Inspection on 20/09/06 for Selwyn Road (1-3)

This inspection was carried out on 20th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Selwyn Road (1-3) 01/11/05

Selwyn Road (1-3) 21/06/05

Selwyn Road (1-3) 20/01/05

Selwyn Road (1-3) 24/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Selwyn Road (1-3) 1-3 Selwyn Road Bow London E3 4PX Lead Inspector Anne Chamberlain Unannounced Inspection 20th September 2006 10:15 Selwyn Road (1-3) DS0000010303.V311987.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 Selwyn Road (1-3) DS0000010303.V311987.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. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selwyn Road (1-3) Address 1-3 Selwyn Road Bow London E3 4PX 020 8983 0036 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) Outward Gloria Lambert-Morris Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: Selwyn Road is situated in the vicinity of Roman Road, off the Mile End Road. The area has good public transport connections with buses and underground trains going west to the centre of London and east past Stratford. Selwyn road is a residential home for 5 adult women with learning disabilities and some challenging behaviours. It comprises two adjoining houses. House number 1 has a ground floor bedroom with en-suite facilities, lounge kitchen and conservatory. On the second floor there are a further two bedrooms with hand basins and a shared bathroom/toilet, also the office/sleep in room. House number 3 has a kitchen and lounge with doors on to a small garden shared with number 1. On the first floor are a further two bedrooms with hand basins and a shared bathroom with separate toilet. The fees of the home are £1,190.25. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Between this and the last key inspection a random inspection has taken place. The findings were reported in the form of a letter to the providers, a copy of which can be obtained on request from the Commission for Social Care Inspection (CSCI). The inspector discussed with the manager, progress on the issues which were the focus of the random inspection. The inspection took place over one day and the aim was to inspect all key standards plus progress on any requirements which were made at the last key inspection. The inspector interviewed the manager and two members of staff. She spoke to three residents and observed the interaction between them and the staff. The inspector viewed key documentation and records, and various files which contain information relevant to residents. The inspector viewed the arrangements for the administration of medication. She made a tour of the premises, excluding four residents bedrooms, as the residents were not in. She also viewed the front and rear gardens. The inspector would like to take this opportunity to thank the residents, manager and staff at Selwyn for their co-operation and assistance with the inspection. What the service does well: The service manages well the different challenging behaviours of the residents and the dynamics between them. There is a homely atmosphere and a staff member told the inspector she liked working at the service because its like a home. The health of residents is well monitored and supported. The manager and staff are skilled and patient. The manager works alongside staff and models good practice. Residents are supported to be as independent as possible and to use their skills and abilities. There is structure and a weekly routine but built into that is variety and choice. Staff are caring and try hard to make sure that residents have fun and enjoyment. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The information about the service is good. Assessment information could be better presented. EVIDENCE: The inspector viewed the statement of purpose and service user guide. They meet the requirements of regulation and the inspector would like to commend the manager on their clear layout and user friendly presentation. The inspector viewed the assessment information in a residents file. The assessment information is quite old and although there is updated information in various other documents like the resident information file, the inspector felt it would be best to produce a new updated assessment and archive the old information. The manager agreed with this and said that she is part way through doing this for all the residents. The inspector was quite satisfied that any prospective resident would be properly assessed before being offered a place in the home. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Support plans need updating. Residents take their own decisions and risks are assessed. EVIDENCE: The inspector viewed a support plan on a residents file. The plan was comprehensive including plans for meeting psychological needs. It was signed by the resident, but was two years old. The manager stated that support plans are revisited every 3 - 6 months. The inspector felt it would be best to produce a new updated support plan and archive the old information. The manager agreed with this and said that she is part way through doing this for all the residents. The manager explained that residents have regular keyworking meetings where they are encouraged to take individual decisions and make plans. The inspector viewed evidence of regular keyworking sessions with discussions recorded. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 11 There are also regular house meetings where residents make decisions. The inspector viewed the records of these and noted that they generally take place fortnightly. The manager gave the example of an invitation being received at the home for some outside event. This would first be discussed in a team meeting and then passed to the house meeting. The manager stated that a wide variety of risks are assessed and the inspector viewed evidence of this on file. However the inspector noted that on the file she was inspecting the risk assessments and service user plan had become mixed together and needed to be properly separated. Record keeping is discussed later in the report, under standard 41. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Residents engage in a wide range of meaningful activities. They enjoy a community presence and sustain good relationships with family and friends. Meals at the home are pleasant, and the food is nutritious. EVIDENCE: Four of the residents attend a local day centre and the fifth attends two other centres. In addition to this there are a range of activities inside and outside of the house which residents take part in. One resident is keen on craft activities and the inspector admired some models she had made in plasticine. The manager said that two of the residents have made themselves responsible for watering the garden in the evenings. One resident is having a 60th birthday celebration at the weekend and she had been shopping with her keyworker in the west end, the night before, for a new outfit. The manager stated that all the residents attend a local church most Sundays. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 13 Residents at Selwyn have good contact with friends and family. One resident has two sisters and visits them alternately every fortnight. Another sister visits her at home. One resident visits her parents every Saturday, another resident has a sister who visits alternate weekends and takes her out, another resident visits her Mum who lives close by. Her sister also visits. Another resident has a boyfriend. She visits him and he comes to see her with his keyworker. They see each other several times a year. The inspector viewed the activity and daily log sheets to evidence the community links, social inclusion and personal relationships which the residents enjoy. Daily log sheets evidenced the everyday routines of the residents. Every resident has a day when they catch up with laundry, room tidying and other chores. One resident has two days at home and she visits the local library on one of them, where she likes to use the computer. The inspector observed interaction between residents and staff and felt that residents are treated respectfully and they have built up trust in staff. The rights of residents are respected. The manager stated that letters are handed to residents unopened. They then usually ask their keyworker for assistance in reading the letter, and filing it in their personal file. The manager explained that there is a choice of breakfasts foods and residents have lunch at their day centres. When they arrive home about 3.30p.m. they are offered drinks, and dinner is around 6p.m. The residents choose in advance what they would like to eat, each contributing a dish idea. A menu plan is made. The inspector viewed the pictoral meals guide which the home uses to prompt menu ideas. The menu is very flexible and residents decide individually on the night whether they want to eat what is scheduled. There is always a good stock of other foods available. One resident sometimes says she does not want anything hot and would rather have a sandwich. Three of the residents are able to make themselves a sandwich. After dinner residents have free access to snacks including fruit. One resident is autistic and part of her behaviour pattern is snacking. She is encouraged to snack on fruit which is prepared and laid out for her. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Personal support is given sensitively and physical and emotional needs are met. Afterlife arrangements will be made in accordance with residents wishes. EVIDENCE: As well as in their support plan, the personal support needs of residents are recorded in an induction folder. All new staff can quite quickly acquaint themselves with the personal details and preferences of residents. In discussion with a staff member the inspector was told she had read the folder and it gave a good picture of each resident. The folder is illustrated with drawings for example, how to work a residents en-suite shower properly. There are only female staff working at the home. The manager discussed with the inspector the health needs of the residents and the arrangements which the home has for meeting them. The manager was able to discuss knowledgeably the medical investigations which one resident is currently undergoing. The manager explained that residents get their dental care and chiropody treatment from the local London Hospital. All the residents have some Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 15 challenging behaviour and the hospital is usually able to provide a nurse who is experienced in learning disability. This works better than using a local clinic, where the behaviour of the residents can sometimes cause difficulties. The inspector viewed the arrangements for the administration of medication. The residents at the home all take medication except one who has a number of creams applied to her dry skin. The medications are quite complex and as some of them are taken at lunchtime arrangements have to be made with the day centre. These arrangements appear to work effectively. Each resident has medication information i.e. a sheet which explains how I take my medication and a sheet giving information on each medication taken. There is also a medication administration record sheet (MARS) and a stock recording form, although this was missing in one case and incorrect in another. A staff member had made a sheet because she could not access a new printed sheet from the office over the weekend. The manager said that there are spare sheets but the worker had not realised this. The manager must reinforce the arrangements for spare MARS sheets with the staff. The inspector attempted to balance a medication. This was impossible and it was discovered that a delivery had not been written in. The manager must ensure that all medication received into the home is recorded. The manager must regularly audit the medication recording herself to ensure that it is correct. The previous key inspection required the manager to ensure that residents are given an opportunity to express their views and preferences regarding ageing, illness and death and have them recorded on their files. The manager noted on the file of a resident the notes of a meeting where ageing, illness and death had been discussed. The manager said that she had had a productive meeting with the resident and her sister. They had been able to make clear decisions regarding afterlife arrangements. The manager stated that she has been through a similar exercise with the other residents and has just two more recordings to type up and put on file. In addition the manager has made contact with the local undertaker and he going to come to the home to give the residents a little talk about the service he provides. The inspector felt that the requirement had been sensitively and effectively met. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The views of residents are considered and they are protected from abuse. EVIDENCE: The inspector viewed the complaints policy and procedure which has timescales. She also viewed the complaints form and the complaints recording form, progress log for a complaint and complaints monitoring form. The manager said that they had had a recent complaint from a relative that the television picture was not good. The house has two new televisions and they have both been tuned in. However the manager agrees the pictures are not good. And thinks the aerial needs adjustment. She has contacted Outward repairs and asked for someone to come and adjust the aerial. Unfortunately the manager was not able to locate the complaints folder but said she has telephoned the relative and advised him of the action taken. She has recorded the call and when the matter is fully resolved she will write to the complainant advising him. The inspector viewed the corporate protection from abuse policy and procedure. The policy refers to allegations being reported with the consent of the resident. The manager was clear however that it is not necessary to obtain the consent of a resident before reporting an allegation. She said she viewed the matter as non-negotiable, and was clear it is her duty to report any allegation of abuse with or without the permission of the resident. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 17 The policy refers to multi-agency working and states that the local authority social services will call a strategy meeting. The manager is fully aware that the procedure followed by the home must co-ordinate with the procedure of the local authority. The manager stated that she had tried to obtain the London Borough of Tower Hamlets protection of vulnerable adults policy and procedure, but had so far been unsuccessful, and was using a policy from a neighbouring borough. The inspector advised the manager to make a further attempt to obtain the local policy. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The environment of the home is good, comfortable, clean and hygienic. EVIDENCE: The inspector made a tour of the premises, excluding four residents bedrooms, as they were out. She viewed front and rear gardens. There were some requirements at the previous inspection and these had been met as far as possible. The manager is somewhat dependent on the landlords of the property, for some works. The premises were homely, comfortable and safe although redecoration is needed in places The manager has requested this and is waiting for the work to be done. In conversation with a staff member she told the inspector that she and another staff would like to further improve the home with greater attention to detail. She also said the home had been very hot during the summer and she Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 19 hoped that next year the home will have some air conditioning. The manager said that she is seriously looking into getting an air conditioning unit for the conservatory, which gets very hot. The manager stated that staff are aware of the need for hygiene and control of infection in the home. They wear gloves when assisting residents with personal care and anti-bacterial spray is used on surfaces. The home does deal with foul laundry and has ordered a washing machine which has a sluice facility. This will be installed in the downstairs laundry room, which will get a decor face lift at the same time. The inspector noted that the laundry room which in the other house on the first floor has an impermeable floor and the washing machine has a high temperature programme. The manager pointed out that she has posted a note to staff to ensure that the tumble drier is free of fluff, in response to a requirement made at the random inspection. Both kitchens looked clean and tidy on visual inspection. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Recruitment practice is good and the staff at the home are competent. They are trained and supervised. EVIDENCE: Both the staff members interviewed by the inspector had come to the home with considerable previous experience. The manager confirmed that previous experience is part of the organisations recruitment criteria. The manager stated that almost all the current staff group have NVQ 2. She said that anyone who joins the organisation without this is encouraged to undertake it. The inspector viewed the organisational recruitment policy which is robust and safeguards residents. She was not able to cross reference the policy with staff files as personnel information is kept at head office. The manager stated that in addition to their induction staff all have mandatory annual core training. Unfortunately she did not have the programme for this year printed but said it is available on the server. She did however show the inspector the programme for 2004-2005. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 21 The manager said that staff indicate in supervision what courses from the programme they would like to attend in addition to the mandatory training. The manager also showed the inspector the training profile which is sent to her by head office. This lists each member of staff and what training they have undertaken and when. Unfortunately it has not yet been updated for 2006. In addition to the above the manager has a file of training certificates where she can check on what training staff have undertaken. The inspector was satisfied that the staff are appropriately trained to meet the needs of residents. The manager stated that supervision is scheduled for once a month for all staff. Occasionally it is not possible to deliver the supervision due to sickness or leave. The inspector viewed supervision records for two members of staff which confirmed the above. The inspector noted that the supervision form was well designed and that the manager had recorded discussions and set goals appropriately. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The home is well run, and residents views underpin the quality assurance programme. Record keeping safeguards residents and their health and safety is promoted. EVIDENCE: The manager is now registered. She is well qualified to run the home and has many years experience in social care. The manager also has experience as a trainer and the week before was training other managers in the management of staff performance. The manager is currently undertaking NVQ 4 and said that when she has done this she plans to immediately undertake the Registered Managers Award. The home and wider organisation collects quality assurance feedback from residents in a number of ways. The home has two listening books. Staff are encouraged to record the requests of residents in these books, so that the Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 23 communication is not lost. A communication book is also used to keep track of things, and a diary. The manager stated that residents and families are sent questionnaires. A resident completed one recently with her sister. If family are not available keyworkers assist. They are advised by the manager to be as neutral as possible and encourage the residents to express their real views. The manager did not have feedback forms available to show the inspector as these are sent straight to head office. The residents also attend Outward forums which are user led and have an agenda set. The inspector discussed file management with the manager. Residents have a main file and a working file where current keyworking issues are recorded. Although record keeping in the home is generally good the inspector noted that keyworking notes had not been signed or dated. The manager agreed that the residents main files are unwieldy and contain a lot of information which could be archived. When the inspector attempted to locate information the punched pockets kept coming off the ring binders. The inspector felt that staff would be discouraged from using these files which would tend to waste their time. The manager agreed to remove from the main files information which could be archived. The inspector viewed evidence of safe working practices. The London Fire Brigade carried out an inspection of the home in July 2006. They noted two minor deficiencies, the need for an additional smoke alarm and the resiting of an outside fire exit. The manager confirmed that the smoke alarm has been installed and the resiting of the gate is in hand. The job has been measured up and she awaits the work. The fire risk assessment had been reviewed by the manager on 19/01/06.There was a weekly checklist for the emergency call system which had been completed up untill 5/09/06, fire alarm checks were completed up untill 10/09/06. The water temperatures had been checked up until 28/08/06 and fridge freezer temperatures were recorded up until 20/09/06. Food probe temperatures were recorded. There was a checklist for sleep in staff for locking the house up at night. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 2 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x 2 3 x Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA2 YA6 YA20 Regulation 14 15 13 Requirement The manager must update the assessment of residents needs, on their files. The manager must update the support plans on residents files. The manager must reinforce the arrangements for spare MARS sheets with the staff. The manager must ensure that all medication received into the home is recorded. The manager must regularly audit the medication recording herself to ensure that it is correct. The manager must ensure that keyworking notes are signed and dated by staff. The manager agreed to remove from the main files information which could be archived. Timescale for action 01/01/07 01/01/07 01/11/06 4. 5. YA41 YA41 17 17 01/11/06 01/01/07 Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 26 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 YA24 Good Practice Recommendations The manager to pursue an air conditioning unit for the conservatory for next summer. Selwyn Road (1-3) DS0000010303.V311987.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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. 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