Inspection on 24/04/06 for Shirley Gardens, 43

This inspection was carried out on 24th April 2006.

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

Other inspections for this house

Shirley Gardens, 43 16/04/07

Shirley Gardens, 43 24/11/05

Shirley Gardens, 43 21/10/04

Shirley Gardens, 43 29/07/04

Shirley Gardens, 43 09/10/03

Shirley Gardens, 43 29/07/03

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

CARE HOME ADULTS 18-65 Shirley Gardens, 43 Ealing London W7 3PT Lead Inspector Sarah Middleton Unannounced Inspection 24th April 2006 09.15 Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shirley Gardens, 43 Address Ealing London W7 3PT 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 810 0431 0208 567 1704 Ealing Consortium Limited Robert Michael Phillips Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: 43 Shirley Gardens is a facility for seven service users with mental health needs, both under and over 65 years of age. The home is also registered for people with physical disabilities but it is not wheelchair accessible and there is no lift or special equipment. Ealing Consortium Ltd manages the home. It is owned by Ealing Family Housing Association, who is responsible for repairs and maintenance. The home is a three storey house, located in a cul-de-sac in a residential area of Hanwell, close to the Uxbridge Road. Adjoining the home is a block of flats for eleven tenants for whom an outreach service is provided by the residential homes staff team. Some of the flats can be accessed from the homes office. The home has seven single bedrooms, located over the three floors, one of which is on the ground floor. The ground floor also has two small lounges, a dining room, kitchen, laundry, sleeping-in room and office. The first and second floor each have three bedrooms. There are three bathrooms with toilets, one on each floor, and two additional separate toilets. There is a staff shower in the sleeping-in room. The large car park is accessed from Shirley Gardens and there is a garden to the front, with access to the Uxbridge Road. The staff team consists of the Registered Manager, two senior support workers and support workers. There is one domestic worker. There is a minimum of two staff on each shift and one member of staff sleeps in at night. There is no waking night cover. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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. The inspection process was from 9.15am-4.30pm. The Inspector carried out a tour of the home and inspected service user plans, staff files and maintenance records. Three service users and two members of staff were spoken with as part of the inspection. It must be noted that it is sometimes difficult to ascertain the views of service users with mental health needs. There were no visitors at the time of the inspection. There were no service user vacancies at the time of the inspection. The Registered Manager was present and assisted with the inspection process. Two of the previous five requirements had been met, two had not and one had partially been met. The Inspector made an additional five new requirements from this inspection. All the key Standards were inspected during the inspection. What the service does well: What has improved since the last inspection? The home had been working on encouraging service users to carry out small independent living tasks, such as assisting with their laundry or making a snack. There are various systems in place to review the quality of care offered in the home this ensures areas needing improvement are identified and addressed. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 6 What they could do better: Activities must be offered on a regular basis to all service users. These can be as small and low key as service users feel comfortable with. However there must be a plan as to how to improve interest and motivation so that wherever possible service users keep their existing skills and possibly develop new skills. The recording of activities and tasks offered to service users is important to demonstrate the home is committed to supporting and encouraging service users to take part in activities and interests. The home must ensure the meals service users eat are, wherever possible, recorded. Staff can then monitor what type of foods service users are eating and whether this is sufficient to maintain a healthy weight. In addition food that is opened must be covered and dated when opened or prepared, so that service users do not eat out of date food. Health needs must be identified for all aspects of health care, including dentists and opticians etc. These needs must be evident on care plans and risk assessments must be completed if service users refuse to address particular health needs. The home must consider balancing service users choice against the home’s duty of care. Medication systems must be reviewed as a similar medication error identified at the last inspection was identified at this inspection. Staff must record when medication has been administered to safeguard the service users. Also creams and liquid medicines must be dated when opened to ensure out of date stock is not used. There have been ongoing issues regarding providing a secure entrance to the home. The main gates now have an intercom system, but no video camera. The lock for the gates does not currently work and therefore the gates were still left open. This entrance is used on a regular basis by the local community and therefore could pose a risk to the service users, their home and the surrounding area. This must be addressed as soon as possible to protect those that live and work in the home. Finally it was noted that there was a malodour on the first floor of the home, this must be addressed in order to provide a pleasant environment to live and work in. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 7 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. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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): 2&4 Service users are assessed prior to admission to ensure the home is confident they can meet their needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: The home had admitted a new service user four weeks prior to the inspection. The referrer had sent to the home information regarding the service user and the Registered Manager then carried out a pre-admission assessment to determine if the service user was suitable to move into the home. This assessment was viewed and detailed the prospective service users needs, such as, their health needs, ability to manage finances, their likes/dislikes and general abilities. The Registered Manager confirmed they would always aim to assess, along with another member of staff, any service user referred to the service to ensure as much information was gathered. The newly admitted service user confirmed they had made a few visits to the home prior to moving in. The Registered Manager, evidenced to the Inspector the planning involved in ensuring the service user had opportunities to visit, have a meal and stay overnight in order to meet other service users and members of staff. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 The service user plans viewed were detailed, relevant and reviewed on a regular basis, thus ensuring staff had information on how to meet service users identified needs. Service users are encouraged to make decisions and are supported to make choices throughout various aspects of their lives. Service users are able to take risks and guidelines are in place to identify and minimise risks. Risk assessments are to be completed regarding those service users who refuse to engage with health professionals, see Standard 19, as this had been an identified shortfall. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users identified personal and social care needs would be met. These were up to date and monthly summaries were available. Guidelines were also in place on each service user to promote a consistent way of working when supporting the service users. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 11 One care plan viewed was of the recently admitted service user. Staff had made clear guidelines and had identified potential risks to this service user. The Registered Manager explained this was an ongoing working document, as staff were still getting to know the service user and identifying further information about them. The Inspector was encouraged to see how much information was already available regarding this service user, as this ensured staff were aware of the service users abilities and limitations even at this early stage of their admittance. Daily records were viewed; some were very detailed and outlined care provided and any activities the service user had taken part in, however a few daily records were not so detailed. A recommendation was made that all daily records should be consistent in the detail and information written. Service users do not currently have independent advocates, the Registered Manager is aware of the need to promote this for the benefit of the service users. Where able, service users manage their own finances and this is encouraged in whatever way is suitable for the service user. Staff spoken with could describe various ways they support service users to make decisions in their lives. Staff were aware of individual’s likes and dislikes and worked to promote and encourage service users throughout their day. Risk assessments were viewed and those seen were detailed and up to date. All service users smoke and are allowed to smoke in their bedrooms. Risk assessments were in place for this potentially hazardous activity. Risk assessments had not been completed on those service users who refuse treatments and check-ups by some of the health professionals. This is a requirement combined with Standard 19. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16 & 17 Service users are encouraged to develop their personal skills. Some activities are offered to service users, however service users would benefit from more structured activities/tasks being offered to them. Those service users who can access local community resources do so as and when they feel able to. Staff support those service users who need assistance to go to out into the community to maintain social inclusion. Holidays and occasional day trips are offered to service users to give them a break away from the home and usual routines. Visiting is encouraged to maintain family and friends relationships. Service users rights are acknowledged and respected by the staff team. There are ongoing issues to ensure service users are eating a healthy and well balanced diet. Improvements have been made regarding recording meals service users eat, although there is still scope to improve in monitoring and recording service users meals. Food stored in the home needs to be covered and dated when opened or prepared to ensure it is safe to eat. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 13 EVIDENCE: The home has ongoing difficulties with motivating the service users to take part in most activities, whether these are in the home or in the community. Staff spoken with felt that the staff team were committed and enthusiastic to promote various activities and tasks for service users but that for many service users they were either not interested in taking part in an activity or they felt it was the staff’s job to do particular tasks. One service user spoken with stated they had retired and did not want to do much with their time other than sleep or watch some television. Whilst another service user said they enjoyed keeping busy doing little jobs around the home, but only when they felt able to do so. The Inspector discussed with the Registered Manager ways the home could make further attempts to develop and promote activities. Staff must evidence when activities have been offered and refused by service users. A requirement was made for more attention to be paid to this area of the home. Many of the service users are able to go out into the community independently, however, as noted above, many choose not to. At times this can be due to their mental health needs, such as a dislike of noise and crowds, or due to anxiety levels becoming too high. One service user informed the Inspector they often became anxious if they were asked to go out with staff. The Inspector spoke with one service user who was happy to go out and meet up their friends and staff encourage this service user to maintain this activity. Another service user enjoys having beauty treatments and will occasionally visit the local hairdresser. This service user now has a new electric wheelchair that should enable staff to escort them out into the community on a more regular basis. Service users have opportunities to go on day trips with staff and have annual holidays. Last year service users had holidays and these were a success. There are plans for holidays to take place again this forthcoming year for those wishing or able to take part in having a break. Some service users have family and friends and contact is encouraged by staff. Friends sometimes visit service users at the home, although visitors have to be clear regarding appropriate times to visit. Service users are able to have keys to their room to ensure they have some level of privacy. Those service users who are able to read receive their own personal mail. Staff informed the Inspector that where a service user is not able to read, then staff read their mail out to them. Staff were seen to interact with service users throughout the inspection in a positive and approachable manner. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 14 Service users are able to spend time alone or with others as they choose. Service users are encouraged to assist with their personal laundry tasks, some choose to opt out of this activity whilst others take part willingly. Menus were viewed and demonstrated that service users were asked the meals they would prefer. The Registered Manager said there were ongoing difficulties in ensuring service users eat a well balanced diet. The kitchen is not locked and for some service users they pick at food throughout the day, the evening or during the night. Although there is a separate dining room and table, the Inspector was informed that service users do not all sit and eat together, many eat at a later time or in the lounge or their rooms. When this occurs, occasionally staff are not aware of what a service user has eaten or if they have eaten a meal that day. Staff are aware of the need to provide fresh nutritious meals and provide these on a daily basis. However for many of the service users they choose to eat food that is unhealthy. Service users weight is monitored and for one service user this is daily. Staff have made an improvement in recording meals, although the Inspector found there to be several gaps for some of the meals and a requirement was made that staff must be more vigilant. One service user is diabetic and members of staff remind this service user about the need to eat low sugar foods. Those service users asked stated that overall the food was ok and that there was plenty of it. The kitchen was tidy at the time of the inspection and fridge/freezer temperatures had been taken on a regular basis and were within an appropriate range. The home has two fridges and the Inspector noted that in both there was food that had been opened, not covered and had no dates of opening written on them. A requirement was made for dates of opening on to be labelled on prepared/opened foods. The Registered Manager described the difficulties in paying close attention to the food used in the kitchen as service users are in and out of this room all the time. However this monitoring could form part of the shift plan throughout the day to ensure staff know, as part of their role, the need to review the kitchen and fridges and thus maintain a hygienic and safe kitchen. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 15 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 Service users receive personal support in private and in a way they prefer. Most health needs had been identified and were being met, however there were some shortfalls identified that could place service users health and welfare at risk. The shortfall identified in the medication systems for monitoring medication administered and recording could pose a risk to service users health. EVIDENCE: The two female service users living in the home receive same gender personal care support, as this was their preference. The majority of the other service users can carry out personal care tasks independently, although most require prompting to change clothes and to bathe. It is noted on daily records when service users are not washing or changing their clothes. This can be an issue for some of the service users who are reluctant to monitor their personal hygiene. Staff members encourage and discuss these ongoing difficulties with service users and are aware that a certain standard of hygiene must be promoted within the home to ensure service users remain as clean and tidy as they are able to. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 16 Staff and service users spoken with confirmed times for getting up and going to bed are flexible and that they choose the clothes they wish to wear. The Inspector was satisfied that staff knew the service users preferred routines and worked to support them in their daily lives. Health needs on some of the care plans were very clear, with evidence that service users had seen relevant health professionals, however on other care plans this was not so evident. This was discussed with the Registered Manager who acknowledged the need to improve evidencing how the health needs for all service users, including basic health needs such as Oral hygiene and foot care is documented. If service users refuse particular health appointments this must form part of their care plan and other relevant documentation so that staff can monitor any unmet needs. The home is hoping to introduce a health check that might meet this current shortfall. A requirement was made regarding documenting and addressing health needs more clearly. As noted earlier service users weight is monitored closely mainly due to the service users different eating habits. The service user who has diabetes is under the local diabetic clinic. Medication Administration records were tracked and gaps were noted for one service user for the day before the inspection. The Registered Manager and other staff members had noted this error prior to the start of the inspection and this mistake was rectified during the inspection. All other records had been correctly completed. A check on the medication stock found that an “as and when” medication, Paracetomol, was not correct and two tablets were missing that had not been recorded as being administered. This error could not be explained. The same medication had been identified as incorrect at the last inspection, although for different reasons and a re-stated requirement was made that medication systems must be reviewed and made more robust. Creams and liquid medicines must also have dates of opening written on them to ensure out of date stock is never used, a requirement was made for this to be addressed. Staff receive training on medication and have worked through the medication competency forms. No service users self medicate and there were no controlled drugs at the time of the inspection. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 17 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 The home has a clear complaints procedure and service users felt they could talk to Management if they had any issues in the home. Systems are in place to protect vulnerable adults. EVIDENCE: The home has a complaints procedure and those service users asked stated they would talk to the Registered Manager if they had any concerns. There had been no formal complaints noted for several years. The Registered Manager confirmed he would clearly indicate on the complaints records any action taken if a complaint or concern was made. Staff had received training on safeguarding adults. Staff spoken with stated they would report any adult abuse concerns to Management. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 home is welcoming and spacious for the service users. The lock that is broken on the main gates poses a potential security risk for those living and working in the home, this has been an ongoing concern at previous inspections. Service users bedrooms offer them the independence and privacy they need. The home was being maintained to the best standard it could considering that all the service users smoke. EVIDENCE: A tour of the home was carried out and samples of rooms were viewed. Overall these were being maintained satisfactorily. There has been an ongoing issue and requirements made relating to the security of the entrance and exit to the home. There is access from the main road and from the residential street to the home and many people have access to the garden/grounds of the home and consequently this could pose a risk to the building and its surrounding areas. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 19 The home itself is secure and the Registered Manager is confident there is no risk to the actual property. The housing association has finally fitted an intercom system to the main gates and these gates will eventually be closed all the time. The housing association had not installed a video camera, although the Registered Manager stated this had been agreed. The Registered Manager will monitor the situation and if he feels a video camera is needed to ensure staff are confident of who is asking to come into the car park and the garden/grounds of the home then he will liaise with the housing association to make sure the home and surrounding areas are as secure as they can be. The lock on the gates is broken and therefore the previous requirement has been re- stated as this issue has yet to be completely resolved. The sofas in the living room had many cigarette burns in the covers. The Registered Manager showed the Inspector evidence that new sofa covers and two new chairs had been ordered and were due within the next few weeks. The Inspector acknowledged the difficulties in keeping certain rooms clean as service users smoke which inevitably make these areas smell. Cigarette ash was seen to be all over the table where several service users were sitting. The Registered Manager stated this would have all been cleaned the night before but that this was common in the home due to the service users abilities to maintain certain standards. A service user showed the Inspector their bedroom; these are all single and spacious. Service users can personalise their rooms as much as they wish to and these rooms offer service users the privacy they need when they choose to be alone. The home has domestic help, although they were sick on the day of the inspection. The laundry facilities are located in a separate room and staff mainly carry out laundry duties. Staff have received training on health and safety issues that include infection control procedures. The Inspector noted that on the first floor there was a malodour and informed the Registered Manager. A requirement was made for this odour to be addressed. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 & 36 Service users are supported by an experienced and committed staff team. Service users benefit from a stable small staff team who are aware of service users needs. Recruitment procedures are robust and safeguard service users health and safety. Training is available and aims to meet the needs of the staff members and subsequently the service users. Staff receive regular one to one supervision and support in order for them to perform in their roles to the best of their abilities. EVIDENCE: Staff were observed to be patient and accessible to the service users. Many of the members of staff have worked in the home for several years and are familiar with the needs of the service users and how best to support them. The majority of the staff team have either obtained an NVQ or are in the process of completing this qualification. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 21 Staff asked stated they felt there were sufficient numbers of staff working at any one time in the home. Currently there is one staff vacancy that has been filled and the Registered Manager is waiting for all the necessary checks to be carried out and is hopeful this person will commence employment within the next few weeks. Staff confirmed that agency staff are rarely used and that the team work well together. Regular staff meetings take place and a team review day had taken place whereby staff had looked at both their roles and personalities within the team and at the home and improvements that could be made. The staff employment files viewed contained, completed application forms, identification, photographs, two references, Criminal Record Bureau disclosure numbers and medical declaration. The training courses staff have received were viewed. These showed when staff had attended both mandatory and non-mandatory courses. Staff spoken with were happy with the level and type of training offered to them. Additional specialist training on subjects such as epilepsy and mental health are also offered. Staff receive a detailed induction and work in a supernumerary capacity, observing other experienced staff until they feel confident to work unsupervised. Staff confirmed they received regular supervision and that it was a two way process where they could seek advice and guidance. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 & 42 Service users and staff benefit from a well run home. Systems are in place to monitor and review the quality of care offered in the home. The servicing records and health and safety records were up to date and safeguarded those that live, work and visit the home. EVIDENCE: The Registered Manager has been in post for over two years and had obtained the Registered Manager’s Award and is an NVQ assessor. Staff spoken with stated the Registered Manager was flexible, approachable and maintained a visible presence in the home. There are various systems in place to review the quality of care offered in the home. Customer, (service user) satisfaction surveys had been carried out and an action plan was viewed following on from service users comments. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 Page 23 The Registered Manager carries out a monthly audit and sends this report to their line manager. This covers various aspects of the home, such as staffing, medication and policies. The home also has monthly Regulation 26 visits and these reports are submitted to the CSCI. Discussions took place with the Registered Manager regarding considering having an overall summary of the various different systems and their findings with any action to be taken for the forthcoming year. This summary of all that has taken place the previous year would be more accessible to service users and to the Inspector. A recommendation was made for this to be considered. Servicing and health and safety records were viewed. Water temperatures had been taken on a regular basis. The Portable Appliance testing and the Gas Safety record were up to date. Fire drills had been taken on a regular basis and with various members of staff. The housing association completes a detailed annual fire assessment on the whole building, although this was recently out of date. The Registered Manager informed the Inspector that a new fire alarm system was due to be fitted the following week. Health and safety checks are carried out on each service users bedroom on a monthly basis. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 3 x x 3 x Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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 YA9YA19 Regulation 12(1)(a)(b)(2)(3) Requirement Timescale for action 31/07/06 2. YA12 The health needs of service users must be clearly recorded with risk assessments completed where service users require support and/or refuse health appointments/treatment. 12(1)(b)16(2)(m)(n) The home must demonstrate how activities are planned/offered to the service users & record when these are offered/refused. 16(2)(i)17(2) Every effort must be made to ensure the service users enjoy and are encouraged to eat a nutritious, wholesome and suitable diet. To demonstrate this, the recording of meals taken or refused must be recorded wherever possible in accordance with Regulation 17 (2), Schedule 4 (13). (Previous timescale of DS0000027714.V288943.R01.S.doc 31/05/06 3. YA17 25/04/06 Shirley Gardens, 43 Version 5.1 Page 26 31/01/06 not met) 4. YA17 13(4)(c) Food opened/prepared must be covered & the date of opening/preparation written on it. The medication administration systems are required to be reviewed where the systems in place are not sufficient robust to identify errors. (Previous timescale of 31/12/05 partially met) 25/04/06 5. YA20 13 (2) 28/04/06 6. 7. YA20 YA24 13(2) 13(4) 23 (1)(a) Liquid medication/creams 25/04/06 must be dated when opened. The security of the 08/05/06 garden/grounds & consequently the building must be addressed, providing a secure and private environment for the service users. (Previous timescale of 31/01/06 not met) The malodour on the 1st floor must be identified and addressed. 25/04/06 8. YA30 16(2)(k) 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 YA6 Good Practice Recommendations Daily records should clearly detail the care & activities service users have engaged in. DS0000027714.V288943.R01.S.doc Version 5.1 Page 27 Shirley Gardens, 43 2. YA39 An overall summary report of all the various quality assurance systems should be developed & made available for inspection & service users. Shirley Gardens, 43 DS0000027714.V288943.R01.S.doc Version 5.1 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. 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