Inspection on 23/11/05 for Rosemont Road, 62

This inspection was carried out on 23rd November 2005.

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

Other inspections for this house

Rosemont Road, 62 19/04/06

Rosemont Road, 62 13/06/05

Rosemont Road, 62 12/01/05

Rosemont Road, 62 19/08/04

Rosemont Road, 62 15/10/03

Rosemont Road, 62 21/05/03

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Rosemont Road, 62 Acton London W3 9LY Lead Inspector Sarah Middleton Unannounced Inspection 10:50 23 November 2005 rd Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 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 Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 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. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosemont Road, 62 Address Acton London W3 9LY 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) 0208 752 1165 00000000000 Ealing Consortium Limited Mr Leigh Pain Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: 62 Rosemont Road is a home registered for three service users with learning disabilities and additional physical disabilities. All three of the service users are wheelchair users. The home opened in 1994 and is situated in a quiet residential area of Acton. The shopping centres of Ealing and Acton are within easy access. The home is owned by a housing association and managed by Ealing Consortium Ltd. The house is a semi-detached property on two floors. There is a lift between the ground and first floor. A lounge, dining room, kitchen, laundry and assisted bathroom are all located on the ground floor. The first floor has three bedrooms and an office. There are wide corridors suitable for wheelchair users. The garden to the rear of the property has recently been improved for the service users to access. The staff team consists of the Registered Manager and a team of support workers. They provide twenty-four hour care and support with regard to personal care and practical tasks. The home has one waking night member of staff working during the night period. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of just less than three hours, 10.50am-1.45pm, was spent at the inspection. The Inspector carried out a tour of the home and inspected service user plans and maintenance records. Two staff were spoken with and one service user very briefly was spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with learning and communication disabilities. One of the previous eight requirements was met at this inspection and several new requirements were set at this inspection. The Registered Manager was not present during the inspection although he was consulted on the telephone where the Inspector had any queries or questions. What the service does well: What has improved since the last inspection? The home had met one previous requirement regarding writing dates of opening on liquid medication. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 6 What they could do better: The home must consider how to meet the requirements, as many are re-stated from the last inspection. The staff team should be aware of whether requirements have been met and the location of particular records to ensure the Inspector can inspect the home thoroughly with or without the presence of the Registered Manager. Two of the requirements are regarding the maintenance of the home. The lift, although had recently been fixed, does not always operate, as it should do. Therefore this remains outstanding as needing to be resolved. Secondly the central heating was not working at the time of the inspection. This has been an ongoing problem for several months. Records indicated that the Registered Manager had contacted the relevant person to fix the problem and several visits had been made to the home without any success. This must be monitored to ensure service users health and safety is not jeopardised by ongoing problems with the maintenance. Furnishings and flooring must be cleaned or replaced if they are stained, worn or damaged to ensure the home provides a warm and homely environment for service users and visitors. Care plans and information on service users needs must be clearly dated and reviewed on a regular basis to ensure they are relevant to the current needs of the service user. Health and safety records must be in order and equipment must be tested as required. These must not be out of date to ensure service users welfare is safeguarded. In addition fire drills must be held regularly to ensure both staff and service users are aware of how to respond in the event of a fire. Training must be available on relevant subjects, for example on the protection of vulnerable adults and infection control. This must be offered for both new staff and existing staff to ensure they have the skills and knowledge required to carry out their work effectively. Medication must be administered as prescribed and signed for on the medication administration record sheets. There were several gaps identified on the records with no explanation for these gaps and a tablet left in one of the service users blister packs. The CSCI had not been contacted regarding these errors. The home must be vigilant and report any incidents/errors to the CSCI with appropriate investigations held to identify why these errors had occurred. The home must carry out a review of the quality of care, this includes examining Regulation 26 reports, sending out questionnaires, gathering service users views and any other internal audits carried out. Once all of these have Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 7 been completed an annual report of the overall findings must be available for the CSCI and service users. Finally staff files were not viewed, as the Registered Manager was not present during the inspection. However, they were spoken with on the telephone regarding the contents of the staff files held in the home. There have been consultations regarding information to be held in the home. Until this is resolved all information noted in Schedule 2, including Criminal Record Bureau checks, should be available for the Inspector to ensure recruitment systems are robust and protect service users. 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. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The terms and conditions/contract was not available for inspection. These documents must be in place for the service user and/or their representatives to ensure they have sufficient information regarding the home and the agreement for them to reside in the home. EVIDENCE: Terms and conditions and/or a contract from the placing Local Authority could not be located on individual service user files. Staff spoken with were not aware of the location of these documents, or if they were in place. There have been ongoing difficulties in obtaining a contract from the placing authority, however terms and conditions in respect of the accommodation must be available along with any agreement between the provider and the Local Authority. This is a re-stated requirement. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Overall the health and personal care needs of service users had been identified. Improvements could be made regarding ensuring files hold relevant and up to date information about the service user. Some documentation was not dated, this must occur to ensure all aspects of the care plan are relevant to the current needs of the service user. Where possible service users are encouraged to make decisions. However, as the lift door does not open automatically, one service user’s independence is limited in the home, as they have to rely on staff to assist in opening the door of the lift. This ongoing problem must be addressed. Risk assessments were in place and noted potential risks in a service users life and ways to minimise those identified risks. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 11 EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive although information on service users were in different files, which at times made it difficult to clearly locate information about the individual service user. Monthly summaries had been completed by the keyworkers and six monthly reviews had been held. Service user’s files must be monitored, as on one service user’s file there was information about another service user. Some of the information on the files could have been filtered out to ensure the most relevant and up to date information was available for the Inspector and any staff working with the service users. One file had been sorted through and a member of staff acknowledged the need for a file that clearly indicates service users needs. Some of the documentation viewed on service users did not have dates on them. Therefore it was not clear when it had been developed. This is a requirement. The lift door was recently fixed, however it continues to have problems in automatically opening when one of the service users might want to use the lift independently. This ongoing problem has been reported numerous times by the Registered Manager and has been reported on Regulation 26 reports. However as this problem has not been resolved this is a re-stated requirement. The service users are encouraged to make decisions, and although two service users are non-verbal, staff felt overall they could identify when a service user is happy or unhappy. One staff member did state they had asked the Registered Manager for training on communicating with service users who are non-verbal, to ensure they are working to the best of their ability and meeting the needs of the service users. Often staff acknowledged service users likes/dislikes are known through experience of working in the home and recognising when they are making a choice/decision about something. Risk assessments were in place and covered a variety of areas of a service users life, such as eating and drinking, moving and handling and their environment. These were up to date and reviewed earlier in the year. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 Social activities were in place and aimed to offer a varied life for service users where they could also access community resources. Visiting and seeing family or friends is promoted by the home to maintain contact and relationships. Mealtimes and meal provision is well managed and service users are offered a varied and healthy diet to maintain optimum health. EVIDENCE: Due to the level of disabilities the service users are not able to seek employment however they have various interests and staff aim to provide stimulation and occupation for the service users on a daily basis. Day centres are accessed and service users often receive one to one support to go out and access community resources such as shops, or restaurants. Where possible service users also use public transport to visit places such as the zoo. Staff are aware of service users abilities and preferences and seek to offer opportunities to use as much of the community facilities they can access. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 13 Visitors are encouraged to the home and staff support service users to visit their families on a regular basis. Menus were available and reflected choices. Staff said service users showed in different ways if they did not like a particular meal, for example pushing the food away or not eating it. Individual meals are recorded to ensure staff can monitor the diet of service users. Two service users were eating a takeaway during the inspection with staff cutting up food and assisting service users where needed. Lunchtime seemed unhurried and staff interacted positively with the service users. The kitchen was clean and tidy at the time of the inspection. Food opened and stored in the fridge had dates of opening written on them. Fridge temperatures were taken and were recorded within an appropriate range. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Service users receive personal care in private from staff. The home monitors specific gender care and records, where needed, any care given and where relevant, reasons why, to ensure service users and staff’s welfare is protected. Shortfalls in the recording of medication administered or reasons why it has not been administered must be addressed to safeguard service users health and safety. EVIDENCE: Service users require various levels of personal care support by staff and some can indicate preferences regarding specific gender care. Due to a recent reported situation/incident, if there are only male members of staff working on a shift and they need to assist with personal care for one of the female service users, then two members of staff must be present and it must be recorded. One staff member spoken with was supporting a service user with personal care at the start of the inspection. They were aware of when the service user could be left alone to wash independently and when they were needed to offer assistance. Service users are encouraged to choose the clothes they want to wear and can decide when they want to get up or go to bed. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 15 Staff spoken with stated they communicate relevant information to staff, in handover, supervision or in staff meetings. This is in order to share any changes or thoughts on a service user and to work in a consistent way. Samples of the medication administration records were viewed. One service users tablet was still in the blister pack, yet it had been signed for as if it had been administered. In addition there were several gaps where staff should have signed the records. This is a requirement. Where medication errors have occurred, the Registered Manager must investigate these errors and take appropriate action. In addition the CSCI must be informed when medication errors have occurred, along with the action taken following identifying the error. Liquid medication had a date of opening on it. The home does not hold controlled drugs and no service users self medicate. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There is a complaints procedure in place, although the home must constantly be aware of the service users needs and abilities in being supported to make a complaint. Systems are in place for the protection of vulnerable adults, POVA, however staff must receive information and training on this subject to ensure staff have the skills and knowledge to respond appropriately in the event of a potential POVA situation. EVIDENCE: The home’s complaints file had no record of any complaints having been made. The CSCI has not directly received any complaints. It is difficult to ascertain how able and confidently some of service users would be able to make a complaint to someone if they were unhappy about something in particular. This is where staff must be vigilant with regards to service users behaviour and methods of how they communicate to ensure service users have an opportunity to let someone know if they have concerns or a complaint. There have been no formal protection of vulnerable adults, POVA, investigations, although as mentioned earlier there has been a reported incident that the Registered Manager, in consultation with the local authority’s POVA co-ordinator is investigating. The Inspector has been informed of the incident and the Registered Manager had sent documentation regarding the investigation so far. The home has adjusted some of their procedures for when staff are assisting with personal care in order to protect both service users and staff. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 17 At the last inspection it had been identified that most members of staff had not received training on the protection of vulnerable adults. Due to recent events it is imperative this is a priority and that staff have up to date knowledge and information about this sensitive and important subject. This is a re-stated requirement. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Overall the environmental standard of the home is satisfactory. However flooring that becomes stained must be either cleaned or replaced in order to offer a homely and pleasant home for service users. Furthermore, the heating and boiler in the home must be in good working to provide a safe and warm environment. Service users bedrooms were individualised and offered the space to create a private room for service users to relax in. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. One service user’s bedroom on the first floor looked worn and had several stains on it. This must be cleaned or replaced. This is a requirement. Overall the home is bright and homely with photographs on the walls, making it feel personal for the service users. The home has been having problems with the central heating and the boiler for several months. On several occasions the problem has been reported to the appropriate person and a maintenance person has come to the home to fix the boiler/heating. However on the day of the inspection the heating was not working, small heaters were being used to keep the home at a warm temperature. As winter approaches this ongoing problem must be resolved. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 19 The Inspector was informed the maintenance person was to return to the home in two days time to fix the heating. A requirement was made that the heating must be maintained in good working order. Bedrooms are single rooms and are individual, personalised and spacious to offer service users time in their rooms if they want privacy. One service user likes to have photographs of members of staff who are working and the activities they are taking part in each day. This is on a large part of their bedroom wall. The home was clean and tidy at the time of the inspection. The laundry room was not viewed at this inspection. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Service users are supported by competent staff, who receive regular training. The training offered covers NVQ courses and other relevant subjects in order to meet service users needs. Staff must receive training and information on infection control to ensure staff are fully aware of the guidelines, policies and procedures to protect service users health and welfare. The staff team aim to work in a consistent way in order to offer continuity of care. Staff employment files were not viewed but must contain all documents as listed in Schedule 2 of the Care Standards Act 2000 in order to safeguard service users. EVIDENCE: Staff are encouraged to study the NVQ courses and most of the staff had either finished the NVQ level 2 or were in the process of completing it. Staff described how they felt equipped to meet the needs of the service users through training, experience and through sharing and receiving information with other members of staff. Staff have an awareness of the communication needs and health needs of the service users. Those spoken with were confident they could understand and meet the identified needs. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 21 As noted earlier, where staff recognise the need to receive refresher information or up to date theories on how to effectively communicate with service users who are non-verbal, then staff feel able to request this additional support. One staff member has recently left the team and one new member joined the team a few months ago. Therefore there are staff vacancies, however, the home has a regular team of relief workers who work shifts as and when required. Staff meetings have not been held every month and as it is a small team, not all staff attend every meeting. It is recommended that staff meetings are held more frequently. Staff spoken with said the team worked well together. Staff employment files could not be viewed, as the Registered Manager was not present at the inspection. However the Inspector spoke to him on the telephone and they confirmed that on some staff files, the Criminal Record Bureau checks are stored at the head office and not in the home. This is an ongoing situation and is a re-stated requirement. Individual staff training records were viewed. Staff had not received training on infection control, this is a re-stated requirement. Staff had received training on mandatory subjects such as food hygiene, epilepsy and moving and handling. Staff spoken with were happy with the level of training offered to them. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39 & 42 The Registered Manager has an open style of management and has a visible presence in the home on a daily basis. There must be a system in place to demonstrate that the home has carried out a quality assurance review in order to identify ways to improve the quality of life for service users. A report of all the findings must be available for both the CSCI and service users. The shortfalls in servicing records could pose a risk to service users, staff and visitors safety. In addition, fire drills must take place on a regular basis in order for staff and service users to know how to respond effectively in the event of a fire. EVIDENCE: Staff spoken with commented on the approachable manner of the Registered Manager. Staff were comfortable in approaching the Registered Manager if they had any concerns or queries. The Registered Manager works shifts alongside staff to ensure they have a visible presence in the home. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 23 A report of any reviews that have taken place in the home was not available for inspection. This had been a previous requirement at the last inspection. The home must continuously look at the care offered, using various methods to achieve the information they need. Through carrying out regular reviews the home can identify areas that need improving and acknowledge areas that work well in the home. Servicing records were viewed at random. The testing for Legionella was out of date, as was the Portable Appliance testing. This is a re-stated requirement. The systems for maintaining service records needs to be reviewed and a robust system implemented, as old certificates and records could be stored elsewhere in the home to ensure it is easy to locate up to date information on items that have been serviced and tested. The fire equipment had been tested but there had only been two fire drills this year. Fire drills must be more regular, held at different intervals and with different members of staff. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rosemont Road, 62 Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 2 x DS0000027741.V254913.R01.S.doc Version 5.0 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 YA5 Regulation 5(1)(b) & 5(3) Requirement A contract/terms & conditions with the Local Authority must be available to the service users. (Previous timescale 03/10/05 not met) Service user’s care plans & personal care needs must be dated, up to date & reviewed on a regular basis. The Registered Person must ensure that every effort is made to maintain the lift so that it can be used independently. (Previous timescale 03/10/05 not met) Medication Administration Sheets must accurately reflect medication that has been administered. If it is not administered the reason must also be recorded on these sheets. The Registered Person shall make arrangements by training or through other measures, on the protection of vulnerable adults. (Previous timescale 01/09/05 not met). Timescale for action 28/02/06 2. YA6 15(2)(b) 31/01/06 3. YA7YA29 12(1)(b) 23(2)(n) 31/01/06 4. YA20 13(2) 23/11/05 5. YA23 13(6) 31/03/06 Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 26 6. YA24 7. YA24 8. YA34 9. YA35 10. YA39 11. 12. YA42 YA42 The carpet on the 1st floor in one service user’s bedroom must be cleaned & made good or replaced. 23(2)(c) The central heating & the (p) ongoing problems with the heating & boiler must be fixed & maintained in good working order. 19(1) The Registered Person shall ensure employment records are available for the CSCI at the inspection. (Previous timescale 01/08/05 not met). 18(1)(c)(i) The Registered Person must ensure that staff receive training in areas relevant to the work they are to perform, for example on Infection Control. (Previous timescale 01/09/05 not met). 24 Regular reviews of the quality of care provided in the home are required to be carried out & a report of the findings made available for service users & CSCI. (Previous timescale 03/10/05 not met). 23(4)(e) Regular fire drills must be held & at different intervals with different members of staff. 13(4) Up to date servicing records 23(2)(c) must be available in the home for inspection. These include, the testing for Legionella and Portable Appliance Testing. (Previous timescale 01/08/05 not met). 23(2)(d) 31/03/06 25/11/05 28/02/06 31/03/06 31/03/06 23/11/05 31/01/06 Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 27 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 YA33 Good Practice Recommendations It is recommended that staff/team meetings are held on a regular basis. Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Rosemont Road, 62 DS0000027741.V254913.R01.S.doc Version 5.0 Page 29 - 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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