Inspection on 24/05/05 for Spring Grove Road, 231

This inspection was carried out on 24th May 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 but made no statutory requirements on the home.

Other inspections for this house

Spring Grove Road, 231 20/07/06

Spring Grove Road, 231 09/12/05

Spring Grove Road, 231 13/09/04

Spring Grove Road, 231 27/04/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 231 Spring Grove Road Isleworth Middlesex TW7 4AF Lead Inspector Jane Collisson Unannounced 24th May 2005 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 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 Stationary 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. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spring Grove Road 231 Address 231 Spring Grove Road, Isleworth, Middlesex, TW7 4AF Telephone number Fax number Email 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 758 2966 Milbury Care Services Ltd. Ms Teresa Franze Care Home 2 Category(ies) of Learning Disability registration, with number of places 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate one named service user over the age of 65 years old as agreed by the Commission for Social Care Inspection on 27th July 2004. The service user may remain resident until such time when the home shall be unable to meet the service user’s assessed needs and care plan. Date of last inspection 13/9/04 Brief Description of the Service: 231 Spring Grove Road is a home for two service users with learning disabilities, one of whom is over 65 years old. It is a detached three bedroomed house, situated on a busy road in Isleworth, and close to public transport to Hounslow Town Centre and Brentford. There are local shops within walking distance and the day centre and college are also close by. The home is owned and managed by Milbury Care Services. The communal areas consist of a lounge, with a separate kitchen/dining room. The office, laundry room and staff toilet are located in an outbuilding located in the small back garden. There is a bathroom on the first floor, with a bath and separate shower cubicle, and a separate toilet. The third bedroom is used as the staff sleeping in room. The neighbouring house, at 233 Spring Grove Road, is a home for three service users and the Registered Manager is registered for both homes. The Deputy Managers post also covers both homes. There is a separate Senior Support Worker and a team of Support Workers for each house. They provide support with personal care, practical tasks, leisure and social activities. There are two staff on duty at all times, with one sleeping in staff at night. Both service users use the Milbury Day Centre and West Thames College, which are local. There is a house car available. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Tuesday 24th May 2005 at 2.30pm. The Registered Manager was not present as she was on holiday. A short additional visit was made on 2nd June 2005 to discuss the outstanding requirements. On the first visit, a staff handover was taking place, with two staff leaving and two staff coming on duty. The Operations Manager for the area was present for part of the visit and the home’s Deputy Manager was also available. On the first visit, both service users were out, one at the local college and one on a day trip to Brighton with the day centre, both returning at about 3.30pm. On the second visit, both were at home, enjoying a lunch with the staff members on duty. Since the last inspection in September 2004, the Manager has been registered with the Commission for Social Care Inspection. She is also the Registered Manager of 233 Spring Grove Road, the neighbouring home. Although some redecoration of the house is due, and it will benefit from this, it continues to be a pleasant and comfortable environment for the service users, and has a homely atmosphere. The kitchen/dining area is a busy area, with staff and service users making good use of it and easy communication was seen to take place. The service users enjoy a full programme of activities. As there are only two service users and sufficient staff, they are offered the choice to go out separately or together. The opportunity to participate in the running of the home is evident, with staff were enabling the service users to maintain their independent living skills. Both service users like to relax in the lounge, watching television. Their bedrooms are personalised and both expressed their satisfaction with their rooms. The staff on duty were part of the permanent staff team and, at present, only bank cover is used and no agency staff. What the service does well: Provides sufficient staff in the home to allow for the service users to have a high level of support, with ample opportunity for outings and leisure pursuits. Provides a comfortable and personalised environment for the service users, with a homely atmosphere. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 8 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 standard(s) 1, 2, 5 As there have been no new service users in the home for some years, the procedures for new service users to be admitted have not been used, but are in place. The contract/terms and conditions information is still required to be provided to service users and their representatives and this has been long outstanding and must be completed. EVIDENCE: The information about the home has been amended since the last inspection to take staff changes into account. Both service users have now been in the home for some years and there needs are well-known and documented. They continue to be enabled to attend the day activities they enjoy and leisure and social pursuits. It was a requirement at the last four inspections that the contract/statement of terms and conditions must be completed fully for each service user and agreed with them or their representatives. This has not been carried out but the Operations Manager has stated that Milbury Care Services have prepared the documentation but it is awaiting approval. This work must be completed to allow service users and the representatives to have details of the charges payable and to understand their rights and responsibilities. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 9 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 standard(s) 6, 7, 8, 9 The lifestyle enjoyed by the service users is of their choosing, they are able to make decisions and encouraged to do so. Their needs continue to be met by the facilities available in the local area, which are easily accessible to them and provide for their current needs. EVIDENCE: The information on care plans and risk assessments are in place and these are reviewed on a regular basis. The care plans are not in a format which either of the service users would be able to fully understand and this should be considered as both would be able to access a pictorial/visual format. The home does not have computer equipment, which would enable these to be produced, and it is strongly recommended that this is made available. Both service users are able to make decisions about their daily lives and were seen to express their wishes during this inspection. Because of the small size of the home, the daily routines are based on the two programmes in place for the service users, who enjoy activities separately and together. Both expressed their continuing satisfaction with the running of the home and of the staff support they receive. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 10 One service user has been supported for many years to access the nearby cafés and shops and continues to be able to do so. This allows her the opportunity to continue to have some independence but within the boundaries she chooses. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 11 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 standard(s) 11, 12, 13, 15, 17 Because of the one-to-one staff ratio and availability of transport, it is possible for the service users to enjoy a wide range of activities both individually and together. This was demonstrated through the records and the information from service users and staff. EVIDENCE: The service users have continued to make use of the local college and day centre which provide courses they enjoy and they are supported by the staff team to do so. Both service users were seen to be assisting with the running of the home by washing up and clearing away after a meal. Both service users are in an older age group and attend some courses at the college which are specifically designed for older people. Certificates of attendance for these courses are displayed in their rooms and the service users said that they continue to enjoy their activities. One service user is particularly good at art and craft and examples of these were displayed around the home. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 12 The service users said that they enjoy outings and holidays, although one remarked that the journey to Brighton that day had been very long. The service users have attended annual holidays together. Both service users were aware that this year’s holiday to Bognor was booked and they indicated that they were looking forward to it. Photographs of past holidays and other outings are displayed around the home. There is limited family involvement for one service user due to family members living at a distance but the other service user has contact on a regular basis. Both service users were seen to be enjoying the meals prepared by the staff at a relaxed and pleasant evening mealtime. Because there are only two service users, the menu is based on the meals that they both enjoy and a dietician has been involved to encourage a healthy diet to be provided. Plenty of fresh fruit was seen on this unannounced inspection, which was readily accessible to the service users. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 13 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 standard(s) 18, 19, 20 The information available in the service users’ files indicated that their health and medical needs are being met. However, the information does require some streamlining to be able to follow through each separate set of appointments and visits made to various professionals, both to monitor progress and for ease of use by staff. EVIDENCE: Both of the service users require support with their personal care and the female staff members provide this. Risk assessments are in place for bathing. The separate shower was found not to work on this inspection, although staff said that the bath is currently the preferred option by the service users and the shower is not used. A shower attachment was added to the bath at the time of the last inspection to assist with hair washing. It was seen from the information recorded that the health needs of the service users are being met. There is a separate health care file for each of the service users. Each evidenced that there is support for the service users to attend a wide variety of health appointments including those to the hospital. Many of these are ongoing, and it is recommended that the files are streamlined so that the appointments for different departments are kept separately, together with the recorded outcomes, to make monitoring easier. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 14 Other health visits, such as chiropody, dental and optical, are made as required and details all visits are recorded on separate sheets so that these can be monitored. Only one service user has medication at present. The Medication Administration Record sheets were found to be up to date and there were no medication errors recorded. The Boots Monitored Dosage System is used and Boots visit the home to provide training and to check the medication. All of the staff have had training in medication administration. However, it was recommended at the last inspection that the medication competency procedure is introduced which would give provide consistent training and ongoing monitoring for the staff team. It should also provide staff with a basic knowledge of the medications prescribed. This has not been introduced. The Registered Manager said that a new Milbury Training Officer is in post and it is strongly recommended that that more robust medication training is introduced. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 15 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 standard(s) 22, 23 There have been no complaints or adult protection issues recorded in the home although the information and procedures are in place should either be required to be reported. EVIDENCE: Both service users, one of whom has good verbal skills, indicated that they would be able to make their concerns known to the relevant staff should the need arise to do so. There were no recorded complaints made and the service users expressed their satisfaction with the running of the home and the staff team. There have been no adult protection issues raised in the home. All of the staff have had training in the protection of vulnerable adults and the London Borough of Hounslow’s Adult Protection flowchart is displayed in the office for easy reference. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 16 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 standard(s) 24, 25, 26, 27, 29, 30 An environment is provided for the service users which is very much their own home and it has the facilities they require. The redecoration of some areas of the home is overdue, and the refurbishment of the bathroom must also be considered for the future. EVIDENCE: The home is comfortable and pleasantly furnished. The service users were watching television and relaxing in the lounge during the inspection. The kitchen is large, with patio doors to the small garden. This area is furnished with a large dining table which can seat the service users and staff comfortably. The table and chairs are new. The garden, though concreted over, has a seating area and the garden furniture was in the process of being replaced during the inspection. The garden is used by service users and staff who smoke. The office and laundry room are located in a small outbuilding in the garden and are suitable for the needs of the home. It was a requirement at the inspection in September 2004 that that the work on the emergency lighting system, on the advice of the London Fire and Emergency Planning Authority, must be carried out. This was not carried out within the timescale given, but has now been completed. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 17 At the last inspection, the fire door on the ground floor was found not to close properly when the magnetic holder was released. As a maintenance person was present, this work was ordered and completed. It was found to be in good working order at this inspection. It was noted at the last inspection that one of the service users’ bedrooms is due to be decorated but this work has not yet been carried out. The Operations Manager said that this was due to be done, along with other areas of the home, within the next budget. This was due to be released shortly. It was discussed with the service users about the redecoration of the their bedrooms and both were able to express their preferences. Both rooms were shown by the service users and were seen to have the items they wish to have. Both rooms are personalised with pictures, photographs and ornaments and have sufficient furniture and fittings to meet the service users’ needs. One service user chooses to keep her room locked to maintain privacy. The bathroom is located on the first floor, together with a separate toilet. Apart from the provision of a staff toilet in the outbuilding, service users and staff share these facilities. The bathroom has a separate shower cubicle but this was found not to be working during this inspection. Although not used by the service users currently, this needs to be maintained in working order should it be required. No specialist equipment is required by either of the service users currently to use the bath. The bathroom tiles were previously painted over. The paint was removed but it remains in the grouted areas. The bathroom would benefit from refurbishment and this should be included in future budget plans for the home. The service users continue to be able to use the stairs without any difficulty and this was demonstrated during this inspection. There are rails on both sides of the stairs. No specialist equipment is identified as being needed at present although this should be seen to be reviewed regularly, as both service users are in an older age group. The home was found to be maintained to a good standard of cleanliness. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 Improvements have been observed with the introduction of a permanent staff team and a Registered Manager and a Deputy Manager, after a long period without management staff. The recruitment and employment records still require further work to ensure that service users can be better safeguarded. Training is happening on a more regular basis which will should assist with the development of a more effective staff team. EVIDENCE: The current staff team, with the exception on a bank staff member who works at 231 and 233 Spring Grove Road, are permanent members of staff who have been in post for some time. It was a previous requirement, in September 2004, that sufficient staff must be recruited to cover the rota, allowing for staff training, holidays and absences. This has been an ongoing concern in the home for some time, but the situation has improved. However, the establishment hours are 212.5 per week, which includes management hours. The hours of the Registered Manager are supernumery and the Deputy Manager’s hours are shared with 233 Spring Grove Road. 198.5 hours are currently provided by the care staff, with the Deputy Manager, which is sufficient to cover the rota of two staff on at all times. There is still no allowance for annual leave, sickness or training and this is currently covered by staff overtime or bank staff. This still needs to be kept under review to ensure that a consistent staff team is maintained and health and safety is not compromised by long working hours. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 19 It has not been fully demonstrated that service users are being safeguarded by the procedures carried out for the recruitment of staff. A requirement made at the inspection in September 2004 that, when the information required for the employment of staff is obtained, its accuracy is verified prior to the employment commencing. A staff member’s file examined on this inspection showed that gaps in employment records continue to be noted and there was no evidence of a current Criminal Records Bureau disclosure, although a POVA First check appeared to have been carried out. This does not include the name of the staff member so could not be fully verified. The Operations Manager said that Milbury Care Services have employed a Human Resources officer at their regional office so that this work will now be carried out centrally. The information required at the last inspection must be shown to have been obtained and all of the information required under Regulations 17 and 19 of the Care Homes Regulations 2001 must be in place and available for inspection. The information on a service user’s right to work was not complete and the Registered Providers need to ensure that this is verified. Although many of the staff had undertaken training, not all had participated in all of the core training courses at the last inspection. Infection control training was required to take place and the records showed that four of the seven staff had now had this training. The remainder need to attend this. A small number of the staff still require training in first aid, epilepsy, and health and safety. The Registered Manager needs to ensure that her training schedule shows the dates of the courses to ensure that refresher training can be arranged as required. At the last inspection, it was recorded that the standard of at least six supervisions a year, for each staff member, would be met. All supervisions were being undertaken by the Registered Manager but the Deputy Manager has now undertaken training to be able to supervise staff and should be commencing shortly. A schedule is maintained to demonstrate that supervision sessions have taken place. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42, 43 The home has benefited considerably from having a permanent Registered Manager in place and the management team has been strengthened by the appointment of a Deputy. This has resulted in a better quality of life for the service users and the development of the staff team. However, health and safety issues are not being sufficiently reinforced to the staff team and they must be made aware of the importance of reporting non-functioning equipment, when management staff are not around, to ensure health and safety are maintained. EVIDENCE: The Registered Manager has now been in post for nearly two years and improvements have been made in the running of the home for the benefit of service users and staff. She has an NVQ4 in care and is undertaking the Registered Managers Award. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 21 A relaxed and friendly atmosphere in the home is maintained and a good relationship between the service users and staff, who interact well with good humour, was noted A full and detailed audit on the home has been completed. However, the audit does not contain a summary which assesses the quality of life in the home, where this has improved and where improvements can be made. This needs to be done as the Registered Providers are required to provide information for the service users and the Commission for Social Care Inspection, under Regulation 24 of the Care Homes Regulations 2001. 40. New policies and procedures were put into place in June 2004. These were due to be reviewed in June 2005. The Operations Manager was made aware of the fact that some of the policies and procedures do not always show staff that they need to report to the Commission for Social Care Inspection under the Care Homes Regulations 2001. An example was the incident and accident reporting which does not show that Regulation 37 notices are required to be submitted. When the policies and procedures are reviewed, they need to include reference to the Care Homes Regulations 2001 where applicable. 42. When the refrigerator and freezer temperature records were checked, it was found that the refrigerator temperature has been recorded at either 8ºC or 9ºC for some days, without any action being taken. Although the recording book shows the safe levels at which the equipment should operate, the staff did not seem aware of the need to take action. It was possible to turn the refrigerator to a lower level and this was done and the staff were asked to ensure that, should the temperature not reduced sufficiently, then action must be taken to repair or replace it. Staff need to be reminded on a regular basis of their health and safety obligations and monitoring by senior staff must take place to ensure that appropriate action is taken. It was a requirement at the last inspection that full business planning information must be available for inspection. Although a business plan was not available at this inspection the Operations Manager was able to show the budgets for the proposed redecoration of the home although this had not yet been finally agreed. The financial records for the home are sent to the Commission for Social Care Inspection as previously agreed but the Registered Manager has limited input into the budgets for the home. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 22 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 3 3 x x 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 x 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 231 Spring Grove Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 x 2 3 G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 23 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 5 Regulation 5 (1) b Requirement The Contract/statement of terms and conditions must be completed fully for each service user and agreed with them or their representatives. THIS IS A REQUIREMENT RESTATED FROM THE THREE PREVIOUS INSPECTIONS. (Previous timescale of 31/10/05 not met). The shower must be kept in working order to enable choice to be offered to the users. The information required to be obtained for the recruitment and employment of staff must be verified, complete and available for inspection. All staff must undertake the core training courses and refresher courses as required. (Previous timescale of 31/10/04 not fully met). A report from the audit of the home, identifying the outcomes and how improvements can be made, is required. This needs to be available to service users, their representatives and the Commission for Social Care Inspection when completed. Timescale for action 31/7/05 2. 3. 27 34 23 17 (2) Schedule 419 (1) (b) Schedule 2 18 (1) (c) (i) 31/7/05 31/7/05 4. 35 31/7/05 5. 39 24 (1) (2) & (3) 31/7/05 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 24 6. 42 13 (4) (a) (c) 23 (2) (c) 13 (4) (c) 7. 42 Staff must be aware of their health and safety obligations and of ensuring the faulty equipment is reported. The refridgerator must be repaired or replaced if found not to be working satisfactorily. 10/6/05 10/6/05 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. 2. 3. 4. 5. Refer to Standard 6 19 20 27 Good Practice Recommendations That computer equipment, to provide visual care plans and other materials, which can be accessed by the service users, is provided. That streamlining of the medical and health files takes place in order for easy access and monitoring of needs. It is strongly recommended that the medication training is reviewed to provide a competency based procedure. That the refurbishment of the bathroom is considered, looking at the future needs of the service users. 231 Spring Grove Road G61-G10 S22906 Spring Grove 231 V228631 24.05.05 Stage 4 .doc Version 1.30 Page 25 Commission for Social Care Inspection Ground Floor 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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