Inspection on 15/10/07 for Turning Point Hazel House

This inspection was carried out on 15th October 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Turning Point Hazel House 04/10/06

Turning Point Hazel House 29/11/05

Turning Point Hazel House 08/03/05

Turning Point Hazel House 17/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Turning Point Hazel House 67 Warwick Road London SW5 9ST Lead Inspector Tony Lawrence Key Unannounced Inspection 15th October 2007 09:45 Turning Point Hazel House DS0000026015.V348865.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 Turning Point Hazel House DS0000026015.V348865.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. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Turning Point Hazel House Address 67 Warwick Road London SW5 9ST 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) 020 7244 7533 020 7244 6874 christine.dearden@turning-point.co.uk www.turning-point.co.uk Turning Point Limited Ms Christine Dearden Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: Hazel House is a large terraced property providing accommodation for up to 10 people with a mental illness. The registered provider is Turning Point Ltd. a registered charity. Accommodation over the five floors includes a non-smoking dining area, kitchen, laundry and a toilet on the lower ground floor. The team office, sleep-in room, lounge, toilet and separate shower room with toilet are on the ground floor. There are four bedrooms on the first floor, two on the second and four on the third floor. All floors where service users are accommodated have bathing and toilet facilities. To the rear of the home there is a large garden, which is shared with the occupants of the surrounding buildings. The home is accessed via steps up to the front door, and the upper floors by internal stairs. The home is not accessible for people with limited mobility. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Monday 15th October 2007 from 09:45 – 16:30. The Inspector spent time talking with people living in the home, staff on duty and the home’s Manager. The care of two residents was tracked by talking with them and staff and checking care records kept in the home. Ten residents and four members of staff returned confidential questionnaires sent out as part of this inspection. Their responses and comments are included in this report. The weekly fee for the service is £1,033.69. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 6 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 Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has produced excellent information for potential new residents. Admissions are not made to the home until a full care needs assessment has been completed. EVIDENCE: During this visit the Inspector discussed the home’s referral and admission policy and procedures with residents, staff and the manager. Three residents said that they felt they had been involved in making the decision to move into the home and all said that they had visited the home before moving in. The Manager also confirmed that a transition programme had been agreed with one resident’s care manager and staff from their previous placement that included a series of weekend visits and overnight stays before the person chose to move in. The Manager also explained that the procedures are flexible and can be shortened or extended if necessary. All 10 residents who returned confidential questionnaires said that they had received enough information about the home to enable them to make an informed choice to move in. The home has produced an excellent Residents’ Handbook that is provided to all new residents. The Handbook includes the home’s mission statement, information on staff working in the home and recommendations from existing residents. The Handbook uses photographs to make the information more interesting and accessible to all potential residents. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 8 Both of the care plan files checked by the Inspector during this visit included a full care needs assessment completed by a care manager and assessments by other clinicians and staff from the home. Both files also included a copy of the resident’s contract with the local authority and a Licence Agreement with Turning Point. 3 staff who returned confidential questionnaires said that they were ‘always’ given enough information about new residents’ care needs. 1 person said they ‘sometimes’ were given enough information about new residents. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home involves residents in the planning of care that affects their lifestyle and quality of life. Staff have skills and abilities to support and encourage residents to be involved in the development of their care plan. Staff must make sure that risk assessments are always completed when potential risks are identified. EVIDENCE: ‘We encourage service users to regain their life skills by working with them in a person centred approach and holistically’. Comment from a member of staff. During this visit the Inspector reviewed the care plan files of two people living in the home. Both files included a detailed care plan produced by the resident, supported by staff working in the home. The care plans covered the individual’s physical and mental health needs, medication, finances and daily living skills. The plans included realistic, achievable goals for residents to work towards. Staff who spoke with the Inspector during this visit had a very good knowledge of individual’s care needs and how they should be met in the home. Residents told the Inspector that they had been involved in writing their care plans and all said that staff had supported them to decide what should be included and agreed goals with them. There was clear evidence that care Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 10 plans are regularly reviewed, involving residents and people involved in their care. Residents told the Inspector that they were consulted about aspects of life in the home and supported to make decisions for themselves. Three residents said that staff were approachable and supportive when asked for advice, support or information. All 10 residents who returned confidential questionnaires said that they were able to make decisions about what they did each day. 6 of the 10 residents said that staff ‘always’ listened to them and acted on what they said. 2 people said staff ‘usually’ did this, 1 person said staff ‘sometimes’ did this and 1 person said staff ‘never’ listened to them or acted on what they said. The two care plan files reviewed during this visit included detailed risk assessments that covered potential risks that had been identified for the person concerned. These included road safety, smoking, wandering and use of alcohol. A detailed risk assessment had been also completed for both people before a recent week’s holiday away from the home. Following this inspection, staff need to improve the ways that risks to one person living in the home are assessed and recorded. In particular, staff must make sure that, where residents smoke in their bedrooms, a risk assessment is completed. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a strong commitment to enabling residents to develop their skills. Residents are supported to access and enjoy opportunities available in the local community. EVIDENCE: During this visit residents told the Inspector that they were able to take part in activities they chose, in the home and the local community. Some people said they go to sessions at local day services and others said that they spend their time in the home or visiting relatives and friends. The home has a variety of communal areas where residents can spend time and two people told the Inspector that they often spent time in the lounge. One person said that they chose to spend most of their time in their bedroom. All ten people living in the home recently went to Butlin’s for a week’s holiday, supported by the home’s staff team. Two people told the Inspector that they had enjoyed the holiday and photographs taken during the week were displayed around the home. Care plans included information and contact details for residents’ relatives, friends and other significant people. Staff said that they could support residents to stay in touch with other people, if necessary. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 12 Care plans and daily care notes included references to residents taking part in activities of their choice. During this visit, one member of staff was due to visit a local mosque with one resident, but this had to be rearranged. This is an example of the home’s emphasis on addressing issues of diversity and equality in the home. Information about Turning Point’s equality and diversity policies is displayed throughout the home and the Inspector also saw information about events to mark Black History Month and a faith calendar that showed significant dates and religious festivals. All 10 residents who returned confidential questionnaires said that they could do what they wanted during the day, in the evenings and at weekends. The home has a well-equipped and spacious kitchen where residents can prepare their own meals. There is also a bright and comfortable dining room for residents’ use. The Inspector saw that residents and staff are undertaking some excellent work to develop individual menu books for each person living in the home. This is being done at the resident’s own pace, with the intention of each person having their own record of meals and recipes that they can use to make choices about their diet. The notice board in the kitchen where menus and information about healthy eating is displayed has been decorated with one resident’s excellent artwork. Two residents told the Inspector that they were always able to choose the food they ate and staff would support them with budgeting and shopping, if required. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans give a comprehensive overview of residents’ healthcare needs. The home has an efficient medication policy and procedures that staff understand and follow. EVIDENCE: The two care plan files reviewed by the Inspector during this visit included good information about each person’s healthcare needs and how these would be met in the home. There was evidence of good links with Community Mental Health Teams, GP’s and other clinicians. Care plan reviews included consideration of the person’s physical and mental health needs and agreed action plans to meet identified needs. Following recent legislative changes, staff and residents are working to produce information about support that is available to help people stop smoking. This work has resulted in some creative displays of information that is displayed around the home. The Inspector felt that the home has a clear medication policy that is followed consistently by the staff team. The home uses a Monitored Dosage System supplied by Boots and prescribed medication is delivered in blister packs every 28 days. There is secure storage for all medication in a lockable metal cabinet in the staff office. The Inspector checked the Medication Administration Record Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 14 (MAR) sheets for all 10 people living in the home. The records were well maintained and up to date and the Inspector saw no errors or omissions. Staff make good use of codes to show why medication may not be given on occasion. It is a recommendation of this report that staff should make sure that photographs of new residents are included in the home’s medication records as soon as possible after they move into the home. Response from the home Photos of residents in medication file We do not at present insist on photographs of referrals prior to being given a place at Hazel House. We find it takes some persuasion and time to get a new resident to agree to have their photograph taken. This is generally because residents tend to be anxious and paranoid being in a new place with knew people around them. We do put photographs of residents on all important documentation once they have agreed; it took a little time for one person to agree to the photograph. His photograph is now on the medication file. All permanent staff know the service users very well. We rarely have situations where we would require agency staff to give medication e.g. once a year we hold a team away day. On these occasions we ensure that the agency staff on duty have a long history of working with us and know the clients well. If some one was new to them, I would personally brief them on how to work with the new service user and how to contact me to get support if needed. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Here is evidence that residents are happy with the services they receive. People feel safe and well supported by the staff team. EVIDENCE: Two residents who spoke with the Inspector were very positive about the support they receive from staff. They described staff as approachable and professional and both people said that they would always talk to any member of the staff team or the home’s Manager if they had any concerns. Both people said that they were asked for their views on the way the home is run and one person mentioned regular house meetings as a forum for discussion about any issues affecting residents. Staff told the Inspector that their induction training had included information about safeguarding adults issues (adult protection). While staff were aware that they are expected to follow the local authority’s multi-agency safeguarding adults policy and procedures, a copy of the procedures was not available in the office for staff reference and use. The Manager was asked to obtain a copy of the procedures and she confirmed that a flow chart showing the procedure had been placed in the staff office the day after this inspection. The home has a clear complaints and compliments procedure that the Inspector saw is displayed throughout the home for residents’ reference. Information provided by the Manager before this inspection is evidence that complaints are recorded and managed in line with Turning Point’s procedures. The Manager has also developed a useful recording form to capture comments made by residents that need a response before they become a formal complaint. 9 of the 10 residents who returned confidential questionnaires said Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 16 that they knew who to speak to if they were unhappy about any aspect of the care they received and two people said that they would speak to their key workers. 9 people also said that they knew how to make a formal complaint. One person said they did not know who to speak to about concerns or how to make a complaint. Managers and staff should make sure that all people living in the home are aware of the complaints procedure. All 4 staff who returned confidential questionnaires said that they would know what to do if a resident, relative, advocate or friend had concerns about the home. Response from the provider Service user understanding of complaints procedure In the report you state that 1 of the 10 service users stated in the questionnaire they did not know how to make a complaint. To enable the service users to have their voice heard with the CSCI questionnaires, the team supported those who have difficulties completing forms. One service user was assisted in expressing his views by his key worker. The key worker informed me of the answers he had helped the service user to write and had discussed it in the staff handover. The service user requested the ‘no’ answer to – ‘do you know how to make a complaint’ and negative to other similar questions about being able to speak and be heard by staff. The service user was clear on the answers he wanted recorded. His key worker asked him did he know who was his key worker (he has worked with the resident for over 2 yrs). The service user answered ‘yes’. His key worker asked him did he feel he could come and talk to him if he needed anything or wanted to talk about anything? The service user said ‘yes he knew this’. His key worker asked him if he still wanted to put the answers to the questionnaire and the service user said ‘yes’. We followed his wishes. We are in the course of revamping our service user induction and will have a document for service users to sign off once we have gone through the complaints procedure with them. This will evidence that at the time of signature the service user understood the complaints procedure. Fluctuations in service user health will affect their comprehension of what a complaint is and how to make it throughout their time at Hazel House. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides accommodation that is appropriate to residents’ specific needs. People who live in the home are encouraged to personalise their bedrooms. EVIDENCE: Hazel House is a large terraced building on a busy main road, close to the shops and transport links in Earl’s Court. It is not accessible to people with mobility problems, as there are steps to the front door and internal stairs to all bedrooms. During this visit the Inspector saw all communal parts of the home and two residents’ bedrooms. The home provides a good standard of spacious accommodation and recent redecoration works have improved communal areas and some bedrooms. There are enough bathrooms and toilets for residents’ use and a choice of communal areas, including a lounge where residents can smoke. There is sufficient office space for the Manager, staff and the home’s part-time administrator. All parts of the home seen by the Inspector during this visit were comfortably furnished and well decorated. The home has a part-time cleaner who works for four hours a day, Monday – Friday. During this unannounced visit, all parts of the home were clean and hygienic. 7 of the 10 residents who returned confidential questionnaires said Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 18 that the home was ‘always’ fresh and clean. 2 residents said that the home is ‘usually’ fresh and clean and 1 person said the home is ‘sometimes’ fresh and clean. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a diverse staff team that has a balance of all the skills, knowledge and experience to meet the needs of service users. There is evidence that they demonstrate a thorough understanding of the particular needs of the service users, and can deliver highly effective person centred care. EVIDENCE: ‘The home has a clear structure and areas of responsibility and authority are clearly defined. Service users are actively encouraged to participate and their opinions are canvassed and acted upon wherever appropriate’. Comment from as member of staff. ‘The home provides a steady, calm atmosphere with experienced staff’. Comment from as member of staff. During this visit the Inspector spoke with the home’s manager and staff on duty. Information provided by the Manager is evidence that the home has a stable staff team, the majority of whom have worked together for some time. The home has also recently appointed a Deputy Manager. When the Inspector arrived, the Manager was on duty with two care staff. Two more staff were due to work later shifts during the day and two staff are on duty at night. The Inspector considered this level of staffing was appropriate to meet the care needs of the existing group of residents. Throughout the day, the staff team Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 20 worked well together to make sure that residents’ care and support needs were met promptly and appropriately. 2 staff who returned confidential questionnaires said that there are ‘always’ enough staff on duty to meet the needs of individual residents. 2 staff said that there are ‘usually’ enough staff on duty. Staff who spoke with the Inspector were knowledgeable about current practice issues in mental health and all had a good understanding of the care needs of each person living in the home. Staff confirmed that they receive formal supervision with the home’s Manager each month. Staff said that they found the supervision and support helpful and a written record is kept of each supervision session. Staff training records showed that the home’s Manager has a clear understanding of the importance of providing learning opportunities for staff. The Manager has detailed information about training courses that each person has attended, together with a training needs analysis for each person. This shows the statutory and other training that each person needs to complete. Records showed that training that has already been completed or has been booked included Manual Handling, Fire Safety, Medication, Food Hygiene, First Aid and Infection Control. Six staff from the home have completed their National Vocational Qualification (NVQ) Level 2 training and the home meets the standard for 50 qualified staff. Staff told the Inspector that they have the opportunity to go on to their NVQ Level 3 training and one member of staff is also training as a NVQ Assessor. Information provided by the Manager is evidence that all staff have a completed Criminal Records Bureau (CRB) Enhanced Disclosure before they start work in the home. A record of CRB checks is kept in the home for reference. All 4 staff who returned confidential questionnaires said that Turning Point had carried out the required employment checks before they started work. 2 staff said that their induction had covered everything they needed to know to do the job ‘very well’. 2 people said that their induction had ‘mostly’ covered the things they needed to know. All 4 staff who returned confidential questionnaires said that they received training that was relevant, helped them understand and meet the needs of individuals and kept them up to date with new ways of working. All 4 staff also said that they met with the Manager ‘regularly’ to get support and discuss their work. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. She works to continuously improve services and provide an increased quality of life for residents with a strong focus on equality and diversity issues. EVIDENCE: The home has a well-qualified and experienced Manager who has experience of working with people with a mental illness in community and forensic settings. The Commission has registered the Manager as a fit person to manage the service. The Inspector felt that the Manager has a clear understanding of issues affecting people living in the home and how the serviced can be developed to provide even better outcomes for individuals. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 22 Information provided by the Manager before this inspection is evidence that Turning Point has developed and reviewed all of the policies and procedures needed to meet these Standards. During this visit the Inspector checked a variety of care records kept in the home. The Inspector felt that standards of record keeping in the home were very good. Monthly monitoring visits are made to the home and copies of reports are sent to the Manager and the Commission after each visit. The Inspector saw that weekly and monthly health and safety checks were carried out and recorded by staff in the home. Safety assessments have been completed for all cleaning materials and other chemicals used in the home. Two health and safety issues were discussed with staff and the Manager during this visit. Where residents smoke in their rooms, there is a need to make sure that a risk assessment is completed to minimise risks to the resident and other people. Staff must also make sure that opening restrictors are fitted to all windows above ground floor level, to reduce the risk of accidents to residents. Standard 42 - To reduce the risk of accidents, staff must also make sure that opening restrictors are fitted to all windows above ground floor level. Response from the provider: Window opening restrictors There are opening restrictors on all windows above ground floor at Hazel House. The window to room 3 did have restrictors on however they were not working. We did check all of the other windows immediately after you alerted us to the problem in room 3. All of the other window restrictors were working as they should. The window restrictor in room 3 has now been mended. Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 23 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 4 2 3 3 X 4 X 5 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 X 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 3 2 3 Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 24 No 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 YA9 Regulation 13 (4) Requirement To make sure that residents are safe, a risk assessment must be completed for all residents who smoke in their rooms. To make sure that residents are safe, opening restrictors must be fitted to all windows above ground floor level. Timescale for action 30/11/07 2. YA42 13 (4) 30/11/07 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 YA20 Good Practice Recommendations To make sure that medication is managed safely, staff should make sure that photographs of new residents are included in the home’s medication records as soon as possible after they move into the home. Managers and staff should make sure that all people living in the home are aware of the complaints procedure. The Manager should make sure that staff have access to a copy of the local authority’s multi-agency safeguarding adults policy and procedures. 2. 3. YA22 YA23 Turning Point Hazel House DS0000026015.V348865.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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