Inspection on 06/09/06 for Whiteheart Avenue, 27

This inspection was carried out on 6th September 2006.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whiteheart Avenue, 27 13/10/08

Whiteheart Avenue, 27 27/10/05

Whiteheart Avenue, 27 13/05/05

Whiteheart Avenue, 27 09/12/04

Whiteheart Avenue, 27 17/05/04

Whiteheart Avenue, 27 30/01/04

Whiteheart Avenue, 27 15/08/03

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 Whiteheart Avenue, 27 Hillingdon Middlesex UB8 3EP Lead Inspector Sarah Middleton Unannounced Inspection 6th September 2006 09:30 Whiteheart Avenue, 27 DS0000027095.V307325.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 Whiteheart Avenue, 27 DS0000027095.V307325.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. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteheart Avenue, 27 Address Hillingdon Middlesex UB8 3EP 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) 0208 561 7067 Mr. Koosraj Ramaya Unthiah Mr Koosraj Ramaya Unthiah Care Home 3 Category(ies) of Learning disability (0) registration, with number of places Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only service users residing in the home prior to their 65th birthday may be accommodated after their 65th birthday. 27th October 2005 Date of last inspection Brief Description of the Service: 27 Whiteheart Avenue is a bungalow set in a quiet residential area about one mile from Uxbridge Town Centre. Public transport links to other neighbouring shopping centres are a short walk away. The home is registered for three adults with learning disabilities with an exception for those who pass the age of 65 and who have been residing in the home for a period of time prior to this. The home currently provides a service for two adults with learning disabilities. The Service Users are one male and one female who have lived in the home since it was opened in 1990. The property has been extended. There are two single bedrooms, lounge and a kitchen/dining room. The extension houses a sleeping in room with en suite facilities and a fourth bedroom with en suite facilities has been built to the rear of the building. The Staff team consists of the Registered Person/Manager, the Deputy Manager (who is the wife of the Registered Person) and two part time staff. One Serviced User attends a day centre five days per week and the other attends one three days per week. A programme of activities had been produced for the Service Users at weekends and evenings. The Registered Person owns another home for people with learn9ing disabilities in the same road and the Service Users from the two homes are on friendly terms and share activities, holidays and outings. The fees are from £678.48-£743.44 per service user, per week. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection took place between 9.30am-2.25pm. The Inspector viewed a service user’s individual file, a staff employment file and maintenance records. One member of staff was spoken with and one service user, who was present in their home throughout the inspection. The Registered Manager assisted with the inspection process. There were no previous requirements from the last inspection. Five new requirements and three recommendations were made at this inspection. All of the Key Standards were assessed at this inspection. What the service does well: What has improved since the last inspection? There were no requirements made at the last inspection. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 6 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. Whiteheart Avenue, 27 DS0000027095.V307325.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 Whiteheart Avenue, 27 DS0000027095.V307325.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to moving into the home to ensure the home can meet their individual needs. EVIDENCE: The two service users moved into the home in 1990 when the home was first set up. There have been no new admissions since this date. The Inspector viewed the pre-admission assessment used by the home. This had been completed on the service users living in the home. This assessment covered areas such as their physical, social and mental health needs and their ability to perform domestic tasks. These assessments are carried out in conjunction with the service user and where appropriate their representatives or any professionals. The Inspector was satisfied that the preadmission assessment would identify any major needs regarding a prospective service user. Whiteheart Avenue, 27 DS0000027095.V307325.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans were up to date and recorded the service user’s health, social and personal care needs. These identified needs were being met by staff. Service users are encouraged to express their opinions and to make every day decisions in their lives. Risk assessments are completed and aim to identify the risks and record ways to minimise the potential risks to service users and/or others. These assessments aim to promote service users independence. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Inspector viewed one care plan and found that it was detailed, up to date and reviewed on a regular basis. The Deputy Manager completes the documentation regarding the service users. The care plan covered a wide range of subjects, such as the service users routines on waking and retiring to bed. Their individual likes and preferences were clearly recorded on the care plan. Their health, social and personal care needs were also identified and showed where the service user was able to be independent in particular tasks, such as undressing themselves without staff support. The home also completes, on an annual basis, an ageing process assessment that enables staff to monitor the impact ageing is having on the service users. This is of particular importance as one service user is very elderly. Service users are included in the process of developing and reviewing the care plans and evidence was seen that a service user had signed part of the care plan. Daily records were viewed and these detailed the care provided and any activities the service users took part in. The Registered Manager and the member of staff spoken with confirmed that the culture amongst the staff team is to encourage service users to make decisions for themselves. The majority of the staff team have worked supporting the service users for many years and are aware of the service users individual abilities to make informed choices about their daily lives. The two service users have an advocate who visits them at the day centres they attend. The Registered Manager has written to the advocate with the aim of meeting them and discussing any issues or comments the advocate might have with regards to the service users. The service users are not able to manage their own personal finances. A risk assessment was viewed. This was detailed and included such information as the service user’s risk of falling and steps members of staff need to take to minimise the identified risks. Other issues highlighted were using the bath and mobility issues. The service user can also at times hallucinate and the home keeps a record if this service user shows signs of hallucinating. This record enables staff to monitor any sudden changes in behaviour. The risk assessment had been completed recently and is updated on a regular basis. Whiteheart Avenue, 27 DS0000027095.V307325.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and community activities are in place and offer variation and stimulation for the two service users living in the home. Visiting and maintaining contact with family members is encouraged in order for service users to maintain social relationships. Service users rights are respected and promoted in the home. This benefits the service users who like to make daily choices regarding their lives. Meal provision and meal times are well managed and offer service users a healthy and nutritious diet. The items used by staff and service users, such as the fridge, need to be clean at all times to ensure food is kept in hygienic conditions and does not pose a risk to the service users health and welfare. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 12 EVIDENCE: One service user attends a local day centre five days a week and the other service user attends three days a week. The Inspector viewed a monthly and weekly activity programme. These are flexible but offer both service users and members of staff a structured plan to work with. Various activities are on offer such as bowling, baking, day trips and attending once a week the local social club. The home records when main activities have occurred so it is easy to identify how the service users spend their time. One service user spoken with said they enjoyed meeting other people at the day centre and they like to knit both at the day centre and at home. Due to the ageing needs of the service users members of staff are aware that sometimes service users will be tired and might just want to relax and these wishes are respected by the staff team. The Registered Manager commented on how the service users are part of the community and that wherever possible, community leisure resources are accessed, such as the pub, the local Lido and restaurants. The service users mainly access resources in the Registered Manager’s or other staff member’s cars. One service user used to attend church on a regular basis. The Registered Manager stated they were going to contact the local Priest to ascertain if someone from the Catholic Church could visit this particular service user in the home. The service users contact with family members is sporadic. The Registered Manager stated they have encouraged family members to phone or visit. One service user speaks to their niece on the telephone, whilst the other service user receives cards and the occasional visit from family members. Service users have a key to their bedrooms and front doors. The service user spoken with confirmed they have a key to their bedroom. Service users cannot read their personal mail, however the Registered Manager said that members of staff read the mail to the service users. Members of staff were seen to interact with the service user, who was present during the inspection, in a positive manner and they did not talk exclusively amongst themselves. The kitchen was viewed and overall was clean and tidy. However the fridge was not clean and had several marks and stains on the shelves. A requirement was made for this to be cleaned. Meals are recorded, including the packed lunches that service users take to the day centre. Menus were varied offering service users the traditional meals they would be likely to prefer. The service user commented positively about the meals they received in the home. One service user is able to prepare and cook a meal with staff supervision and support. Both service users are encouraged to take part, however minimally, with the preparation of meals. The Inspector discussed the kitchen units and décor of the kitchen, see Standard 24 for further details relating to this room. Whiteheart Avenue, 27 DS0000027095.V307325.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal care support in a way they prefer. Service users health needs were clearly recorded and were being met. The shortfalls in the medication policy and recording systems need to be addressed in order to fully safeguard service users health and safety. EVIDENCE: Staff support the service users with personal care tasks. One service user requires prompts and supervision, whilst the other, a female service user, requires the full support and guidance of a female member of staff. The home always ensures there is either a female member of staff working on shift. Alternatively a female staff member from the other registered home, which is located on the same road, will visit to offer the personal care support as and when required. Times for going to bed and getting up are flexible. The service user described how they could have a lie in bed whenever they wanted to and confirmed they choose their own clothes that they want to wear. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 14 The bathroom has a rail to support those service users with additional support to ensure they can access the bath safely. Health needs were clearly recorded on care plans and indicated where service users require assistance to meet a particular health need. Records clearly indicated the care service users need to prevent any illnesses or conditions developing and it had been documented when a service user had needed to elevate their legs to maintain good health. Service users have access to various health professionals such as GP’s, Dentists and Psychiatrists. Recently, due to a fall, a service user has seen the District Nurse. Service users have their weight taken and recorded on a monthly basis in order to monitor any significant changes. The medication administration records were viewed and these had been correctly completed. For the most part, either the Registered Manager or the Deputy Manager administers medication. If other staff members administer medication then this is carried out under close supervision by Management. Currently there is little medication stored in the home, however the Inspector made a strong recommendation for the home to consider obtaining a professional metal medication cabinet to store the medication safely. The Registered Manager stated they would consider this for the future. The Inspector viewed the medication policy and found it did not contain details of informing members of staff that if there is a medication error or incident relating to medication, then the CSCI must be notified, preferably using the standard Regulation 37 forms. In addition, the policy did not contain information regarding the storage, handling, administration and recording of controlled drugs. A requirement was made for the medication policy to be updated. The Inspector made attempts to count one of the service users loose medication tablets. The Inspector noted how many days it had been administered and the amount recorded when the last medication had been delivered to the home. However the amount available to count did not correspond with the amount that was recorded. The Registered Manager explained that it was likely there had been some medication leftover from the previous month and that this had been carried over to this current month. This current system then proves difficult to carry out spot checks and audit the medication if the actual quantity in the home is not accurately recorded. Therefore a requirement was made for the home to review it’s medication systems to ensure all quantities are clearly recorded in order for spot checks to be carried out successfully and thus ensuring any medication errors are easily identifiable. Whiteheart Avenue, 27 DS0000027095.V307325.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints policy is available and service users are able to make complaints to staff and are confident their concerns would be acted on. Systems are in place to protect the service users. EVIDENCE: The complaints policy is freely available and is located in the kitchen, although the Inspector was informed that the service users do not read. Therefore it is difficult to fully assess if the service users could or would make a complaint. However, the Inspector spoke with one service user, who stated they would speak with a member of staff, if they were unhappy about something and they stated they were sure their views would be listened to. The CSCI has not directly received any complaints regarding the home. The home recently updated its Protection of Vulnerable Adults, (POVA) policy and this details what is abuse and who to report any POVA concerns to. Staff have attended POVA training, with more staff booked on POVA training for later in the year. There have been no POVA allegations made to the CSCI. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a pleasant and safe environment. Service users bedrooms offer them the privacy and space to have their personal possessions around them. The home was clean and tidy at the time of the inspection. EVIDENCE: The Inspector carried out a tour of the home. Overall the home offers service users a homely and welcoming place to live in. The home is situated on a quiet residential road, close to local amenities. The kitchen is beginning to look old and tired and would benefit from new tiles, flooring and units being put in. This is a room used frequently by service users and would be more appealing if it is updated offering a more modern and brighter place to cook and eat meals in. The home should be regularly reviewing the environmental standard of the home to monitor any areas needing to be improved. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 17 As the kitchen is currently a functioning room, with nothing needing to be updated or replaced immediately, the Inspector made a strong recommendation for the kitchen to be considered when planning the maintenance and updating of the home. A service user showed the Inspector their bedroom. This room had new carpet and the service user informed the Inspector they had chosen the colours for the walls. This room was sufficient in size to offer the service user the space they need to relax in. Personal items, such as religious pictures and objects were also present and reflected the personal choices and beliefs of the service user. The service user confirmed they are able to lock their bedroom. The washing machine is located in the kitchen and infection control guidelines were visible in the kitchen. Some staff had received training regarding infection control. Overall the home was clean, tidy and free from offensive odours at the time of the inspection. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of the staff team have obtained an up to date qualification and are competent to support and meet service users identified needs. The recruitment procedures need to be more robust in order to safeguard the service users. The shortfalls in the training offered and training records need to be addressed to ensure the staff have the skills and knowledge to meet all of the service users needs. EVIDENCE: The home encourages staff to obtain an up to date qualification, such as an NVQ. Two members of staff, other than the Registered Manager and the Deputy Manager, have an NVQ level 4 and two members of staff are studying for an NVQ level 2. The Deputy Manager also has employment in a local hospital on a part time basis, so that they are able to keep up to date with any skills and knowledge that could be relevant to the service users. The Inspector spoke with a member of staff and found them to be enthusiastic and motivated to work in the home. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 19 The members of staff present during the inspection were seen to communicate well with each other and towards the service user. The staff team had worked in the home for several years and were aware of the service users specific needs and capabilities. A staff employment file was viewed. This was with regards to the Registered Manager’s son, who prior to working in the home had no previous employment history. The Inspector viewed a completed application form, health declaration and Criminal Record Bureau check. There were no references and no photograph. The Registered Manager explained that he had sought to obtain references from his son’s university lecturers but they had not responded. The Inspector suggested that a reference could be obtained from a member of staff who was a teacher or assessor of the NVQ course that his son had attended. A requirement was made for staff employment files to contain all that is listed in Schedule 2 of The Care Homes Regulations 2001. The Inspector stressed the importance of obtaining the required documentation, regardless of whether a person is a family member. The Registered Manager acknowledged this shortfall and would seek to address this shortfall. The Inspector viewed the training courses attended by staff. It was difficult to clearly ascertain who had attended a course and when as various pieces of information was located in different areas. The Inspector noted there were no clear records to indicate if the Deputy Manager had attended the mandatory training for moving and handling. The Inspector made a requirement for training records to be clear and evidence all the training members of staff, including management, have attended. This will ensure the Registered Manager can be aware of who needs refresher training and prioritise these members of staff. Additional and specialist training must also be sought to ensure the staff understand the changing needs of the service users. The home has an induction booklet that new members of staff would work through. The Registered Manager uses this on an ongoing basis to monitor the progress and development of staff. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well run. The Registered Manager is familiar with the needs of the service users and staff. Systems are in place to review the care provided in the home. Internal reviews are carried out to ensure the home operates in the service users best interests. The health and safety records and servicing records were up to date and protect those living, working and visiting the home. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered Manager is also the Registered Provider and has owned and managed the home for several years. They, along with the Deputy Manager, his wife, have obtained an NVQ level 4 and 5. The Registered Manager is aware of his role and undertakes periodic training to ensure he keeps up to date with information and theories. The home encourages service users to complete questionnaires and surveys, with the assistance of staff. In addition external surveys are given to various people who are familiar with the home, such as day centre staff and health professionals. These are completed on an annual basis. The home also carries out an annual internal audit on areas such as documentation used in the home, such as care plans and risk assessments. Activities and medication systems were also reviewed. The Inspector was satisfied the home regularly reviews the care and the running of the home. The servicing records were viewed at random. The water temperatures were taken of the bath but not the kitchen sink or bathroom hand basin. The Inspector was informed that the water is regulated by safety valves and that the service users rarely use the water independently. The Inspector made a strong recommendation for the water temperatures to be taken of all areas in the home. The testing for Legionella was up to date and clear from infection and bacteria. The Gas boiler had been serviced and the Inspector viewed a letter to confirm this had been carried out. The Registered Manager contacted the company during the inspection, asking for an official certificate. The Inspector asked for a copy of this certificate to be forwarded on to the CSCI. The fire equipment and the Portable Appliance testing were both up to date. Fire drills had been held at regular intervals and at different times of the day and evening. The Inspector viewed the accident book and found that falls and incidents are recorded clearly. The CSCI had been notified of the recent fall a service user had and was satisfied that the home had supported this service user in accessing the relevant health professionals. The London Fire and Emergency Planning Authority had recently visited the home and they had been satisfied with the home’s procedures and equipment. The home fitted those fire doors that had been propped open, the kitchen and lounge door, with magnetic door releasing equipment that respond in the event of the fire alarm being set off. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 23 N/A 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 YA17 Regulation 16(2)(j) Requirement Timescale for action 06/09/06 2. YA20 13(2) 3. YA20 13(2) 4. YA34 19(1)(b) The fridge must be cleaned on a regular basis to ensure food stored in the fridge is not contaminated and is free from bacteria. The medication policy must 30/09/06 include notifying the CSCI if there is a medication error. Also it must include the safe handling, storage, administration and recording of any Controlled Drugs used in the home. The medication systems need 30/09/06 revising to ensure the quantity of loose medication is clearly recorded, along with any leftover medication that is also to be used. This will enable audits and spot checks to be carried out and will enable any medication errors to be easily identified. Staff employment files must 30/09/06 contain all that is listed in Schedule 2 of The Care Homes Regulations 2001 for example two written references. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 24 5. YA35 18(1)(a)(c)(i) Staff must receive training, 29/12/06 both mandatory and specialist training for the work they are to perform. The evidence of training for each individual member of staff must be clear. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA20 YA24 YA42 Good Practice Recommendations It is strongly recommended for the home to consider obtaining lockable metal medication storage. It is strongly recommended for the home to consider updating and having a new kitchen installed in the home for the benefit of the service users. It is strongly recommended the home tests and records the temperatures of the kitchen sink and the washbasin in the bathroom. Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Whiteheart Avenue, 27 DS0000027095.V307325.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!