Care Home: Spring Grove Road, 231

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What the care home does well The home provides a comfortable and homely environment for the people living there. A consistent staff team has helped to provide continuity for the people using the service who have benefited from staff knowing their preferences and needs, particularly in regard to health care. The home is close to local amenities which the residents can enjoy. What has improved since the last inspection? The bathroom has been refurbished. The home has recently acquired a computer, shared with 233 Spring Grove Road, which should assist the team with their record keeping and allow for pictorial aids to be used to support communication for those living in the home. What the care home could do better: We found an error in the medication administration which should have been discovered on an audit. There must be systems in place for the regular auditing of the medication. We found that there were employment records which were not current. The Registered Providers must ensure that there are systems to ensure that records are up-to-date when an inspection takes place. Only two staff appear to have a National Vocational Qualification and the staff must have the opportunity to develop their skills by undertaking NVQ training. The Registered Providers need to provide a timetable to show the target of having 50% of the staff trained will be achieved. An up-to-date fire risk assessment is required to be completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006.The home has been without a Registered Manager for eight months and the procedure had not yet commenced. The Registered Providers must ensure that a manager applies for registration with the Commission for Social Care Inspection. CARE HOME ADULTS 18-65 Spring Grove Road, 231 Isleworth Middlesex TW7 4AF Lead Inspector Ms Jane Collisson Unannounced Inspection 6th August 2008 11:35 Spring Grove Road, 231 DS0000022906.V368578.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 Spring Grove Road, 231 DS0000022906.V368578.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. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Grove Road, 231 Address Isleworth Middlesex TW7 4AF 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 758 2966 Voyage.com Milbury Care Services Ltd Post Vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Spring Grove Road, 231 DS0000022906.V368578.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 categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 2 20th July 2006 2. Date of last inspection Brief Description of the Service: 231 Spring Grove Road is a home for two people with learning disabilities, both over 65. The home is a detached three bedroomed house, situated on a busy road in Isleworth, and close to public transport to Hounslow Town Centre and Brentford. There are local shops within walking distance. The home is owned and managed by Milbury Care Services, now known as Voyage. The communal areas consist of a lounge, with a separate kitchen/dining room. The office, laundry room and staff toilet are located in an outbuilding located in the small back garden. There is a bathroom on the first floor, with a bath and separate shower cubicle, and a separate toilet. The third bedroom is used as the staff sleeping in room. The neighbouring house, at 233 Spring Grove Road, is a home for three service users and the Manager is responsible for both homes. There is a Senior Support Worker and a team of Support Workers for each house. They provide support with personal care, practical tasks, leisure and social activities. There is a minimum of one staff on duty at all times, with one sleeping in staff at night. Both people use the Registered Providers’ Day Centre, which is local. There is a house car available, shared with 233 Spring Grove Road. Spring Grove Road, 231 DS0000022906.V368578.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. We carried out this inspection on the 6th August 2008 at 11.30am. It was undertaken in conjunction with the unannounced inspection of 233 Spring Grove Road as the home shares the same Manager. That took place on the 5th and 6th August 2008. The inspection of 231 Spring Grove Road took approximately four hours. The Registered Manager of both homes left the organisation in December 2007. The Deputy Manager (who will be referred to as the Manager in this report) has been managing the homes and is now applying for registration with the Commission for Social Care Inspection. At the last inspection, the Registered Manager and Deputy Manager were also involved in managing some local supported living units for Registered Providers, but this work has now ceased. The two people who live in the home were met, together with three of the staff team. Both residents are over sixty five years of age. We met them in private, and together in the lounge, where they were able to discuss their recent activities. These had included a visit to a club in Richmond, which is visited regularly, where there had been an exercise class that day. We looked at their files, which included care plans, daily notes, health and medication records. They both have a weekly programme, which includes a number of visits to the local day centre. From the information examined, we saw that they enjoy a number of activities that appear to be in accordance with their own personal preferences. One person had attended a recent short-break at the coast, and we saw the album of photographs which had been produced to remind her of the holiday. There are no specific cultural needs to be met, but one person is able to attend a religious establishment on a regular basis, with the support of volunteers from the church. Since April 2008 there has been a reduction in the staffing hours in the home to 176.5 a week, including 20 hours management time. This was from 212 hours noted previously. This means that, at times, there is single staff cover. Staff said they were working to ensure that this does not unduly affect the residents as one does not always wish to go out. We toured the home and saw maintenance records and the staff files, which are all held at 231 Spring Grove Road for both homes. The Commission for Social Care Inspection’s Annual Quality Assurance Assessment had been completed for this inspection, but the bulk of the information is completed on a Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 6 corporate basis, giving details of organisational changes rather than those affecting the residents of this home directly. Some statistical information was provided regarding the residents and staff. This was the first inspection since June 2006 and an Annual Service Review, which did not involve a visit, was carried out by us in February 2008. This inspection looked at all of the key National Minimum Standards. There were no requirements at the last inspection. have made five requirements. At this inspection, we What the service does well: What has improved since the last inspection? What they could do better: We found an error in the medication administration which should have been discovered on an audit. There must be systems in place for the regular auditing of the medication. We found that there were employment records which were not current. The Registered Providers must ensure that there are systems to ensure that records are up-to-date when an inspection takes place. Only two staff appear to have a National Vocational Qualification and the staff must have the opportunity to develop their skills by undertaking NVQ training. The Registered Providers need to provide a timetable to show the target of having 50 of the staff trained will be achieved. An up-to-date fire risk assessment is required to be completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 7 The home has been without a Registered Manager for eight months and the procedure had not yet commenced. The Registered Providers must ensure that a manager applies for registration with the Commission for Social Care Inspection. 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. Spring Grove Road, 231 DS0000022906.V368578.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 Spring Grove Road, 231 DS0000022906.V368578.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, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is in place for people to understand the aims and objectives of the home although updating is required. Although the assessment process could not be examined, as there have been no new residents, the procedures are in place should they be needed. EVIDENCE: We found that both the Service Users Guide and the Statement of Purpose are in need of updating, including information on the changes in management. The Service Users Guide is photographic and will need to be amended to ensure that the people using the service have the current information. The Manager said he has commenced the changes to the Statement of Purpose, which is now held on the recently acquired computer. The information should be forwarded to the Commission for Social Care Inspection once completed. Both of the residents have lived in the home for some years and there are no vacancies. Therefore, the assessment procedures have not had to be used and this key National Minimum Standard could not be fully assessed. However, the Manager reports in the Annual Quality Assurance Assessment that the assessment procedures are in place should they be required. A copy of the new assessment procedure, which appears very comprehensive, was seen. Spring Grove Road, 231 DS0000022906.V368578.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. Care plans are in place and a more person-centred planning system is being introduced, in a format which should be accessible to the residents. People are supported to retain their independence and are encouraged to make choices. EVIDENCE: Work was being undertaken on care plans so that they become more “person centred” and relevant to the people using the service. We examined various support plans covering the activities the residents undertake, and also information on reviews. The minutes of the more recent reviews, held in June 2008, were not in the files, but reports for the meeting were seen. Both people currently have a care manager from the Local Authority, who attended them. We discussed with the Manager the idea of key workers completing, in the future, a monthly report for each person to support the records being kept up-to-date. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 11 We looked at the daily records, which are maintained on pre-printed forms so that the activities of daily living are personal to the resident. These included any activities undertaken. Both of the people living in the home are able to make decisions about their daily lives. An example of this was that one resident chose not to go on holiday recently and she was able to confirm this to us. We noted that one of the residents was obviously being kept informed of issues affecting her and was able to discuss them with us. Because the home is small, the residents can easily be involved in the day-to-day running and decision-making and this was seen to happen. We found that the residents have been able to continue to retain their independent living skills, in accordance with their abilities, and they were seen to be helping with their laundry on this inspection. Both the residents are in an older age group but remain relatively active. The home currently suits their needs and they have the mobility required to access the first floor bedrooms and bathroom. Spring Grove Road, 231 DS0000022906.V368578.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. Activities that suit the residents’ needs are available to them and they have the opportunity to access the local community. Families are encouraged to remain involved. Meals are varied and in accordance with the residents’ preferences. Support has been available for religious needs to be met. EVIDENCE: Both of the residents attend four half-day sessions at the Registered Providers’ Day Services, which are located nearby. The residents also attend a club in Richmond, on a regular basis, where they said that they had enjoyed an exercise session during the morning of the inspection. One resident had a birthday recently. A party had been held and cards and flowers were still in evidence. The home is located close to a main road, where there are local shops and cafes. There is easy access to Hounslow and other shopping centres. One Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 13 resident attends a local church on a regular basis, with the support of volunteers from the church. One person had recently attended a short-break holiday, with a resident from the neighbouring home. We were able to see photographs from the holiday, which had been placed in a book for the resident to use. Both residents have relatives, and one sees them on a regular basis. They are invited to attend reviews and one had recently done so. The residents have been in the home for some years, one since the home opened. They both appear very comfortable in the home and have a good rapport with each other and with the staff. They were positive about living in the home. Staff provide most of the meals for the residents, including lunches, and the residents are able to choose the meals they wish to have. A varied menu is provided and the residents also said they enjoy meals out. Spring Grove Road, 231 DS0000022906.V368578.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. People are provided with appropriate support with their health and personal care. Medication administration is not routinely monitored. EVIDENCE: Both the residents require some support with the personal care. As there are only female staff, there is always same gender care provided. The two residents share the bathroom and toilet on the first floor and this is also used by staff. The larger bedroom has had a washbasin installed which supports more privacy. We checked the records since the last inspection in 2006 in relation to the health of the people living in the home. We found that both of the residents had been supported with a variety of health needs, some ongoing. The records showed that their needs have been met through regular visits to community services, routine screen visits and through specialist support, and we saw that records and notes are kept of each medical visit. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 15 Both residents currently have medication, which is supplied in a Monitored Dosage System. We checked the medication and the Medication Administration Record (MAR) sheets. There was one error on an “as and when” medication. Eight tablets had been taken out of the packet but only six had been recorded. There were no monitoring systems in place to check when the error could have occurred. It was discussed with the Manager that, even though there is only a small amount of medication, and most of it is in blister packs, it must be monitored regularly. There was a signature on one Medication Administration Record sheet that was not clear, and one signature crossed out. The staff were advised that they must record when they have made any error. There is space on the back of the MAR sheet and this would provide an easily accessible record. Spring Grove Road, 231 DS0000022906.V368578.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. The systems are in place for people to make their concerns and complaints known. Staff are trained in safeguarding adults’ procedures. EVIDENCE: There have been no complaints recorded by the home since the last inspection. Both the residents would be able to make their concerns known, although one has limited verbal communication. One is visited regularly by family members should support be required to make a complaint. There is a pictorial Service Users Guide in place which include the complaints procedure. There has been one issue raised since the last inspection, which resulted in safeguarding adults’ meetings. This was primarily to do with the nonregistered supported living services, which were being supervised by the management team. The services are no longer managed by the Registered Providers. Staff have undergone the training recently for safeguarding adults, using the computerised training system and certificates were seen in the files examined. Spring Grove Road, 231 DS0000022906.V368578.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, 25, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house is comfortable and homely, suiting the current needs of the residents. Bedrooms are pleasantly decorated and furnished. Improvements have been made to the bathroom. The home was found to be clean and well maintained. EVIDENCE: We found the residents in their lounge, watching television. The lounge has comfortable furniture and is pleasantly decorated, with pictures and ornaments. The home also has a kitchen/dining room which is large enough for the residents and staff to sit. There are patio doors from the dining area to the small rear garden. This is concreted over but provides seating and an area for the resident who smokes. The office, laundry area and staff toilet are located in the outbuilding in this area. Both of the residents showed us their bedrooms. Both are nicely decorated, furnished and personalised. The residents indicated that they had all of the Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 18 items they need. There is no lift in the home, but both of the residents are currently sufficiently mobile to use the stairs. No special equipment is needed at the present time. The home has a bathroom and a separate toilet, shared by the two people living in the home and the staff. The bathroom has a separate shower. The bathroom had been in need of refurbishment for some time and this has now been undertaken. The staff are responsible for ensuring the cleanliness of the home and we found the home to be clean and tidy. The office building, which is located in the garden, is also laundry room. Spring Grove Road, 231 DS0000022906.V368578.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, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from a team of long term staff. Staff have the opportunity to undertake a continuous programme of training courses, using a computer. The Registered Providers have not maintained a regular programme of National Vocational Qualifications training. Staff are supported with regular supervision. Staff recruitment practices do not always support the protection of the people using the service. EVIDENCE: We found that the staffing levels have been reduced since the last inspection. Since April 2008, the former level of two staff at all times has been reduced and there are times when only one staff is on duty. We were informed that the times as which there are two staff are varied, to accommodate the needs of the residents. Both residents spend time at the day centre, so are able to access some individual staff time and also have some joint activities. We checked the staff records for the staff working in both homes, which are held jointly at 231 Spring Grove Road. Some staff occasionally work additional hours in both homes, as no agency staff are employed. All of the staff have Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 20 been in post for a number of years and there were no new staff. We discussed with the Manager that, if new staff were recruited, more comprehensive information would be needed. This included references on headed paper if they are from a company, and more details in regard to when staffed worked for the organisation. Gaps in staff employment histories were also seen. There were three staff files which did not show that the staff had up-to-date information on work permits. We discussed this with the Manager and received confirmation from the Operation Manager that up-to-date information was now in place. The Manager was advised to ensure that the dates for expiry are, in future, checked in advance. All records of employment need to be seen to be in place, to be monitored to ensure they are up-to-date and be available for inspection. We saw evidence of only one person having a National Vocational Qualification, although the two staff on duty said that they both had the qualification. This is less that 50 of the staff team. Staff need to be offered the opportunity of developing their skills. The Registered Providers need to provide an action Plan to show how this target can be met and staff offered the opportunity to improve their skills. Since the last inspection, the Registered Providers have introduced training courses on a lap top computer. The majority of staff were seen to have undertaken these and those spoken to said that they found this training satisfactory. There is a foundation health and safety courses, which includes training on first aid, fire awareness, risk assessments, law, infection control, manual handling and ergonomics. There are to be some practical courses to supplement the theoretical training in manual handling and first aid but these have not yet been arranged. In addition staff have taken “e-training” courses in safeguarding adults and food hygiene. There is also an induction course, which some staff have also completed, although they have been in post for some years. It was recommended to the Manager that the training spreadsheet is introduced again to show when staff last had the training in each subject. It was noted that some training did not appear to have been undertaken by staff for some time, such as epilepsy. A training spreadsheet, together with staff development plans, would provide evidence of the training staff have had and the training they require. As the home now has a computer, this information should be easier to maintain. We found that most staff have been supported by receiving regular supervision from the Manager since the Registered Manager left in December. Records were seen in the files to evidence this. We noted that staff meetings had been held three times in 2008. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 21 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 without a Registered Manager but has had a consistent staff team who ensure the people living in the home have continuity of care. The Manager has experience and knows the home and its residents well. Staff have health and safety training and the systems are generally satisfactory, but the home requires up-to-date fire risk assessment. The Annual Quality Assurance Assessment had limited information in relation to the home and its residents. EVIDENCE: Since December 2007, the home has been without a Registered Manager. However, the Deputy Manager has been managing both 231 and 233 Spring Grove Road. He has worked in the service for several years, although mainly at the neighbouring home, and knows the services well. He currently has twenty hours a week management time at 231 Spring Grove Road. He intends to commence the Registered Managers Award. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 22 The Registered Providers have, for some time, been considering applying for deregistration of the home so that the residents will be in supported living. As this is still unresolved, the Registered Providers must ensure that the home has a Registered Manager as it has been without for the past eight months. Both residents are able to communicate their needs to the staff, who know them well. An Annual Service Review is held. However, the one seen in the files, for 2007, had the results of the review but not the information which had informed the report. This included a list of work which was needed to the home. The report, which gives scores out of five for a variety of areas, including catering, the environment and information, was generally positive. The relatives of the residents are invited to participate in the process. We were provided with information in the Annual Quality Assurance Assessment regarding maintenance and servicing. We checked a sample of the records. The small electrical appliance testing was carried out in January 2008. Water temperatures are taken weekly. It had been a long standing recommendation that the home was provided with a computer so that the people living in the home could be supported with pictorial information to aid their understanding and communication. This also provides assistance for the staff to maintain good record keeping. We have also felt that access to the internet would help staff to keep up-to-date with good practice, and current information, but there is no access as yet. The last fire risk assessment was dated 20th June 2006 and needs to be updated in line with current legislation. The fire alarms and emergency lighting had been checked in February 2008 and the extinguishers in September 2007. There were risk assessments for both residents but one did not record that the resident smokes and this needs to be included in the risk assessment. A wall chart recorded that all of the staff, and the residents, had attended fire drills in 2008 and we saw records for five fire drills in 2008. We discussed with the Manager that a number of the files need to be streamlined as some were difficult to access and there were files which were not longer needed or had information which could be archived. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 23 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 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 3 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard 1 YA20 Regulation 13 (2) Requirement The Registered Providers must ensure that there are systems in place for the regular auditing of the medication administration. The Registered Providers must ensure that staff are given the opportunity to undertake National Vocational Qualification training and provide a timetable to show the target of having 50 of the staff trained will be achieved. The Registered Providers must ensure that all of the records of employment are in order and available for inspection. The Registered Providers must ensure that the home has a Registered Manager in post. The Registered Providers must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. Timescale for action 30/09/08 2 YA32 18 (1) (c)(i) 30/09/08 3 YA34 17 (2) Sch.4 (6)(f) 8 (1) (a) 23 (4A) (b) 31/08/08 4 5 YA37 YA42 31/10/08 30/09/08 Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 25 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 YA41 Good Practice Recommendations That there is a training matrix reintroduced to ensure that there is evidence that all of the staff have up-to-date training. That there is streamlining of the records and files to provide easier to access systems. Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Spring Grove Road, 231 DS0000022906.V368578.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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