Inspection on 09/08/07 for Westwood Avenue, 20

This inspection was carried out on 9th August 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westwood Avenue, 20 30/06/08

Westwood Avenue, 20 21/04/06

Westwood Avenue, 20 21/09/05

Westwood Avenue, 20 27/04/05

Westwood Avenue, 20 30/11/04

Westwood Avenue, 20 15/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 20 Westwood Avenue Monpekson Care Limited 20 Westwood Avenue South Harrow Middlesex HA2 8NS Lead Inspector Julie Schofield Key Unannounced Inspection 9th August 2007 8:45 20 Westwood Avenue DS0000017580.V347777.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 20 Westwood Avenue DS0000017580.V347777.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. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 20 Westwood Avenue Address Monpekson Care Limited 20 Westwood Avenue South Harrow Middlesex HA2 8NS 020 8422 4176 020 8422 4176 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) Mrs Pek Enthwhistle Ms Monica Doreen Pryme Jean Page-Defour Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2006 Brief Description of the Service: 20 Westwood Avenue is a registered care home providing personal care, and accommodation for up to 3 service users with learning disabilities. It is owned by Monpekson Care Limited and was opened in 2000. The home is located in South Harrow and is a three bedroom semi-detached house, in a quiet residential street. The home is located within a few minutes walk from a variety of shops, pubs, cafes, post office, local bus and train services and other amenities and facilities. All the bedrooms are single. One bedroom is on the ground floor, and two bedrooms are located on the first floor. There are bathing and toilet facilities on both the ground and first floor. There is accessible street parking and limited off street parking. The home has an enclosed, accessible garden. Details of the fees charged for the service may be obtained, on request, from the home. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday in August and consisted of 2 visits to the home. The first visit started at 8.45 am and finished at 12.20 pm. The second visit started at 4 pm and finished at 6.30 pm. During the inspection a site visit took place, records and policies and procedures were examined, case tracking was carried out, discussions with the proprietor, manager, members of staff and residents took place and the preparation of the evening meal was observed. The Inspector would like to thank everyone for their assistance and for the comments that they gave as part of the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the pond in the garden has been filled in for safety reasons. Some decoration has taken place in the corridors on the ground floor. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 6 Two requirements were identified during the previous inspection in April 2006 and 1 of these is now met. The temperature of the resident’s bath water temperature is monitored by keeping records of this. 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. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 People who use this service experience good outcomes in this area. Receiving information in formats that are accessible to them enables prospective residents to make an informed choice. A comprehensive assessment of need prior to the admission of the resident enables the home to determine whether a service tailored to the individual needs of the resident can be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission for Social Care Inspection was given a copy of the revised service user guide/statement of purpose documentation at the time of the previous inspection in April 2006. It was recommended that residents should also receive a copy of this information. Residents have now been given a copy of the new service user guide, which is in a format suitable for the residents and it was observed that a resident kept their copy in their room. It was noted that a copy has also been placed in their care plan file. The home has an admission procedure, although no new resident has been admitted to the home for several years. The policy is that if a referral is made the proprietor and the manager will carry out a comprehensive assessment of 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 9 the needs of the prospective resident. This information would be in addition to the information provided by the placing authority, which would include a copy of their needs assessment for the prospective resident. On the basis of all this information the home is able to determine whether a service can be provided that would meet the needs of the resident. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People who use this service experience adequate outcomes in this area. In order for the home to monitor the resident’s progress towards meeting targets or goals regular review meetings need to take place. Minutes of review meetings must be kept on file to assure residents that staff are familiar with how to support then when their needs change. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files of each of the 3 residents were examined. Each resident had a care plan file and this contained a comprehensive care plan, that had been recently developed, and which identified personal, health and social care needs. The care plan included information regarding the goals, action and achievements. It is recommended that residents be provided with a copy of 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 11 the care plan in a format that meets their needs. Within the care plan file were records of daily preferences and what assistance the resident needed. There was also guidance for staff in respect of aspects of the resident’s behaviour. There was evidence that review meetings have taken place on a regular basis for one resident but the minutes of a meeting convened by the funding authority in January 2007 were not on file. Reviews were outstanding for the other 2 residents. It was noted that family members are invited to attend review meetings to support the residents, if residents wish. The home uses a system of key workers to provide intensive support to the residents. A member of staff said that the role of the key worker included ensuring that the resident’s needs were met and keeping relatives updated with the resident’s state of health and wellbeing. During the inspection residents were observed exercising their right of choice. They were able to make choices in what they ate, what time they got in the morning, what activities they took part in, what items they wished to purchase out their money and the shop that they wanted to use. A resident said that they chose where they went on holiday. One of the residents has an advocate. The manager said that if a resident couldn’t make their choices known verbally e.g. in respect of the venue for their holiday, the home would consult the family. A general risk assessment was on each residents’ file and it identified the risk e.g. to self, to their health, to others, to property, while in the community etc. A risk management plan was included. These were recently drawn up. There were also risk assessment tailored to the individual needs of the resident e.g. going on holiday, crossing the road, verbally challenging others etc. A copy of the missing person procedure is on display in the open plan dining/kitchen area. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 People who use this service experience good outcomes in this area. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: None of the residents attend a day centre and the manager said that this is their choice. One of the residents said that he would be taking two courses in college from September i.e. Travelling the World and Pathway to Literacy. Two residents take part in art classes and cookery sessions that are held in the home. A programme of activities is drawn up for each of the residents. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 13 Residents use resources and facilities in the community including restaurants, shops, leisure centres, cinema, pubs and parks. Residents use public transport i.e. buses, tubes and taxis. One of the residents enjoys going shopping and there are particular shops that he likes to use. He was pleased to return later in the day with some shopping that he had bought from one of his favourite shops. Residents discussed the holidays that they had taken part in over the last few years. This year 2 of the residents have been to Sweden and both said that they had enjoyed the holiday. The third resident has been to Wales and is going to Italy later in the year. A resident said that they had travelled extensively over Europe and they had a list of places that they wished to visit in the future. The home also arranges outings for residents including a trip to Southend. They are also planning to go to the Notting Hill Carnival, later in August. Residents attend clubs that are held in the evenings or weekends e.g. the Apple club, the 1 to 1 club etc. Staff were knowledgeable regarding the family support that residents enjoyed. One resident receives regular visits from their family and goes out with them for the day. Another resident goes to visit their family each week and an advocate supports the third resident and they sometimes go out shopping together. It was observed that residents are encouraged to be as independent as possible and when 1 of the residents came into the kitchen for breakfast they helped to make their breakfast and cup of tea. During the preparation of the evening meal one of the resident was helping the member of staff. Residents are also encouraged to help with their laundry. Staff respected the privacy of residents and knocked on the door of the resident’s room, waiting to be invited into the room before entering. Residents were able to spend time in their room without unnecessary intrusions. Menus were inspected. A record is kept of what residents have eaten on a daily basis. The menu is varied and wholesome. Sample menus that include pictures have been designed to facilitate resident choice. It was observed that residents were offered a choice at mealtimes, including breakfast. During the inspection an evening meal was prepared that consisted of chicken, kidney beans, swedes, cabbage, carrots and rice. Fruit was to be served as the dessert. Monthly records are kept of residents’ weights. It is recommended that a pedal bin is used in the kitchen and that the freezer is defrosted. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use this service experience good outcomes in this area. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. The health and well being of residents is promoted through regular health care checks and appointments. Residents are supported in taking their medication, as prescribed by their GP, in order to maintain their general health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans included an identification of personal care needs and there was guidance for staff in respect of how to support residents, according to the residents’ preferences. Assistance or prompting was given discretely. Staff were aware of the need to provide consistency of advice when supporting residents and demonstrated this in regard to a resident that they were encouraging to act in a more appropriate manner towards females. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 15 Care plan files included a health action plan. Records were kept of health care appointments and there was evidence that residents had access to routine screening i.e. blood tests. There were also appointments with the dentist, optician, chiropodist and GP. Residents are supported when they attend out patient appointments at the hospital and there were appointments with the dietician and the psychiatrist. The storage of medication was safe and secure. Two of the 3 residents are prescribed medication. Each of these residents has a plastic box with their photograph attached to aid recognition. The home uses the dosette box system of administration of medication and the pharmacist fills these. It was noted that the empty compartments corresponded with the day of the week and the time of day that they were examined. Records were inspected and were up to date and complete. Staff confirmed that they had received medication training. One of the residents has appointments with the psychiatrist and she reviews the medication prescribed on a regular basis. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use this service experience adequate outcomes in this area. A complaints procedure is in place to protect the rights of the residents. Protection of vulnerable adults training for staff contributes towards the safety of residents. However, the lack of a clear procedure, in writing, and available in the home for reference by members of staff compromises the safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure was on display in the open plan kitchen and dining room. Its format was suitable for the residents. The manager said that no complaints have been recorded since the last inspection. She prefers to deal with matters early, before they become complaints. Residents are able to speak directly to her or other members of staff on a daily basis. They can also speak to their key worker during key worker meetings or raise concerns during residents’ meetings. The complaints procedure was examined and included the different stages, the names of the personnel involved in investigation complaints and timescales for action. A resident said that they would speak to someone if there was something that he was not happy with. One of the residents has an advocate. A statutory requirement was identified during the previous inspection in April 2006 that the home’s protection of vulnerable adults procedure needs to be 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 17 reviewed to ensure that there is clarity in regards to the procedure to be followed by staff in response to an incident or allegation of abuse. Although the manager said that the procedure had been amended she was unable to find a copy of the procedure in the home. Therefore the home was unable to demonstrate compliance with the requirement and the timescale has been extended. One of the members of staff on duty confirmed that they attended protection of vulnerable adults training on a yearly basis. They were clear about their responsibilities in the event of a disclosure being made and were aware of the whistle blowing procedure. A copy of the interagency guidelines in the event of abuse was available in the home. A copy of the whistle blowing procedure was also available. Records confirmed that staff have received enhanced CRB disclosures. The home has policies and procedures in regard to the handling of residents’ finances. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 People who use this service experience good outcomes in this area. Residents enjoy comfortable surroundings that are maintained to a good standard although a few minor repairs are necessary. The provision of bathing and toilet facilities maintain the privacy and dignity of the resident. Residents are assured of hygienic surroundings as good standards of cleanliness prevail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit took place. It was observed that the overall standard of maintenance of the home was good. The décor of the home and furniture, furnishings and fittings were of a good standard, comfortable and homely in appearance. It was noted that in one of the first floor bedrooms the wallpaper was becoming detached from the wall, below the window frame. A crack in the wall near the top of the stairs has been filled but not painted over to match the surrounding area. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 19 Residents have access to a pleasant garden at the back of the house with a large patio area, lawn and mature trees and shrubs. The fencing in the garden at the rear of the house was in need of repair. There are bathing and toilet facilities on both the ground and first floors. It was noted that the shower cubicle in the ground floor shower room was raised and involved stepping up and over the rim. The residents currently living in the home are mobile and are able to negotiate this. It would not be suitable for a resident with certain mobility problems. It is recommended that this provision be reviewed in respect of future needs of either current residents or new residents. It was noted during the site inspection that all areas of the home were clean and tidy and free from offensive odours. There is a laundry room in the home. Access to this is either through a door to the front of the house or through the open plan dining/kitchen area. The home does not service incontinent laundry. There is a wash hand basin in the shower room. (It is recommended that the shower room contains a small pedal bin). There was a record that staff have training in relation to infection control procedures. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 People who use this service experience good outcomes in this area. Residents benefit from a service provided by carers that have demonstrated their skills and understanding through NVQ training. Residents are assured of sufficient staff on duty to meet their needs. Recruitment practices must be thorough so that the safety and welfare of residents is protected. The programme of training for staff encourages good working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion took place with the manager regarding the progress being made by the home in meeting the target of 50 of carers trained to an NVQ level 2 or 3 in care. Of the 6 members of staff listed on the rota 1 member of staff has achieved an NVQ level 2, 1 has achieved an NVQ level 3, 1 is currently studying for their NVQ level 4, 1 is currently studying for their NVQ level 2 and the remaining 2 members of staff have both enrolled on an NVQ level 2 training course. Therefore this standard has been met. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 21 At the start of the inspection 2 members of staff were on duty to support the 3 residents. A copy of the rota for week commencing the 11th August was available. It was noted that during the week there are 2 members of staff on duty in the home during the day. On Saturday there are 2 members of staff on duty in the mornings and 1 member of staff on duty on the late shift. On Sunday there is 1 member of staff on duty during the day. The changes to the staffing levels reflect that the number of residents in the home at the weekend is reduced. At night one member of staff sleeps in but is on call. One of the members of staff said that with the staffing levels in the home they were able to “give more value to service users and do more 1:1 work”. Staffing levels were sufficient for the current needs of the existing residents. Three staff files were examined. Files contained an enhanced CRB disclosure. Each file contained 2 references. On 2 files it was noted that 1 of the references was addressed “to whom it may concern” and had been supplied by the applicant. Each file contained proof of identity e.g. passport details. Two of the staff members had residency permits, which were due to expire later in August. It is recommended that the home has a system of recording when required documents are due to expire so that the member of staff can be asked to supply updated documents. The induction training given by the home has been revised and it now is based on the Sector Skills Council’s Common Induction Standards. Records kept were signed and dated. A copy of the Employee Training Plan for 2005 –2007 was available. Individual training profiles did not always record all the training undertaken by staff. Staff meetings are held in the home and minutes were available for 2 meetings that had taken place in 2007 i.e. January and May. It is recommended that staff meetings take place on a monthly basis and that the minutes of these meetings are kept on file, for reference. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use this service experience good outcomes in this area. Continuing to undertake further training enables the manager to develop her knowledge, skills and understanding and to provide a service that is responsive to the needs of residents. Information gained through the quality assurance systems is used to shape the future development of the service and ensure that the changing needs of residents are met. Training for staff in safe working practice topics promotes the health and safety of residents, staff and visitors to the home. Testing and servicing of equipment and systems in the home demonstrate that they continue to be safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 23 The manager has managed the care home for several years and has completed an NVQ level 4 qualification in management. She has undertaken periodic training to update her knowledge and skills and gave examples of training undertaken since the last inspection in April 2006. These included supervision training, protection of vulnerable adults training, infection control and manual handling. The home obtains feedback on the quality of the service provided in a number of different ways. The home has a user-friendly questionnaire for residents and a form to review aspect of life in the home. This information is used to shape the future development of the home and a copy of the development plan for 5/07 to 5/08 was available. Feedback from relatives and professional visitors to the home may be given informally or at review meetings. Residents meetings take place on a monthly basis and the minutes of these meetings were available. The last meeting had taken place on the 24th July. Agenda items for the meetings included likes and dislikes, outings and the quality assurance survey. The home has IIP status. There was evidence in the home that monthly fire drills are carried out. There were valid certificates for the testing of the portable electrical appliances, the fire extinguishers and a valid Landlord’s Gas Safety Record. The manager said that the home was waiting for the certificate for the inspection of the electrical installation to be issued and it is recommended that a copy of this be forwarded to the Commission for Social Care Inspection. A letter from the LFEPA, after a visit to the home in 2006, confirmed that the home was deemed to comply with the regulations in respect of fire safety. There is information in the home regarding staff receiving training in safe working practice topics e.g. manual handling, food handling and infection control. A statutory requirement was identified during the previous inspection in April 2006 that there needs to be evidence that resident’s bath water temperature is monitored. A book to record the temperature of the bath water is kept in the bathroom and was seen. Records were up to date. This requirement is now met. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 14(2) & 15(2) Requirement The registered person must ensure that the placement is reviewed on a regular basis and that the minutes of these meetings are kept on file so that the resident is assured that their changing needs are met. The registered person must review the home’s protection of vulnerable adults procedure to ensure that there is clarity in regards to the procedure to be followed by staff in response to an incident or allegation of abuse so that the a resident is appropriately supported. The registered person must ensure that a copy of the protection of vulnerable adults procedure is available in the home for reference so that a resident is appropriately supported in the event of an incident or allegation of abuse. The registered person must ensure that the minor repairs are carried out to maintain the good standard of accommodation enjoyed by residents. The registered person must DS0000017580.V347777.R01.S.doc Timescale for action 31/12/07 2 YA23 13(6) 01/10/07 3 YA23 13(6) 01/10/07 4 YA24 16(2) & 23(2) 01/10/07 5 YA34 19(4)(C) 01/10/07 Page 26 20 Westwood Avenue Version 5.2 ensure that the validity of references is demonstrated to assure residents that unsuitable persons are not employed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 Refer to Standard YA6 YA17 YA27 YA30 YA34 YA35 YA35 YA42 Good Practice Recommendations The resident should be provided with a copy of their care plan in a format that meets their needs. A pedal bin should be used in the open plan kitchen area and the freezer should be defrosted on a regular basis. There should be a review of bathing facilities in the home in respect of the future needs of current residents or of new residents to the home. A pedal bin should be used in the shower room. A system of recording when required documents are due to expire should be developed so that the member of staff can be asked to supply updated documents. Individual training profiles should be updated on a regular basis. Staff meetings should take place on a monthly basis and the minutes of these meetings kept on file, for reference. The home should send a copy of the certificate of inspection of the electrical installation to the Commission for Social Care Inspection. 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. Extracts may not be used or reproduced without the express permission of CSCI 20 Westwood Avenue DS0000017580.V347777.R01.S.doc Version 5.2 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. 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