Inspection on 24/11/05 for Shirley Gardens, 43

This inspection was carried out on 24th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirley Gardens, 43 16/04/07

Shirley Gardens, 43 24/04/06

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 Ms Jane Collisson Unannounced Inspection 24th November 2005 11:05 Shirley Gardens, 43 DS0000027714.V265393.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 Shirley Gardens, 43 DS0000027714.V265393.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. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 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 0000000000000000 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.V265393.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 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 are 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 five 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.V265393.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th November 2005 from 11.05am until 4.40pm. The Registered Manager was present and four members of the support staff were met. Five of the six service users were met during the day. One was out independently for part of the day, and others were watching television in the lounge or spent time in their own rooms. The sixth service user was in hospital and there is one service user vacancy. For an assessment of all of the key standards, this report should be read in conjunction with the unannounced inspection report of 30th June 2005. The majority of the fifteen requirements made at that inspection have been met. Three are restated and a further two requirements have been made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Although service users have chosen not to participate in services outside of the home, it needs to be demonstrated that their independent living skills are being maintained and developed where appropriate. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 6 Insufficient recording has been made of the meals taken by the service users. Every effort must be made to ensure that they 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. After a number of medication errors in the last year, an error was found in the medication stock on this inspection. The medication administration systems are required to be reviewed where the systems in place are not sufficient robust to identify errors. The security of the building has been an outstanding issue for more than a year. Although some progress has been made recently, the work is not complete and this must be addressed. It is important that service users are given the opportunity to live in a secure environment and have the opportunity to enjoy the garden in private. Although some work has been carried out on consultation with the service users, and identification of areas of improvement, the home has not complied fully with Regulation 24 of the Care Homes Regulations 2001 which requires a review of the quality of care to be produced regularly and a report produced for the service users and the Commission for Social Care Inspection. Please contact the provider for advice of actions taken in response to this inspection. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shirley Gardens, 43 DS0000027714.V265393.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 Shirley Gardens, 43 DS0000027714.V265393.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): 2, 3, 5 Although no new service users have been admitted, the information and systems are in place for any prospective service users to be supported to make a decision about moving into the home. EVIDENCE: There have been no new service users admitted since the vacancy occurred in May 2005, following the death of a service user in hospital. The Registered Manager has been contacted regarding one potential candidate but the procedure for assessing the service user had not yet commenced. The Registered Manager confirmed that the service user will be given every opportunity to visit the home and undertake a trial period stay, as required to meet the National Minimum Standards. It was noted at the previous inspection that changes in the needs of one service user may have to result in a placement in a different home. The Registered Manager said that the service was working to comply with the service user’s wish, which was to remain living at Shirley Gardens in the longterm. To enable this, provision will have to be made for the service user to access the first floor and the possibility of a stair lift was being explored. The Registered Manager was advised to discuss this with the London Fire and Emergency Planning Authority before progressing further with this plan. Should the proposals not prove viable, then action must be taken to ensure that the service user’s needs can be met within a more appropriate service. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 10 Although the Local Authority contracts have not been provided to the service users because the home has a block contract with the London Borough of Ealing, the Registered Manager has put into place information on each file that the service users’ support is contracted with the local authority. This information was seen in the files examined. It is recommended that the provider organisation continues to try, in conjunction with the Local Authority, to provide the full information to the service users as required by Regulation 5 (3) of the Care Home Regulations 2001. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 11 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, 8, 10 Progress has been made in improving the care planning documentation and using it to ensure that service users’ needs and aspirations are being met and they are more involved in the running of their home. EVIDENCE: Following a requirement at the last inspection regarding the out-of-date care plans, action has been taken to make the files more accessible and to update the plans. The review process has been made more formal, with clear guidance in place for staff. This is to ensure that care plans are updated when reviews take place and service users’ needs and aspirations are better reflected and shown to be relevant to their current needs. It is planned that more person-centred planning systems will be introduced in the forthcoming year. The Registered Manager said that the service users have not responded to formal service user meetings but further work, on a one-to-one basis, is being undertaken to listen to their views. The staff at the home have recognised that greater choice and involvement could be provided for the service users, with the need to try and engage them in a wider range of activities, even if Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 12 only on an occasional basis. Service users are now being invited to attend the staff meetings and some have expressed an interest in doing so. Care plans and other confidential documentation are stored in the office in lockable filing cabinets. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 13 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, 16, 17 The service users have generally expressed their preference for a more sedentary lifestyle. Those that are able to go out of the home alone do so, but none have chosen to undertake more formal or educational day activities. Nevertheless, every effort should be made to continue to encourage the service users to pursue other interests. EVIDENCE: Not all of the service users participate in the running of the home or are involved in how it is run. One service user was seen to be quite active in maintaining skills, but another has decided not to continue to assist with the house shopping, which had been a regular task. Whilst the physical disabilities and ageing of some service users may mean that the scope for development is less, the staff need continue to try to keep the service users active and it needs to be demonstrated that every opportunity is given. This was a previous requirement but has not been fully met. Service users have had the opportunity to benefit from holidays away from the home this year. Three service users spoke about the enjoyment of these. The locations included Wales, the Kent coast and a Centre Parcs holiday. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 14 The home is located close to the centres of Hanwell and West Ealing and service users are able to enjoy the local facilities, which include cafes and shops. Those service users who can do so visit independently, others are reliant on staff to assist them. One service user continues to enjoys aromatherapy sessions and visiting the hairdresser. None choose to participate in organised activities, although these are available. Not all of the service users have regular contract with their families, but relatives and friends are welcome to visit the home, and there is sufficient space for them to meet with the service users in private if they wish to do so. The Registered Manager said that efforts have been made to maintain better contact with one service user’s family but this has not been wholly successful. Service users were seen to have their rights respected with regards to the choices they make about their individual lifestyles. This included the way in which they choose to spend their time and whether or not they wish to participate in the communal life of the home. An agreement had been reached with one service user regarding the management of his/her finances to ensure that a risk to the service user’s health, by the inappropriate use of a legal substance, is minimised. It has been a requirement at previous inspections that the meals taken need to be recorded to demonstrate that the service users are being provided with a satisfactory and nutritious diet. Some recording has taken place. However, this does not supply evidence that the provision of a more nutritious diet is provided to the service users, particularly to address the needs which have been identified. These have included insufficient food intake and high cholesterol. It remains a requirement that care plans and risk assessments are regularly updated where there are known concerns, that meals taken must be recorded in sufficient detail to show that they are varied and nutritious, and that every effort is being made to assist and support the service users to improve their health through attention to their diet. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 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): 19, 20, 21 Service users’ support and health needs are changing and the service is having to consider how best these can be met within the service that the home can offer. Decisions will need to be taken as to whether the home can continue to meet those needs for some of the service users. EVIDENCE: Service users have access to the community health professionals, including the Community Psychiatric Nurses and General Practitioners, as and when required. Care Programme Approach meetings are usually held on a regular basis. Because of the changing health needs of the service users, the home has had to consider how it will continue to meet them. The health of one service user has resulted in hospital admissions. At the time of this inspection, there were concerns about a return to the home until the difficulties being experienced have been stabilised sufficiently for staff to continue to meet the service user’s needs. Another service user’s mobility needs have changed, which resulted in another placement, in a nursing home, being sought. The service user does not wish to move and, as mentioned elsewhere in this report, the Registered Manager is exploring ways in which he/she may be able to continue to live in the home. Six of the bedrooms are accessible only by stairs and require service users to have good mobility. This is a concern that may affect other Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 16 service users in the home in the future and their needs should be kept under regular review. A check on the medication stock showed that an “as and when” medication, paracetomol, was not correct and that there were two tablets too many in the packet. Although systems are in place to record the number of tablets left when these medications are given, this error could not be explained. There have been five medication errors, in the last year, reported to the Commission for Social Care Inspection and it is required that the systems in place to monitor the medication stock are reviewed where the system is not robust enough to eliminate these errors. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 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 Since the last inspection, no complaints had been received from the service users and no adult protection issues had been raised. The service users showed an awareness of being able to raise concerns and complaints with the staff. EVIDENCE: There have been no complaints made by the service users in the registered care service at Shirley Gardens. A consultation was planned by Ealing Consortium for December 2005 to support the service users about complaining, incorporating different media. A complaint had been made to the Housing Association that owns the home regarding the time taken to commence the work on the security of, and unauthorised access through, the home’s garden. The outcome of this complaint was still pending during the inspection as the work had not commenced as planned. There have been no adult protection issues raised in the home and the staff have now had training. To help to safeguard the finances that the home deals with on behalf of the service users, the Registered Manager had put in place additional systems. Shirley Gardens, 43 DS0000027714.V265393.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, 30 The communal facilities, which are not used by all of the service users, suit those who do and they are able to relax and enjoy the television or company of the other service users. There are sufficient communal spaces for service users to meet privately with visitors or follow their own pursuits. EVIDENCE: No changes had been made to the physical environment of the house since the last inspection in June 2005 but concerns regarding the security of the grounds, including the garden and car park, are ongoing. Following an Immediate Requirement issued in December 2004 for work to make the grounds of the home more secure, and to stop members of the public from using the them as a thoroughfare between Shirley Gardens and the Uxbridge Road, agreements were reached with the Housing Association to carry out this work. Because it was not completed, a complaint was made by the Registered Manager to Ealing Family Housing Association by the home regarding the time taken to commence the work. The Registered Manager has kept the Commission for Social Care Inspection informed of the progress of the work, to install better security gates and an intercom system, through the year. At the time of the inspection, work on the gates had commenced and a timescale had been placed for the work to be completed within three weeks although this was later found to be in doubt because of problems in fitting the intercom system. Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 19 The Registered Manager said that improvements are starting to be made to the garden and more were planned. The problems with members of the public using the grounds of the home as a shortcut, and the car park as a dumping ground for rubbish and vehicles, has meant a lack of secure and private amenity for the service users for a long period. The service users must be offered the opportunity to enjoy fresh air and the pleasure of a garden, without the intrusion of the public and the lack of security that it brings. The communal areas of the home were found to be comfortable and homely although there had been some damage to the new furniture covers caused by cigarettes. Three of the service users were using the communal facilities, but others prefer to stay in their bedrooms and this is respected. The smaller lounge and the dining room, though not well used, do provide private space for the service users and would give the opportunity for service users to carry out individual pursuits if they wished to do so. The home employs one domestic worker and the home was found to be clean and hygienic on this unannounced inspection. The Registered Manager has agreed that paper towels will be placed in the toilets to assist with infection control. Work on the laundry room floor covering, under the dryer, was required because of hygiene control. There had been difficulties in progressing this work as the dryer, which is gas powered, needed to be disconnected and special flooring was needed. The Registered Manager confirmed that this work was completed shortly after this inspection. Shirley Gardens, 43 DS0000027714.V265393.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): 33, 35, 36 Good progress has been made in trying to meet the targets of having staff NVQ trained. EVIDENCE: Because the staff in the home also provided an outreach service to the tenants in the adjoining flats, records are maintained of the hours which are used to provide that support. The Registered Manager said that an inspection from the purchasers of the supported living service had just taken place. The service to the tenants is provided at certain times of day which should not interfere with the running of the residential service. The impact of the number of hours provided to the supported living tenants needs to be kept under review, particularly if the flats are fully occupied, and it is recommended that that this is reviewed each time a new tenant is admitted or the needs of a tenant change. Any impact on the hours used for the residential service needs to be recorded. Records showed that staff training courses are up-to-date and staff have received training in adult protection and mental health required at the last inspection. The Registered Manager has the Registered Managers Award and has commenced his NVQ Level 4 in Care. Two staff have NVQ Level 3, one staff has submitted her NVQ 2 portfolio and two staff are undertaking their NVQ Level 2. Newer staff are undertaking their Learning Disability Framework Awards and will go on to take NVQs. Three of the staff have their NVQ Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 21 Assessors Award. The Registered Manager said that training for Essential Lifestyle Planning, which a person-centred care planning system, should be funded in the next financial year. Staff are supported with regular supervision sessions and staff meetings. Monthly reports are carried out for new members of staff whilst they are on probation to support them, and identify any needs, as they gain experience of the work. Shirley Gardens, 43 DS0000027714.V265393.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): 37, 38, 39, 41, 42 There has been a regular staff team that has helped to provide for consistency for the service users. It has been recognised that further work is needed to ensure service users are more involved in the ways in which the home operates and this has begun. EVIDENCE: A regular staff team has been in place since the last inspection, with one new member of staff commencing work. This has assisted with providing a more consistent approach and provided more continuity for the service users. There is a pleasant and relaxed atmosphere in the home. The requirement for the review of the quality of care is not fully met in accordance with Regulation 24 of the Care Home Regulations 2001. Some consultation has taken place with the service users and the staff have looked at deficiencies in the service and how these can be improved. A report needs to be produced which looks at all aspects of the care and support provided by the home, the views of service users and representatives, and any quality monitoring systems which have been used. When complete, this needs to be Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 23 distributed to the service users and the Commission for Social Care Inspection. Regular Regulation 26 visits have been made to the home and the submitted to the Commission for Social Care Inspection as required. Ealing Consortium is continuing to produce new policies and procedures for the organisation. Some are still requiring amendment and work needs to be completed so that staff have information on current legislation, particularly the Care Home Regulations 2001, to aid their practice and record keeping. Improvements have been made in the record keeping in the home for the service users. A selection of records checked included the fire precautions, staff and medication files. There were no outstanding health and safety issues at this inspection except for the security issues which have been mentioned elsewhere in this report. The fire alarm, although in working order, is due to be replaced and the Registered Manager said that another quotation as required before this work will be undertaken. Shirley Gardens, 43 DS0000027714.V265393.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 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shirley Gardens, 43 Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X 3 3 X DS0000027714.V265393.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 YA11 Regulation 12(1)(b)16 (2)(f)(h) Requirement The home needs to demonstrate how the independent living skills of the service users are being maintained and developed where appropriate. (Previous timescale of 30/9/05 not fully met) Every effort must be made to ensure that 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). The medication administration systems are required to be reviewed where the systems in place are not sufficient robust to identify errors. The security of the building must be addressed, providing a secure and private environment for the service users. (Previous timescale of 30/09/05 not met) To comply with Regulation 24 of the Care Homes Regulations 2001, a review of the quality of care is required to be produced regularly and include consultation DS0000027714.V265393.R01.S.doc Timescale for action 31/03/06 2 YA17 16(2)(i) 17(2) 31/01/06 3. YA20 13 (2) 31/12/05 4. YA24 13(4) 23 (1)(a) 31/01/06 5. YA39 24 31/03/06 Shirley Gardens, 43 Version 5.0 Page 26 with the representatives of the service users. (Previous timescale 30/09/05 not met) 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 YA5 Good Practice Recommendations It is recommended that the provider organisation continues to try and provide further details of the Local Authority agreement for the service users, as required by Regulation 5 (3) of the Care Home Regulations 2001. It is recommended that the hours available for the registered home are reviewed each time a new tenant is admitted or the needs of a tenant change in the adjoining supported living homes. 2. YA33 Shirley Gardens, 43 DS0000027714.V265393.R01.S.doc Version 5.0 Page 27 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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