Inspection on 11/01/07 for Randall House

This inspection was carried out on 11th January 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Randall House 12/11/08

Randall House 23/01/08

Randall House 23/11/05

Randall House 21/06/05

Randall House 18/01/05

Randall House 19/07/04

Randall House 09/02/04

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

CARE HOME ADULTS 18-65 Randall House 75 Randall Avenue Neasden London NW2 7SS Lead Inspector Julie Schofield Key Unannounced Inspection 11th January 2007 08:10 DS0000017486.V307147.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 DS0000017486.V307147.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. DS0000017486.V307147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Randall House Address 75 Randall Avenue Neasden London NW2 7SS 020 8452 0336 020 8452 8544 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) Mrs Lucille Rabor Mrs Lucille Rabor Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000017486.V307147.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Randall House is situated within walking distance of the shops at Neasden. Randall Avenue is close to a bus route and there is access to/from the North Circular Road. The nearest underground station is Neasden. It is a large detached house with a small area at the front of the house and an attractive garden at the rear of the property. The house has a driveway providing on site parking. There is also parking space available on the street outside the house. The home is registered to accommodate 5 adults with learning disabilities. There are bedrooms on both the ground and first floor with bathing and toilet facilities on both floors. Communal space is situated on the ground floor and consists of a lounge and a separate dining area. There is an office on the ground floor. At the time of the inspection three service users were accommodated in the home. The manager is also the manager of another of the Randall care homes and the proprietor of 3 care homes and a nursing agency. Information regarding the fees may be obtained, on request, from the manager of the home. DS0000017486.V307147.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on a Thursday in January and took the form of 2 visits to the home. The first visit started at 8.10 am and finished at 11 am. The second started at 4 pm and finished at 6.45 pm. During the inspection the manager of the home and the manager of one of the company’s other care homes assisted. The Inspector would like to thank them and the members of staff that took part in the inspection. During the visits a tour of the premises took place, records were examined, discussions took place with the managers and members of staff and care practices were observed. One of the residents lives in the home at the weekends only and was not present during the inspection. The other 2 residents who were present were not able to communicate verbally. What the service does well: The pre-admission assessment procedure is thorough. Prior to the admission of a new resident the home obtains as much information as possible about the person, in their current surroundings, so that the home can determine whether the needs of the new resident can be met by Randall House. The information also helps the staff team to understand the needs of the new resident and what support they will be required to provide. Although 2 of the residents are unable to communicate verbally the staff on duty were able to demonstrate that they understood the ways in which residents communicated their needs. Residents were able to relax in the home and enjoy company or privacy, as they wished. The home is comfortably furnished and decorated. The manager tries to encourage and to maintain contact between residents and their family members. Although one resident has a grandparent in the Caribbean a member of staff went to visit them, with news of the resident when the member of staff was on holiday. DS0000017486.V307147.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000017486.V307147.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000017486.V307147.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A visit to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a resident has been admitted to the home. They are accommodated from Friday evenings until Monday mornings only. Their case file was examined and it was noted that the placing authority had sent a “care plan needs identified” document and a “visual impairment summary” prior to the admission. The home had completed an assessment form but this was not dated. The resident attends a college during the week and a copy of the individual care plan from the college had been received. A copy of a pictorial annual review of the college placement was also on file. There was a record on the file that the resident had visited the home, with their family, prior to their admission. The report of the visited stated that the DS0000017486.V307147.R01.S.doc Version 5.2 Page 9 resident had been shown around the home, including viewing the room that they would be offered. It was noted in the record that the resident would be viewing other care homes and a return visit was made to confirm the choice of Randall House. DS0000017486.V307147.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, 9 Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings convened by the home. Although the resident’s right to make decisions about their life in the home is respected advocacy services would provide residents with additional support. Risk taking contributes towards the resident developing an independent lifestyle and reviewing these ensures that the changing needs of residents are identified and addressed. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the 3 residents’ case files was examined. It was noted that each contained a recently completed care plan covering personal, health and social DS0000017486.V307147.R01.S.doc Version 5.2 Page 11 care needs. One care plan contained a section headed “challenging behaviour”. Within each need identified an objective was set and action recorded to meet the need. Each identified need was subject to monthly evaluations. However entries consisted of “no change to care plan”. The resident that had been most recently admitted to the home had evidence of a review being carried out by the funding authority and the home’s care plan was based on an assessment of needs for daily living document, which had been completed by the deputy manager shortly after the resident had been admitted to the home. While the home had carried out 2 internal review meetings in 2006 for each of the other 2 residents there was no evidence that their funding authority had convened a review meeting of the care plan and placement during 2006. The care plan is not in a format that the service user can understand. Two of the residents are unable to communicate verbally and the member of staff on duty said that she uses the resident’s body language or facial expressions to determine the wishes of the residents. She said that residents are able to demonstrate when they have made a choice and gave the example of a resident not doing something if they didn’t want to do this. Residents do not have the support of advocacy services. Offering choice or encouraging residents to take decisions may begin in small areas and grow as the skills of the resident develop. It was noted that money has been left with the home on behalf of the resident accommodated during weekends only. This was not securely kept. The home also assists a resident with their financial affairs and records were available. The resident also has a savings account and records of this were available. Case files contained risk assessments. These are now reviewed on a monthly basis although the record of this is brief. Each file has a general risk assessment. There were also risk assessments for mobility, manual handling, falling, using the stairs, using their rooms and using community resources, depending on the individual needs of the residents. The home has a missing persons procedure. DS0000017486.V307147.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, 15, 16, 17 Attending day centres and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. Residents are encouraged to maintain contact with their families and friends so that their need for fulfilling relationships are met. The residents’ right to privacy and independence are respected and promoted by staff. The home did not demonstrate that residents received a varied diet. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 3 residents accommodated in the home, 1 resident attends a boarding college during the week and the other 2 residents attend a day centre during the week (Mondays to Fridays). Communication books used by the day centre and by the home contained information about the activities that residents had DS0000017486.V307147.R01.S.doc Version 5.2 Page 13 taken part in at the centre and had enjoyed. There was evidence on the case file that assistance is given with benefit problems, if necessary. Residents need support from members of staff when using resources in the community. The manager said that residents enjoyed going shopping at Brent Cross, going to the park and going out to clubs. Residents use dial-a-ride. Two of the 3 residents have contact with their families. The resident that is accommodated in the home for the weekends only has regular visits from family members and often goes out with them. The other resident has a family member that visits them in Randall House. When visits are made to residents they can take place in the resident’s room or in the lounge. The third resident has a relative living in the Caribbean and the manager sends notes regarding the resident’s health and progress. A member of staff recently visited the island in the Caribbean and went to meet the resident’s relative. Although residents are encouraged to do what they can for themselves 2 of the residents living in the home are dependent on the support of staff for many aspects of daily living. Even though these residents are unable to call out if a member of staff knocks on their bedroom door it was noted that staff respect the resident’s right to privacy. Residents can choose when they wish to spend time in their rooms, alone, and one resident goes to their room when they want privacy. Another resident enjoys listening to music in their room. There is an O.T. who visits the home twice a week (during the week and at the weekend) to work with the residents on an individual basis to encourage and promote independence. The member of staff on duty during the first inspection visit said that they had served tuna, mashed potato and vegetables for the evening meal, the previous day. The member of staff on duty during the second inspection visit said that they had served tuna, spaghetti and vegetables for the evening meal on the day of the inspection. These meals were not the ones listed on the menu. The menu demonstrated a varied and wholesome diet, with African-Caribbean dishes to meet the cultural needs of residents. A record is kept of the meals consumed by residents. During an examination of the kitchen it was noted that both freezers were heavily iced and needed defrosting and that the door of one did not close properly due to the ice that had formed behind one of the drawers in the cabinet. This was drawn to the attention of the member of staff during the inspection. Plastic containers had been placed in the fridge. Although they were labelled and the date on which they were placed in the fridge recorded there was no record of what was inside the container. This was drawn to the attention of the manager during the inspection. The rubbish bin in the kitchen did not have a lid. There was evidence on the staff files that staff had attended food hygiene training. DS0000017486.V307147.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, 20 Residents receive assistance with personal care in a manner, which respects their privacy and dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. However medication training lacks the input of an accredited trainer. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the carer on duty was assisting residents with their personal care and ensuring that they were appropriately dressed for going out. Assistance was provided discreetly and in private. Residents’ case files included daily plans of care, which gave carers guidance on how the resident preferred to be assisted. It was noted that residents were clean and tidy and smartly dressed. The staff team provides carers that share the same cultural background as the residents. There was evidence on the case files that DS0000017486.V307147.R01.S.doc Version 5.2 Page 15 referrals had been made for specialist support, as required, and these included a request for an assessment by a speech and language therapist and by a physiotherapist. When residents’ case files were examined there was evidence of access to health care services in the community. Medication reviews and yearly checkups took place. Residents had received a flu jab in the autumn. There were recent appointments with the GP, dentist, optician and podiatrist. When attending appointments residents are supported by a member of staff or by one of the managers. Specialist support was sought, as appropriate. The storage of medication is safe and secure. The records were examined and were up to date and complete. The administering of medication was observed. Residents in the home are prescribed medication in liquid form. All members of staff working in the home received medication update training in October 2006 and a member of staff on duty confirmed this. One of the management team and not by an accredited trainer gave the training. DS0000017486.V307147.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, 23 A complaints procedure is in place to protect the rights of residents but not all of the residents would be able to use this. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place in the home. It includes information regarding the stages and the timescales involved in the process. It also informs the complainant of their right to contact other agencies and includes contact details for the local office of the Commission for Social Care Inspection. The manager said that no complaints have been recorded since the last inspection. Two of the residents would not be able to use the complaints procedure without the assistance of a family member or an advocate and it is recommended that a referral be made for advocacy services on behalf of these 2 residents. A protection of vulnerable adults procedure is in place. The manager said that no allegations or incidents have been recorded since the last inspection. There was evidence on the staff files that protection of vulnerable adults training had taken place and a member of staff on duty confirmed this. However a new DS0000017486.V307147.R01.S.doc Version 5.2 Page 17 member of staff said that they had not yet received this training. The manager said that the home does not practice restraint. DS0000017486.V307147.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, 25, 27, 30 Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax and enjoy. The privacy of residents is respected by the provision of single bedrooms. Bathing and toilet facilities in the home are sufficient in number and are conveniently located within the home to protect the privacy and dignity of residents. Residents live in a home where overall standards of cleanliness are good Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located in a residential part of the borough with local transport routes and shops close by. The upkeep of the home is good. Level access to the home is through the patio doors in the kitchen/dining area and around the side of the house. Residents enjoy a comfortable and homely environment DS0000017486.V307147.R01.S.doc Version 5.2 Page 19 where communal facilities are sufficient in size for the number of residents. The temperature in the home was suitable for the time of year and weather. There is a lovely garden at the rear of the premises. It has a shaded patio area and there are attractive pots and borders. There are 5 single bedrooms. Each room is sufficient in size to meet the needs of the resident. One of the bedrooms is on the ground floor and is occupied by a resident that has mobility problems. The rooms are comfortably furnished and decorated. One of the bedrooms on the first floor has ensuite facilities and the other bedrooms in the home each have a wash hand basin. On the first floor there is a bathroom with toilet and another separate toilet. The ground floor bathroom includes a toilet and a shower. A site visit took place and it was noted that the home was clean and tidy and free from offensive odours. There was evidence on file that staff have undertaken infection control training. DS0000017486.V307147.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, 33, 34, 35, 36 NVQ training enhances the general skills and knowledge of carers and the home has met the target of at least 50 of carers achieving an NVQ level 2 or 3 qualification. Although staffing levels were sufficient to meet the needs of the residents, the rota failed to demonstrate that the manager’s hours spent on site were sufficient to supervise staff on a day-to-day basis and to monitor the standard of care. Recruitment practices, which include checks and references, protect the welfare and safety of residents. The home needs to ensure that work permits are produced, if required. The home has a training and development plan, which is linked to the aims of the home and new staff receive induction training. Individual supervision sessions, staff appraisals and regular staff meetings help to support staff and to monitor their working practices. Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 9 names of members of staff on the rota, 5 members of staff have completed their NVQ level 2 or level 3 training. A member of staff is an RN DS0000017486.V307147.R01.S.doc Version 5.2 Page 21 and one member of staff is undertaking NVQ level 2 training. The remaining 2 members of staff are also currently undertaking training e.g. a counselling course. The home has now met the target of 50 of carers achieving an NVQ level 2 or 3 qualification. A discussion took place with the member of staff on duty in respect of communicating with residents who cannot speak. The member of staff demonstrated their understanding of non-verbal forms of communication. The rota for the week commencing the 9th January to the 15th January was on display. A carer is on duty in the morning, until after residents have left the home for their day centre and a carer is on duty in the afternoon/early evening to support residents on their return home from day centre. A member of staff on duty at night sleeps in but is on call. At the weekend, when residents are at home, there is a member of staff on duty during the middle of the day. Some members of staff working at Randall House work shifts in the company’s other care homes. There was no record on the rota of the hours worked in total for the company, by these members of staff. Although there was a record of the senior person on call (this consists of a manager from the company) the hours worked on site by the manager were not recorded on the rota. Three staff files were examined, including those of 2 members of staff that had recently joined the company. It was noted that each file contained an application form, job description, 2 references, proof of identity (including a photograph) and an enhanced CRB disclosure, naming Randall Care Homes as the employer. One file did not contain a copy of the contract and another file contained evidence of “limited leave to remain” with a valid residence permit, but no work permit. Two staff files were examined in respect of induction training. The home has a 4 week induction programme and when completed the member of staff signs to acknowledge receipt of training. The induction training record identifies training needs and includes an action plan to meet these. The manager was unable to confirm that the content of the induction training programme met the Sector Skills Council’s standards. Each member of staff has a training profile that records training undertaken. Copies of training attendance/qualification certificates were present on the files examined. There was no evidence that staff had received equal opportunities training. The company has previously forwarded a copy of the training plan to the Commission for Social Care Inspection. It is recommended that the plan is reviewed and updated on an annual basis. There was evidence in the home that regular staff meetings took place (monthly) and a member of staff confirmed this. Staff receive supervision and a member of staff confirmed that staff appraisals had taken place in 2006. There were also copies of staff appraisals dated 2006 on staff files. However, without details of the hours worked on site by the manager, being recorded on DS0000017486.V307147.R01.S.doc Version 5.2 Page 22 the rota it is not possible to determine whether the day to day arrangements for the supervision of staff are sufficient. DS0000017486.V307147.R01.S.doc Version 5.2 Page 23 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, 42 The registered manager has developed her knowledge through further training and this contributes towards understanding the needs of residents and staff. Service satisfaction questionnaires help to monitor the quality of the service provided to residents and contribute towards the development of the service. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. However knowledge must be up dated so that it reflects current standards of good practice. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use and the manager needs to ensure that appointments for these checks are made before certificates expire. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000017486.V307147.R01.S.doc Version 5.2 Page 24 The registered manager has completed her Registered Manager’s Award and has shown evidence of this on a previous inspection. She is also a qualified RGN. She has managed the home since its initial registration. Within Randall House feedback from residents is limited and 2 of the 3 residents are unable to take part in a residents’ meeting. Feedback from relatives, acting on behalf of residents, is also limited. The manager said that quality assurance was therefore a company responsibility. The company has developed satisfaction survey forms. These were distributed in 2006 to family members of the residents, to the CPN’s, to social workers etc. The manager said that, so far, 6 completed questionnaires have been returned. These were available for inspection and it was noted that they contained positive feedback on the quality of the service provided. The manager said that the information would be collated and used in the development of the service. At the moment the home has a combined business and development plan. Staff were aware to their duties in respect of the health and safety of visitors to the home and made the Inspector aware, on their arrival at the home, of the location of fire exits. During the 2 inspection visits a bleeping noise was coming from the fire alarm panel. Both staff and managers said that a number of visits had been made to the home, including a visit on the day prior to the inspection, from 2 companies to try to rectify the fault, but without success. The manager said that despite the bleeping the fire alarms were operational. The manager said that another call had been made and they were waiting for a visit. Certificates for attending training courses in respect of safe working practices, which were present on staff files, were examined. It was noted that food hygiene certificates had been awarded within the last 3 years. Certificates for first aid and manual handling, which were valid for 1 year, had expired. The testing of the fire alarms and conducting of fire drills were recorded and were regular and up to date. Fire extinguishers had been recently serviced. There was a valid certificate for the electrical installation and a valid Landlords Gas Safety Record but the certificate for the testing of the portable electrical appliances was out of date. DS0000017486.V307147.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X DS0000017486.V307147.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA7 YA17 Regulation 16.2 16.2 Requirement That money held in the home on behalf of a resident is kept in a secure place. That residents are offered a varied diet, without the main ingredients of a meal being duplicated on 2 consecutive days. That the freezers are defrosted on a regular basis to ensure that the doors are able to close with a tight seal. That containers placed in the fridge have labels, which include a record of what, is inside. That a pedal bin is used in the kitchen for collecting rubbish. That medication training is arranged for staff and that it is given by an accredited trainer. That all staff receive protection of vulnerable adults training. That the hours worked on site by the manager, and recorded on the rota are a minimum of 17.5 hours per week. That when a member of staff works in more than 1 Randall care home the total weekly hours worked for the company DS0000017486.V307147.R01.S.doc Timescale for action 05/02/07 05/02/07 3 YA17 16.2 05/02/07 4 5 6 7 8 YA17 YA17 YA20 YA22 YA33 16.2 16.2 18.1 13.6 17.2S4.7 & 18.2 12.1 05/02/07 05/02/07 01/06/07 01/04/07 05/02/07 9 YA33 05/02/07 Version 5.2 Page 27 10 YA34 19.1 11 12 13 14 YA42 YA42 YA42 YA42 13.4 13.5 23.4 13.4 are recorded on each home’s rota. That evidence of a work permit is kept on file when a member of staff is given “limited leave to remain”. That first aid training is undertaken when certification expires. That carers renew their manual handling training certification on an annual basis. That the fault on the fire alarm panel is repaired. That a copy of a valid certificate for the testing of the portable electrical appliances is forwarded to the CSCI. 05/02/07 01/04/07 01/06/07 05/02/07 05/02/07 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 4 5 6 7 8 9 Refer to Standard YA6 YA6 YA6 YA7 YA9 YA17 YA34 YA35 YA35 Good Practice Recommendations That the monthly evaluations are more detailed. That the home contacts the funding authority and requests a date for the funding authority to review the care plan and placement. That care plans are in a format that residents can understand. That advocacy services are arranged for residents who are unable to communicate verbally. That the monthly reviews of the risk assessments are more detailed. That the staff on duty follow the menu so that a varied diet is maintained. That a copy of the contract/statement of terms and conditions is kept on the personnel file. That staff receive equal opportunities training. That the induction training programme in the home meets Sector Skills Council’s specifications. DS0000017486.V307147.R01.S.doc Version 5.2 Page 28 10 11 YA35 YA39 That the training plan is reviewed and updated on an annual basis. That the development plan is reviewed and updated in the light of the information received from the completed satisfaction survey forms. DS0000017486.V307147.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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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