Care Home: Cavendish Road

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What the care home does well People living in the home receive a good standard of care. The staff are caring and have a good knowledge of peoples needs. The care given at this home is person centred and the residents are treated as individuals. Residents are involved in their care, as able, decisions about their life and their choices are respected. The majority of staff feel supported and work well as a team. Comments received included, "Communication of needs is generally good and consistent, through handovers and good use is made of the communication book", "using staff hours flexibly to allow special activities", and "increased choices for residents". Staff spoken to said that they worked well as a team and felt much more involved in the running of the home.A relative stated to the question, "What do you feel the care home does well as follows, "The staff show love and affection to the residents and are friendly to me as a parent". What has improved since the last inspection? The environment has been enhanced by new furniture in the lounge, replacement of the flooring in the laundry areas, new fridge/freezers as well as putting up pictures of the residents around the home. The garden areas both at the front and back is being better maintained. Person centred care has developed significantly involving residents much more in all aspect of their care and running of the home. Record keeping in respect of recruitment of staff, assessments and care planning systems continues too improve. CARE HOME ADULTS 18-65 Cavendish Road 274 A&b Cavendish Road London SW12 0BS Lead Inspector Davina McLaverty Key Unannounced Inspection 3rd June 2008 09:00 Cavendish Road DS0000010177.V364603.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 Cavendish Road DS0000010177.V364603.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. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish Road Address 274 A&b Cavendish Road London SW12 0BS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8675 9957 020 8675 9957 Melanie.Holloway@mst-online.org.uk www.stepforward.org.uk Metropolitan Support Trust Melanie Louise Holloway Care Home 9 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care hone only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Physical disability - Code PD The maximum number of service users who can be accommodated is: 9 2. Date of last inspection 13th December 2007 Brief Description of the Service: Cavendish Road is a registered home for nine adults who have a learning disability, two of whom also have a physical disability. The home itself is two adjoining houses referred to as House A and B when in fact the home is run as one unit. There are two lounges, two kitchens and two separate laundry rooms. Parking for two cars is available. The property is situated within a ten-minute walk from Balham underground and main line station and high street. The home is owned and managed by Metropolitan Support Trust. Fees vary depending on assessed need. Additional charges are made for some outings and holidays. Residents are made aware of the inspection report at the residents meeting. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection included an unannounced visit to the service on the 3rd June 2008. We met with the manager and staff on duty. We looked at records, the environment and things at the home that had changed since we last visited. We asked the Manager to complete an Annual Quality Assurance Assessment (AQAA), which is a self assessment of the service, which helped us to form some of the judgements made in this report. A very detailed AQAA was received, which stated how the home has improved as well as identifying how the home could do better. We also looked at all the information we had received from the home since the last random inspection carried out in December 2007. Prior to this inspection surveys were sent to the home to distribute to the people living there, their relatives, professionals working with residents and staff, to comment on their experiences of the service. At the time of the inspection six surveys were received from resident’s relatives, six from staff and four from residents who had been supported by staff to complete the form. One professional survey was received. Responses from surveys were mainly positive and where relevant are reflected in the report. What the service does well: People living in the home receive a good standard of care. The staff are caring and have a good knowledge of peoples needs. The care given at this home is person centred and the residents are treated as individuals. Residents are involved in their care, as able, decisions about their life and their choices are respected. The majority of staff feel supported and work well as a team. Comments received included, “Communication of needs is generally good and consistent, through handovers and good use is made of the communication book”, “using staff hours flexibly to allow special activities”, and “increased choices for residents”. Staff spoken to said that they worked well as a team and felt much more involved in the running of the home. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 6 A relative stated to the question, “What do you feel the care home does well as follows, “The staff show love and affection to the residents and are friendly to me as a parent”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cavendish Road DS0000010177.V364603.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 Cavendish Road DS0000010177.V364603.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 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written information about the home is available to residents. Residents’ needs are effectively assessed. Residents are able to visit and stay at the home before deciding to move in. EVIDENCE: There is a Statement of Purpose and Service User Guide, which include information about the home and how to make a complaint. The Service User Guide is currently in two formats, one written, the other with minimum text and with more pictures/symbols, which is more appropriate for the resident group. There are appropriate procedures for the assessment and admission of new residents. On receipt of a referral, assessments are carried out by the home to make sure that individual needs can be met by the service. This will include visits and overnight stays to the service. Support plans are then put in place once the person has moved into the home. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good support plans are in place and these address the identified needs of individuals. Residents are supported by staff to make decisions about their lives. Individual risk assessments are carried out to support and protect residents in their daily lives. EVIDENCE: All residents have an individual support plan, of which three were examined. The quality of the information in them had improved significantly and was easily accessible. Recording detailed the person’s individual needs, their strengths and preferences. Support plans also contained evidence of regular in - house reviews taking place. One care manager stated, “the manager and the deputy of the home have been helpful and I often attend network meetings Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 10 with my client’s key worker”. Most service users do not have an allocated care manager and the manager regularly liaises with the duty managers re: her residents needs and is requesting reviews in order to address staffing levels in the home, which is minimal. The home carries out appropriate risk assessments to enable residents to take risks as part of an independent lifestyle. The home operates a key worker system and time is allocated for one –to one time for discussion and activities to take place. A resident spoken to knew who their key worker was and said that they met with them regularly. Staff spoken with were knowledgeable about residents needs. One survey states “ the staff have been excellent in supporting my client with her decision and are very accepting of her one –to -one worker carrying out activities with her”. Residents are supported to make choices about their daily lives and are consulted about decisions that affect them. The home consults significant others, such as family members and health care professionals, about residents care where necessary. One resident spoken to said that they are able to choose how they spend their time at the home and is consulted about how the home runs. Staff spoken with described how they are trying to involve residents more in the operation of the home e.g. checking of the first aid boxes with a staff member. House meetings also take place, although due to the lack of verbal communication of several of the residents, the record of these meetings was brief. We noted that greater thought had gone into recording decisions following these meetings and some of the residents now signed the notes following the meeting. The AQAA states “the home aims to have a speech and language therapist to visit on a regular basis to give more knowledge on how to communicate better with individuals who have speech and language difficulties”. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to develop their skills. Residents participate in activities appropriate to their needs and preferences. Residents are involved in their local community. Resident’s ‘rights and responsibilities are promoted. Residents are supported to develop and maintain relationships with their families and friends. Residents enjoy the food provided by the home and are involved in planning the menu. EVIDENCE: Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 12 Three residents told us that they did lots of different activities and made choices about the things that they wanted to do. Everyone living at the home take part in activities and lifestyle that they choose. Six people attend day centres regularly. Of the other two residents, one receives individual support to go out during the day and the other person, due to their age, chooses to stay at home, although staff are looking at getting them 1 to 1 support to increase contact with staff. This person told us that they are quite happy watching television and that they enjoyed living at Cavendish Rd. Another resident who attends day centre also receives 1 to 1 support in the evenings and at weekends due to their needs. Residents use the local community including leisure facilities such as gyms, pools, pubs/cafes, shops and public transport. Some residents attend social clubs such as Gateway and Generate. The home occasionally organises group activities for people to share in together. Birthdays are always acknowledged and celebrated with friends and family being invited if the person wants that. Pictures of such celebrations were seen on the wall of the home. Holidays are also encouraged and supported and one resident told us how much they were looking forward to going on holiday to Blackpool. Residents are involved in the planning of the menu. Three residents are now actively involved in increasing their cooking skills and regularly participate in cooking their own meals. The menu seen was varied and a record is maintained of meals served. Fresh fruit was available and people said that they liked the food. Cultural and dietary needs are considered and respected. Residents are encouraged to stay in touch with their families. Surveys from relatives were very positive regarding the care and support they felt their relative was receiving. Comments included, “I am very old now but the home supports my son to visit me and should anything happen to me, I know that he will be well cared for. Thank you very much for all the years he has been with you”, “ I do feel that the carers do a very good job looking after each individual person’s needs”, and “she gets everything she needs and they keep me informed”. Another said that “the weekly rota for activities improves her quality of life”. Resident’s cultural, spiritual and dietary needs are also respected. Currently, two residents regularly go to church. One resident regularly eats food from her cultural background. In the AQAA staff have stated, “Each service user has an individual assessment that incorporates their cultural and spiritual needs” and “We are also always on the look out for more ways to celebrate each service users cultural background, and offer activities and opportunities to express these”. Several staff have attended “Equality and Diversity Training”, which is an on – going training within the organisation. The staff team also reflects the gender and cultural difference of the residents with a mix of male and female staff working at the service. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 13 Equality and diversity issues were seen to be addressed in the support plans looked at, and from discussion with the staff on duty and in the questionnaires received. One survey states, “my service user seems happy to relate to everyone there and it is a relaxed, anti-discriminatory atmosphere. Cavendish Road DS0000010177.V364603.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports residents to maintain good health, and any changes in residents’ needs are effectively identified and addressed. Residents are supported to access specialist healthcare resources where necessary. Medication on the whole is appropriately managed although some improvement is required in respect of controlled drugs. EVIDENCE: The inspection provided evidence that the home liaises well with healthcare professionals when necessary and responds to any changes in resident’s needs. Guidelines for the delivery of individual care are in place and staff follow these guidelines accurately. Staff reported that residents are supported to maintain good health in the way that they choose. Health care needs are documented and annually reviewed. Contact details for the relative or carer and GP are recorded for each person, Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 15 just in case of an accident or emergency. Each person is also registered at the local opticians and dentist. Staff support residents to attend appointments and a record is maintained. Evidence of this was seen on the files looked at. The home maintains good links with Wandsworth Community and Intervention Team and will refer residents to the team if specific issues arise. Evidence of professional’s involvement was seen on the files and staff confirmed in surveys that appropriate help would be thought. Staff described how personal care needs are carried out in a supportive and dignified manner. Residents spoken with confirmed this as did comments in surveys receive e.g. “I have noticed that staff respect the privacy and dignity of service users”. The AQAA states that staff support service users with dignity, respecting privacy at all times and supporting their own independence. Guidance and /or support is given based on individual needs- ranging from full intimate care to shaving to verbal prompts. As stated earlier, evidence of the support levels needed were seen in residents individual support plans. There is a procedure for the safe handling of medication. Staff are trained in this area. Medication is stored, recorded and administered following the procedure. Medication in House A was looked at and found to be appropriately managed, with the exception of a PRN controlled drug. Staff in the home said that it has not been necessary to administer this medication, however, there was no separate controlled drug register. The drug was detailed on the Medication Administration Record for the resident. A controlled drug register should be available in the home. The AQAA states that the home has introduced a Medication Competency Test, which ensures that staff are aware of the side effects of medications and how to spot changes in someone’s condition. Surveys received, with the exception of one, did not raise any concerns re health care needs. The survey that raised an issue concerning not being notified, stated that they were immediately rectified, following discussion with the manager. Cavendish Road DS0000010177.V364603.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place. The manager makes sure that all staff are aware of their responsibilities regarding Safeguarding of Vulnerable Adults. EVIDENCE: The home has an appropriate complaints procedure and a whistle – blowing policy, which enables staff to report any concerns they have about bad practice. Since the last inspection the commission has not received any complaints. The complaint book at the home showed two complaints made by one resident regarding staff interaction with another resident. The concerns were seen to be satisfactorily discussed and resolved. Two residents spoken with said that they knew who to speak to if they were unhappy about something at the home and that they would feel confident about raising concerns with staff. Surveys from relatives and residents (although the majority had been supported by staff to complete) confirmed that they knew how to make a complaint. The home works within the local authority policy on the Safeguarding of Vulnerable Adults and the majority of staff have attended training in this area. On–going refresher courses are currently being arranged. Team meeting Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 17 minutes demonstrated that the manager used this forum to remind staff of their responsibilities regarding the Safeguarding of Vulnerable Adults and the whistle blowing procedure. The AQAA states that the home is planning to develop a user friendly guide to complaints and concerns, as well as develop a user friendly format for requesting feedback from residents. Cavendish Road DS0000010177.V364603.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): 24,25,26,27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying at the home benefit from a clean, comfortable and homely environment. EVIDENCE: The home is divided into two units (House A and House B) with their own kitchens, lounges, bathrooms and laundry areas on the ground floor. The home was seen to be comfortable with good access to both units within the home. Since the last inspection new locks have been fitted to COSHH cupboards, a new boiler installed and new flooring installed in the laundry rooms. Fridges have been replaced in both kitchens. Communal areas seen were homely with new furniture in house B lounge. New pictures of residents had been put up in both the lounges as well as in the hallways which makes the home more “homely”. There is also a notice board, which identifies with pictures staff on duty for each shift. All areas were clean and hygienic when we visited. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 19 Three bedrooms were seen, all of which had been personalised with the residents choice e.g. posters, ornaments, soft toys and lamps. Residents had their own televisions and CD players. Two residents spoken to said that they liked their bedrooms very much. The two ground floor bedrooms are wheelchair accessible with adapted ensuite facilities. All adaptations have been approved by the occupational therapist with training given to all key staff in using the aids. Other bathrooms and toilets seen were functional and clean. The home is proposing over the next year to convert to a level access wet room to ensure that the changing needs of some of the current residents are provided for. Both front and back gardens had been tidied and new plants planted, which make these areas attractive and pleasant to be in. The home was observed to be clean and hygienic and free from any offensive odours. Cavendish Road DS0000010177.V364603.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient staff to meet residents needs. Staff are appointed following an appropriate recruitment and selection procedure. Staff are supported in carrying out their role. EVIDENCE: A number of staff have worked at the home for several years and therefore are very knowledgeable regarding the resident’s needs. People living in the home said that they liked the staff and felt well supported. The staff team told us that they worked well together and that communication in the home was good. In discussion with the manager, she acknowledged that not all staff had received all mandatory training and that part of the reason for this was due to Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 21 the organisation now being managed by a different organisation. We were shown evidence of correspondence to the training department regarding the needs of the staff team in respect of mandatory training. The manager is currently in discussion with her managers re external training for staff and endeavours to discuss training topics during team meeting and supervision to ensure that staff are kept abreast of practice until the training becomes available. Individual training plans were in place. The AQAA states that only 4 of the 11 staff need to complete their NVQ training. Three staff surveys raised concerns regarding staffing levels in the home, comments included, “more staff are needed to provide highest level of service, however, the manager has worked out staff hours to allow for more flexibility and allow special activities to take place”, “a few more staff are needed to meet the needs of the service users”, and “I do not feel that the staffing levels reflect the needs of the service users. Early shifts are ok however, there are constraints on the late shifts – individual programmes are more difficult to carry out with only three staff divided between two houses (9 service users). The same person states that “although registered as one service, logistically it is two. With one staff team which I feel it holds us back from developing service users potential” and “stop calling it two houses and make it clear to everyone that its one integrated service”. Staffing levels must be kept under review with care managers particularly if a resident needs change where difficulties may arise in meeting residents support plan goals. Staff spoken with said that they felt equipped to do the job and that support is always available. They described the manager as “hands on” and knowledgeable. The AQAA states the service has improved over the last twelve months as follows, “that overall the team are more motivated, morale is higher than it has been previously and there is more evidence of service user focus and team work”. There is an organisational recruitment policy in place. The organisation carries out appropriate checks on all staff. Evidence of this was seen through examining the “proformas” for the three new employees in the home. Staff spoken with said that they had regular meetings with their manager , both on their own and as a team and that they felt well supported. Minutes of staff meetings were seen. Cavendish Road DS0000010177.V364603.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear direction and leadership within the home and is well respected. The home is well run. This service seeks the views of the people residing there as well as other interested parties regarding the running of the home. EVIDENCE: The manager provides clear direction and leadership within the home and is well respected. She has almost completed her Registered Managers Award and is now registered with the Commission as the home manager. The home is well run with both staff and residents telling us of the positive improvements put in place since the managers arrival. Clearly, this service seeks the views of the people residing there as well as other interested parties regarding the running of the home. Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 23 The home carries out its own quality assurance system and reports back to the organisation if any concerns come to light via surveys. In the AQAA the manager has stated that the home is looking at how it can develop the local quality assurance system further to incorporate feedback from users and staff and develop a way to meaningfully use the information gathered. Residents meetings are held monthly and notes are made. A development plan is in place for the service. Copies of monthly visit reports were not seen to be in place, although the manager stated that visits do take place. Copies of reports made following these visits must be available in the home. Spot checks on several health and safety systems in the home were sampled these included, fire testing, fire drills, fridge and freezer temperatures and hot water temperatures. All were found to be satisfactory. The manager reported that since the merger with Metropolitan in April 2007, the transition did not go as smoothly as predicted and that the disruption has impacted across the company impacting on residents and staff. The manager is endeavouring to meet with senior managers to discuss the impact and how they can minimised. Cavendish Road DS0000010177.V364603.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 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 x 3 x 2 x x 3 x Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA39 Regulation 26(3) (4) Requirement Copies of Monthly visit reports must be available in the home. Timescale for action 30/06/08 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 Good Practice Recommendations A controlled drug register should available in the home. Consideration should be given to re-naming the home to Cavendish Rd to avoid confusion given that there is one team of staff for both of the units. Staffing levels should be kept under review. YA33 Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Cavendish Road DS0000010177.V364603.R01.S.doc Version 5.2 Page 27 - 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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