Inspection on 05/08/05 for Vicarage Road (1&3)

This inspection was carried out on 5th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Vicarage Road (1&3) 07/01/08

Vicarage Road (1&3) 06/12/06

Vicarage Road (1&3) 21/09/05

Vicarage Road (1&3) 22/02/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Vicarage Road 1 & 3 1 & 3 Vicarage Road Dagenham Essex RM10 9SX Lead Inspector Joanna Moore Unannounced Inspection 05 August 2005 10:00 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. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Vicarage Road 1 & 3 Address 1 & 3 Vicarage Road 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 592 8734 The Avenues Trust Ltd Janet Kedgley CRH Care Home 8 Category(ies) of LD Learning Disability registration, with number PD Physical Disability of places Within a total number of 8 Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 22 February 2005 Brief Description of the Service: 1 to 3 Vicarage Road is a newly purpose built 8 bedded unit comprising of two connected bungalows set on a housing development. The home is registered to provide care for service users with learning disabilities and/or physical disabilities and current residents have very high care needs, staff use their knowledge of service users means of communication to efectively undertsand their needs as the range of verbal communication that service users are able to use is limited. All of the current service users previously resided in Little Highwood Hospital, a long stay instititution due for closure. the home is operated by Avenues Trust which is a registered Charity. All the bedrooms are en-suite, there are two large dining/sitting areas, two kitchens, two laundrys and two garden areas. The home also has its own custom built vehicle, which staff drive to take service users out on outings. At the time of the inspection there was one vacancy and one service user who was in hospital and not likely to return to the home. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to improve its recorded induction process for new staff. The home needs to implement a program of regular supervision for staff. The home needs to have clear receipts for all purchases and the repayment of money owed to avenues. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 6 The home was needs to provide suitable heating and ventilation to make it a nice place to live and work. 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. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 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 Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 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) 2,3,4,5 Service users and staff benefit from a comprehensive needs assessment process prior to the admission of the service user. Service users are given the opportunity to visit the home so that they become familiar with it and can “test drive” it before a final decision on the appropriateness of the placement is made. The organisation must make available sufficient information to service users and/ or their representatives as to the terms and conditions of occupancy EVIDENCE: All the service users have come from a long stay hospital. All have had detailed care management assessments that included a needs led assessment, Occupational Therapist report, a client profile and a record of a daily plan for each service user prior to admission. The moving in process for all clients included regular visits to the home and overnight stays. Service users were all admitted on a trial basis which was reviewed to ensure the ongoing appropriateness of the placement. There had also been an advocacy service in operation whilst service users were transferring over to the home. This has now been withdrawn. The inspector was informed that when referrals are made in the future for prospective residents that the manager intends to supplement the initial needs assessment with a visit to the client to see how the home could support them. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 9 The Staff used their knowledge of the communication methods which service users use such as verbal, non verbal and behavioural cues. Staff collectively and individually were observed to have the skills to work with service users on a daily basis. No individual contract is in place, which outlines the services, which residents can expect, and the house rules. The organisation is required to develop a service user contract which includes all matters which are outlined in the national minimum standards and explain it to service users, their families and advocates. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 10 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 &10 Staff worked hard to enable service users to have a fuller understanding of their world and what was happening in their lives. EVIDENCE: In every bedroom and lounge throughout the building there was evidence of work ongoing to enable service users to have a fuller understanding of their world and what was happening. This was achieved through the provision of sensory materials on the walls and activities within the home. The Inspector examined three service users care plans. These comprised of a pen picture of the service user, communication methods, medication requirements, personal care needs, continence management and sleeping patterns. A daily record is written in a diary. Each service user has a key worker linked with the Person Centred Planning process. The Registered Manager and staff informed the Inspector that all the service users had either very limited verbal communication skills or none. All the service users are able indicate through individual communication methods such as pointing or using behaviour to express their preferences. None of the service users undertake activities that necessitate any limiting of decision Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 11 making. Service users the inspector was informed were being encouraged to learn how to make basic choices within their lives which is for some a new skill. Staffing levels are high due to the care needs of the service users and therefore staff are on most occasions able to support the individuals expressed wishes at any given time. The Inspector saw a number of risk assessments carried out on activities such as moving and handling, choking, swimming, using the kitchen, shopping and use of wheel chairs in the community. Staff were aware of confidentiality and all files were held securely. A confidentiality policy was in place and discussed with staff during the induction process. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 12 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) 12,13,14,15,16, &17 Service users within their care characteristics are offered various opportunities to gain a greater understanding of their home and wider community through the provision of activities both inside and outside of the home. Service users are provided with a suitable, varied and nutritious diet. EVIDENCE: Due to care characteristics and care needs no service users have access to employment or formal educational placements, neither are service users eligible for formal day service provision. Instead the home develops its own activities, which are organised daily according to the skills and preferences of the service user and the weather on any given day. In every bedroom and lounge throughout the building there was evidence of work ongoing to enable service users to have a fuller understanding of their world and what was happening through the provision of sensory materials on the walls and activities provided. Equipment included a special electric beanbag, sensory strip lights, and tactile patches on the wall. Service users are encouraged to Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 13 participate in household chores alongside staff according to their ability. The lounge/ Kitchen diner is a single large room so preparation of food is viewed as a communally enjoyed activity whether doing it or purely watching. On the day of the inspection one service user was out on a trip with staff to thursford to celebrate his birthday. One lady had celebrated her birthday by going out to lunch and having afternoon tea and cake in the garden. Sensory equipment was provided in the home, as were puzzles, videos and music. Trips which had occurred included monthly canal boat trips, seaside excursions, a trip to Colchester Zoo and the local carnival. Most service users had gone on a week long holiday but one service users was enjoying individual day trips as at this time going away was likely to cause him distress. The local shops and the park at the end of the road are also apparently popular for short trips. Two service users have regular contact with family members visiting the home. The other service users have either little or no contact with family members and the home is attempting to improve or initiate contact with other families. Due to their care characteristics service users have little awareness of their rights or means to express them however staff continue to maintain and support service users rights through their interaction with them and ability to respond to their needs. The home provides a varied and nutritious diet which service users were observed to enjoy. Plenty of fresh fruit was available and was provided to service users. The home is able to offer puree, soft food and diabetic diets and would examine its ability to provide specific cultural diets as required. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 14 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 Service users receive support from all appropriate professionals to ensure that their healthcare needs are met. Personal care is provided in a way, which meets their needs and accords dignity. Service users are protected by robust systems to ensure the safe storage and administration of medication. EVIDENCE: Staff use their knowledge of the service users communication and preferences to provide personal care in a way, which is in line both with the service users needs and preferences. All the service users need total personal care. All personal care is given in their own room unless a bath is needed. Service users are encouraged to give what personal care they can to themselves but this is very limited. There is no rush to be up at a particular time so staff try to ensure there is one to one time with the service user when getting them ready for the day. Service users are encouraged to express preferences for what they wish to wear. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 15 Support is received from the local Community Learning Disability Team and the home is able to contact them for advice and support on any aspect of the service users care. Service users are also supported by other relevant professionals such as the district nurse, GP, dietician, epilepsy nurse, psychologist, and speech therapist. The manager advised the inspector that they were in the process of arranging optical checks. Two service users medications were checked as part of the inspection. The medication administration records (mar) tallied with the medication held and the records had been signed at the point of administration for each day. The home uses a monitored dosage system. A medication policy was in place. The home holds a book of medication returned to the pharmacy for destruction. Homely remedies used within the home are approved by the GP and consist of simple linctus, calamine lotion and paracetamol. Homely remedies the inspector was advised would be recorded on the rear of the mar sheet. Medication was stored in an appropriate locked cupboard. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 16 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 organisation had effective complaints and adult protection policies in place to respond to any concerns and to protect service users. Service users finances were not fully safeguarded in that the levels of money that could be held on site for service users according to the organisations insurance was not clear and receipts for money paid to avenues in respect of a joint purchase must be clearer. EVIDENCE: No complaints had been received since the last inspection. The home has an appropriate complaints procedure in place, which is available in a pictorial format and displayed in the hallway. Service users may make their dissatisfaction known, however due to their care characteristics would find it very difficult to effectively formally complain. No formal advocates are involved with service users at present. The inspector was advised that advocates had been involved in the process of service users moving in and that their services could be purchased on an individual case by case basis should the need arise. The Registered Manager informed the Inspector that all staff are trained in Adult Protection. The home did not have the appropriate Local Authority’s Adult Protection policy in place and is required to obtain a copy. The home has a whistle blowing policy. The Registered Manager is Appointee for all the service users and her immediate line manager is signatory for all the service users. All service users’ benefits are paid directly into their bank accounts and their rent deducted from these accounts as well. Any spending undertaken by staff on service user’s behalf has to be counter signed by the Registered Manager. Two service users finances were checked, there was a record, which showed money taken out of the bank account and transferred to the personal saving account, Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 17 and spending could be evidenced via receipts. The money held on site for the two service users tallied with the records held. It is required that when a group purchase is made on behalf of residents by avenues of which an element has to be paid back by individual service users e.g. a holiday, that a clear record of this transaction is held and receipt for the money received issued to the service user. The manager was unclear as to how much service users money could be held on site without breeching the insurance limit, It is required that this be clarified in order to ensure that service users money is appropriately insured. The manager is required to confirm how often Avenues Trust will audit service users personal finances. Three service users are under the Court of Protection. A discussion was held with the manager re the processes which would need to be instigated should an adult protection matter arise and the need to refer staff suspended in relation to adult protection allegations to the Pova list. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 &30 Service users benefited from a safe, well maintained, decorated and furnished home which met their needs. The home was however failed to provide suitable heating and ventilation to make it a nice place to live and work due to problems with the under floor heating. EVIDENCE: The home is a newly built purpose designed home. All bedrooms are single, wheelchair accessible, have en-suite facilities and ceiling hoists. All bedrooms were individually decorated and furnished and held items of individual interest. Bedrooms were also provided where appropriate with additional sensory stimulating equipment. All bedrooms are lockable and provided with magnetic door closures linked to the alarm system. There is plenty of communal space with large dining/ sitting rooms decorated and furnished in a homely manner. There are plenty of toilets and shower rooms in the building with additional specialised bathrooms. There are also separate laundry facilities. At the time of the inspection the under floor heating was switched on and could not be controlled. It was hot day and all the windows and doors were open in order to attempt to maintain an ambient temperature but it was not possible. The Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 19 environment was not pleasant to live or work in. Staff commented that they found the conditions unpleasant and were concerned regarding safety as the windows needed to be kept open at all hours of the day and night. Service users the staff also felt were suffering from the build up of heat especially those with limited mobility and were not clear as to whether the heat was affecting the behaviours and wellbeing of service users. The premises are maintained by a housing association. The home does not have dedicated cleaning staff. Care staff as part of their duties undertake cleaning. Disposable gloves and aprons were provided to minimise the risk of infection when providing intimate personal care. The home was clean and tidy on the day of the inspection. Aids and adaptations required by service users had been assessed by an Occupational Therapist prior to the service users moving in. The home was well equipped to meet the service users needs through the provision of overhead and mobile hoists, grab rails and specialist beds. There was however a shortage of storage for wheelchair which were being stored in the bathrooms. It is strongly recommended that the organisation review arrangements for storing wheelchairs when not in use. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 & 36 Service users benefited from staff team of regular workers who were trained and competent to do the job and can meet their needs. Service users were protected by a robust recruitment procedure. The home failed to evidence that it appropriately supported staff with comprehensive induction and regular supervision. EVIDENCE: A clear management structure is in place both in the organisation as a whole and within the home. Staff job descriptions were clear and staff were familiar as to their roles and responsibilities. At the time of the inspection a disciplinary investigation had been ongoing in relation to a member of staffs conduct, this had not been notified to the commission as required under regulation 37. The disciplinary process could be evidenced as clear and transparent through letters held on file. There are six care staff in total for mornings and afternoons and two waking night staff. On the day of inspection there were two senior staff, four care staff and the manager. This was to support a service user attend hospital and to accompany one service user out for the day. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 21 Recruitment records were examined for three staff which evidenced robust recruitment practices in place. For each staff member there was a copy of their evidence of identity, application form, CRB check, medical declaration, two written references and a photograph. For each post a clear person specification was in place. From letters held on file it was clear that the organisation checks staffs’ legal entitlement to work in the UK. All staff appointments were subject to a probationary period and from then on staff will receive an annual appraisal. A clear induction program was in place, which covered key areas of the organisation including policies and procedures and human resource issues as well as health and safety and client care. However of the three completed inductions which the inspector requested one was not available and another recorded it as completed a year after commencing employment. It is required that staff receive a comprehensive induction at the point of employment and through the probationary period. 19 staff were in post, of these 6 had completed NVQ level 2 in care and one had completed level3, with another two of the level 2 trained staff studying level 3. One staff is studying nursing training. Four more staff are enrolled to begin level 2 in September. 12 out of 19 staff therefore have either completed, are studying for or are to be shortly enrolled on at least NVQ level 2 or above care training course and the home is clearly working towards achieving a 50 minimum of staff trained to a minimum of NVQ level 2. Three staff files viewed evidenced staff receiving training in First Aid, Administration of Medication, Management of Aggression, Understanding Challenging Behaviour, fire, manual handling, food hygiene and infection control. Staff meetings were recorded as happening regularly. Staff individual supervisions according to the organisations policy should be held monthly and according to the national minimum standards at least six times per year. Of the three staff files viewed none could evidence a regular system of staff supervision in place. One staff had two recorded supervisions in the past year anther had three and for the third staff no supervision could be evidenced. It is required that staff receive supervision to carry out their jobs effectively, it is recommend that this be carried out at least six times per year. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37,40,41,42 & 43 Service users and staff benefit from clear leadership from the manager and organisation as a whole. Service users are protected by clear and accurate recordkeeping and policies and procedures. The health and safety of service users and staff are protected. EVIDENCE: The manager was registered within the past twelve months and was assessed by the Commission to be a fit person to manage the home. Ms Kedgley has over 20 years experience in working with people with learning disabilities and previous to this role held the role of deputy manager. Ms Kedgley has completed her NVQ level 4 in care and is the process of upgrading this to the registered managers award. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 23 Statutory records were held appropriately either accessible or confidential according to the type of record. Records viewed included the visitors book, complaints record, staffing rota, staff recruitment, service user assessments, care plans and daily records, finances, accidents and regulation 26 visits. Records as a whole were satisfactory and kept up-to-date unless detailed in the specific section relating to the record. The service manager for the home carries out a monthly health and safety audit. An external health and safety audit was carried out in April. The fire records evidenced regular checks of fire prevention and fighting equipment and fire evacuations taking place. All hazardous chemicals were stored in locked cupboards. Servicing and checking systems were in place for equipment such as hoists. The gas safety certificate had expired; the registered person is required to obtain a new valid gas safety certificate. The electrical certificate remains valid until 2009. The home undertakes a number of checks that include fire drills, fire equipment tests, call bell checks, a recent legionella check and risk assessments on working practices. Health and safety is part of any new staff member’s induction and the home has a health and safety representative. There are accident reporting procedures in place. The home is one of a number run by Avenues and there was no information to suggest that the home was not financially viable. Appropriate insurance was in place in relation to employers, public, and products liability in addition to professional indemnity. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 1 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vicarage Road 1 & 3 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 2 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 25 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 Requirement The organisation is required to develop a service user contract which includes all matters which are outlined in the national minimum standards and explain it to service users, their families and advocates. The regsitered person is required to obtain a copy of the Local Authority’s Adult Protection policy. It is required that a reciept is issued for money paid to avenues. The manager is required to clarify with the insurance company how much of service users money can be held on site. The manager is required to confirm how often Avenues Trust will audit service users personal finances. The regsitered person is required to ensure that the homes heating can be set to an ambient temperature and controlled throughout the home. The registered person is required to inform the csci of any G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Timescale for action 1.12.05 2. 23 13 1.10.05 3. 23 17 4. 23 13 immediate and ongoing no later than 7.9.05 1.10.05 5. 23 13 1.10.05 6. 24 23 7. 37 37 immediate and ongoing no later than 7.9.05 immediate and Page 26 Vicarage Road 1 & 3 Version 1.40 notifiable incidents in writing within 24 hours. 8. 35 18 It is required that staff receive a comprehensive induction at the point of employment and through the probationary period. It is required that staff receive supervision to carry out their jobs effectively. the registered person is required to obtain a new valid gas safety certificate. 9. 36 18 10. 42 23 ongoing no later than 7.9.05 immediate and ongoing no later than 7.9.05 immediate and ongoing no later than 1.10.05 immediate and ongoing no later than 7.9.05 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. Refer to Standard 24 36 Good Practice Recommendations It is strongly recommended that the organisation review arrangements for storing wheelchairs when not in use. it is recommend that supervsion be carried out at least six times per year. Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vicarage Road 1 & 3 G55 S0000060786 Vicarage Road 1_3 V246342 050805 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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