Inspection on 11/07/05 for Spring Grove Road, 233

This inspection was carried out on 11th July 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Grove Road, 233 23/07/07

Spring Grove Road, 233 20/06/06

Spring Grove Road, 233 01/12/05

Spring Grove Road, 233 06/12/04

Spring Grove Road, 233 10/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Spring Grove Road, 233 Isleworth Middlesex TW7 4AF Lead Inspector Jane Collisson Unannounced 11 July 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. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spring Grove Road, 233 Address 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 568 0263 Milbury Care Services Limited Teresa Franze Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 6/12/04 Brief Description of the Service: 233 Spring Grove Road is a detached house situated on a busy road in Isleworth, near to the London Road and the A4. There are local shops and public transport links within walking distance. Hounslow Town Centre and Brentford are within easy reach. The home is registered for three service users with learning disabilities. The current service users have lived in the home since it opened in 1995 and all have profound learning disabilities and are nonverbal. All three men have good mobility. The owners and care providers are Milbury Care Services. The home has three bedrooms, one on the ground floor and two on the first floor. There is a bathroom and toilet on the first floor and a separate toilet on the ground floor. The communal space consists of a lounge/dining room, kitchen and an area between the two rooms which currently houses the fridge/freezer. There is a small office on the first floor and the sleeping-in room is in the loft, accessed by a staircase. The washing machine and dryer are housed in an alcove next to the bathroom. There is a small garden to the rear with a lawn, shrubs and seating. The staff team consists of the Registered Manager and Deputy Manager, who also manage 231 Spring Grove Road, a Senior Support Worker and eight Support Workers. There are three staff on each shift, with one waking and one sleeping-in staff during the night. The team supports the service users with personal care and practical tasks, leisure and social activities. Local day services are accessed for the service users and a house car is available. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 11th July 2005 from 3.15 to 6.35pm. The Registered Manager was present, with four of the staff team. All of the service users were at home. All of the service users were met, the staff on duty were spoken to during course of the inspection and records and documentation were examined. A service user from another home, who assists with the cleaning, was also present. There was a pleasant atmosphere in the home, with service users seen to be relaxing in the lounge and garden. The majority of the requirements from the last inspection have been carried out and four requirements were made at this inspection, including one which was restated from the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: The staff do not have access to a computer in the home. The provision of this equipment would allow the staff team to maintain and update records and to produce pictorial information which could aid communication with the service users. There is also a lack of equipment to provide stimulation, within the home, for the service users. Professional advice should be sought to ensure that the service users have the opportunity to take advantage of any new equipment and technology that are available for non-verbal service users. Whilst regular recording of hot water, fridge and freezer temperatures has been taking place, it did not appear that staff were reporting when these were outside of the safety zones or taking action to correct them. The management staff need to ensure that staff fully understand the reasons for the health and safety checks and take the appropriate measures to correct or report them. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 6 Not all of the information produced centrally by Milbury Care Services has been available within the timescales set at past inspections. This includes updated terms and conditions for the service users and their representatives. The Registered Providers need to ensure the information required under the Care Homes Regulations 2001 is available for staff to use. The policies and procedures need to be reviewed regularly and provide the information to assist the staff team to maintain record keeping to a good standard and to understand the legislation under which the policies and procedures are made. Repairs and maintenance have been an issue in the home for some time. Now that the home has been brought up to a good standard of decoration and maintenance, the Registered Providers need to ensure that this can be sustained and that requests for repairs and refurbishment are carried out speedily. 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. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 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 Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 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, 5 As there have been no change of service users in the home for ten years, the admission procedures have not been required to be used. However, these are in place should they be required. The terms and conditions still need to be provided and this has been a long outstanding requirement which the Registered Providers must address. EVIDENCE: The information, which is required to be in place to assist service users and their representatives to make a decision about the home, is in place. The Registered Manager said that she will need to update the Statement of Purpose shortly to take account of the new staff members recruited. No new service users have been admitted, so the admission procedures could not be assessed. It has been a long outstanding requirement that the terms and conditions are updated to take account of the National Minimum Standards and Care Homes Regulations 2001. The Registered Manager said that she understands that these have been completed and are awaiting approval. The Registered Providers need to ensure that service users and their representatives have these issued to them once they are in place. None of the current service users would be likely to fully understand the Service Users Guide and Terms and Conditions, even in a visual format, but all have family members who are able to represent them. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 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, 9 There are good care planning systems in place which reflect the needs of the service users and how support is provided. The risk assessments are relevant to the activities undertaken by the service users. EVIDENCE: Each of the service users has files which contain details of personal information, social and health needs. Regular reviews of their care have been held with Social Services staff, families, the day centre and key workers and management staff. Samples of the daily notes kept were examined and showed that these are related to the service users’ care plans and provide information on their activities and wellbeing. Goals have been set at reviews for the staff to support the service users to achieve. Although the service users are not able to express their wishes verbally, they are encouraged by the staff to make decisions. Staff showed an awareness of their likes, dislikes and how they are able to express their choices. Staff said that one service user is now able to demonstrate to the staff that he wishes to go out. It was observed during the inspection that another service user responds well to staff requests and questions much more positively than was noted at past visits to the home and that good progress has been achieved. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 10 It was seen that the safety of the service users has been considered in a variety of settings, including travelling in the car and being out of the home. The Registered Manager has put into place all of the risk assessments required at the last inspection and those which were already in place have been reviewed. Risk assessments have also been put in place for work carried out by a service user from another registered home who provides assistance with cleaning the home. This was in response to a requirement at the last inspection. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 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) 12, 13, 15, 17 The opportunity for activities and leisure pursuits is much improved, with the staffing levels allowing for service users to be supported individually. Progress is being made in helping the service users to expand their range of activities. A varied diet is being provided. EVIDENCE: All of the service users have been given the opportunity for personal development through additional day services and outings. This has been an area where improvements have been demonstrated over the past inspections and progress made in helping the service users to enjoy new experiences. One service user has been encouraged to go out much further than in previous years, and has now been on a short break holiday. The Registered Manager was in the process of arranging a holiday abroad for one service user during this inspection and another short break is to be arranged, in the autumn, for the other two service users. Wherever possible, service users are supported to carry out small domestic tasks, such as putting laundry away. The Milbury day centre is accessed by two of the service users and courses at the local college have been booked for September. Although none of the service users’ families were met on this occasion, the staff said that they have been appreciative of the progress being made. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 12 Because of their disabilities, the service users who are not generally able to enjoy television and other indoor activities which are available to many service users. Recommendations have been made at previous inspections for the provision of equipment, such as computers, to be explored which would aid non-verbal service users and provide an additional activity and stimulation. This is particularly important for The Registered Manager said that a referral has been made to the Occupational Therapist for computer equipment for one service user but that this has not yet been actioned. Another service user previously had computer equipment which he was said to enjoy. If the Occupational Therapist visit is not forthcoming, other assistance with the provision of suitable equipment needs to be explored. All three service users continue to have contact with their relatives, either by the families visiting the home, or by service users being taken to their family homes. Staff facilitate this where needed so that contact with older relatives can continue. A barbecue had been held in the garden, on the day prior to this visit, for twenty three people who included service users from other homes, staff and relatives. Photographs had been taken to record this event. Photographs are used around the home to show the various activities enjoyed by the service users. An evening meal was prepared of lamb, potatoes and vegetables which the service users were seen to be enjoying. Improvements have been made to the dining area, with a table large enough to seat all the service users and staff. The menu showed a good variety of food and one service user is supported with a low cholesterol diet. Notes from the dietician’s visits, to assist with menu planning, were seen in the care planning files. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 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, 21 The records demonstrate that the service users’ health needs are known and well supported by the staff team, who access the professional services required. Service user are supported with hospital and other medical appointments. EVIDENCE: All of the service users require support with personal care. Although none of the service users are able to comment on the support they receive, they would be able to indicate, non-verbally, if they were unhappy. At this inspection, service users were observed to be treated with respect and with good humour. Appropriate medication attention has been sought where required. One service user’s records showed that referrals have been made for medical and behavioural problems and he was supported to undertake the required hospital visits. Changes in medication were required which have alleviated the difficulties. A psychologist is employed by Milbury Care Services has provided support and advice to the staff to work with the service users. The medication administration was not examined on this inspection. None of the service users would be able to express their wishes with regards to death and dying, but all have families who are involved in their support and are able to make decisions on their behalf. The wishes of the families are recorded in the care planning files. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 14 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 The procedures are in place for the staff and others to use for complaints and adult protection procedures. Service users are protected by staff having had training to support them to recognise and report adult protection issues. EVIDENCE: None of the service users would be able to make a verbal complaint and none have been made for the last three years. However, the procedures are in place should an issue occur and all have family members who would be able to advocate on their behalf should a concern arise. There have been no adult protection issues in the home for more than two years. The records showed that the majority of staff have attended training for adult protection and the Registered Manager has attended Protection of Vulnerable Adults management training with the London Borough of Hounslow’s adult protection staff. For the protection of the service users, particularly in view of their lack of verbal communication, staff who have not attended Protection of Vulnerable Adults training need to do so as soon as possible. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 15 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, 28 The home has slowly improved in the last two years to provide a much more comfortable and homely environment for the service users. Maintenance issues have been addressed more promptly, although this has required some perseverance by the management staff and is an area which the Registered Providers still need to address. EVIDENCE: A programme of refurbishment and redecoration was required to bring this home up to a reasonable standard. Although this was not met within the timescale set, and had been outstanding for some inspections, the work was recently completed and has greatly improved the communal areas. A number of improvements have been made with new carpets, furniture, pictures and photographs helping to enhance the environment for the service users and the staff who work with them. There are plans to have the French windows to the garden, which have caused difficulties because of their maintenance, replaced. Work has been carried out in the garden by staff and it now provides a pleasant area for the service users to enjoy, with seating for all of the service users and staff. It has been agreed to remove a neighbour’s overgrown shrubs, which overhang the garden, as the communal fence is damaged. This Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 16 should improve the garden further. The environment has also been improved by the work to the front garden. Staff are to be commended for their work in the gardens. There have been concerns for some years about the lack of speed with which maintenance, redecoration and repairs have been undertaken by the Registered Providers. Few requirements have been completed within timescale. Now that the home has been brought up to a good standard, a cyclical programme needs to be put in place to ensure that this is maintained and a responsive repairs service needs to be available. The service users do not usually spent much time in their bedrooms, showing a preference for the communal areas. However, improvements have been made to make the rooms more comfortable. All of the bedrooms are maintained in a clean and tidy manner with suitable storage and seating. There is one bathroom and two toilets for the use of service users and staff. All of the service users are able to use the bath without special equipment and no other adaptations are required in the home at the present time. It was noted, however, that the shower attachment did not work. This had been reported by the Registered Manager for repair. A hand dryer has been installed in the bathroom and toilet to improve infection control. The communal areas consist of a large “through” lounge, with a comfortable seating area and a dining area close to the garden. Whilst there is no separate area where private meetings can take place, the service users’ bedrooms, the garden or part of the lounge could be used if required. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 17 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) 31, 32, 35, 36 After a long period without a full, permanent staff team being recruited, this has now been achieved. This provides for much better training and development opportunities for the staff, and consistency for the service users. EVIDENCE: The home, and its neighbouring home at 231 Spring Grove Road, which has two service users, are managed jointly by the Registered Manager and Deputy Manager. The Registered Manager also supervises the Deputy Manager of two supported living homes but confirmed that the majority of her time is spent at 231 and 233 Spring Grove Road. This situation needs to be kept under review by the Registered Providers and it needs to be demonstrated that there is sufficient time available for the management of the registered homes. The Senior Support Worker and a team of eight Support Workers provide the cover only to 233 Spring Grove Road. There is a sufficiently large staff team to provide for three staff on each shift, with one waking night and one sleeping in staff member. This staffing ratio provides for the service users to have the opportunity for individual outings and activities. A record of the training courses attended by the staff was provided and showed that the staff have undertaken the majority of the core training courses, such as first aid, fire safety and manual handling. Some staff have also attended more specialised training courses for autism, non-violent crisis Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 18 intervention and epilepsy. These need to be extended to all staff in due course. Staff are now undertaking Learning Disability Award Framework induction and foundation training before commencing their NVQ training. The Senior Support Worker is training to be become an NVQ Assessor. It is recommended that the training record being maintained is extended to show the dates the training was undertaken as courses will be requiring updates and it needs to be shown that these are planned and take place. The staff team are supervised regularly by the Registered Manager and the Deputy Manager and a schedule of the supervisions is maintained. Staff indicated that they are well supported. Regular staff meetings are held and annual appraisals were seen to have taken place for those who have been in post for more than a year. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 19 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, 41, 42 The management of the home has much improved in the last two years. A full, permanent staff team allows for better support and management systems to be introduced and for staff to develop their skills. However, monitoring of the health and safety systems are still required to ensure that staff understand and maintain good practice. EVIDENCE: The Registered Manager has now been in post for nearly two years. The running of the home has greatly improved, which has benefited both the service users and staff. She has an NVQ Level 4 in care and has nearly completed the Registered Managers Award. The staff team were found to be well organised. The home has with a relaxed atmosphere and a good relationship between the service users and staff was observed. Milbury Care Services produced new policies and procedures in June 2004. Not all of these make reference to the staff responsibilities in relation to the Care Homes Regulations 2001. This would assist the staff, particularly new staff, to better understand their responsibilities when record keeping. When the policies Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 20 and procedures are reviewed, they should include reference to the Care Homes Regulations 2001 where applicable. Although record keeping is satisfactory, with monitoring in place to ensure that checks are undertaken, there were some discrepancies in the records found. These included the hot water temperatures that had been recorded at an unsafe temperature on several occasions. The refrigerator and freezer temperatures were also recorded incorrectly. There was no evidence that action had been taken although the temperatures on this inspection were found to be satisfactory. It has been recorded that staff have been reminded, at staff meetings, about this concern. The recording and monitoring systems must be sufficiently robust to ensure that discrepancies are noted immediately as these are areas of potential risk to the service users. The Registered Manager needs to ensure that the staff who continue to either record incorrectly, or who fail to report faulty equipment, are aware of their obligations regarding health and safety. The home remains without a computer to aid better record keeping and provide for the service users to have ready access to visual materials. It remains a recommendation that the Registered Providers provide computer equipment in the home. At the previous inspection, not all of the required documentation to evidence the maintenance and servicing could be located. For most of the maintenance undertaken, certificates or documentary evidence is now in place. The testing of small electrical appliances was carried out in January 2005 and the annual Gas Check in October 2004. The Registered Manager provided evidence of the Legionella testing after the inspection. The fire records were examined and regular fire drills have been taking place. A record of the fire awareness training given by one of the senior staff is recorded for each staff member and a chart is being kept to show the number of fire drills that each staff member attends. Staff in post for the last year have nearly all undertaken four drills. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 21 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 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 2 3 x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Spring Grove Road, 233 Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 3 x G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 22 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 YA5 Regulation 5 (1) b Timescale for action The Contract/Statement of terms 31/8/05 and conditions must be completed, agreed and signed by the service users’ representatives. (Previous timescale of28/2/05 not met) The Registered Providers must 30/9/05 ensure that all areas of the home are maintained on a regular basis, with a programme of ongoing refurbishment, and there is a system for repairs which ensure the works are carried out within reasonable timescales. The Registered Providers must 31/8/05 demonstrate that the Registered Manager has sufficient time available for the management of the home. The Registered Manager must 31/8/05 ensure there is sufficient monitoring of the maintenace records for accuracy and that staff are fully aware of their responsibilities and obligations regarding health and safety. Requirement 2. YA24 23 (2) (b) (c) & (d) 3. YA31 18 (1) (a) 4. YA41 13 (4) (a) (b) & (c) Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 23 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. Refer to Standard YA12 YA35 YAQ41 Good Practice Recommendations That the provision of equipment, such as computers, be explored to provide the non-verbal service users with additional activities and stimulation. That the training records being maintained are expanded to show the dates the training was undertaken to ensure that updated training is planned and takes place. That a computer, to aid better record keeping and provide for the service users to have ready access to visual materials, is available to the staff. Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Spring Grove Road, 233 G61-G10 s22907 233 Spring Grove Rd v233201 110705 Stage 4.doc Version 1.30 Page 25 - 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. 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