Care Home: Coverdale Road (2)

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)

What the care home does well The home provides a very good person centred service based on the thoughts, wishes and needs of the individual with support provided by a dedicated and caring manager. The home is fresh and clean. What has improved since the last inspection? There is now clarity in the aims of the service and it is no longer closing. The home now has a core of are permanent staff. Staff were undergoing person centred training to further develop peoples care plans. The staff are working together with the people who live in the home to develop a specific space for each person within the garden What the care home could do better: Although there are good pre employment checks and systems in place for safeguarding people who use the service. The manager must ensure that they follow up safeguarding referrals. Work to support individual residents to develop a person centred plan must be completed. Repairs and redecoration of the bathrooms need to be completed. CARE HOME ADULTS 18-65 Coverdale Road (2) 2 Coverdale Road Shepherds Bush London W12 8JL Lead Inspector Ann Gavin Key Unannounced Inspection 12th May 2008 11:00 Coverdale Road (2) DS0000035470.V362925.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 Coverdale Road (2) DS0000035470.V362925.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. Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coverdale Road (2) Address 2 Coverdale Road Shepherds Bush London W12 8JL 020 8749 9559 020 7386 6601 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) London Borough of Hammersmith and Fulham Miss Hannah Cronin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Coverdale Road is a registered care home providing accommodation and personal care for 6 people with a learning disability. At the time of this inspection there were 4 men and 2 women living in the home. The house is close to shops, public transport and other services. Hammersmith and Fulham Social Services Department own the property and manage the service. Service users have single bedrooms and access to spacious communal rooms and a pleasant, paved rear garden. The building is not suitable for people who use a wheelchair use or have mobility problems, as access is via steps at the front and the kitchen and dining room are on the lower ground floor. People living in the home attend local day services, while also spending time at home and using community facilities, supported by care staff. Coverdale Road (2) DS0000035470.V362925.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 star. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection on Tuesday 8th May 2007 from 11:00 – 18:45. The inspector met with all six people living in the home, the manager and four staff. Everyone was very welcoming and the inspector would like to thank both the people who live in the home and the staff. During the day the care of three people was tracked through meeting them, looking at their care plans and other relevant documentation and talking to staff. Also a tour of the home was completed and other health and safety records were looked at. The inspection also looked at the safeguarding practices within the home as part of a CSCI national focus. There were positive responses received from health professional questionnaires and from all of the six people who live in the staff as well as from the staff. Their responses have been included in the report. What the service does well: What has improved since the last inspection? There is now clarity in the aims of the service and it is no longer closing. The home now has a core of are permanent staff. Staff were undergoing person centred training to further develop peoples care plans. The staff are working together with the people who live in the home to develop a specific space for each person within the garden Coverdale Road (2) DS0000035470.V362925.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. The summary of this inspection report can be made available in other formats on request. Coverdale Road (2) DS0000035470.V362925.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 Coverdale Road (2) DS0000035470.V362925.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into the home have their needs and aspirations assessed. EVIDENCE: Coverdale Road has been through a period of uncertainty over the last two years with the possibility of closure due to the lack of access within the home for anybody with mobility difficulties. One person has moved, as their needs could not be met within the home. The council, after consultation has decided to keep the home open with plans to offer a service to people as a transitional home or for people with challenging behaviour. On this basis a person was admitted to the home last year. This person is quite independent .The home received an assessment of this persons care needs from their care manager. A senior from the care home then carried out their own assessment of the person needs and to see whether Coverdale Road was a suitable placement. The information received from the manager in their Annual Quality Assurance Assessment (AQAA) highlighted how the staff member who visited the prospective resident to see their views about the move also spent time with the staff and a family member to gain a full picture of their needs and hopes. Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 9 They also spoke with the people living in the house about a new person visiting and possibly moving in. The person received a gradual introduction into the home over four visits. On the first visit they met the other people in the home and saw their room, the next two visits they stayed for dinner. The fourth visit they also stayed overnight. Coverdale Road (2) DS0000035470.V362925.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): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good standards of care planning, and risk management that reflect the wishes and aspirations of service users. Staff need to make sure these are kept up to date and further develop person centred planning. EVIDENCE: ‘Staff maintain a homely, supportive environment’ Extract from healthcare professional questionnaire During this visit the care plan files of three people living in the home were checked. One person had an excellent and comprehensive care plan dated 2006 and an assessment completed in March 2007. Coverdale Road does monthly care plans. This person has had some major changes in their physical abilities, which has led them to need to sleep in the downstairs lounge. There has been no review of their care plan and no full assessment of their current Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 11 and future needs. The risk assessment had taken into account their new circumstances and it was clear that staff were fully aware of how this person w anted to be supported. There were key points about how this person likes to dress, their main interests, all which were reflected in the way the person, appeared and interacted during the day. However the care plan needs to be kept up to date and reflect the persons current needs. This persons finance also had not been reconciled since December 07 although the practice of the home is to do it monthly. Another care plan looked at also needed developing to reflect their current needs. The final care plan seen had an excellent profile of the person with a clear picture of how this person communicates and best to relate and gain how they might wish to be supported. Three staff were away on person centred training and it is planned that they will take the lead with the staff in further developing the care plans. Given the changing nature of the service and the changing needs of the people in the home the local authority must also make sure that each person’s placement is reviewed regularly. Some very good interaction between staff and service users was observed during this visit. Staff on duty knew the care needs of each person and were observed spending time with people. Throughout the day, staff were seen offering service users choices about the care and support they receive and this was always done using the method of communication preferred by the service user, including signs from the Makaton Vocabulary. Coverdale Road (2) DS0000035470.V362925.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to take part in a range of age appropriate activities, in the home and the wider community. EVIDENCE: ‘Staff implement guidelines and give person centred care’ Extract from healthcare professional questionnaire There were three people at home in the morning. One person was at a medical appointment and two people were at day centres. One person was supported out into the community. This person was attending a day service but they did not want to continue. Staff are building up their abilities by going out each day, which is working well. It was a warm day and people made use of the garden and were sitting relaxed in the shade of an umbrella. The manager showed how staff member Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 13 are working with people to create their own space within the garden so that they can chose and sow their plants and flowers and watch them grow. There was a discrete white line drawn in the wall showing each persons patch. Everyone who wished had helped over the weekend to prepare the base for the hanging baskets. There were trays of plants ready for planting. People who live in Coverdale Road have a range of activities these include walks in the local area, visits to parks, shops, cafes and pubs, church services, classes and visits to the home by both a massage therapist and a reflexologist. The majority of the people in the home enjoy the weekly reflexologist visits. The massage therapist visits are once a month. The daily shift plans show the activities that people have done during the day and it’s important that all staff complete these. However on most days there was a good recording of how people relaxed both within the house and in the community. The house had some lovely fresh flowers in the downstairs lounge, which had been chosen by one of the people who live in the house. They were proud of their display that they do on a weekly basis. The manager spoke of the monthly residents meetings that are normally informal around suppertime or with coffee and cakes. This appears to be the best setting for all so that people feel able to express what they wish, share news and plan for outings and meals. During the day people who live in the home had drinks and snacks and there was a relaxed atmosphere around the kitchen. The manager showed the new display book menu that has been produced using photographs of peoples favourite foods. It was a varied selection and showed the work staff are doing to encourage people to think of healthy menus. Each week the people in the house choose a meal and are encouraged to help in the preparation of the meal. People are supported to make their own drinks. During the day people chose were they wished to eat their meals. Some sat in the kitchen others in the other lounge and some people also chose to eat in the garden. Coverdale Road (2) DS0000035470.V362925.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. Coverdale Road has good links with relevant health care professionals. The people who live in the home have full access to health care services and their health care needs are well documented. Care Plans indicate how people like to be supported. EVIDENCE: ‘ The staff act quickly. They care for their residents’ ‘Staff are punctilious about reporting changes to their residents health and Extracts from healthcare professional questionnaires are generally well briefed when accompanying residents to their appointments’ People’s healthcare needs are well documented and advice is sought from healthcare professionals. There are good links with the local G.P’s community and specialist nurses. One of the people in the home had to undergo some hospital investigations recently. The staff prepared them by producing an excellent pictorial easy access book describing the procedure. This also was used to ascertain their capacity to consent for the investigations. Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 15 The health care needs of some of the people in the house have increased and staff are looking at completing full assessments. They are aware of the limitations of the layout of the house and have worked hard to accommodate one persons needs as stated earlier in the report. The manager spoke of how they are trying to ensure that any moves that may be necessary, due to increasing healthcare needs, are done gradually and only once all information is shared and an appropriate placement is found. It is clear that people see Coverdale Road as their home and the manager and staff feel the responsibility of maintaining people’s wishes and abilities. The medication records and cupboard was checked. The medication was stored well and all medicines were labelled. The medication records were clear and well maintained. The feedback from local healthcare professionals was very positive and has been included throughout the report. The two comments made about improving the service were that staff need to develop their observation and reporting and to optimise communication when accompanying residents to appointments. Coverdale Road (2) DS0000035470.V362925.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. People living in the home are able to express their concerns and have them addressed. The system in place for referring safeguarding issue must always be checked. EVIDENCE: ‘We have an informal complaints procedure in place both for visitors and for residents. The informal complaints for residents are done in a symbol format. There is also a formal complaints procedure in place which are complaints taken up by the council. We have also added a suggestion box. Most of the residents are fully aware of how to complain. This is addressed at every residents meeting, and also they are always asked if they need to complain about anything. ‘ Extract from the Annual Quality Assurance Assessment (AQAA) completed by the manager Coverdale road has a complaints book and there has been no complaint noted since the last inspection. Talking with the manager and looking at residents meeting notes confirmed that any concerns are dealt with and noted within the meeting. It was suggested that any concern or ‘complaint’ also be noted in the informal complaint book so as to be able to both monitor and complete any quality assurance checks. It was clear from how the manager and staff related to people and through recording that people are encouraged to make ‘complaints’ or air their views. Looking at the accident and incident book highlighted an incident where one of the people in the house hit another. The process for initiating a safeguarding Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 17 referral is to fax the incident form and comments to the local authority who would normally respond and arrange a strategy meeting. However on this occasion there was a delay in sending the fax and also no response was received. The manager has spoken with the safeguarding lead and is aware of the procedure and the need to check all referrals. The notification of the incident was sent immediately after the inspection and a strategy meeting was called for that week. All referrals safeguarding issues must be reported to the Social Services and the CSCI without delay Three staff spoken with said they would report any concerns or safeguarding issues to their manager. They all said they had attended safeguarding training but it was all about 2 years ago. Training on safeguarding should be held regularly for all staff. During this visit the finance records for three people living in the home were checked. The records were well maintained and receipts were in place for any expenditure involving residents’ personal money. The monthly reconciliation of people’s monies must also be kept up to date by staff. Coverdale Road (2) DS0000035470.V362925.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): 24,26,27,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home generally provides a good standard of private and shared accommodation though it is not fully accessible to people with mobility problems. There is a need to tend to the heating and ventilation of the upstairs bedrooms. EVIDENCE: Coverdale Road is a large end-terrace house in a residential part of Shepherd’s Bush. It is close to local shops, cafes and transport links, including bus routes and a tube station. It is a three-story town house with a basement and steps leading up to the front door. The house is not suitable for people with mobility problems and does not lend it self to any adaptations. However the home provides rails on the stairs and it also has aids in the bathroom to support people whilst bathing. A tour of all communal parts of the home and 4 people’s bedrooms highlighted the good standard of decoration. All the people who live in the home have Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 19 made their bedrooms their own with personal furnishings, photographs and belongings. One of the people is temporarily sleeping in the lounge on the ground floor following an accident were they broke their arm badly which has effected their mobility. The manager is working closely with others to look at all other alternatives. Looking at the bedroom on the top floor one door was propped open with a fan heater. All the bedroom doors of the people living in the home must be fitted with approved door guards to allow for safe propping open of doors for ventilation and to ensure that people would be protected in the case of a fire. The room needed air but the window once opened cannot close properly. The windows in resident’s rooms must be able to be opened safely to allow for ventilation. The tour of the home also highlighted the fact that the top floor does not have central heating but relies on electric heaters. The home must review the heating of the residents bedrooms on the first and top floor to ensure that their safety and comfort. Equally the bathrooms seen had not been part of the redecoration and looked drab, shabby and in need of both repairs and redecoration so that the people in the home can enjoy a homely environment. One of the people in the home showed the attractive garden with patio furniture. There were plants and hanging baskets waiting for the people to plant them. The manager said how one of the staff has been working closely with the residents to divide up the garden so each can plant their own flowers and pots. The garden was being used during the day. People sat with a cup of tea and one person had their meal there. The staff that work at night carry out the key cleaning of shared rooms and the fridge/freezer temperatures and the ironing. However this is only once the people who live in the house are settled. The hovering and washing is done during the day. Given that the needs of some of the people living in the home have increased it may be that the situation around cleaning duties could be reviewed. The home was fresh and clean throughout. Coverdale Road (2) DS0000035470.V362925.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Coverdale Road ensures that people living in the home are supported by sufficient staff. EVIDENCE: ‘Compassionate approach to individuals seem to know their clients well’ Extract from healthcare professional questionnaire ‘All staff have at least two years work experience in the social care field prior to applying for permanent posts at Coverdale. Service users have been part of the interviewing process for the recruitment of new staff.’ Extract from the Annual Quality Assurance Assessment (AQAA) completed by the manager ‘The manger is nice very strict re paperwork about being on time and that the residents come first. If the residents are not settled we are to leave everything else and only take it up when they are settled’ Comment from staff member Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 21 Coverdale now have six permanent staff having recruited two senior and two residential care workers. Information received from the manager prior to the inspection stated that all staff need to have two references and a Criminal Records Bureau (CRB) Enhanced Disclosure before they start work in the home. The manager also stated that the people who live in the home are part of the interviewing process. The staff files were not seen during this inspection they are held in the Human Resources department of the Town Hall All agency staff have had their pre employment checks carried out by the agency who then supply the CRB number to the home. All the permanent staff are qualified to NVQ level 3 and there are always two members of staff on at all times. On arrival at Coverdale Road there were three staff on duty plus the manager who had accompanied a resident to the doctors. The extra staff member is assigned to the person who is in need of extra care since their accident. The training records are held on the home computer but the system was not working properly so the records were sent to the commission the following day. The training records showed that three new staff had not as yet had any safeguarding training and other staff had training in 2006. All staff need to have regular training in safeguarding. The records for other training showed that little training has been done over the last year, which would reflect the situation with the home possibly closing. Now that the home is remaining open the manager has planned future training for staff. The last two years have been a difficult time for the staff managing a period of uncertainty over the future of the home. The manager said they have had two staff away days to look at what the experience has been for all and how to consolidate the staff team with the new focus of the service. There has been a high level of sickness with one of the staff which has had its effects. The manager is planning to monitor sickness more closely. Staff meetings are held regularly and supervision has been divided between the manager and the deputy manager. The two supervision records checked confirmed this. The deputy manager is leaving Coverdale Road and the manager and staff have decided to replace the post by two seniors. Coverdale Road (2) DS0000035470.V362925.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 home has a good manager and service users are consulted about the care and support they receive. EVIDENCE: ‘The manager is really good always focuses on ‘It’s their home’ and need to ask people what they want to enable the people who live here’ Comment from staff member The Manager has worked at Coverdale Road since 2003 and has a background also in mental health services. The deputy manager was around for part of the inspection though was leaving the service the following day. Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 23 Talking with the people who live in the home and the staff it was clear that they had a good rapport and good leadership from the manager. It was unclear however how the manager received support as the service manager is no longer in post and there are no longer any service specific meetings or any peer support meetings. They have supervision from another manager. It is important that there are clear structures of support in place in order that the manager can continue to support the people who live in the home and the staff. There were no records of any regular visits by the person in control with as part of the quality assurance for residents and staff. The provider must ensure these are reinstated and copies of the reports sent to the CSCI. The manager has plans to send put the annual questionnaires to the people who live in the home and their relatives and other people who have links with the service. There was evidence of regular house meetings where people views are sought about the care and support they receive. These are informal meetings over a meal which the manager says works best for the residents. The health and safety rerecords seen were well kept and up to date. There was a good fire plan in place and a monthly fire risk assessment is completed. It is noted that staff need to undertake fire training annually. Coverdale Road (2) DS0000035470.V362925.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 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 22X0 21 Score 3 3 3 X 3 X 2 X X 2 X Coverdale Road (2) DS0000035470.V362925.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 15 Requirement Work to support individual residents to develop a person centred plan must be completed. This is a repeat requirement. Original timescale of 31/07/07 not met. The provider must make sure that each person’s placement is reviewed on a regular basis. This is a repeat requirement. Original timescale of 31/07/07 not met All safeguarding issues must be reported to Social Services and to the CSCI without delay to ensure that residents are appropriately supported. All staff must have regular training in safeguarding. The home must review the heating of the residents bedrooms on the first and top floor to ensure their safety and comfort. The windows in resident’s rooms must be able to be opened safely to allow for ventilation. The bathrooms need both repairs and redecoration so as to maintain the dignity of residents DS0000035470.V362925.R01.S.doc Timescale for action 31/07/08 2. YA7 15 31/07/08 3. YA23 37 31/05/08 4 5 YA23 YA26 13 (6) 23(2) p 30/06/08 31/07/08 6 7. YA26 YA27 23 (2) p 23 30/06/08 31/07/08 Coverdale Road (2) Version 5.2 Page 26 8 YA39 26 9 YA42 23 by having a suitable and homely bathroom that meet their needs. The social services must ensure that there are regular visits by the person in control with a written record of each visit as part of the quality assurance for residents and staff. All the bedroom doors of the people living in the home must be fitted with approved door guards to allow for safe propping open of doors for ventilation and to ensure that people would be protected in the case of a fire. 31/05/08 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. Refer to Standard YA39 Good Practice Recommendations The social services should make sure that there is regular ongoing support for the manager in order that they may continue their good practice and support of the residents. Coverdale Road (2) DS0000035470.V362925.R01.S.doc Version 5.2 Page 27 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 Coverdale Road (2) DS0000035470.V362925.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. 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!