Inspection on 23/03/07 for Real Life Options 96 Harrowdene Road

This inspection was carried out on 23rd March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Real Life Options 96 Harrowdene... 03/09/07

Real Life Options 96 Harrowdene... 18/11/05

Real Life Options 96 Harrowdene... 20/05/05

Real Life Options 96 Harrowdene... 08/12/04

Real Life Options 96 Harrowdene... 09/09/04

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

CARE HOME ADULTS 18-65 Real Life Options 96 Harrowdene Road 96 Harrowdene Road Wembley Middlesex HA0 2JF Lead Inspector Andreas Schwarz Key Unannounced Inspection 23 & 28th March 2007 08:00 rd Real Life Options 96 Harrowdene Road DS0000017454.V328210.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 Real Life Options 96 Harrowdene Road DS0000017454.V328210.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. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Real Life Options 96 Harrowdene Road Address 96 Harrowdene Road Wembley Middlesex HA0 2JF 020 8904 3543 020 8904 3543 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) www.reallifeoptions.org Real Life Options Ms Kylie Miles Care Home 6 Category(ies) of Learning disability (4), Physical disability (2) registration, with number of places Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: 96 Harrowdene Road is a care home providing personal care for 6 adults with learning disabilities, including up to two service users who may also have physical disabilities and who are accommodated on the ground floor. The home has no vacancies. The home is situated on a busy road that links East Lane with the Harrow Road. The nearest underground tube station is North Wembley. There are also bus routes along the two main roads. The property has off street parking and there is a separate entrance and exit. However there is also parking available in the street outside the house. The house consists of two floors. There is a seating area in the very large entrance hall, a lounge, conservatory, dining room, kitchen, laundry and two service users bedrooms on the ground floor. Two bedrooms have an en-suite shower and toilet. There is a bathroom, separate toilet, office and 4 service users bedrooms on the first floor. Fees and charges for the home can be obtained from the manager. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two days and lasted 8 ½ hours. The inspector spoke to all service users and observed staff administering medication and getting residents ready to go to the day centre. The inspector spoke in detail to one member of staff. The manager Mrs Allen (Maternity Cover for Registered Manager) and deputy manager Mrs Milner were available to support the inspector during this unannounced inspection. The inspector viewed care plan files, staff files and other relevant documents to support his judgements. The inspector would like to thank service users, staff and management for making him welcome during this unannounced key inspection. What the service does well: What has improved since the last inspection? The home has filled both vacancies and new residents appear to have settled in well. The home has built a second en-suite bathroom on the ground floor. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 6 The home has met one of the three requirements made during the last key inspection. One resident has purchased new furniture for his bedroom. 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. Real Life Options 96 Harrowdene Road DS0000017454.V328210.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 Real Life Options 96 Harrowdene Road DS0000017454.V328210.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New prospective residents are involved in the assessment process and have an opportunity to test drive the home prior to moving in. EVIDENCE: The home has an assessment and referral policy, which has been reviewed. The inspector viewed one assessment during this inspection, which was undertaken by the registered manager and the regional manager of Real Life Options. There was a detailed transition plan in place and trial visits have been recorded. The resident is non-verbal and information was obtained by involving the service user’s previous placement. After six weeks the home undertook a placement review, which was attended by social worker, key worker, home manager, regional manager and day service. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plan are in a suitable format and service users are involved in the care planning process, residents are encouraged to make choices and risks are managed and assessed to good standard EVIDENCE: The inspector viewed two care plans and two Person Centred Planning files during this inspection. It was noted that care plan files are very untidy and unorganised. The manager informed the inspector that she is in the process of addressing this and showed the inspector an index, which will be implemented in the future. Care plans have not been reviewed; staff informed the inspector that care plans should be reviewed every six months. The inspector noted however that service users Person Centred Plans have been reviewed. All residents have an allocated key worker and co-key worker. Staff observed and spoken to demonstrate very good knowledge of service users cares needs. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 10 The inspector observed residents making choices during breakfast. Staff informed the inspector that residents are non-verbal, but they know if residents do not like something. This was recorded in service users Person Centred Planning document, which also addressed service users communication needs. Records showed that one of the residents who have recently moved in has no access to her bank account and is therefore not able to withdraw money. The organisation has borrowed money to this service user since moving in. Staff at the previous placement still has access to the service users money, which gives some reason for concern. The inspector informed the manager to investigate this and keep the inspector informed of the progress. The inspector assessed three financial records during this inspection, all records have been correct, it was however noted that on some occasions service users have paid for staff meals, when going out with residents. The inspector informed the manager that this practice must stop and residents must be reimbursed by the home. The home has a van, which is insured appropriately The home has a range of very good risk assessments in place and staff has attended risk assessment training. Risk assessments have been reviewed and changes have been recorded. Risk assessments address individual as well as collective risks to service users as well as staff. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents access day services and have opportunity of accessing the community; there is a lack of recording these activities clearly. EVIDENCE: All residents’ access a day service managed by Real Life Options four days a week and have one day off. On the day residents are off from the day centre they access either local colleges, go swimming or do activities of their choice. The day centre is involved in the care plan process and records have been viewed to feedback on progress. Residents have a weekly timetable in the Person Centred Planning file. The inspector observed residents leaving the home to go to restaurants, shopping and the college during both days of this inspection, staff informed the inspector that service users have been and will be going to concerts. Receipts provided some evidence of this. The inspector viewed daily records as part of Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 12 the case tracking, but could not find one entry of such activities taking place. This was discussed in detail with the manager. The deputy manager informed the inspector of service users being on the electoral register, but no records of this was available in service users files. Staff informed the inspector that residents go to church and Person Centred Planning records confirmed this, but none of this has been recorded in service users daily records. The home has a sexuality policy in place, which has pictures and symbols to reach a wider audience. One resident informed the inspector that she has a boyfriend at the day centre and one resident told the inspector of receiving regular contact from a family member. Residents can make contact with nondisabled people when going out, but the daily records did not show this. Staff informed the inspector that they would knock the door before entering a resident’s room, this was observed during this inspection. Bathrooms can be locked from the inside for privacy. Service users preferred form of address is recorded in the Person Centred Planning file. The inspector observed staff interacting with residents appropriately and with respect. Residents have been seen to move freely around the home. The inspector observed residents clearing the table following breakfast. The home has a large garden and the inspector was told that the garden is maintained by an external company, the inspector suggests to involve residents with the up keep of the garden if they choose to do so, provided detailed risk assessments are in place. The home has a menu in place, which provides a varied, nutritious and cultural appropriate diet. One resident informed the inspector of liking chicken and rice, which was included in the menu. Fridge and freezer temperature is taken daily. The weekly menu was not dated and four different menus have been displayed on the notice board, it was therefore not clear which menu was for the week of the inspection. The home is providing a special diet for one resident and a record of this was displayed in the kitchen. Breakfast observed was relaxed and staff has not rushed service users. Fruit and vegetable as well as drinks have been available during this inspection. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided appropriate personal care and healthcare support and are encouraged to wash, dress, etc. independently if they are able to. There is a need to provide appropriate equipment to aid service users mobility. EVIDENCE: Staff is supporting service users in their personal care, guidelines and preferences are recorded in service users Person Centred Planning files. Bathrooms can be locked from the inside to maintain service users privacy. Residents have been dressed appropriately to their gender and time of the year. The inspector noted that one of the wheelchairs was tied together with string. Staff informed the inspector that the chair has been broken and the home is not able getting it fixed. The deputy manager told the inspector that on occasions transport has been refused due to the broken wheelchair, this is not acceptable and must be addressed. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 14 Staff informed the inspector that the home has excellent relationships with the local GP and regular visits are recorded in detail. All residents have had a full blood analysis and medication has been reviewed regularly. Residents have specialist input from physiotherapists and attend dentists, chiropodists regularly. Health records viewed are detailed and of very good standard. Service users weight is monitored and checked monthly. Residents have an annual health action plan in place, it was noted however that these have not been reviewed. The inspector observed staff administering medication, this was judged as appropriate and procedures and policies have been followed. The home is administering medication with two members of staff, both of them sign on the Medication Administration Sheet, on three days signatures was not legible as one signature was above each other. Medication Administration Sheet are legal documents and the home must ensure that signatures are legible. The home has a medication policy, which has been reviewed and is available in a userfriendly format. The home is using Boots Monitored Dosage System and staff has received medication training in their induction. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and self-harm. EVIDENCE: The home did not have any complaints recorded since the last inspection. The inspector viewed incident records and incidences have been followed up and reviewed. The complaints policy is available in the office for staff, the inspector suggested to display the complaints policy on the notice board in the kitchen. The complaints policy is judged as compliant with National Minimum Standards. The home has an abuse policy in place and local Protection of Vulnerable Adults guidelines are available. Staff has attended Protection of Vulnerable Adults training. Staff spoken to showed good understanding of Protection of Vulnerable Adults processes and how to report allegations of abuse. The home has a whistle blowing, masturbation policy, anti bullying policy and other policies and procedures in place to protect service users. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and warm home, which is clean and free of any offensive odours. EVIDENCE: The inspector undertook a full tour of the building and one service user invited her into his room. The home is nicely decorated and spacious, the following issues must be addressed. The extractor fan above the hob in the kitchen was very dirty and must be cleaned. The large kitchen draw is loose and must be replaced or repaired. The kitchen worktops look very used and masking has holes, which could lead for bacteria to grow, this must be replaced or repaired. The home has a conservatory, which can be accessed from the lounge via a step. There are two residents in the home who use a wheelchair, which will not be able to access Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 17 the conservatory independently; the home must provide a ramp for the conservatory. The home has a large garden and patio area; the patio area has a lot of grass and moss growing, which must be removed. An external company maintains the garden, provided residents are interested and appropriate risk assessments are in place the inspector recommends involving service users in the upkeep of the garden. The ironing board cover is very worn and ripped and must be replaced. The extractor fan in the upstairs bathroom is dirty and must be cleaned. The service users room viewed by the inspector was nicely decorated and felt very comfortable, the inspector noted however a damp patch, which must be repaired. Staff explained to the inspector that the home had drainage problem in the past, which has been repaired; there is however a large damp patch on the right hand side of the fire place in the lounge, which must be repaired. The home has a utility room, and a washing machine as well as clothes dryer is provided. The flooring is impermeable and the COSH cupboard was locked. The home was clean and free of any offensive odours during this inspection. The home has an infection control in place, which recently has been reviewed. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a diverse, experienced and skilled staff team. Appropriate recruitment policies and procedures protect residents from unsuitable staff. EVIDENCE: The inspector viewed four staff files during this key inspection, the manager informed the inspector that currently three staff are registered to do their National Vocational Qualification in Care, but all three staff need to re-register as they have not started their qualification. One member of staff has a National Vocational Qualification in Care; previous inspections required that a minimum of 50 of care staff employed must have appropriate qualifications in care, which is still found to be outstanding. The home does not employ staff under the age of 18. Staff come from a varied background and have a range of skills and experiences, which could be beneficial to the residents. For example one member of staff has trained as a physiotherapist, but her training is not accepted in the United Kingdom. Staff demonstrated very good knowledge of Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 19 service users needs and disabilities and residents benefit from a longstanding staff team. The temporary manager has started to reorganise staff files, which makes it much easier to find the required documents and records. All files viewed by the inspector included Criminal Records Bureau checks, application forms and passport copies, with the exception of one file, this was pointed out to the manager. References are kept at Real Life Option’s head office. The home has a recruitment policy in place and all appointments are subject to a six months probationary period. The home offers a wide range of mandatory and specialist training. Certificates are kept in staff personal files and training records are in place, but are in need of being updated. New staff receive a detailed induction following the Learning Disabilities Award Framework principle, which lasts over eight days, this is commendable. Permanent staff is covering annual leave and sickness and an agency can be used if permanent staff is not available. Staff has received regular supervisions and records have been made available for inspection. The home is using internal and external training providers. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced temporary manager manages the home until the registered manager returns from maternity leave. Residents are regularly involved and consulted in the running of the home. Residents Health and Safety is not compromised and safe working practices are in place. EVIDENCE: The temporary manager has been in post since February 2007, staff and residents have been very positive about the support they receive. The manager is implementing a number of changes to some of the systems in the home, which is welcomed by staff spoken to during this inspection. The temporary manager has started doing her National Vocational Qualification in Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 21 Care, but did not complete. The home has a deputy manager employed who has been working at Harrowdene Road for a number of years. The home has a range of different quality assurance systems in place. The inspector viewed a monthly quality assurance audit, which addresses maintenance, Health and Safety, Medication, Record keeping, etc. In addition to this the inspector viewed a detailed quarterly Health and Safety audit. The annual report is available in a user-friendly format and takes service users as well as families views into account. The organisation is preparing an annual business plan, which was available for inspection. The inspector viewed all certificates, which have been current and valid, Portable Appliances Test Certificate (Expires 23/01/08); Landlords Gas Safety Certificate (Expires 01/08/07), Electrical Installation Certificate (Expires 06/09/11). All fire records have been in order, with the exception, the last weekly fire tests has been undertaken on the 25/01/07. All staff has received formal fire safety training and the fire risk assessment has been reviewed. Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 22 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 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 2 X 3 X 4 X X 2 X Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(b) Requirement All care plans must be reviewed six monthly as per Real Life Option’s care plan policy. Care plan files must be restructured and re-organised. Residents must not pay for staff lunch and must be reimbursed for previous payments. Financial situation of one of the residents living in the home must be addressed and resolved. The inspector must be kept informed of the progress. The home must ensure that residents access the community regularly and records of these activities must be made available for inspection. All residents must be registered with the electoral register and records of this must be available. Weekly menus must be clearly dated to ensure that the menu DS0000017454.V328210.R01.S.doc Timescale for action 30/04/07 2. 3. YA6 YA8 17(3)(a) 13(6) 30/04/07 15/04/07 4. YA8 20(1) 30/04/07 5. YA13 16(2)(n) 15/04/07 6. YA13 12(3) 31/05/07 7. YA17 17(1)(a) Schedule 15/04/07 Real Life Options 96 Harrowdene Road Version 5.2 Page 24 4.13 8. YA18 23(2)(c) is corresponding with the correct week. The home must ensure that wheelchairs and other technical aids are in good working order and safely to use for service users and staff. The health action plan must be reviewed annually. 30/04/07 9. 10. YA19 YA20 12(2) 13(2) 30/04/07 The manager must ensure that 15/04/07 signatures on the Medication Administration Sheet are legible. The extractor fan above the kitchen hob must be cleaned. The loose draws in the kitchen must be repaired or replaced. The kitchen worktop must be repaired or replaced. The sealant on the kitchen worktop must be replaced. The home must provide wheelchair access to the conservatory. The weeds and grass between the patio paving stones must be removed. The home must replace the ironing board cover. The extractor fan in the upstairs bathroom must be cleaned. The damp patches in one of the residents’ rooms and the lounge must be repaired. 50 of carers must achieve an National Vocational Qualification DS0000017454.V328210.R01.S.doc 11. 12. 13. 14. 15. YA24 YA24 YA24 YA24 YA24 23(2)(c) 23(2)(c) 23(2)(c) 23(2)(b) 23(2)(a) 15/04/07 15/04/07 30/04/07 30/04/07 31/05/07 16. YA24 23(2)(d) 15/04/07 17. 18. 19. YA24 YA24 YA24 23(2)(c) 23(2)(d) 23(2)(b) 15/04/07 15/04/07 31/05/07 20. YA32 18(1) 30/09/07 Page 25 Real Life Options 96 Harrowdene Road Version 5.2 in Care level 2 or 3 qualification. (Previous timescale of 31/12/05 & 30/06/06 not met). 21. YA34 19 Schedule 2.3 9(2) The manager must ensure that 15/04/07 all staff files include a copy of the staff members’ passport and proof of the right to work in the United Kingdom. The registered manager must 31/12/07 achieve an National Vocational Qualification in Care level 4 qualification in management and care. Not assessed, registered manager on maternity leave (Previous timescale of 31/12/05 & 30/06/06 not met). 23. YA42 22(4)(c)(v) The home must ensure to undertake fire tests weekly. 15/04/07 22. YA37 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 YA22 YA24 Good Practice Recommendations Complaints procedures should be made available throughout the home. That a doorstopper is fitted to the skirting board of the wall in the dining room where the door handle has gouged a hole in the plasterwork. (Previously Recommended) Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 26 3. YA24 Provided residents are interested and appropriate risk assessments are in place the inspector recommends involving service users in the upkeep of the garden. All training records should be regularly updated. 4. YA35 Real Life Options 96 Harrowdene Road DS0000017454.V328210.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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