Inspection on 12/09/06 for Southwood Gardens

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southwood Gardens 02/11/05

Southwood Gardens 30/06/05

Southwood Gardens 18/05/04

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 Southwood Gardens 2 Southwood Gardens Ilford Essex IG2 6VF Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 12/09/06 & 06/10/06 9:30 Southwood Gardens DS0000028454.V305069.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 Southwood Gardens DS0000028454.V305069.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. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwood Gardens Address 2 Southwood Gardens Ilford Essex IG2 6VF 020 8551 8497 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) southwood@nor.co.uk Norwood Ravenswood East Ms Roberta Lynn Devitt Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd November 2005 Brief Description of the Service: Southwood Gardens is a registered care home for six younger adults with learning disabilities run by Norwood, a not for profit, Jewish organisation. It is situated in Barkingside, in the London Borough of Redbridge, close to a small local shopping area and other amenities. The house is divided into two selfcontained three-bedroom flats. The aim of the scheme is to offer a smallscale, family style environment which encourages maximum independence for the service users. All service users have their own bedrooms which are well furnished and decorated. One bedroom in each flat has an en-suite bathroom. Shower rooms are shared between the other two service users in each flat. Office and staff sleeping in accommodation is separate. There is a spacious well maintained garden at the side and rear of the house. Appropriate communal space is provided. The manager and staff support service users to maintain and develop independent living skills, attend college for various courses, as well as accessing community facilities locally and at the Leonard Seiner Centre (Jewish community centre) in Barkingside. Staff who have experience and skills to cope with these needs are employed in the home. Extensive training is provided organisationally to all the staff as part of their induction training, with ongoing training being provided as identified jointly by the staff and the manager. Personal care is provided on a 24-hour basis, and health care needs are met by staff supporting service users to attend appointments with health professionals. The fees range from £3000 - £4,300 per month. A Statement of Purpose and Service Users Guide are available to the service users and their representatives. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two separate visits on 12/09/06 and 06/10/06. This was a key inspection as part of the inspection programme for 2006/2007. Both flats were visited on the first day and staff on duty were interviewed. Staff records were examined on the second day and service user records were examined on the first day. Service users were spoken to on both days of the inspection and were asked to give their views of the service and their experience of living at Southwood Gardens. Discussion took place with the registered manager on both days. Care staff were asked about the care that service users receive, and were also observed carrying out their duties during both visits. All the service users spoken to expressed satisfaction with the service provided at the home and the care they receive. An enforcement notice was issued on third January 2006 for breach of Regulations in relation to failure to carry out monthly Regulation 26 visits. At this inspection concern still remains that the registered providers have not been able to sustain the level of compliance required. The inspector would like to thank the manager, staff and the service users for their input and assistance during the inspection. What the service does well: During both days of the inspection staff were observed providing service users with assistance and support and respected their right to make decisions. Staff support the service users to maintain family links inside and outside the home and their involvement is encouraged, with individual service users’ agreement. Service users’ physical health care needs are monitored and this ensures that service users’ needs are recognised and met. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 6 A wide range of activities are provided for each service user according to their capabilities, needs and wishes and service users are supported by staff to participate in these. The service users live in a clean and comfortable environment and regard the flats as their home. What has improved since the last inspection? What they could do better: Following the issue of a statutory requirement notice on 3rd January 2006, the inspector began to receive reports of monthly monitoring visits required by Regulation 26 on the provider’s assessment of the quality of the service provided in the home. However this improvement has not been sustained. A quality assurance questionnaire should be sent to relatives and health professionals annually and views gained from the service users about the operation of the home. Once this information has been gained an analysis should be undertaken to gauge whether the home is meeting its stated aims and objectives in the Statement of Purpose. Although staff files inspected contained the information required, these should be kept in an orderly manner so that information can be easily accessed. Each staff file should include a photograph of the person employed. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 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. Southwood Gardens DS0000028454.V305069.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 Southwood Gardens DS0000028454.V305069.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): 2 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. A detailed pre-admission assessment procedure is used to gather information about a prospective service user and to assess their needs. Prospective service users and their relatives are able to visit the home prior to their admission. Trial stays are offered before the service user decides if they wish to live there permanently. EVIDENCE: The organisation have developed a detailed pre - admission assessment procedure and a detailed pre - admission assessment is undertaken of all prospective service users by an admissions officer based at the organisation’s head office, who then refers the person to an appropriate home where the person’s needs can be met in discussion with the manager for the home. The registered manager is then able to confirm if they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. Evidence confirms that the assessment is conducted professionally and sensitively and involves the service user, their family or representative of the service user. The admission will only take place if the registered persons are confident that the staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 10 There have been no new admissions to this home since October 2002. The inspector is satisfied that the above process would be followed by the service should a vacancy arise. The files for three service users were examined. There was evidence on these files to show that the service users’ needs are re - assessed regularly and care plans are updated if they need to change. Family members and other professionals involved in the care of each individual service user are fully consulted and involved. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 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): 6,7,9 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users’ health, personal and social care needs are set out in an individual plan of care, and are detailed enough to provide staff with sufficient information about how to meet the service user’s individual needs on a day-today basis. Staff provide service users with assistance and support to enable them to make decisions about their own lives and appropriate risk assessments are in place. EVIDENCE: Southwood Gardens is split into two flats accommodating three service users in each flat. The service users are encouraged to be as independent as possible by staff. The service users require varying levels of assistance and prompting from the staff and this is duly provided. The care plans for three service users were examined. Staff and service users were asked about the care being provided. Each service user has an individual personal plan, which outlines the service users individual needs and how these will be met. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 12 Evidence was seen on the day of the inspection that the service users who were not involved in any regular activities were asked about what they would like to do. The service users spoken to confirmed this. The service users knew who their key workers were and said that they would talk to them or the manager or deputy if they had any problems. Evidence was seen on daily logs that staff prompt and assist service users to carry out tasks according to their capabilities and needs. Comprehensive risk assessments are in place for the different activities that service users take part in and service users are supported by staff to carry out their chosen activities, within this framework. Daily records showed that staff record what the service user has done every day which reflects their care plan and daily activity plan. The individual personal plans are reviewed regularly and updated to reflect changing needs. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users have opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. The home is particularly good at being able to meet the cultural and religious needs of people from a Jewish background. Service users’ rights are respected and responsibilities are recognised in their daily lives. Service users enjoy their meals and are asked on a daily basis to choose from the menu which they have already agreed. They often help staff to prepare meals. Special diets are catered for, especially the provision of kosher diets in line with Jewish faith and customs. EVIDENCE: The service users were asked their views, and the lifestyle of the service users was observed as well as care plans being examined. Most of the service users attend college, and participate in activities in the community and at the local Jewish community centre Leonard Seiner Centre. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 14 Service users go out to the cinema, bowling and various other daily activities including swimming, shopping and eating out. The daily routine is set by the activities that the service users are involved in, which are outlined in their daily activities plan. The service users confirmed that they do activities that were listed on their activity plans. The activity plans show that these routines promote individual choice and freedom of movement. Staff support individuals to pursue their own interests and hobbies. Staff support the service users to maintain family links and friendships inside and outside the home and their involvement is encouraged, with individual service user’s agreement. One of the service users regularly spends weekends at home and contact with the families of the other service users is encouraged and supported by staff. Relatives and friends are able to visit at any time and no restrictions are placed on visiting times. No relatives were visiting at the time of the inspection. The inspector was informed that a senior member of staff is going to start a mens support group to discuss mens issues. The proposal has been agreed and discussed previously at residents’ meetings by the service users. Meals are recorded on a daily form and there is a menu set for each week. Service users spoken to stated that they enjoyed the food and are offered a choice on a daily basis. They often help staff to prepare meals. Special diets are catered for, especially the provision of kosher diets in line with Jewish faith and customs. On the day of the inspection the inspector observed a service user helping staff to prepare lunch. The inspector, staff and some of the service users sat together to have the meal which was nutritious. Sufficient food stocks are maintained in the home and some food deliveries are made from specialist shops who sell food items suitable for the provision of kosher diets. Staff are aware of individual likes/dislikes and were aware of service users who have special dietary needs. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The medication policies and procedures are clear and the staff have received training to ensure safe administration of medication to the service users. Service users’ physical health care needs are monitored which ensures that service users’ needs are recognised and met. EVIDENCE: All the service users residing at Southwood Gardens require varying levels of support but generally manage to carry out their own personal care with some prompting and assistance from staff. Generally, personal care is provided by staff of the same gender to males and females. Service users’ physical and emotional health needs are met by staff who understand their needs and provide appropriate assistance as required. One service user who has difficulty expressing emotions received professional help to express his feelings and this has helped him cope within the group. Another service user who suffered a bereavement has also received individual help and support to cope with this. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 16 Organisational policies and procedures for the handling and recording of medicines in the home are available. The majority of staff have received an appropriate level of training as part of the induction programme. The care plans were examined and records of referrals to specialist healthcare professionals and appointments were being kept. Records examined showed that service users are seen by dentists, opticians, chiropodist, district nurses and doctors as and when required. Staff also support service users to attend outpatient clinics. A record is maintained of the current medication for each service user and the staff working in the home have received updated medication administration training. None of the service users administer their own medication as they are not able to do so. Medication administration records were observed to be appropriately completed. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 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 quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The manager and staff make every effort to sort out any problems and concerns. All complaints and issues of concern are recorded and followed up so that the service users and their relatives feel confident that their complaints are listened to and will be acted upon. All staff working in the home have received training in adult protection/abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There is a written policy and procedure for the protection of vulnerable adults and whistle blowing. All newly recruited staff receive abuse awareness training during their induction training. Evidence was seen that most staff have repeated the above training and two new staff are due to complete this training. The staff spoken to as part of the inspection process, confirmed that they have completed adult protection training and were clear as to their responsibilities to report any potential abuse and of what the reporting lines should be. There were two adult protection matters that were subject to investigation since the last inspection. The registered person has followed procedure and kept the inspector informed whilst addressing these matters which are now resolved. The complaints procedure is also available in pictorial format and the service users spoken to confirmed that they would know the procedure to follow Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 18 should they have a complaint. No complaints were recorded in the complaints log and the manager stated that minor complaints are dealt with verbally. The manager is aware that all complaints must be recorded with the outcomes noted. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 19 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 quality in this outcome area is good. This judgment is made using the available evidence including a visit to the service. Both flats are comfortable, clean and hygienic which enhances the well-being of the service users. EVIDENCE: As stated above Southwood Gardens is split into two flats accommodating three residents in each flat. Both flats were clean and free from odours throughout. Individual care plans and daily records show the importance of stressing personal hygiene to the service users for example washing hands frequently. The inspector was shown around the downstairs flat by a services user. All the service users’ bedrooms are individually decorated and filled with personal possessions. Service users spoken to said that they liked their bedrooms and felt comfortable and safe in them. The lounge and dining area were bright and clean. There is a large garden at the back and to the side of the house which is accessed via the downstairs lounge and office. One of the service users attends the gardening project and a number of fellow attendees as well as the project manager arrived at the home on the day of the inspection, to do some gardening. The garden is well maintained and is a safe area for service users to enjoy during fine weather. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 20 Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home employs staff in sufficient numbers, to meet the needs of the service users. There is an organisational procedure for the recruitment of staff, which is robust and provides safeguards for people living in the home. EVIDENCE: The organisation continue to recruit staff from overseas (mainly Phillipines). They undergo a twelve week induction programme and shadow the existing staff group, which assists their learning and development before working on shifts. All the staff have job descriptions and are aware of the management structures. There are no vacancies at the home at the present time, however one staff member who is pregnant has moved to work elsewhere. Those hours are covered by a cluster staff team who have previously worked at the home and are aware of the individual needs of service users at Southwood Gardens. The staff are competent and qualified to do their jobs and are selected from a qualified group of applicants who have experience of working with people with multiple disabilities in their country of origin. All staff recruited from abroad work a six-month probationary period and under go all the relevant training via the organisation, before enrolling on NVQ level 3 courses. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 22 On the day of the inspection, the inspector spoke to two staff members from the Philippines who confirmed that they have received thorough induction training and continue to attend relevant training courses provided by the organisation. Evidence of staff having completed a variety of training was seen on the individual staff files. In discussion with staff, it was evident that they fully support the main aims and values of the home. Staff have developed a good knowledge and understanding of the Jewish culture and faith via the induction programme and ongoing training provided by the organisation. Service users said that the staff are kind and caring towards them and know what they need. The manager was satisfied with the level of staffing provided at the present time and the use of peripatetic staff has been reduced. The manager acknowledges that permanent staff provide continuity and consistency to the service users which is vital for their safety and security. Staff records were examined and showed that service users are supported and protected by the organisation’s recruitment policy and practices. Staff supervision is taking place and all staff are having formal supervision with the manager and the deputy. Training records were also examined and showed that staff are given the opportunity to attend ongoing training as part of effective service delivery. Of the care staff employed, one staff member holds an NVQ level 2, two staff hold an NVQ Level 3 and one staff holds an NVQ Level 4 qualification. Three other staff are in the process of applying for NVQ 3s. Hence more than 50 of the staff hold NVQ qualifications for which the organisation must be commended. Although the staff records examined contained a photocopy of the staff member’s identification and photograph, the inspector recommends that the manager records staff details on the enclosed employment record form on each staff file together with a photograph of each member of staff for clarity and identification. The staff files to be organised in a way which provide information easily. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 23 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, 40,41, 42 The quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The manager is an experienced and qualified person. The home is run in a way which ensures that the service users’ best interests are safeguarded by the home’s recordkeeping. Staff are aware of the lines of accountability and monitoring systems within the home are robust enough to ensure that the manager is fully appraised of any issues relating to the day-to-day running of the home and the specialist needs of the service users. EVIDENCE: The manager is experienced and has managed the home for the past four years. She has completed the Registered Managers Award and the NVQ level 4 course. The home is run in a way which provides a safe environment. The service users’ health, safety and welfare are met by the staff working in the home. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 24 All records are held securely. Service users would be able to have access to their records. All accidents are recorded and appropriate action is taken when required. Induction training for new stuff is being achieved with further ongoing training being offered. Health and safety checks and the associated records were appropriately completed in line with the Regulations. Individual risk assessments for each service user are in place. A statutory requirement notice was issued on 3rd January 2006 for failure by the responsible individual to undertake monitoring visits to the home in compliance with the Regulation 26 of the Care Home’s Regulations 2001. Since the issuing of this notice the registered individual did comply with this Regulation. However, the responsible individual has failed to carry out monthly visits at Southwood Gardens since June 06. Discussions have been held with the responsible individual reinforcing the Regulation under which these visits are required to be conducted, and the obligation of the organisation to monitor and report on the quality of the service provided in the home. These reports must be made available to the commission promptly. A requirement has been made and the Commission will consider further enforcement action. The inspector was informed that lay monitoring visits are regularly undertaken by lay monitors appointed by Norwood and one of the representatives of “relatives of the Parry group” which is a group of parent representatives. An auditor appointed by the organisation carries out regular financial audits. However, an annual quality assurance review of the whole service should take place, about the operation of the home. The opinions of service users, relatives and any health professionals as well as other representatives involved in the care of the service users must be sought. This quality audit should be analysed and the findings should be annually reported on and also form part of the Service Users Guide. The inspector was informed by the responsible individual that as part of this process a user lead focus group called “people first” has been formed to seek the views of the service users, indicating that this process has begun. Three service users from Southwood Gardens attend these meetings. A working group has also been formed with “BUILD” (British Institute of Learning Disability) as part of this process. The requirement relating to this has been re - iterated. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 25 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 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 3 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 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 2 2 3 3 3 3 Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 26 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 YA38 Regulation 26 Requirement The registered individual must ensure that monthly monitoring visits are being carried out as is required by regulation and the report forwarded to the CSCI promptly. The registered person to ensure that an organizational formal quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. Previous timescale of 31/09/05 not met. Timescale for action 30/11/06 2 YA39 17/18 31/12/06 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 YA34 Good Practice Recommendations The inspector recommends that the manager includes the enclosed employment record form on each staff file together with a photograph of each member of staff for DS0000028454.V305069.R01.S.doc Version 5.2 Page 27 Southwood Gardens clarity and identification. The staff files to be organised in a way which provide information easily. Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford 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. Extracts may not be used or reproduced without the express permission of CSCI Southwood Gardens DS0000028454.V305069.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!