Care Home: St Quintin Avenue, 1

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What the care home does well What has improved since the last inspection? Senior staff have made considerable progress in developing PCPs and in making documents and other materials accessible. The statement of purpose and service user`s guide have been updated and produced in an accessible format. The purchase of additional multi media equipment has enhanced residents` participation in PCPs, reviews and meetings. Progress in developing PCPs has continued, with good use of photos, colour and illustrations. The range of community activities available to residents has increased and good record keeping allows senior staff to monitor residents` activity programmes. Residents` participation in activities within the house, in particular in cooking, has also increased. The building has been redecorated and new furniture ordered, though much of it had not yet arrived at the time of the inspection. The admission of two new residents into the established group is being well managed. Both residents present challenges and difficulties have arisen but staff have put strategies in place with the involvement of the learning disability team. Visits on behalf of the provider are taking place regularly, with detailed reports available. What the care home could do better: Staff must ensure that strategies recommended by the learning disability team are included in support plans and that risk assessments cover risks indicated in previous reports and assessments. While recording has improved, staff must ensure that appropriate language is used and that sufficient detail is included in daily reports. CARE HOME ADULTS 18-65 St Quintin Avenue, 1 1 St Quintin Avenue North Kensington London W10 6NX Lead Inspector Sheila Lycholit Unannounced Inspection 6th May 2008 10:40a St Quintin Avenue, 1 DS0000010848.V362887.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 St Quintin Avenue, 1 DS0000010848.V362887.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. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Quintin Avenue, 1 Address 1 St Quintin Avenue North Kensington London W10 6NX 020 8968 3438 020 8968 3246 bimbososanya@lookahead.org.uk 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) Lookahead Housing & Care Mr Bimbo Abiodun Sosanya Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Quintin Avenue, 1 DS0000010848.V362887.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: whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief Description of the Service: The service is run by Look Ahead Housing and Care for 6 people with a learning disability. The house, which is arranged over 4 floors, is spacious, with a pleasant garden leading off the lower ground floor. Most of the bedrooms, which are all single, are of above average size. The house is in a tree-lined avenue in North Kensington, close to shops, services and public transport. The service users, who have high needs, attend day services in Kensington and Chelsea or Westminster. The building is not suitable for wheel-chair use, though the front entrance is ramped and one service user, who has restricted mobility, is able to manage the stairs to the lower ground floor. There are no vacant places. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The unannounced inspection took place on Tuesday 6th May 2008 from 10.40am until 4.20pm. Three residents were at home in the morning and three were attending day services. The residents who were at home went out to lunch with staff and kept appointments during the day. All returned at about 3.30pm, when some got ready to go out to a regular dance session. The Manager and Deputy Manager were on duty and made themselves available throughout the visit. The Manager had completed an annual quality assurance assessment (AQAA). Eight staff returned questionnaires and two parents completed surveys on behalf of residents. In addition to meeting with the Manager and Deputy Manager, the Inspector spoke with two recently recruited staff in private. The Inspector made a tour of the building and looked at two residents’ rooms. There are no vacancies at the project. Fees are negotiated individually with the local authority. What the service does well: What has improved since the last inspection? Senior staff have made considerable progress in developing PCPs and in making documents and other materials accessible. The statement of purpose and service user’s guide have been updated and produced in an accessible format. The purchase of additional multi media equipment has enhanced residents’ participation in PCPs, reviews and meetings. Progress in developing PCPs has continued, with good use of photos, colour and illustrations. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 6 The range of community activities available to residents has increased and good record keeping allows senior staff to monitor residents’ activity programmes. Residents’ participation in activities within the house, in particular in cooking, has also increased. The building has been redecorated and new furniture ordered, though much of it had not yet arrived at the time of the inspection. The admission of two new residents into the established group is being well managed. Both residents present challenges and difficulties have arisen but staff have put strategies in place with the involvement of the learning disability team. Visits on behalf of the provider are taking place regularly, with detailed reports available. 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. St Quintin Avenue, 1 DS0000010848.V362887.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 St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. An up to date statement of purpose and service user’s guide are now available in an accessible format. The admission of two new residents was well planned and managed. EVIDENCE: Since the last inspection the statement of purpose and service user’s guide and contracts have been updated and expanded to provide all relevant information in an accessible format. Two new residents have moved into the house – the first new admissions for a number of years. Both new residents moved from local services and considerable information was already available about their needs, though it was not clear that staff had been alerted to the need to ensure that scissors were kept secure during visits from one prospective resident. Assessments were undertaken by the Manager and copies of the assessments and transition plan were seen on file. Both prospective residents visited St Quintin’s on a number of occasions, staying for an increasing length of time before moving in. Records show that the needs of existing residents are regularly assessed by relevant members of the multi professional learning disability team. St Quintin Avenue, 1 DS0000010848.V362887.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, 8 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have made considerable progress in developing person centred plans, using a range of media. The use of multi media has enhanced the participation of residents in their PCPs and reviews and enabled families to appreciate progress made. Risk assessments need to include all concerns, including issues identified in earlier assessments and prompt action should be taken to implement any works agreed. EVIDENCE: The purchase of additional equipment, including a laptop and projector, has allowed staff to support residents’ participation in the development of their PCPs and in reviews. The Manager commented on how one family had realised that their daughter was able to participate in outside activities to a much greater extent than they had realised after seeing a presentation at her review. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 10 A completed PCP was seen for one resident, which was produced to a high standard and clearly showed her involvement. Records show that the development of PCPs for the four long-standing residents is well advanced. PCPs for the most recently admitted residents are still being compiled. Records show that their reviews have taken place and excellent notes of the meetings have been produced in an accessible format. Risk assessments for the two newest residents, both of whom present challenges, were looked at. These showed that staff had considered a range of possible risks and developed strategies to minimise the risk to the individual and to others. Reports on file relating to one new resident indicated concerns in previous placements regarding sexually inappropriate behaviour, which were not reflected in her current risk assessment. Staff need to show that all previously identified risks have been considered. After an incident early in the morning it was decided, following an assessment, that a door alarm should be fitted to the bedroom door for one new resident, so that staff are alerted to her movements. Action regarding the door alarm had not yet been taken. St Quintin Avenue, 1 DS0000010848.V362887.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Senior staff have given a priority to the development of tenants’ communication skills over the past 12 months. Staff have taken steps to expand the range of community activities available to residents and have actively sought out new services and venues. Good relationships have been established with families, who take an active part in residents’ lives. A number of residents are being supported to take part in preparing food and drink and staff have maintained an emphasis on healthy eating. EVIDENCE: Senior staff have recognised the need for staff to communicate consistently with residents, as well as to support the language skills of the two new residents. Staff have attended a range of workshops and training in communication, as well as having the support of the local Speech and Language Team. Staff are booked onto Makaton training provided by Westminster Council in the coming month. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 12 All but one of the residents attends day services for part of the week. In addition, each person has an activity plan in line with their PCP. The range of activities available has been expanded and staff have actively sought out new services and venues. Activities at weekends, which were rather limited at the last inspection, have considerably improved. Staff record activities throughout the day. Most of these notes were well written, though a note that ‘she chilled out’ written 3 times in one day, needed further explanation. Feedback about the service was received from 2 parents who completed questionnaires on behalf of residents. This feedback was very positive, with one parent noting ‘all the staff are doing their best to help our daughter’. Records show that good contact is maintained with families, the majority of whom visit regularly. The poor relationship between one parent and the staff team remains unresolved. Staff support residents on holidays in the UK and abroad. One resident is going abroad with staff for the first time this year. Residents’ cultural and religious needs are identified. A number of residents attend the local church each Sunday and staff seek out relevant cultural events. Menus were seen for the main meal, which showed that meals are varied and freshly prepared. Individual records of food intake are kept for each resident. Residents’ weight is regularly monitored, with referral made to a Dietician where necessary. Staff have successfully supported one resident to maintain her weight loss. The low weight of another resident is causing concern. Action is being taken to increase his nutritional intake by the use of prescribed food supplements and ensuring that he eats at all mealtimes. Since the last inspection, a number of residents now take part in preparing food and drink in the kitchen with staff support. St Quintin Avenue, 1 DS0000010848.V362887.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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Support plans are well written and reflect staff’s detailed knowledge of residents’ needs. A high priority is given to ensuring that health needs are identified and monitored, with the support of health care colleagues. Sound medication policies and procedures are in place. EVIDENCE: Each of the residents at St Quintin’s needs support with personal care, with four people needing assistance with all aspects of their care. The support guidelines for 3 residents were looked at, which were detailed and showed that staff were fully aware of how residents prefer to be assisted. Records of review meetings show that residents’ health care needs are monitored carefully and referrals made to health care colleagues when any concerns are identified. Over the past year staff have identified a number of issues relating to residents’ health, which have been followed up and action taken. One resident has been provided with further equipment after staff became concerned that her condition was deteriorating. Additional grab rails St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 14 have been fitted. In addition residents are supported to attend regular checks, including dental and optician appointments. Medication is supplied by Boots, using a monitored dosage system. Recent MAR sheets seen were fully completed. Where medication was given ‘as required’ the reason for giving the medication was noted on the reverse of the MAR sheet. The Service Manager checks medication as part of his visits on behalf of the provider. Records show that he had identified some issues, which he had discussed with the staff team. New staff spoken with confirmed that they did not administer medication until they had completed training and been assessed as competent. St Quintin Avenue, 1 DS0000010848.V362887.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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. St Quintin’s has a comprehensive complaints procedure, which is displayed in the home and included in the service user’s guide. Staff demonstrate a good awareness of the vulnerability of residents and take prompt action to investigate concerns. EVIDENCE: St Quintin’s has a customer involvement policy, which is included in the business plan. An annual forum has taken place over the past 2 years to provide an opportunity for families to become more involved in the development of the service. The third meeting was planned for the end of the month. The local advocacy service has represented the interests of a number of residents at St Quintin’s. The complaints procedure is displayed in the home and is included in the new statement of purpose and service user’s guide. One complaint has been received since the last inspection, which is being investigated. The Manager confirms that all staff attend training in safeguarding adults. Two staff were attending training on the day of the inspection. Look Ahead Housing had a safeguarding policy and procedure and staff have access to the local multi agency policies and procedures. Information about the Mental Capacity Act is displayed in the office. Four safeguarding adults referrals have been made in the past 12 months. Discussion with staff confirms that they are aware of the procedure to follow if they have concerns. Incidents are recorded in detail, with body charts used to note any marks or bruises. St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 16 Reports of visits on behalf of the provider show that the Service Manager checks a sample of residents’ finances at his monthly visits. St Quintin Avenue, 1 DS0000010848.V362887.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, 26, 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The building is well maintained and provides a pleasant and spacious environment for residents, with good access to local services. EVIDENCE: The building is a 4 storey house situated in a pleasant residential road in North Kensington, close to local shops, services and public transport. Residents have a choice of communal areas, including a sitting/TV room and sensory room on the ground floor and a large dining room with additional sofas on the lower ground floor leading out to the enclosed garden. Since the last inspection a number of rooms have been redecorated and new sofas have been ordered. New storage cupboards in the dining room allow files and equipment to be put away. The building is not fully accessible. The front entrance is ramped and there is a ground floor bedroom, which is used by a resident with restricted mobility. She St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 18 is currently able to manage the stairs to the dining room with staff assistance. The installation of a lift remains under consideration. The majority of the single bedrooms are of above average size and are furnished and decorated to reflect residents’ interests. Two bedrooms were looked at during this visit, including the room of one of the newest residents. Both rooms were clean and tidy and contained a large number of personal possessions. The newest resident had brought in some of her own furniture, including her bed and family photos were well displayed. The home has a range of bathrooms and lavatories, including an assisted bath. A shower and lavatory are available for staff use on the top floor. A small office, which is also used for sleeping in, is situated on the top floor. This has been re-organised since the last inspection to provide more comfortable facilities for staff sleeping in by moving some of the office equipment elsewhere. As noted elsewhere in this report, additional grab rails have been installed to assist one resident, following an assessment. The laundry room was in good order. A new washing machine has been purchased since the last inspection. The building was maintained to a high standard of cleanliness throughout. St Quintin Avenue, 1 DS0000010848.V362887.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 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have access to a range of relevant training, including NVQs and Look Ahead Housing’s own training programme. Staff are well supported by regular supervision, team meetings and annual appraisal. EVIDENCE: Feedback from staff in their questionnaires and in discussion showed that they were positive about working at St Quintin’s and felt supported by the Manager and Deputy Manager. One member of staff left in the past 12 months to work elsewhere in the organisation. There are currently 2 vacant posts and one member of staff has just gone on maternity leave. Recent recruitment interviews did not result in any successful appointments. Vacant posts are covered by regular agency staff. Staff rotas reflect the high needs of residents and provide for at least 3 support staff on duty on day shifts and 1 member of staff on waking night duty and 1 sleeping in. Rotas allow for a formal handover between shifts. Look Ahead Housing has a policy of encouraging all staff at St Quintin’s to achieve NVQs. Six support staff have achieved at least NVQ2 and three are studying for NVQ3. The two most recently appointed staff confirmed that NVQ St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 20 training had already been discussed with them. In addition to NVQ training, staff have access to Look Ahead Housing’s training programme and workshops run by Westminster Council and the Royal Borough of Kensington and Chelsea. The Inspector spoke with the two new staff who have recently started working at St Quintin’s. Both have previous experience of working in a social care setting. They confirmed that they had received a formal induction and had already attended a range of training organised by Look Ahead, with further training booked for later in the month. Both staff confirmed that supervision sessions had been arranged. One member of staff commented on the ‘great support she had received’ and both said that they could always discuss any issues with the Manager or Deputy Manager. Recruitment checks are carried out by Look Ahead’s HR Team, who confirmed during the visit that CRB checks had been carried out for new staff. Staff confirmed in their questionnaires and in discussion that they receive regular supervision, normally monthly, from the Manager or Deputy Manager. Look Ahead also has a system of annual staff appraisal. Team meetings are held at least monthly and are recorded. Records show that staff confirm that they have read the minutes of the meetings. A team building day, with the theme of communication, was planned for later in the month. St Quintin Avenue, 1 DS0000010848.V362887.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, 38, 39, 40, 41, 42 and 43 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 by the Manager, supported by the Deputy Manager, who have both shown a commitment to developing the service. Steps have been taken to strengthen the financial viability of the project, through agreements with RBKC, the main commissioning authority. Health and safety is given a high priority. The Manager is receiving a higher level of support from the organisation and visits on behalf of the provider are now taking place regularly. EVIDENCE: The Manager has achieved NVQ4 and the Registered Manager’s Award and expects to complete a degree in Learning Disability in July this year. The Deputy Manager is undertaking NVQ4 and the RMA. The Manager and Deputy Manger have taken steps to develop the project through a programme of staff development and training. Staff commented on the good support they receive St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 22 from the Manager and Deputy Manager, who make themselves available out of hours, if staff need advice. After a period of uncertainty when the service had two vacancies for a considerable period, the Manager took steps to make contractual arrangements with the Royal Borough of Kensington and Chelsea to strengthen the financial viability of the project. Two placements made by RBKC have ensured that the project is now full. The project has a business plan, which includes the diversity plan, to assist the Manager in delivering an effective service. Look Ahead Housing has a well established policy of customer involvement, although the tools made available to Managers have tended to be geared towards more independent customers. The establishment of the families and carers forum, together with the increased use of accessible documents and materials, has contributed to a higher level of involvement. Look Ahead Housing has comprehensive policies and procedures, which are available in the office and on the intranet. In discussion staff confirmed that they were given copies of key procedures to read as part of their induction and also shown how to access information via Look Ahead’s intranet. Records are generally well kept, though staff must ensure that appropriate language is used, for example the behaviour of one resident in her behaviour guidelines was referred to as ‘her antics’. Information in the working files held in the dining room for easy access by staff must contain the most up to date information, particularly regarding support and behaviour guidelines. The health and safety of residents and staff is given a high priority. A series of regular checks are undertaken and recorded. Staff attend health and safety training as part of their induction. The fire risk assessment was updated on 31st March 2008. Records show that the fire detection system is regularly serviced. The fire alarm is tested weekly at different points. Fire drills take place every 2 months at different times of the day. The water system is tested annually for Legionella. The temperature of hot water is checked monthly. Records show that action was taken promptly when temperatures became too high at some outlets. Fridge and freezer temperatures are taken daily by night staff. The fridge and freezer were in good order, with packets of food labelled with the opening date. Accidents and incidents are recorded in detail, with body charts used where appropriate. Visits on behalf of the provider are taking place regularly, with detailed reports available in the home. The Manager reported that support from the organisation has improved, with regular meetings with Look Ahead’s senior managers as well as his line manager’s visits to the project. St Quintin Avenue, 1 DS0000010848.V362887.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 4 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 3 3 2 3 3 St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13 Requirement Risk assessments should include all identified risks, including concerns raised in previous assessments. Where action is agreed following an incident, for example the installation of a door alarm, steps should be taken promptly to carry out the work. Staff must ensure that they use appropriate language when recording and that daily notes contain sufficient detail. The most recent strategies recommended by the learning disability team for managing behaviour should be available in the working files. Timescale for action 30/06/08 2 YA41 17 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Quintin Avenue, 1 DS0000010848.V362887.R01.S.doc Version 5.2 Page 25 St Quintin Avenue, 1 DS0000010848.V362887.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. 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