Inspection on 20/06/05 for Rela Goldhill Lodge

This inspection was carried out on 20th June 2005.

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

Other inspections for this house

Rela Goldhill Lodge 12/06/07

Rela Goldhill Lodge 04/10/06

Rela Goldhill Lodge 10/04/06

Rela Goldhill Lodge 24/10/05

Rela Goldhill Lodge 24/02/05

Rela Goldhill Lodge 04/06/04

Similar services:

Ashlong House

Foxley Lane (121a)

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

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

CARE HOME ADULTS 18-65 RELA GOLDHILL LODGE Wolfson Court Limes Avenue London NW11 9TJ Lead Inspector Anthony Lewis Unannounced 20th June 2005 at 09.30am 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 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 Stationary 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. RELA GOLDHILL LODGE Version 1.10 Page 3 SERVICE INFORMATION Name of service Rela Goldhill Lodge Address Wolfson Court, Limes Avenue, London NW11 9TJ Telephone number Fax number Email 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 8905 5229 020 8455 8250 Simon Morris for Jewish Care Steven Wax PC Care Home only 21 Category(ies) of SI Sensory Impairment registration, with number PD Physical Disability of places RELA GOLDHILL LODGE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Limited to 21 adults with a physical disability including visual impairment. 2 Two specified service users who are over 65 years of age may remain accommodated in the home. 3 The home must advise the registering authority at such times as either of the specified service users vacates the home. Date of last inspection 24 February 2005 Brief Description of the Service: Rela Goldhill Lodge is owned and managed by Jewish Care, who are the largest providers of health and social care services for the Jewish Community in the UK. The home is registered to provide residential accommodation and care for a maximum of twenty-one young Jewish adults with physical disabilities and sensory impairment. One accommodation is used for respite and short-term care. The staff team also provide outreach support to people living in their own flats, opposite the home. Staff are available on a twenty-four hour basis. The home is situated in a residential part of Golders Green, near to Golders Green and Brent Cross underground stations, local shops and bus routes and Brent Cross Shopping Centre, all of which are a short distance from the home. The home is purpose built as part of Wolfson Court, which was opened in 1992. The home occupies all of the first and part of the second floors. The remainder of the building provides warden supported accommodations for elderly people. The home has wheelchair accessibility throughout. There are twenty-one single bedrooms, each with en-suite shower and toilet facilities. The home also provides support with all aspects of personal care and daily living. There is also support for service users to enable them to be part of the local community and to develop and maintain work, education, leisure and social activities. The home adheres to the religious beliefs and practices of the Jewish religion and customs, taking into account religious holidays and festivals. RELA GOLDHILL LODGE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place at 9.30am on Monday 20th June 2005 and was completed at 3.50pm. The registered manager was available throughout the inspection process and was very helpful and accommodating. In order to gather evidence for this inspection, five residents and four staff were spoken to formally and in private. Three other residents were spoken to informally throughout the day. Evidence was also gathered by indirect observation of residents and staff throughout the day and by viewing three staff files and a number of other files, policies and procedures and safety certificates. There was also a tour of the home with the registered manager and later with one of the residents. What the service does well: What has improved since the last inspection? What they could do better: All areas of the home must be well maintained at all times to ensure that residents, staff and visitors to the home feel comfortable and that they are confident that the registered providers are taking maintenance issues seriously. The lifts must be regularly inspected and the certificate kept on the premises to ensure that people using the lifts are not put at risk. All staff must receive protection of vulnerable adults training in order comprehensively meet RELA GOLDHILL LODGE Version 1.10 Page 6 the needs of residents and to ensure that residents are safe from any form of direct or indirect abuse. All domestic staff working in the home must have their own individual file to ensure that vital information is available. Fire drills must be carried out on a quarterly basis to ensure that residents and staff are aware of emergency procedures in the event of a fire and to ensure that residents, staff and visitors are not put at risk in the event of a fire in the home. The water tank must be cleaned and chlorinated to ensure that residents, staff and visitors are not at risk from legionnaires disease and the home must ensure that they obtain a further certificate from an authorised provider to show that they have received a new water test, which is free from legionella. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. RELA GOLDHILL LODGE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection RELA GOLDHILL LODGE Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3. Residents are confident that the home will be able to meet their needs and are provided with the relevant information to make an informed choice as to whether to move into the home or not. EVIDENCE: The registered manager, with the support of residents, has produced a comprehensive statement of purpose, which contains the information stipulated in Schedule 1 of the Care Homes Regulations. The service user’s guide is also comprehensive and up to date and includes the summary of the previous inspection report. The statement of purpose and the service user’s guide, were both revised in May 2005. The home has an admissions procedure, which contains the procedures for preparations by staff prior to a new resident moving into the home. It also contains the procedures to follow when the new residents actually moves into the home and the residents immediate requirements. New residents are provided with an induction and an explanation of the policies and procedures and the medication needs, which is kept in their file. The registered manager said that the deputy manager, assistant head of home or himself carry out the initial assessment of prospective residents. Information regarding resident’s assessments were seen in their file. The home provides residential care to the Jewish community, ensuring that all traditions and religious beliefs are met. Some of the staff are themselves RELA GOLDHILL LODGE Version 1.10 Page 9 Jewish and have a good understanding of Jewish customs. The most recent member of staff was spoken to and found to have a reasonable knowledge of the Jewish faith. Residents spoken to were satisfied with the way in which their ethnicity is adhered to by the staff. The home does provide emergency or respite care and information is available in the home’s statement of purpose. RELA GOLDHILL LODGE Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8, 9 and 10. Residents are able to voice their opinions and individual needs and are confident that any information regarding them is kept safely and securely in the home with access limited to a need to know basis. EVIDENCE: The home has a Project Group. The stated aim of the group is to provide a “collective voice”, in improving the quality of life for residents in and outside of Rela Goldhill Lodge, as an action group. All residents are invited to the meetings. The project group is in addition to the residents meetings and as stated in the minutes of the first project group meeting, the group is to look at issues other than just the day to day running of the home. The first project group meeting was held on 6th June 2005 and will in future be a monthly meeting. Residents were able to discuss issues regarding their GP, health and safety, relocation of the home, staff shortage and access to buses. At the residents meeting on 6th May 2005, the minutes showed that residents were able to discuss issues regarding the garden, holidays, the project group and the blue bathroom, which was out of use for a few days. The home has a risk assessment file, which contains information on risks inside and outside the home to residents and the action taken to minimise the risks. The registered manager said that senior staff carry out all risk assessments. RELA GOLDHILL LODGE Version 1.10 Page 11 The files showed that the risk assessments were reviewed in May 2005 as per a requirement at the previous inspection. Two residents who are wheelchair bound, stated that they are able to travel independently to local shops if they so wished. The home has a missing persons procedure and the two residents spoken to, said that they are aware that they should inform staff if they are leaving the home for safety reasons. At the previous inspection, a requirement was made that all resident’s files are contained in a lockable cabinet this requirement has been met. All resident’s files and confidential information was kept in the staff office in a metal lockable chest of drawers. The home has a policy and procedure document on residents or others who may wish to view information contained in resident’s files. Application must be made to the registered manager. RELA GOLDHILL LODGE Version 1.10 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 16 and 17. With staff support, residents have the opportunity to develop emotionally and educationally within the home and outside in the community. Resident’s rights are being respected and residents are treated with respect and dignity by the staff team. EVIDENCE: The registered manager stated that residents are supported in their personal development by the staff team. He went on to say that two residents attend college for computing and basic business studies. Also, another resident does data processing as voluntary work five days a week and has his own greeting cards business, which his father provides support for. The registered manager also stated that Jewish Care has an employment project for getting residents into some form of work. Two residents spoken to said that they are able to access local shops either on their own or with staff support. One said that he enjoys going out alone and knows the local area. The registered manager stated that some residents access their local synagogue and that some residents go to pubs and shops in the area. All of the residents are Jewish and are supported in asserting their RELA GOLDHILL LODGE Version 1.10 Page 13 identity by the staff team. The home is located in a predominately Jewish area with Jewish shops, places of worship and other Jewish community activities and support available to them. One resident has, in his bedroom, computing equipment, Digital Versatile Disc, DVD player, a television, a telephone, a stereo system and other audio and communication equipment, which is part of his interests. He also has his own greeting card business, which is co-ordinated from his bedroom. The newly appointed activities co-ordinator was spoken to and discussed her duties and responsibilities regarding activities for residents. Residents and the activities co-ordinator were observed arranging flowers, which were put on display in the hall. Throughout the inspection, staff were observed interacting with residents. At all times staff were courteous, and supportive of residents. Staff were observed knocking on resident’s bedroom door prior to entering. Staff were overheard using resident’s first names when speaking to them. Staff were also observed spending time talking to resident individually, singing and generally interacting with residents when they had spare time and not with each other. The home has three chefs who provide wholesome nourishing meals to residents. The homes four weekly cyclical menu was seen. It contained a variety of meals that, as staff and two residents said, is compiled by the staff and the residents. The chef was spoken to and although not Jewish, he has a good knowledge of observed appropriate practices regarding meals and residents with special dietary needs. Lunch was taken with the residents. All residents seemed relaxed and chatted freely. Staff were observed supporting residents who needed support with eating. The staff were patient and residents lunch was unrushed. RELA GOLDHILL LODGE Version 1.10 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. Residents’ personal care needs are being met in a way that they prefer and to their requirements by a competent staff team. EVIDENCE: The home has bathrooms and shower rooms on each floor, which are lockable to ensure residents’ privacy and dignity when staff are supporting them with their personal care. On a tour of the building, the registered manager ensured that he knocked on bathroom/shower room door prior to entering. Doors were appropriately locked when residents were inside. The registered manager described how staff support the residents with their personal care, especially when being transferred from their bedroom to the bathroom. The registered manager also described how residents are transferred from their wheelchairs into the bath. All bathrooms and shower rooms had specialist lifting equipment and special baths and showers for residents with physical disabilities. One resident spoken with is wheelchair bound. She said that staff are very supportive and sensitive when doing her personal care. She went on to say that she was able to get up and go to bed when she wished and that staff were very helpful. At the previous inspection, a resident was concerned by the lack of communication of one of the night staff who supports him with his personal care. At this inspection, the same resident was spoken to and said that there has been improvements with the said member of staff. RELA GOLDHILL LODGE Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Residents are assured that any complaints that they may make will be taken seriously and thoroughly investigated and that the homes recruitment and training programme will protect them from any form of abuse. EVIDENCE: The home has a comprehensive complaints policy and procedure, which outlines how and who to complain to and the investigation procedure. There is also information contained in the statement of purpose and complaints file regarding making a complaint, with the Commission’s address and telephone number included. Two residents were asked if they have had to make any complaint since the previous inspection. Both said that they have not had to make any complaint and both were aware of whom to speak to if they wanted to complain about anything or anyone. At the previous inspection, there were some concerns that the domestic staff, who work in the home regularly, did not have proof of a Criminal Records Bureau (CRB) check. The registered manager said that all domestic staff now have a CRB. The registered manager went on to say that all CRBs are kept with the domestic contractors and produced a copy of the domestic staff’s CRB number, the name of the person and the date that the CRB check was obtained. All staff spoken to had received protection of vulnerable adults training, including the newest member of the staff team who has been working at the home for the past four weeks. She was able to appropriately relate her understanding of abuse. RELA GOLDHILL LODGE Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. Residents are provided with all of the homely comforts and specialist equipment in order to meet their needs and to ensure that they are comfortable and safe and that their privacy and dignity is maintained at all times. EVIDENCE: Jewish Care has been proactive in ensuring that all residents are safe and protected from strangers entering the home. The entrance to the home has a discrete close circuit television, (CCTV) system, with monitors in the office to monitor who is entering the home. Visitors must first press the bell and identify themselves before being allowed into the building. The home has been designed to meet the needs of residents with physical disabilities and those who use wheelchairs. One resident spoken to, was not happy with the condition of part of the home. On touring certain parts of the home with him, he pointed out areas where damp had caused the plaster to flake. He also highlighted areas where there were hairline cracks in the wall and areas where plaster had fallen off. He said that he was not happy with the condition of these areas. On speaking to the RELA GOLDHILL LODGE Version 1.10 Page 17 registered manager, he stated that he was aware of the maintenance issues and that they would be sorted out in the near future. A requirement is made that the maintenance issues identified in this report are rectified. All of the bedrooms in the home meet the National Minimum Standards for room sizes. Three resident’s bedrooms were viewed, all contained sufficient furnishings and fittings. All have en-suite shower/toilet. The rooms were decorated and equipment provided was a reflection of resident’s preferences, hobbies and interests. One resident spoken to said, “I really liked my bedroom and I like living here”. All resident’s bedrooms have en-suite facilities. In addition, there are also bathrooms and shower rooms on each floor, all specially equipped to meet the needs of residents with physical disabilities. All communal areas of the home seemed comfortable. Two residents spoken to said that they were comfortable in the home and that the staff look after them well. The registered manager said that most residents prefer to remain in the lounge/diner on the first floor and at times in their bedroom. There is also another lounge come kitchen on the second floor, which is not used much. The registered manager said that it is mainly used for independent living skills training. There is also a staff room and an area for staff lockers. The home has ensured that the needs of all of the residents with physical or sensory disabilities are met. Residents have walking frames and electric wheelchairs for moving about the home freely. There are also two lifts and the home is equipped with hoists. All bedrooms, bathrooms/shower rooms, toilets and communal areas are fitted with call alarm systems. Whilst touring the building, the alarms were tested in two resident’s bedrooms and a bathroom. On each occasion staff had called on the intercom within a minute to ascertain what may be wrong. On checking the lift maintenance book, there had been a number of occasions when one of the lift doors were not opening and closing properly on 5th June 2005. On enquiring about the lift certificate of inspection, the registered manager could not find it. He also stated that there was an ongoing dispute regarding who is responsible for the maintenance of the lifts. A requirement is made that the registered persons ensure that the lifts are inspected and serviced regularly and that the certificate is available for inspection. RELA GOLDHILL LODGE Version 1.10 Page 18 On touring the home, it was found to be free of any offensive odours. The premises was clear and tidy throughout. The home also has a policy and procedures file on the control of infectious diseases. RELA GOLDHILL LODGE Version 1.10 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34 and 35. Residents are confident that the staff team have the skills and experience to meet their needs and that they are generally protected by the homes recruitment procedures. Although the home is not ensuring that they have comprehensive information on all staff working in the home. EVIDENCE: Five staff files were viewed, all contained the information required in Schedule 2 of the Care Homes Regulations. Staff files also contained their Criminal Records Bureau checks. At the previous inspection a requirement was made that all staff have a copy of their job description in their file. On viewing five staff files, including the most recent member of staff, all contained a copy of their job description. Five staff members were spoken to individually and in private. Each had a good knowledge of the residents. The newest member of the staff team, although not Jewish, had a good basic understanding of some of the Jewish customs. The majority of the staff spoken to had been employed in the home for many years and have the skills and experience to meet the needs of the residents. Staff turn over is relatively low. The registered manager said that there are staff meetings every week. The minutes of the most recent staff meeting, which was held on 1st June, was seen and contained discussions on transferring RELA GOLDHILL LODGE Version 1.10 Page 20 telephone calls in the home, Shabbat/Sabbath, tidying of the office, night staff coverage and resident’s meetings. Through looking at three staff files, there was evidence that staff were being recruited appropriately. Staff files seen had two references and Criminal Records Bureau checks and terns of conditions. A requirement was made at the previous inspection that all staff working in the home has Criminal Records Bureau checks, including the domestic staff. The registered manager stated that all domestic staff files are kept at their agency. There was however, copies of confirmation from the agency informing the home that alls domestic staff have CRBs, with their name, date and the CRB number supplied. There were no personal files for the domestic staff working in the home, which was part of a requirement at the previous inspection. A requirement is made that all domestic staff who are regularly working in the home must have their own individual file. This requirement is restated. On speaking to the newest member of staff, she stated that she has completed the training in the protection of vulnerable adults and has other courses coming up. The registered manager stated that all staff working in the home have now received training in the protection of vulnerable adults. RELA GOLDHILL LODGE Version 1.10 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 40, 41 and 42. Resident’s health and safety is being put at risk due to the registered providers not ensuring that fire drills are carried out regularly and that the water tank is kept clean. EVIDENCE: The registered manager’s approach throughout the inspection was professional and cordial. There are regular staff and residents meetings to enable staff and residents to voice their opinions and concerns. Residents have taken a lead role in forming a project group, which is different from the resident’s meetings and in addition to the resident’s meeting. A requirement was made at the previous inspection that all staff concerns and complaints are dealt with in a supportive manner. Two staff spoken to said that there had been some improvement and issues were discussed at staff meetings. The home has developed the written policies and procedures as set out in appendix 3 of the Care Home Regulations 2000 and which are appropriate to the home. RELA GOLDHILL LODGE Version 1.10 Page 22 All personal files and records pertaining to the residents, staff and the home are kept in the main office or the staff office in lockable cupboards. The registered manager had done some work in ensuring that staff files are up to date and in a structured format. The registered manager stated that all staff, including the newest member of staff, have completed the lifting and handling course. The home has a fire safety file, which includes policies and procedures. Records viewed showed that tests are carried out of fire alarms on a weekly basis from various points in the home. The last such test was carried out on 17th June 2005. Staff recently completed fire safety training on 16th March and 8th June 2005. The file showed that the last fire drill took place on 6th September 2004. The registered manager realised that fire drills must be carried out more frequently in the home. A requirement is made that the registered persons ensure that fire drills are carried out on a quarterly basis and a record of the test and outcomes is kept in the home. Records show that the last emergency lighting test was carried out on 10th December 2004. The last fire authority inspection visit took place on 24th February 2005 and took three hours. The report highlighted that some fire doors were not closing correctly. Records show that the aforementioned doors were repaired on 9th May 2005. There was also a certificate of fire alarm test carried out on 14th December 2004 and an emergency lighting test carried out on 9th December 2004. The certificate of gas service was seen and showed that the gas system in the home was tested on 15th January 2005 and was satisfactory. There was also a hygiene certificate dated 17th April 2005 for the kitchen. The home’s electrical system was tested on 5th March 2004 and the home received a Portable Appliances Test in October 2004. A portable water analysis was carried out on 21st March 2005 of the domestic water system. The storage tank was found to have a moderate amount of sediment/debris inside. The inspector recommended that the tank be cleaned and chlorinated. The registered manager stated that he is awaiting a cleaning date. A requirement is made that the registered persons ensure that the water tank is cleaned and that they obtain a further certificate from an authorised provider to show that they have received a new water test, which is free from legionella and a copy of the certificate of cleaning is forwarded to the Commission. RELA GOLDHILL LODGE Version 1.10 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 2 3 Standard No 11 12 13 14 15 RELA GOLDHILL LODGE x 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 3 x 2 3 x Version 1.10 Page 24 16 17 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x 3 x 3 3 1 x RELA GOLDHILL LODGE Version 1.10 Page 25 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 YA24 Regulation 23 (2) (b) and (d) Requirement Timescale for action 08/08/05 2. YA29 3. YA34 4. YA42 5. YA42 The registered persons must ensure that maintenance issues identified in this report are rectified. 23 (2) The registered persons must (b), (c) ensure that the lifts are regularly inspected and serviced and the that certificate is retained in the home. Schedule The registered persons must 2 and 4 ensure that all domestic staff and 17(2) who are regularly working in the (a) and home must have their own (b) individual file. (Timescale of 28/02/05 not met). 23 (4) (c) The registered persons must (i) and (v) ensure that fire drills are carried and (e) out at least quarterly and a record kept of the test and outcomes. 13 (3), The registered persons must (4) (c) ensure that the water tank is cleaned and that they obtain a further certificate from an authorised provider to show that they have received a new water test, which is free from legionella and a copy of that certificate, is forwarded to the Commission. . 08/08/05 08/07/05 29/07/05 29/06/05 6. RELA GOLDHILL LODGE Version 1.10 Page 26 7. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations RELA GOLDHILL LODGE Version 1.10 Page 27 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI RELA GOLDHILL LODGE Version 1.10 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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