Care Home: Rosemont Road, 62

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What the care home does well The home provides the residents with opportunities and different experiences. Residents often receive one to one support to access places in the community. The staff team are committed to offering a good standard of care for the residents living in the home. What has improved since the last inspection? Overall the staff team were up to date with the training they need to support residents safely. What the care home could do better: A number of requirements were made and several shortfalls were noted during this inspection visit. These shortfalls were relating to various areas, such as a lack of clear care plans, a lack of risk assessments completed on all potential risks and health needs had not been fully assessed and addressed. The home needs to implement more robust medication procedures to ensure residents are safeguarded from errors occurring. Evidence of the induction new staff work through also needs to be available. There were shortfalls in health and safety areas, such as fire drills not being held on a regular basis and no evidence of an environmental risk assessment. The Manager Designate and Registered Provider must take every step to address the areas noted above. CARE HOME ADULTS 18-65 Rosemont Road, 62 Acton London W3 9LY Lead Inspector Sarah Middleton Key Unannounced Inspection 19th November 2007 10:20 Rosemont Road, 62 DS0000027741.V348890.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 Rosemont Road, 62 DS0000027741.V348890.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. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemont Road, 62 Address Acton London W3 9LY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 752 1165 00000000000 hm62rosemont@ealing.org.uk Support for Living Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: 62 Rosemont Road is a home registered for three service users with learning disabilities and additional physical disabilities. All three of the service users are wheelchair users. The home opened in 1994 and is situated in a quiet residential area of Acton. The shopping centres of Ealing and Acton are within easy access. The house is a semi-detached property on two floors. There is a lift between the ground and first floor. A lounge, dining room, kitchen, laundry and assisted bathroom are all located on the ground floor. The first floor has three bedrooms and an office. There are wide corridors suitable for wheelchair users. The staff team consists of the Registered Manager, Senior support worker and a team of support workers. They provide twenty-four hour care and support with regard to personal care and practical tasks. The home has one waking night member of staff working during the night period. Residents pay a contribution towards their rent and the remaining fees, which vary, are funded through Social Services. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 10.20am-6.10pm. The term “resident” will be used in this inspection report and replaces the previously used term “service user”. The term resident refers to the people living in the home. The term “we” will be used in this inspection report and refers to the Inspector who carried out the inspection. The Registered Provider has merged with another local Registered Provider and the name has changed to Support for Living. The previous Registered Manager of the home left his position earlier in the year and a new Manager Designate started a few months ago. In addition, a new post was made for a senior support worker and this position has been filled. We spoke with one resident and three members of staff. The Manager Designate completed an Annual Quality Assurance Assessment and this was viewed prior to the inspection visit. All of the Key National Minimum Standards were assessed. Two of the three previous requirements were met and ten new requirements were made. What the service does well: What has improved since the last inspection? Overall the staff team were up to date with the training they need to support residents safely. Rosemont Road, 62 DS0000027741.V348890.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. Rosemont Road, 62 DS0000027741.V348890.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 Rosemont Road, 62 DS0000027741.V348890.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. Prospective residents would be assessed prior to moving into the home. EVIDENCE: The home has not had a new resident move into the home for some years. We viewed a blank pre-admission assessment that would be used to assess a prospective resident. This includes information on their social, health and personal needs. The assessment considers the particular needs and abilities of the prospective resident. The home considers whether it can offer a place to a new resident, and where possible makes alterations, such as providing a waking night member of staff to ensure the most recently admitted resident was safe at night. Rosemont Road, 62 DS0000027741.V348890.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 adequate. This judgement has been made using available evidence including a visit to this service. The lack of clear care plans and risk assessments could place residents at risk, as their individual needs had not been clearly identified and recorded. Residents are supported and encouraged to make daily decisions. EVIDENCE: We viewed one resident’s file and examined a recent review. Residents are involved in the review and can attend and if able to, are supported to contribute to the discussions. Other professionals such as the day centre staff and the Aromatherapist had also completed a report providing an update on the resident. Monthly summaries were seen which outlined the activities the resident had taken part in along with any issues over the past few weeks. A personal care assessment had been completed in early 2006 but there was no evidence to suggest this had been reviewed and updated. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 10 The Annual Quality Assurance Assessment stated care plans are in place. However there was no clear care plan available that outlined the residents’ needs and aspirations. Reviews are not written in sufficient or appropriate detail to be used as a care plan to inform staff of residents’ individual needs. This was discussed with the keyworker and senior support worker. The file viewed had many out of date documents and it was difficult to locate the information needed. A requirement was made for care plans to be developed with residents. Keyworkers meet with the residents on a one to one basis and this could also be a time used to consider the current care plan, once it is in place. The residents living in the home do not have an advocate. This was discussed with a member of staff and he agreed to look into the possibility of identifying an advocate for one of the resident’s. Staff spoken with confirmed they support residents to make decisions. Although some residents do not use verbal communication, other forms of communication are used, such as body language, gestures and sounds. Residents are not able to manage their own finances. Risk assessments were viewed. The moving and handling assessment was dated 2004 and another risk assessment seen was dated early 2006. Risk assessments need to be reviewed and updated on a regular basis. Staff must consider the potential risks posed to the residents and towards others. A member of staff acknowledged that there were more potential risks regarding one of the resident’s but these had not been documented. This shortfall had been identified at the last inspection and is a re-stated requirement. Rosemont Road, 62 DS0000027741.V348890.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, 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 are able to take part in appropriate activities both in the home and community. In order to maintain social relationships, residents are supported to see relatives or friends. Residents’ rights are acknowledged and respected. Residents are provided with a varied diet that considers the preferences of the residents. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents have opportunities to engage in various activities, such as attend a local day centre and the hydrotherapy pool. Community resources are accessed, such as the temple, theatre and the pub. The home has its own form of transport and staff confirmed that public transport is also used, as there are good bus routes and a train station nearby. A member of staff explained that he is looking at the activities on offer to ensure the residents have positive and regular stimulation and occupation. Holidays are supported, with one resident having just returned from a holiday and another resident had been away for a long weekend. The home ensures sufficient numbers of staff support the residents safely on the holidays. One resident has regular contact with relatives and staff confirmed they would support the residents to see relatives or friends. The residents are not able to use the telephone. Due to the nature of the residents’ disabilities they do not have keys to their bedrooms. One member of staff described how he reads the residents mail individually to them. Residents are able to spend time in their bedrooms or with others, which is usually in the kitchen/dining room. Staff were seen to interact with the residents throughout the inspection. The home is considering holding resident meetings. These meetings would be reviewed, once implemented, to ensure they are worthwhile for all the residents. We viewed the kitchen and menus. Overall menus showed some variation for the residents and included residents’ preferences. There is still some scope for improvement with staff needing to consider including healthier options. Records of the meals residents had eaten had been recorded, although some gaps were noted. This was discussed with the senior support worker. Residents’ likes and dislikes of foods were seen, although after talking to staff it was agreed that these lists should be reviewed and updated. Overall the kitchen was clean and tidy. Fridge and freezer temperatures had been taken and were within an appropriate range. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Residents receive personal care support in their preferred way. Residents’ health and well being could be jeopardised if they fail to receive regular health checks. The shortfalls in accurately using medication records could pose a risk to the residents. EVIDENCE: We were informed that residents could choose who provides personal care to them. Where possible same gender care is provided, but at times this is not always possible. Personal care is always carried out in private and if male staff are carrying out this task, then another member of staff is located close by. Where needed, specialist equipment is provided, such as adjustable beds and hoists. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 14 Health needs were discussed and although this area is looked at during review meetings, as stated earlier there were no care plans clearly recording current health needs. We were told that one resident does not attend the dentist. Staff could not provide any explanation for this and there was no plan for staff to follow to ensure the resident’s oral hygiene was being monitored. A requirement was made for all residents health needs to be identified, recorded and met. All residents have a GP and the home is currently seeking advice from the speech and language therapist to provide information about communication and Makaton. Support from a Physiotherapist is also being sought. We viewed medical appointment records that note when a resident has seen a health professional and any treatment or advice given. As noted earlier, it was difficult to fully access all the information needed, such as viewing a current weight chart. One weight chart was seen but this was dated 2004. It is important for up to date and relevant information to be readily available for all those concerned. A sample of medication was viewed. The home records how residents like to have their medication given to them, as residents are not able to selfmedicate. Medication is stored in a metal locked cabinet. Staff receive initial medication training but this does not appear to be offered after this. The Manager Designate and senior support worker are exploring training and information on medication for the staff team, as they have recognised that staff would benefit from having this offered on a regular ongoing basis. The medication is briefly checked three times a day at each handover but loose medication that is kept in bottles or boxes is not counted or checked on a regular basis. A requirement was made for this to be implemented and evidenced. A count was made on a small sample of medication and this was found to be correct at the time of the inspection. Two gaps where staff signatures should have been on the Medication Administration Records were seen. This was brought to the attention of the senior support worker and a requirement was made for staff to complete these records accurately. All members of staff need to know the importance of administering and recording medication carefully. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Residents’ views and concerns would be listened to and acted on. Systems are in place to protect residents from abuse. EVIDENCE: One resident is able to clearly express her concerns and complaints. She stated if she was unhappy she would talk to the senior support worker or the Manager Designate. It is more difficult to assess how the other residents would be able to be clear about what they might be unhappy about. Although some staff described how residents would show their feelings by turning away or pushing away something, such as a meal. The complaints procedure is visible in the dining room, however the residents are not able to read. The home has not received any complaints, but a book was seen where concerns and comments would be noted. A complaints form was also seen that would be used if a complaint was investigated. The home has the Local Authority’s policy and procedure on adult abuse. Staff received training on this subject, although staff would benefit from having training and information on this subject provided on a more regular basis. The senior support worker stated he would look into the next available training. The home has not had any adult abuse investigations since the last inspection. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 16 We counted one resident’s money. Residents pay towards certain items, such as toiletries, taxis and clothes. The money counted was correct. The residents’ money is counted at each handover. All financial transactions are recorded and receipts are obtained. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The shortfall regarding the décor in the communal areas means the home, in certain areas, looks neglected and unwelcoming. Overall the home was clean and free from unpleasant odours. EVIDENCE: The home has a new housing trust that is responsible for the maintenance of the property. The communal areas of the home have needed painting for sometime and this had been identified at the last inspection. Certain areas, such as the living room and hall are in need of attention as walls are marked and looking unwelcoming. The Service Manager, who was present for part of the inspection, acknowledged that the communal areas need work and the new housing trust is aware of this. A re-stated requirement was made for this to be addressed. The bathroom has had a new assisted Parker bath fitted however the housing trust have not finished the work in this room. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 18 We were informed that the housing trust would be visiting to inspect the home. Subsequent to the inspection we were informed that the bathroom work would be completed in the next two weeks and that other areas of the home would be addressed. We were satisfied that staff have been liaising with the housing trust to ensure this work is finished. Two residents bedrooms have been painted and a third resident has been spending time choosing curtains and colours for her bedroom. Residents are involved in choosing the décor and other items for their own personal space. The home is looking to use the communal living space as a lounge area and sensory room. The Annual Quality Assurance Assessment stated that a new television and sensory equipment would be purchased. Overall the home was clean and free from odours at the time of the inspection. The laundry room was not viewed on this inspection. The maintenance records showed that the washing machine had broken down a few times over the past year but recently had been working well. However on the day of the inspection it had broken down again. This would be reported to the relevant company in order for it to be fixed as soon as possible. The senior support worker confirmed that residents’ clothes are washed separately and soiled items are washed separate to residents’ main items of clothing. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 19 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. A competent and effective staff team support the residents. Robust recruitment checks protect the safety of the residents. The training programme meets the needs of the staff team and consequently the residents. EVIDENCE: The staff team have two new members who have commenced with the Learning Disability Award Framework (known as LDAF). The NVQ course is also available to staff and three members of staff are waiting to start this course. Some of the staff have worked in the home for sometime and have a range of experiences and knowledge. One member of staff said he was spending time getting to know the residents and learning how they communicate. The members of staff spoken with were committed to supporting the residents and improving the care provided to them. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 20 Wherever possible agency staff are used only when the regular staff team or relief/casual workers are unable to work. The senior support worker explained that only external agency staff who are familiar with the home are asked to work. There were no staff vacancies in the home. The staff team is a mixture of genders and ages. Staff meetings take place once a month and the staff had recently attended a team review day. This is where aims and objectives are looked at and tasks are set for the staff to work on specific areas of the home. Since the appointment of the Manager Designate, the home has begun re-organising some of the files and looking through the paperwork. This is still a working progress and staff were aware there were still outstanding files needing to be tidied up. There is always a minimum of two staff working on each shift. The rota was viewed and this seemed flexible according to the activities being offered. Additional members of staff work where particular activities need extra staff. Samples of staff employment files were viewed. The main staff files are held at the local head office therefore the home holds information on a checklist. Those viewed confirmed that full employment history, including any details of employment gaps had been obtained, Criminal Record Bureau disclosure numbers were present, two references had been obtained and a medical health disclosure had been completed. Training was discussed and individual training records were viewed. Some staff had attended adult abuse (known as POVA) training in 2006. The new members of staff had attended POVA training this year. It was recommended that staff receive refresher training every year to ensure all staff know what action to take if they have any POVA concerns. Other mandatory training was up to date. Moving and handling training had been provided this year, but training records stated it was to be provided only every three years and not on an annual basis. This needs to be confirmed to ensure staff have the skills and knowledge to support the residents safely. The home would benefit from devising a document that shows the overall staff training needs and training attended. Therefore this could be viewed at a glance when checking that the staff team were up to date with the training they need to attend. This was discussed with the senior support worker. The Mental Capacity Act 2005 was discussed and the staff team were not aware of this legislation. It was strongly recommended that all staff receive information and training on details of this Act and how to use it in their daily working practice. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 21 Staff confirmed they had received an induction and had shadowed existing members of staff. There was no evidence to show what new members of staff learn and go through when getting to know the residents and the home. The induction programme needs to be detailed to ensure the residents are protected and supported safely by competent staff. A requirement was made for this to be addressed. Rosemont Road, 62 DS0000027741.V348890.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 is well managed with systems in place to support both residents and staff. To support a review of the quality of care, residents’ views should be obtained and considered when providing a development and improvement plan for the home. The lack of regular fire drills and an environmental risk assessment could place residents safety at risk. Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Manager Designate has been in post for approximately five months. She has applied to study for an NVQ level 4 and the Registered Managers award. Those staff asked spoke positively about the support they receive from her. Staff had also said the home had coped earlier in the year when there was no Registered Manager working in the home. The home has monthly Regulation 26 visits carried out and these look at various aspects of the home. Furthermore we were informed that surveys had been carried out with residents, but there was no evidence available to show the outcome of these surveys and any action taken. Although the staff team state they seek the residents views on daily matters about the home, the residents’ views need to be obtained about the care they receive in the home and this should be easily available. A requirement was made for this to be addressed. Furthermore the Manager Designate needs to develop a short report outlining the developments in the home and encompass a summary of all the quality care systems in place in the home. Discussions took place with the Service Manager, who confirmed that no such report has been developed. A requirement was made for this to be devised and available for residents and inspection. Samples of maintenance records were viewed. The fire risk assessment had been completed, and a document showing the individual resident’s capability to respond to a fire was available. The fire equipment had been serviced in October 2007. Fire drills had not been held on a regular basis. These must be held at different times of the day and night and all staff need to attend various fire drills throughout the year. A requirement was made for this to be addressed. The testing for Legionella, Gas safety check and Portable Appliance test were up to date. As highlighted earlier in the report, the file containing the above information was messy and many certificates, that were several years old remained in this file, making it difficult to locate certain documents. This was brought to the attention of the senior support worker. The home did not have an overall environmental risk assessment completed. A requirement was made for this to be addressed. Rosemont Road, 62 DS0000027741.V348890.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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 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 2 3 x 2 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 20 21 Score 3 2 2 x 3 x 2 x x 2 x Rosemont Road, 62 DS0000027741.V348890.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(1) Requirement Timescale for action 15/03/08 2. YA9 To ensure residents needs are identified and met a detailed care plan must be implemented. 12(1)(b)13(4)(b) Risk assessments must be in place for all potential hazards/risks to both residents & others. (Previous timescale 05/05/06 not met). 31/01/08 3. YA19 4. YA20 5. YA20 12(1)(a)13(1)(b) To ensure residents health needs are being met, all residents must have access to advice and treatment from a health care professional. 13(2) To safeguard residents, Medication Administration Records must be completed correctly. 13(2) For residents’ health and welfare to be protected, evidence of regular counts and checks on all the medication must be in place. 10/01/08 20/11/07 19/01/08 Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 26 6. YA24 23(2)(d) To provide a welcoming home the communal areas of the home need to be painted. Evidence of the induction new staff go through must be available to ensure residents’ are supported by a competent staff team. Residents need to be supported and encouraged to express their views on the home. These views should also be considered and acted on. A short report or summary regarding the improvements the home has made and aims and objectives for the forthcoming year needs to be devised and available for residents and inspection. To protect the residents health and welfare regular fire drills must be held. To ensure residents live in a safe home an environmental risk assessment must be completed. 31/03/08 7. YA34 18(1)(c)(i) 31/01/08 8. YA39 24(3) 31/03/08 9. YA39 24(2) 31/03/08 10. 11. YA42 YA42 23(4)(e) 13(4)(c) 31/01/08 31/01/08 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. Refer to Standard YA35 YA35 Good Practice Recommendations It is recommended for the staff team to have information and training on the Mental Capacity Act 2005. It is recommended for the staff team to receive refresher DS0000027741.V348890.R01.S.doc Version 5.2 Page 27 Rosemont Road, 62 information and training on the Protection of Vulnerable Adults, (POVA). Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Rosemont Road, 62 DS0000027741.V348890.R01.S.doc Version 5.2 Page 29 - 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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