, be reviewed to create a simpler system. Park Avenue 4 DS0000010748.V333419.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): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home supports people living at the home to engage in a wide variety of educational, leisure and daily living activities of their preferences both within the home and in the community for which it is commended. They are encouraged to maintain positive relationships with their family members and friends, and their rights and responsibilities are respected. People’s 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 people living at the home included details of a wide range of activities that they are involved in. I saw daily shift plans that list the Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 13 names of all the staff on duty and the work or activities that they are to undertake with individual people living at the home. If the activity does not take place, staff record the reasons why and any alternatives offered. The information in the daily shift plans are linked to the information contained in each person’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, swimming, pub visits, cinema trips and drives in the home’s van. Records, staff and a person living at the home also advised that regular contact with friends and family is encouraged. This was confirmed by daily care records and records of visitors to the home. Whilst I was at the home people were returning home from day services and other activities organised outside of the home. Those spoken to and with whom I spent time with indicated that they had enjoyed their daytime activities and were able to engage in activities of their choices within the home. People living at the home go on at least one holiday each year, there also trips arranged to the seaside and other places of interest during the year. This year one person had been on holiday to Barbados, another to Tenerife and others to Norfolk. Care plans indicated that people living at the home 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 people will be involved in, on a daily basis. The home has a 4-week set menu (with picture aids) and staff advised that individuals have the opportunity to take it in turns to make meal choices for everyone. People who do not like the meal selected still have the option to make their own choices. I observed people 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.V333419.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): 18, 19 and 20. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living at the home are supported with both physical and emotional health needs according to their preferences, and detailed guidelines are available to support them, for which the service is commended. The home has stringent medication practices and safeguards as appropriate to minimise potential risks to people living at the home. EVIDENCE: Care plans include information about peoples’ physical, emotional and social needs as appropriate. Daily records, discussion with staff and people living at the home and observation of interactions within the home indicated that these needs are being addressed appropriately, with the preferences and choices of people living at the home in mind. Information is maintained regarding all GP, hospital and health care appointments as appropriate, indicating that regular contact is maintained with health care professionals. Detailed guidelines are available to support staff in addressing challenging needs or behaviours from people living at the home. These are produced in Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 15 conjunction with psychologist involvement which is available from the provider organisation, for which the service is commended. There are no people self-administering medication at present. Inspection of staff training certificates and a staff training matrix produced by the manager indicated that all staff were provided with training by the local pharmacist in the use of the NOMAD system. Some but not all staff working in the home have received external training in the administration of medication, and it is recommended that further staff undertake external training in this area. 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 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 completed appropriately by staff as required at the previous inspection. Use of PRN (as and when) medicines appeared to be appropriate, and the reason for administration was being recorded on the medication administration records (MAR sheets). Guidelines for the use of PRN medication were available within people’s care plans, but it is recommended that guidelines for the administration of PRN medication be maintained within the medication administration file for easy reference by staff. Park Avenue 4 DS0000010748.V333419.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): 22 and 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Regular residents’ forums ensure that people living at the home have a formal channel through which their concerns can be expressed and resolved. Appropriate procedures are in place and some staff have been trained in adult protection to ensure that people 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 a 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 person living at the home, but informal arrangements were in place for seeking their views on a regular basis. Staff spoken to confirmed this as did entries recorded within peoples’ care plans and daily notes. Some certificates were available evidencing that staff members had received adult protection training as appropriate, however I had recorded from a Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 17 previous inspection that evidence was available that all staff members had undertaken training in this area. A certificate was available in the most newly recruited staff member’s file, as appropriate. This indicated that the training matrix for the home was not fully up to date, and a requirement is made under Standard 35 accordingly. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home environment is comfortable, clean and safe and is generally in a good state of repair and decoration. People living at the home 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 they 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 person living at the home who becomes agitated and destroys decorations such as pictures, placing other people at risk of injury. Despite the constraints of decorating communal areas, people living at the home are able to decorate their rooms according to their tastes. I was able to view the majority of peoples’ rooms, and was told that all people living at the home had chosen the colour schemes for their rooms. One person spoken to Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 19 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 people being incontinent. The home has a large garden at the rear, which was maintained appropriately. Staff and people living at the home confirmed that they used the garden frequently with risk assessments in place for the level of supervision each person needed when using this area. Given the nature of some peoples’ disabilities, I noted that there were relatively few repairs required within the home. The repairs required at the previous inspection had been undertaken, although one person’s cupboard needed to be repaired again following further damage. New linoleum flooring had been provided in the top bathroom and the cracked glass pane on the front door had been repaired. The exterior of the home was in a reasonable state of decoration. Following the previous inspection a schedule was presented to the CSCI for the redecoration of the external areas of the home. Inspection of the home indicated that the board under the bath in the 2nd floor bathroom needed to be repainted, the ground floor shower ceiling ring (supporting the shower curtain) was broken, and this must be replaced, and the adjoining toilet, missing water tank top, must also be replaced. The bin lid in the laundry was worn, and appeared difficult to keep clean, and this must be repainted or replaced, and the issue of cracks on the ceiling of the laundry room must also be addressed, as noted in the last responsible individual report. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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. Appropriately experienced and qualified staff support people effectively according to their individual needs. Stringent recruitment practices and frequent staff supervision are in place to ensure the protection of people living at the home as far as possible. However further staff training in a number of areas is required to ensure that peoples’ needs are met in line with best practice at all times. EVIDENCE: Three 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. Inspection of staff supervision records indicated that this was now occurring regularly as required at the previous inspection. This was confirmed by staff members spoken to. The manager noted that the home’s policy is for staff to have individual supervision sessions on a monthly basis. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 21 Staff files included certificates of all relevant training courses undertaken by staff including health and safety, food hygiene, autism awareness, working with challenging behaviour, breakaway techniques, Makaton, person centred planning and epilepsy. Staff spoken to advised that training provided was useful and relevant. Over fifty percent of staff members had obtained an NVQ (National Vocational Qualification) in care at level 2, as appropriate. A chart recording training undertaken by each staff member was available for the home so that training needs could be targeted easily. At the previous inspection this chart was not current, as it included staff members who had left and did not include all new staff members, and it had been updated as recommended. New staff members advised that they had induction training at head office prior to commencing work at the home. I noted that staff training certificates were not available for all training completed on the training matrix for the home, and some, but not all staff members had completed training in first aid, manual handling and fire safety. A requirement is made accordingly. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 22 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): 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 home is managed effectively to ensure that peoples’ needs are appropriately met. There are effective quality assurance procedures to ensure that peoples’ preferences are taken into account and that the standard of care and support remains high. Residents’ best interests are safeguarded by the home’s record keeping procedures. The health and safety of staff and people living at the home is generally protected appropriately, although there is room for improvement in a small number of areas. EVIDENCE: The registered manager had completed the Registered Manager’s Award at NVQ level 4 as appropriate. Discussion with the manager, individual staff members and one person living at the home indicated that the manager is very Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 23 knowledgeable about the needs of people living at the home, and supports staff effectively to meet these needs. 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 person living at the home 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, and I had received reports of unannounced visits by the provider organisation to the home on a monthly basis as appropriate, as required at the previous inspection. Staff files indicated that they have received training in health and safety and food hygiene, as appropriate, however further training is needed in first aid. Each week a different member of staff is assigned the responsibility of completing a health and safety check list. Fire alarms were being tested weekly as appropriate, and there was evidence that fire drills were being held regularly as required at the previous inspection. Appropriate gas, electrical and portable appliances testing certificates were available for the home. Although appropriate thermostatic valves had been fitted to hot water outlets, the temperature of hot water from all outlets in the home be monitored on a regular basis and recorded as required. An annual legionella test had not yet been carried out for the home although this was required at the previous inspection. The manager advised that this had been undertaken on 21st May 2007. A detailed fire risk assessment was available for the home, however it was completed in March 2006 and was due to be reviewed. It is recommended that fire alarm system test certificates be kept in the maintenance file, for ease of reference. Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 24 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 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X 3 2 x Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23(2bd) Requirement The registered persons must ensure that the board under the bath in the 2nd floor bathroom be repainted, The ground floor shower, ceiling ring must be replaced, The adjoining toilet water tank top must be replaced. The bin lid in the laundry must be repainted, and the issue of cracks on the ceiling of the laundry room must be addressed. The registered persons must ensure that staff training certificates are available for all training completed and all staff members complete training in first aid, manual handling and fire safety. The registered persons must ensure that an annual legionella test is carried out for the home (Previous timescale of 06/10/06 not met) and the fire risk assessment is reviewed at least six-monthly. The manager DS0000010748.V333419.R01.S.doc Timescale for action 22/06/07 2. YA35 18(1ci) 24/08/07 3. YA42 13(4a) 08/06/07 Park Avenue 4 Version 5.2 Page 26 advised that these were addressed shortly after the inspection. 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. Refer to Standard YA6 YA20 Good Practice Recommendations It is recommended that a simplified care planning system be put in place, so that important information can be found easily and repetition is avoided. It is recommended that guidelines for the administration of PRN medication be maintained within the medication administration file, and further staff undertake external training in the administration of medication. It is recommended that fire alarm system test certificates be kept in the maintenance file. 3. YA42 Park Avenue 4 DS0000010748.V333419.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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