Care Home: Halsbrook Road

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What the care home does well The `Statement of Purpose` and `Service User Guide` provided comprehensive information about the home. Work was in progress to ensure that other documents such as the complaints procedure were presented in a suitable format for the people living in the home. People said that they liked living at Halsbrook Road and said that staff helped them to go out and do the activities that they enjoyed. Support was provided to meet people`s personal care needs and to attend medical appointments and health checks. Records provided information about peoples likes and dislikes and included practical suggestions for staff about promoting personal choice. People were supported to keep their bedrooms tidy and to contribute to the running of the home. Significant events and allegations were reported to the Commission for Social Care Inspection (CSCI) and to social services for investigation.The home has a stable team of staff. Staff were familiar with peoples preferred routines and recognised when people were unhappy or anxious. Visiting arrangements were flexible and relatives were invited to attend social events and meetings. People said they liked the meals prepared in the home. The food provided was varied and people`s favourite dishes were included on the menu. The home was well organised and staff felt supported. What has improved since the last inspection? The manager had completed risk assessments for all of the people living in the home. Assessments provided useful information for staff about the action they should take to maintain peoples safety. Staff had reviewed the list of non- prescription medicines that they can give to people. The new list provides more detailed guidance for staff about the medicines listed. Staff made a record of medicines that were supplied to the home. Medicines seen were stored in their original container. Work had been carried out to improve ventilation in the ground floor bathroom and to repair areas that were damp or damaged. The electricity installation was inspected and a number of new lights had been fitted. Regular fire drills were taking place. Drills were carried out at various times of the day so that all staff had an opportunity to check that they were familiar with the fire procedure. What the care home could do better: Care plans were satisfactory but it was not always clear how much progress had been made towards meeting personal goals. One person was not able to do some of their regular activities because of difficulties with transport. Work was in progress to resolve this issue. There were no records about non- prescription medicines that were bought into the home. Staff completed regular stock checks for medicines that were supplied in packets and boxes. This record was difficult to follow in parts. The records maintained in the home must enable staff to account for all medicines. Pre- employment checks were carried out for new staff but there was limited information about these checks in the home.Tinned and dried food was stored on wooden shelves in the larder. This surface should be replaced or painted to provide a smooth surface for cleaning. The passenger lift had not been inspected for over a year and it was not clear if the water tanks and pipes should be disinfected. CARE HOME ADULTS 18-65 Halsbrook Road 43a Halsbrook Road Kidbrooke London SE3 8QU Lead Inspector Maria Kinson Unannounced Inspection 12th October 2007 09:20 DS0000070757.V353187.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 DS0000070757.V353187.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. DS0000070757.V353187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halsbrook Road Address 43a Halsbrook Road Kidbrooke London SE3 8QU 020 8856 0707 020 8856 0707 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) Outlook Care Mr John Philip Parsonage Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000070757.V353187.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 home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 27/10/06 Date of last inspection Brief Description of the Service: 43a Halsbrook Road is owned by the London and Quadrant Housing Association and managed by Outlook Care. The service currently provides care and accommodation for six men with a learning disability, some of whom also have a mental health disorder or challenging behaviour. The Home is a purpose built unit on two floors with hard standing to the front and side of the building and gardens on two sides. All the rooms are single occupancy, and all but one are on the first floor. On the ground floor there is a communal lounge, kitchen, dining room, laundry room and conservatory. The home is located in a quiet residential area close to the old Rochester Way. There are local shops and a doctors surgery nearby, and the shopping centres of Eltham, Woolwich and Lewisham are a short bus ride away. The current fees charged by the home for each person is £1,312.81 per week. This does not include additional charges such as holidays, clothing, toiletries, hairdressing and recreational activities. This information was supplied to the commission on 12/10/07. DS0000070757.V353187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In the period since the last inspection the company that was responsible for managing the service had changed. Outlook Care is the new Registered Provider. Outlook Care registered with the Commission for Social Care Inspection (CSCI) on 01/10/07. This inspection took place on 12/10/07, twelve days after the change of provider and was unannounced. A number of new policies and procedures, documentation and systems were being introduced. The inspector spent seven hours talking to some of the people that lived and worked in the home, examining records and observing care practices. Eight members of staff, five relatives and five health care professionals were asked to provide written feedback about the service. One response was received from a relative. At the time of this inspection there were five people living in the home and one vacancy. What the service does well: The ‘Statement of Purpose’ and ‘Service User Guide’ provided comprehensive information about the home. Work was in progress to ensure that other documents such as the complaints procedure were presented in a suitable format for the people living in the home. People said that they liked living at Halsbrook Road and said that staff helped them to go out and do the activities that they enjoyed. Support was provided to meet people’s personal care needs and to attend medical appointments and health checks. Records provided information about peoples likes and dislikes and included practical suggestions for staff about promoting personal choice. People were supported to keep their bedrooms tidy and to contribute to the running of the home. Significant events and allegations were reported to the Commission for Social Care Inspection (CSCI) and to social services for investigation. DS0000070757.V353187.R01.S.doc Version 5.2 Page 6 The home has a stable team of staff. Staff were familiar with peoples preferred routines and recognised when people were unhappy or anxious. Visiting arrangements were flexible and relatives were invited to attend social events and meetings. People said they liked the meals prepared in the home. The food provided was varied and people’s favourite dishes were included on the menu. The home was well organised and staff felt supported. What has improved since the last inspection? What they could do better: Care plans were satisfactory but it was not always clear how much progress had been made towards meeting personal goals. One person was not able to do some of their regular activities because of difficulties with transport. Work was in progress to resolve this issue. There were no records about non- prescription medicines that were bought into the home. Staff completed regular stock checks for medicines that were supplied in packets and boxes. This record was difficult to follow in parts. The records maintained in the home must enable staff to account for all medicines. Pre- employment checks were carried out for new staff but there was limited information about these checks in the home. DS0000070757.V353187.R01.S.doc Version 5.2 Page 7 Tinned and dried food was stored on wooden shelves in the larder. This surface should be replaced or painted to provide a smooth surface for cleaning. The passenger lift had not been inspected for over a year and it was not clear if the water tanks and pipes should be disinfected. 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. DS0000070757.V353187.R01.S.doc Version 5.2 Page 8 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 DS0000070757.V353187.R01.S.doc Version 5.2 Page 9 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 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure indicated that a care needs assessment would be undertaken before people moved into the home. EVIDENCE: The registration and public liability insurance certificates were displayed. A copy of the new Statement of Purpose and Service User Guide was supplied to the commission. The Statement of Purpose provides information about the home and about the new company that was managing the service. The Statement of Purpose contained all of the information required but a few details should be updated. The manager agreed to make the necessary changes. The Service User Guide was easy to follow and included pictures to make it easier for people using the service to understand. One person had moved out of the home since the last inspection. This person was now living more independently in the community. DS0000070757.V353187.R01.S.doc Version 5.2 Page 10 It was not possible to assess the arrangements and procedure followed by staff when admitting new people into the home, as all of the current people had lived there for some years. The new admission procedure stated that written information would be obtained from the funding authority and the manager would complete an assessment of the persons needs. DS0000070757.V353187.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support plans included information about people’s personal goals and hopes for the future. People were encouraged to make day- to- day decisions for themselves and were supported by relatives and advocates to consider more complex issues. EVIDENCE: The care records for two people were examined. The files seen included information about the person’s history and background, an individual support and activity plan and various risk assessments. The previous recommendation to ensure that risk assessments were signed, dated and reviewed regularly had been addressed. There was evidence that people were able to attend and contribute to care and life planning review meetings and that relatives were invited to attend. Records indicated that one person did not want to attend a day centre and that DS0000070757.V353187.R01.S.doc Version 5.2 Page 12 they disliked using signs or pictures to communicate. Information was easy to follow but progress with identified goals was not always recorded until the plan was reviewed. Staff should establish some regular means of reviewing progress. See recommendation1. The monthly review records that were completed by the key worker and the person they were key working had lapsed in recent months. This document provided a summary of significant events and ensured that the people using the service had a regular opportunity to tell staff what they liked and disliked about the service. People said they were able to make choices about how and where they spent their time in the home and community and were supported to take part in activities that they enjoyed. Care plans provided guidance for staff about promoting personal choice and records showed that staff encouraged people to choose their clothing, breakfast and the route when they went out for a walk. Records showed the people using the service were encouraged to participate in the running of the home. Some people had assisted staff to purchase food for the home or to prepare and serve meals. People were supported to keep their room clean and tidy and to assist staff with their laundry. DS0000070757.V353187.R01.S.doc Version 5.2 Page 13 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to pursue personal hobbies and interests and to maintain contact with their family and friends. Work was in progress to establish suitable travelling arrangements for some people. EVIDENCE: Some of the people living in the home attended educational or skills based training sessions at local colleges or day services. People that found large group activities difficult were supported to be active and to pursue personal interests on a ‘one to one’ basis. People said that staff provided support to go swimming, attend social clubs and events and to go shopping. Records showed that in recent weeks some of the people using the service had spent time with their relatives, had been swimming or out for lunch, for a drive or walk and had spent time in the home watching television, listening to music and playing with their personal possessions. All of the people living in the DS0000070757.V353187.R01.S.doc Version 5.2 Page 14 home had been on holiday during the summer and some of the photographs taken during these trips were displayed in people’s rooms. Work opportunities were explored with the people living in the home. Two people received support to attend part time voluntary jobs in the community. One person said he worked in a café at a local hospital twice a week serving food and keeping the café clean and tidy. He said he was not able to attend as frequently as he used to because of transport difficulties. This issue was discussed with the manager. The new contract for managing the service did not include the provision of a car or minibus. Other options such as jointly purchasing a vehicle had been explored with the people using the service and their representatives but an agreement could not be reached. Taxi cards had been requested for all of the people living in the home but staff reported that this service was not always reliable. Some of the people living in the home were able to use public transport but some people became anxious or found this too strenuous. It was evident that difficulties with transport were causing some disruption to peoples usual routines. See recommendation 2. One relative provided written feedback about the home. The respondent said that staff were always able to meet his family members needs and indicated that he was satisfied with the care provided in the home. The relative said his family member was “very happy” at Halsbrook Road. Some relatives visited regularly and a number of people said they liked spending time with their family. The current menu was examined. Staff said that the deputy manager usually developed the menu with suggestions from the people living in the home. The menu included a good variety of different foods and people were able to request an alternative if they did not like the dishes listed. Everyone said they liked the food provided and one person added, “You get lovely big dinners here”. People spoke about their favourite meals, which included roast dinners and fish and chips. Some people were able to prepare hot drinks and snacks for themselves and others assisted staff to purchase food or serve meals. DS0000070757.V353187.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support was provided to meet people’s personal care needs and to identify and address health issues. The management of medication was satisfactory overall but some additional records were required. EVIDENCE: People were allocated a key worker who was responsible for overseeing their care. Staff spoke about the progress that people had made in recent years and were pleased that they had been able to assist one person to prepare for more independent living. Most of the people living in the home required some form of support with personal care. This was provided in a flexible manner and at the time that suited the individual. People were encouraged to maintain their independence even if this involved some additional work for staff. Records were maintained about medical appointments and health checks. In recent months some people were supported to receive chiropody or dental treatment or to attend appointments with their GP or Psychiatrist. A medical DS0000070757.V353187.R01.S.doc Version 5.2 Page 16 information form was prepared for each person. This form was used to provide information for hospital staff if the person was admitted to hospital or to show other professionals if the person was unwell whilst on holiday. Because the home has a stable team of staff health issues could be identified and addressed quickly. Two medication charts were examined. Records of receipt and administration of medicines were good and all medicines were in stock. Staff maintained a list of medicines received in the home and recorded stock levels. This document was a little difficult to follow as there was no running total and it was not always clear if new supplies were received before or after medication was administered. See recommendation 3. The list of ‘over the counter’ or homely remedy medicines had been reviewed and updated and was agreed and signed by the GP. There was no record of receipt of these medicines and it was not possible to establish if stock levels were correct. The Registered Person must be able to account for all medicines used in the home. See requirement 1. Some staff had attended medication training updates and the manager was due to attend medication audit training. DS0000070757.V353187.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to protect people from abuse and to ensure that complaints and concerns were managed effectively. EVIDENCE: The home had not received any complaints since the last inspection. The relative that provided written feedback about the home said they knew how to make a complaint and said their concerns were always dealt with appropriately. A personalised copy of the complaints procedure was being developed for each of the people living in the home. This will include photos of the people they speak to if they have any concerns. The complaints and compliments policy and procedure was examined. The procedure was available in a variety of different formats and was easy to follow. There was clear information about the process and timescales for responding to complaints and details of whom they could contact if they were not satisfied with the response. The home had made one referral since the last inspection to the local authority adult protection team. This issue was investigated but was not substantiated. Staff knew they should report allegations of abuse or misconduct to senior staff and had received safeguarding training. DS0000070757.V353187.R01.S.doc Version 5.2 Page 18 The home had good systems for safeguarding peoples personal money. Two sets of records were checked and were found to be correct. All incoming and outgoing money was recorded and receipts were retained where possible. People said they were able to spend their money on the things they liked and were able to go out regularly and do the activities they liked such as swimming and shopping. DS0000070757.V353187.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and odour free. Work was in progress to make the communal areas more homely and comfortable for the people living in the home. EVIDENCE: The landlord was responsible for maintenance issues. The building was maintained to a satisfactory standard and all of the issues identified during the previous inspection had been addressed. The extractor fan in the ground floor bathroom had been replaced and further work to improve the ventilation in this room was under consideration. Action had been taken to resolve the damp area behind the toilet and to repair the wall leading to the laundry and the loose panel in the kitchen. The vacant bedroom had been redecorated and some new lights had been fitted. DS0000070757.V353187.R01.S.doc Version 5.2 Page 20 The people living in the home had chosen a new carpet for the lounge and staff said that the stained carpet in one of the bedrooms would also be replaced. New furniture for the lounge and conservatory had been ordered. A part time domestic worker was responsible for keeping the communal areas clean and tidy and support staff assisted the people living in the home to clean and tidy their bedrooms. All areas were clean, tidy and odour free. The wooden larder cupboard shelving was not an easy surface to clean and this area did not appear to be included on the cleaning schedule. See recommendation 4. A local authority environmental health officer carried out a routine inspection in 2007. No concerns were identified. DS0000070757.V353187.R01.S.doc Version 5.2 Page 21 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 and 35. 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 stable team of staff that provide good support for the people using the service. Staff recruitment procedures were thorough but the records kept in the home did not always reflect this. EVIDENCE: The arrangements for staffing the home had not changed. There were three support staff on duty on each daytime shift and two support staff overnight, one of whom slept on the premises and was on call. Staffing levels were increased to cover appointments or meetings if necessary. The manager was available during office hours Monday to Friday and there was an on call person for advice outside these hours. Three staff had left since the last inspection and two new staff had just completed their orientation period. Retention of staff was good. This provided good continuity of care for the people using the service. DS0000070757.V353187.R01.S.doc Version 5.2 Page 22 50 of staff had attained a vocational qualification at level two or above. Some of the other members of staff were undertaking this training. The commission had agreed that staff records could be held centrally if a form summarising all the checks was kept in the home for inspection. The forms for two members of staff were requested but could not be located. This information was supplied to CSCI after the inspection. See requirement 2. Relevant checks were undertaken but there was no evidence to show that one person that was appointed prior to the introduction of the Care Homes Regulations was physically and mentally fit for the role. The information on one application form did not correspond with the information on the person’s passport. The manager was asked to obtain further information about this issue. The registered company has a dedicated training department and staff also had access to local authority training sessions. The manager said that he had completed a training analysis to enable the new provider to identify staff training needs. Staff were not able to comment about training arrangements, as the new provider had only taken over responsibility for this issue in recent weeks. It was not possible form a judgement about this standard. DS0000070757.V353187.R01.S.doc Version 5.2 Page 23 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, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The atmosphere in the home was open and supportive. Health and safety issues were satisfactory overall but the manager must ensure that checks are carried out in a timely manner. EVIDENCE: The responsibility for managing this service changed from Choice Support to Outlook Care on 1st October 2007. There was no evidence that this change had caused any disruption for the people using the service. The manager and most of the staff had opted to transfer to the new organisation. An open day to introduce staff from the new company was held in the home. DS0000070757.V353187.R01.S.doc Version 5.2 Page 24 The manager was assessed by the commission in July 2006 and was found to have suitable qualifications and experience to manage a care home for people with a learning disability. The manager has a B.A. (Hons) in Social Sciences, a Master of Arts in Sociology and Law, a NVQ 4 in Management and the Registered Managers Award. The manager received regular supervision and was able to speak with his line manager for advice or support at any time. Since the last inspection a new deputy manager had been appointed. This person had transferred from another Outlook Care Service, so was able to assist the manager and staff to implement the company’s policies and procedures and paperwork. Staff said the manager was approachable and always listened to their concerns. A number of people that lived in the home visited the manager during the inspection for a chat or to discuss their plans. It was evident that the manager had established good working relationships with staff and the people using the service. The manager said that the new provider had an established quality assurance system, which included monthly feedback to head office, regular audits, spot checks, monthly unannounced visits as required by regulation and satisfaction surveys. As this inspection took place two weeks after the transfer of registration from Choice Support to Outlook Care it was not possible to fully assess this standard. The management of health and safety issues was mostly good. All of the records seen, excluding the lift inspection and Legionella risk assessment, were satisfactory. The passenger lift inspection was a little overdue and a risk assessment or evidence of chlorination of the water tanks could not be located. See requirement 3. The previous requirement to ensure that the mains electricity installation was inspected had been addressed but some remedial work was due to take place. Fire safety arrangements were good. Fire safety equipment was checked and serviced regularly. The fire extinguisher in the laundry room appeared to have been missed during the regular inspection. The manager agreed to address this issue. Fire drills were taking place regularly and included both day and night staff. The new provider had arranged for a fire safety risk assessment to be completed. Some staff had not received fire safety training for some time. The manager had identified this issue and advised the new provider about this. Work was in progress to complete assessments for hazardous substances used in the home. A list of the products used had been compiled and data sheets had been requested from the supplier. DS0000070757.V353187.R01.S.doc Version 5.2 Page 25 Hot water temperatures were checked regularly and the maintenance department were advised about temperatures that were above the recommended level. DS0000070757.V353187.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 X X X 2 X DS0000070757.V353187.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No - new service. 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 YA20 Regulation 13 Requirement Timescale for action 05/01/08 2. YA34 19 3. YA42 23 The Registered Person must ensure that adequate records are maintained about all medicines received in the home. This includes homely remedies. The Registered Person must 05/01/08 ensure that the agreed forms for recording staff recruitment checks are kept in the home. The Registered Person must 05/01/08 arrange for the passenger lift to be inspected and a Legionella risk assessment to be completed. A copy of these reports must be forwarded to CSCI. 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 YA2 Good Practice Recommendations The Registered Person should ensure that records show what progress people are making in meeting their personal goals. DS0000070757.V353187.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA13 YA20 YA30 The Registered Person should ensure that a suitable means of getting to and from activities and events is established for all of the people using the service. The Registered Person should ensure that medication records provide a complete audit trail. The Registered Person should ensure that the larder room is kept clean and that the shelving unit is made of a material that is smooth and washable. DS0000070757.V353187.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000070757.V353187.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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