Inspection on 01/09/08 for Helena Road (2c-2d)

This is the latest available inspection report for this service, carried out on 1st September 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Helena Road (2c-2d) 02/03/06

Helena Road (2c-2d) 06/06/05

Helena Road (2c-2d) 04/10/04

Helena Road (2c-2d) 07/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 23/11/2008.

CARE HOME ADULTS 18-65 Helena Road (2c-2d) 2c-2d Helena Road Plaistow London E13 0DU Lead Inspector Anne Chamberlain Unannounced Inspection 1st September 2008 10:00 Helena Road (2c-2d) DS0000022837.V370467.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 Helena Road (2c-2d) DS0000022837.V370467.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. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Helena Road (2c-2d) Address 2c-2d Helena Road Plaistow London E13 0DU 0208 470 1382 0208 586 9118 ronnie.tallon@east-living.co.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) East Living Limited Mr Ronnie Tallon Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Helena Road (2c-2d) DS0000022837.V370467.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: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 10 15th January 2007 Date of last inspection Brief Description of the Service: The service is home to ten service users, five of whom are now over 65 years of age. The accommodation is purpose built and is situated in a residential area of Plaistow. It comprises two units joined by a courtyard. One unit houses six people and the other four. Service users have their own bedrooms and share communal facilities. All accommodation is ground floor and wheel chair accessible. The manager has an office on the first floor, in an unregistered part of the building, and there is another office on the ground floor where most of the records are kept. There are two small gardens and a car park. The home is owned and managed by a not-for-profit organisation, East Living, formerly known as East Thames Care (Housing Group). East living is a subsidiary of East Thames, which is a registered social landlord. The homes weekly fees are in the region of £1054. Its mission is to make a positive and lasting contribution to the neighbourhoods. Helena Road (2c-2d) DS0000022837.V370467.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 two stars. This means that people who use the service experience good quality outcomes. This report is written on behalf of the Commission for Social Care Inspection (CSCI) and the terms we and us will be used throughout. The manager submitted an Annual Quality Assurance Assessment (AQAA) before the site visit, and this included useful information about the service. The site visit of the inspection lasted for seven hours and we looked at the files for two service users and two staff members as well as other key documentation. We made a tour of the communal areas of the premises, and inspected the arrangements for the administration of medication. We were joined on the inspection by an expert by experience - a person who has personal experience of the type of service being inspected. The role of the expert by experience is to gather evidence from a users perspective to complement our evidence. Her findings have been integrated into this report. We would like to take this opportunity to thank everyone who was involved in the inspection for their contributions. What the service does well: The expert by experience noted that one service user said she was happy living at Helena Road and said she had lived there for 17 years. The expert noted that the staff are friendly. Helena Road is a well run service which provides a secure and stable home for service users. The environment of the home is homely and comfortable and clean. Service users have opportunities to get out and about. The level of NVQ training in the staff is high. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The inspection resulted in fourteen statutory requirements (none of which are restated) and three good practice recommendations. The home must review its adult protection training and practice and ensure that each and every allegation or suspicion of abuse is properly reported to the safeguarding officer at the local authority, and notified to the CSCI. First aid and manual handling training must also be renewed by staff who have not done it for over a year. Medication practice must be improved with proper recording of administration. The service must make sure it does not ask service users to pay for things (like the replacement of a worn bed base) which the organisation must provide. Daily activities and one to one activities should be recorded in a uniform way following one system. Key documentation, assessments and plans must be signed by service users and staff, and dated. Reviews must be properly evidenced with the name of the person who undertook the review, and not just a printed date. Health information (which may also be held electronically) must be kept up to date in the files of service users, so that it is available to staff. Control of Substances Hazardous to Health (COSHH) items must be safely locked away, including old paint cans and tools. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 7 The loose brick outside the fire exit of unit 1 should be removed as it is a trip hazard in a fire evacuation. Opened food in refrigerators must be labelled with the opened on date. Minor maintenance issues identified in unit 1 must be attended to. 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. Helena Road (2c-2d) DS0000022837.V370467.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 Helena Road (2c-2d) DS0000022837.V370467.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): 2 Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Prospective service users would have their needs properly assessed. EVIDENCE: The home has not admitted any new service users for some time. There is adequate assessment information on the files of existing service users. The manager agreed that should a service users needs change significantly over a period of time, or suddenly, a reassessment would be undertaken. Helena Road (2c-2d) DS0000022837.V370467.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 and 9. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Assessed and changing needs are reflected in individual care plans. Risk assessment is undertaken and service users are supported to take their own decisions. EVIDENCE: We viewed the files of two service users. They had individual care plans and these were complemented by person centred plans. The care plans are standardised and this helps keep information clear and accessible. However the pages are obviously derived from common templates, and there were instances of the personal pronoun not having been changed, so a female was referred to several times as he and his. This should not happen and a recommendation has been made. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 11 We were concerned that key documentation is not routinely signed and dated by service users and staff. Documentation must be signed by service users and staff to evidence that service users have been included and for a staff member to own and take responsibility for the work. If a service users chooses or is unable to sign this can be recorded in the appropriate space. A requirement has been made. There was evidence that care plans are reviewed regularly. There was evidence that service user are empowered to take decisions in their lives, one person centred plan stated that the person needs were having his own personal space, being able to make choices and having complete say in what goes on in his life. Daily logs evidenced people making choices about how to spend their keyworker days. One gentleman is over eighty years old and we noted that when we visit he is sitting in the lounge in his own favourite chair. He looks quite alert and interested in what is going on in this room. This is his choice of how to spend his day and it is respected. Residents have a meeting once a month where decisions are made by them and minutes are kept. The two files we inspected evidenced risk assessment and review of risk assessment. However risk assessments need to be signed and dated by the service users and the person undertaking and recording the assessment, and this was not usually done. Also the evidence of review of assessment was sometimes just a typed date. This is not compelling evidence that a document has been reviewed. We recommend that reviews of documents are signed and dated by the person undertaking the review, to provide compelling evidence that it has taken place. Helena Road (2c-2d) DS0000022837.V370467.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 and 17. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities for personal development and they take part if a variety of activities of their own choice. Family contact is supported and peoples rights and dignity are respected. Service uers are offered a healthy diet and enjoy their mealtimes. EVIDENCE: When we arrived at the home we were greeted by a service user from the garden of unit 2. She called out and looked happy and indeed for the rest of the visit whenever we saw her she pointed to her outfit which she seemed really pleased to be wearing. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 13 Service users attend day centres, church services, art and craft classes, etc. They also have a day each every week when they can do things one to one, with their keyworkers. Daily records and keyworker notes evidenced the activities people undertook on their keyworkers days, sorting out their rooms, going shopping, going to the pub for lunch, etc. We did note that daily logs and one to one sheets sometimes duplicated recording and sometimes one to one sheets had not been recorded. We suggest that the home decides whether they need one to one sheets for keyworker days, or will just record one to one days in daily logs. When they have decided on a system they should stick with it. The expert by experience did state in her report The service users who were at home did not seem motivated as they were sitting in the lounge watching TV or dozing off. Our comment on the above would be to take into account the ages of the service users five of whom are over sixty five years of age and one is in his eightys. We would expect generally lower levels of activity in older people. The expert also said Service users are given good support with their activities. The home has a flexi staff system, where staff come in the mornings to support service users to go out in the community while other staff stay at home with those service users who wish to stay at home. We witnessed some nice interaction between one service user and a worker who was in her room. They were both enjoying some dance music on the radio and the atmosphere was very cheerful. Some service users have family contact, one visits his mother regularly, and this is supported by the staff. Service users are treated with respect and their dignity is protected. We observed a staff member hurrying into the corridor to help a service user to adjust his dress. Service users can all eat at the table together and usually do at dinner in the evening. They can also eat alone or in a smaller group if they want to. The manager states in his AQAA that service users are supported to prepare snacks. There is a menu and service users can add to or change this at their residents meetings. When we inspected the kitchens we saw plenty of healthy foods stored, fresh and frozen. Helena Road (2c-2d) DS0000022837.V370467.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 and 20. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users are supported in a sensitive way and their physical and emotional needs are met. Medication practice needs to be improved. EVIDENCE: We noted evidence on files that health needs physical and emotional, are addressed. Service users had attended appointments with a variety of professionals. Both service users had My Health Matters, health action plans. However some of the information regarding health had not been updated on the files, for example a sheet for 2008/2009 appointments had nothing written on it, and there was a sheet regarding epilepsy and medication, the last date on which was 12/8/05. This information had been updated on the computer by the manager on 7/7/08 but the information had not been transferred to the file. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 15 The manager must ensure that the files give up to date health information so that staff have ready access to it. There was a medication information sheet on a file written in 1.7.03 and 1.7.04 and not updated since. It should be made clear that this information is continued elsewhere, or the sheet archived. We inspected the arrangements for the administration of medication. On his AQAA the manager states No staff are allowed to administer medication before they have attended the medication training and successfully completed the East Living training, with practical supervised sessions, also new staff will need to complete Boots MDS work book and theory test. We were very concerned to note a number of gaps where there was no signature in the boxes on the Medication Administration Record (MAR) sheet as follows: Service user A - one medication - August 18th p.m.,19th p.m. 27th mid afternoon and p.m. and 28th mid afternoon and p.m. Service user B - two medications - August 19th p.m., 21st p.m., 28th p.m. and 30th p.m. Service user B - August a third medication on 28th p.m. The manager stated that an audit is undertaken regularly of the medication arrangements, but has not occurred since these errors were made. The manager must identify the staff member or members who made the above medication errors and consider whether they need to undertake medication training before they are permitted to dispense medication again. Helena Road (2c-2d) DS0000022837.V370467.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): Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users are listened to and they are protected from abuse. However practice in the area of adult protection must be improved. EVIDENCE: The expert by experience stated in her report When we rang the bell to the home, the member of staff who opened for us did not ask for our identity and did not ask us to sign the visitors book. She went and sat in the little office and we knocked on the office door to tell her why we were there. A requirement has been made that proper security procedures are followed in order to protect service users. The home has a complaints policy and leaflet which were seen at the last inspection. The manager stated in his AQAA that a record of all complaints is kept and that complaints are dealt with in a timely and professional manner. The home uses a corporate adult protection policy which works in conjunction with the local authority policy. The home now has a copy of this local authority policy. We noted on the file of a service user that she had physically assaulted fellow residents on three occasions on 9/9/07 10/10 and 25/1/08. No safeguarding Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 17 referrals had been made following these assaults and no regulation 37 notifications had been made to us. We explained to the manager that the above actions should have been undertaken and two requirements have been made. The manager states in his AQAA that every service user is risk assessed individually, with regards to the management of money. He further states that bank accounts were opened for each resident and most of these have been converted to current accounts with pass books to improve security and reduce the risk of fraud. We noted from the file of a service user that on 4/7/08 she went out with her keyworker to price up a new bed base for herself. On 11/7/08 she went out and bought it with her own money. We asked the manager why the service users had done this and he advised it was because her old bed base was worn out. The home has a responsibility to provide in rooms occupied by service users adequate furniture, bedding and other furnishings and a requirement has been made. The manager must refund to the service user the money she spent on buying her own bed base. A concern was raised by a service user about a particular member of the care staff. This was passed on to the manager. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The environment of the home is good, clean, comfortable and homely. EVIDENCE: When asked if the home environment needed any improvement, a staff member said that she thought it was time they had a new carpet in the lounge. In our view the carpet does not fall below an acceptable standard but the request was passed on to the manager. He said that he is aware that a new carpet would improve the environment in the lounge. We toured the premises and some issues regarding safety were picked up. These are discussed under the outcome area Conduct and Management of the service. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 19 We noted a top cover off of a radiator in a bathroom near the fire exit in unit no 1. This needs to be replaced. We also noted the cover off a light fitting near the fire exit in unit no 1. This needs to be replaced. The environment of the home is good, safe, clean and comfortable. Service users rooms were glimpsed through open doors, They are individually decorated and looked very pleasant. The expert by experience noted good wheelchair access throughout the service. She said the environment was clean and accessible to wheelchair users on the ground floors (there is not upper floor). She said the bathrooms and toilets are also clean and of good size. The laundry room has an impermeable floor and the washing machine has a programme which washes at a very hot temperature. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The staff are competent and well qualified but their training needs to be improved. EVIDENCE: The home employs fourteen and a half permanent staff including the manager and deputy manager. We spoke to one of the care staff who told us that she had worked at the home for many years, retired, and then gone back again three years ago. She said that she enjoys the work and she certainly seemed to have excellent interaction with the service users. Another staff member was familiar to us from a previous inspection. She had come back to work from maternity leave and seemed to know the service users well. We looked at recruitment, training and supervision for two staff. The recruitment information is kept at head office but the manager stated in his Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 21 AQAA that new posts are not confirmed until a satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures are received. The two staff whose files we looked at had not had adult protection training recently, one not since 2006 and one not since 2003. They were also overdue for first aid training. One staff member had not had food hygiene training since 2004 and one had not had manual handling training since December 2006. Core topics which we would expect staff to renew every year include adult protection training, manual handling, health and safety to include food hygiene, and first aid and a requirement has been made. The manager stated in his AQAA that ten staff have NVQ2 one has NVQ3 and the deputy manager has NVQ 4 (as well as the manager). Helena Road (2c-2d) DS0000022837.V370467.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 and 42. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is well run and quality is assured. Health and safety practice must be improved. EVIDENCE: The home is generally well run. The manager states in the AQAA that he has fifteen years of management experience and NVQ level 4 in management and the registered managers award. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 23 The organisation has various methods of collecting quality assurance information from service users. The manager stated in the AQAA ,that there is a quality assurance inspection every month carried out by himself, and there is another monthly inspection carried out by higher management. Also a residents survey is conducted. The manager stated in the AQAA that a scheme based residents survey is planned for within the next twelve months. We were concerned to note that the COSHH cupboard was unlocked. This is a walk in cupboard and was stacked with COSHH substances. In the cupboard were also old paint tins and a toolbox with tools in it. We also noted that the under sink cupboard in unit 1 was locked on the right hand side, but not on the left hand side, so there was ready access to more COSHH substances. There were a number of old paint cans outside of the fire exit door in unit no 1, and also a loose brick standing just outside of the door. In unit no 2, it was noted that the refrigerator contained an opened pack of butter which had no opened on date on it and was obviously not fresh, also a carton of juice which had no opened on date on it. It was noted that some foods had bought on dates on them. This is not good practice, the date which is needed is the opened on date. In his AQAA the manger states that the fire risk assessment and evacuation policy are reviewed regularly and fire evacuations for both units are conducted on a three monthly basis. In the laundry room there is a notice asking people to avoid losing items over the back of the washing machine and drier, because this is a fire hazard. We asked the manager about this and he said that inevitably some things slip across the shiny surfaces and down behind the machines, but a staff member periodically lowers herself behind the machines and retrieves them. We recommend that the service place a piece of wire mesh over the space where items fall. This should solve the problem whilst allowing sufficient ventilation to the back of the machines. We looked at safety records and noted: The hot water temperatures are taken and recorded on a weekly basis. The ARJO bath was serviced on 13/5/08 Gas safety record was dated 11/3/08 The fire alarm had been tested on the day of the inspection 1/9/08 and before that on 23/8/08, 14/8/08 etc. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 24 The electrical installation underwent a periodic inspection on 22/9/04 There was a list of items for the Portable Appliances Test (PAT), dated 14/8/08 and the manager said that this is when it was done and the certificate is awaited. We noted that the front cover on the fire alarm system had been left hanging after the alarm test and pointed this out to the manager. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 25 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 2 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 x 35 2 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 3 x x 3 x Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA6 Regulation 12(2) Requirement Key documentation relating to service users i.e. their care plans, must be signed and dated by the service user and a representative of the service. Key documentation relating to service users i.e. their risk assessments, must be signed and dated by the service user and a representative of the service. The manager must ensure that the files give up to date health information so that staff have ready access to it. The manager must ensure that there are arrangements for the recording handling, safekeeping and safe administration and disposal of medicines received into the care home. The manager must identify the source of the medication errors which occurred between 19th and 29th August 2008 and consider whether a staff member or members need to undergo further medication training before they are permitted to administer DS0000022837.V370467.R01.S.doc Timescale for action 01/11/08 2. YA9 12(2) 01/11/08 3. YA19 13(1) 01/11/08 4. YA20 13(2) 01/10/08 5. YA20 13(2) 01/10/08 Helena Road (2c-2d) Version 5.2 Page 27 medication again. 6. YA23 13(6) 23(4) The home must follow proper security procedures, like signing visitors into the home, in order to protect service users and visitors. 13(6) Should a service user assault another service user, the adult protection policy must be followed and a referral must be made to social services safeguarding. 37 Should a service user assault another service user a notification must be made to the CSCI. 16(2)(c) The home must provide adequate furnishings to service users, including beds. They must refund to the service user the money she spent on her own bed base. 23(2)(p The top missing from a radiator in a bathroom close to the fire exit in unit no 1, must be replaced. 23 (2)(p) The cover missing from a light fitting near the fire exit in unit no 1 must be replaced. 18(1)(c)(1) Staff must renew their core 13(4)(c) topics every year including adult protection training, manual handling, health and safety to include food hygiene, and first aid. 13(4)(c) All fresh foods stored in refrigerators must be labelled with the date of opening. 13(4)(c) All COSHH substances must be safely locked away. 01/10/08 7. YA23 01/10/08 8. YA23 01/10/08 9. YA23 01/11/08 10. YA24 01/12/08 11. 12. YA24 YA35 01/12/08 01/12/08 13. 14. YA42 YA42 01/11/08 01/11/08 Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 28 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. 3. Refer to Standard YA6 YA9 YA42 Good Practice Recommendations The manager should ensure that the correct personal pronoun is used in the care plans of service users. Reviews of risk assessments should be signed and dated by the person undertaking the review to provide compelling evidence that it has taken place. We recommend that the manager place a piece of wire mesh over the space where items fall behind the washing machine and tumble drier. Helena Road (2c-2d) DS0000022837.V370467.R01.S.doc Version 5.2 Page 29 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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