Inspection on 11/09/06 for 109-111 Mollands Lane Project

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

109-111 Mollands Lane Project 07/08/07

109-111 Mollands Lane Project 07/03/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 111 Mollands Lane Project 111 Mollands Lane South Ockendon Essex RM15 6DJ Lead Inspector Mrs Bernadette Little Unannounced Inspection 11th September 2006 09:50 111 Mollands Lane Project DS0000064863.V320387.R03.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 111 Mollands Lane Project DS0000064863.V320387.R03.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. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 111 Mollands Lane Project Address 111 Mollands Lane South Ockendon Essex RM15 6DJ 01708 856592 01708 856592 satashcommunitycare@hotmail.co.uk www.satashcommunitycareprojects.co.uk Satash Community Care Project Limited 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) Mrs Thanaletchmi Loganathan Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: 111 Mollands Lane is a semi-detached property in a quiet residential area. It is registered to provide care to four younger adults who have a learning disability. There is one ensuite bedroom on the ground floor, along with a large lounge, separate dining room, activities room, kitchen and a small office at the front there were three further bedrooms upstairs two of which are ensuite and there is an additional separate bathroom. There is adequate private parking to the front of the property and a large garden, which is accessible to residents at the rear. There is a covered area on the patio with a table and chairs available for residents who wish to smoke. The weekly fee is £1,050.00p as advised by the pre-inspection questionnaire and confirmed by the registered manager at the site visit. Additional charges/costs are incurred by residents relating to chiropody, purchase of personal toiletries, college course fees and some activities. The registered manager advised that the home provide twenty pounds per resident per week towards activities and generally residents pay for anything in excess of this. The home however pay for all holiday and transport costs and have their own vehicle. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of 111 Mollands Lane and six hours were spent at the home. Three residents were living at the home at the time of the inspection. Three residents, two staff and the registered manager were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for one resident were case tracked and were sampled for another resident. A pre-inspection questionnaire had been received from the home prior to the site visit and information from this document was also used to inform this report. Discussion of the inspection findings took place with the registered manager during the inspection and guidance and advice was given. Six completed comment cards were received from relatives/visitors/friends. All stated that they were welcomed by the staff/manager into the home at any time and could visit their friend/relative in private. All also stated that they were satisfied with the overall care provided by the home. Comments included Satash Community Care Project gives quality care and Satash Community Care Project have worked closely with the family to help my (relative) as much as possible during the transition. I feel that all members of staff should be commended for their efforts, in particular the manager of the home. One completed comment card was also received from the care manager of a funding authority. All responses were ticked as positive. What the service does well: Satash Community Care Project gives the residents a lovely, comfortable place to live that was kept clean and was nicely decorated. Residents are encouraged and assisted to access lots of different activities to help them have busy and fulfilled lives. This includes evenings and weekends. Residents and staff were comfortable with each other and had built relationships. Residents were involved with staff in choosing things and making decisions, and were helped to take risks in an ordinary lifestyle way. The management team consider carefully who will be admitted to the home rather than quickly filling vacancies, and listen to the feelings of the other residents living there, to try to make sure that people will get on with each other. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 6 Since the home of opened in January 2006 staff have had a lot of training, and more is planned to ensure the best quality care is able to be offered to residents. What has improved since the last inspection? What they could do better: More standards were looked at this time and so the home has some new tasks to complete. They need to make sure that a basic care plan is in place ready for when a resident is admitted, until they have the chance to make a new one with the resident that is person centred. The management need to make sure that all staff have the basic mandatory training and staff should be provided with a contract of employment. The registered owner needs to make sure that the monthly reports needed under Regulation 26 continue to be done. The managers also need to ask residents/their families/other professionals working with them, for their view about how the home is run and the service that is provided there. All staff need to be part of a fire drill regularly. Checks on the water system should be more thorough. The home should get agreement from the residents’ GP about any shop bought medicines they may wish to give. A protocol (a plan) should be in place of when residents should have ‘ as required’ medication. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 7 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. 111 Mollands Lane Project DS0000064863.V320387.R03.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 111 Mollands Lane Project DS0000064863.V320387.R03.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): 1,2,4,5 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and other interested people were given information about the home so they could know whether it was right for them. Pre-admission assessments had been undertaken to make sure that the home could meet the resident’s need effectively. EVIDENCE: A copy of the statement of purpose and the service user guide was seen to be available in the lounge and a copy was also seen in the vacant bedroom. A resident spoken with said that they had seen the documents and knew about them. A detailed assessment process was evidenced in the records for a recently admitted resident. This showed that the resident had been involved in the process of choosing the home, along with other professionals and relatives. Records and discussion also confirmed that the resident had had opportunity for a trial visits, including overnight stays. The registered manager stated that the home have had several referrals, but that it is important to them to choose 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 10 the right resident for the home, as well as the home be right for the resident. She also advised that the views of other residents are considered as important as part of the assessment of any prospective resident. Contracts were in place on those resident files sampled. Statement of terms and conditions were also available, which included confirmation of a trial period and were signed by the home and the resident. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents were involved in the writing of their care plan, which meant their views and wishes were taken into account. The home helped residents to make decisions so they could take reasonable risks in an ordinary way. EVIDENCE: A summary of care needs was in place but a full care plan was in not place on the care file for the most recently admitted resident. A basic interim care plan must be in place for each resident on admission. The resident said that they had sat with their key worker to compile the care plan and that, had it not been for the site inspection taking place, they had been due to sit with the registered manager to write the full care plan today. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 12 A care plan was sampled for a longer-term resident. This has been written from a person-centred approach and continues to develop. It included information on likes and dislikes as well as issues such as occupation and leisure, communication, health needs including medication, finance, sleeping, diet and eating and personal care needs. Several risk assessments were in place appropriate to the individual residents and relating to the environment and daily living. These supported the care plan, for example in relation to residents going out independently, road safety, abuse, making hot drinks, showering/bathing or the opening upstairs windows. They had been signed by the resident. Residents were aware of their care plans and freely went to access them to assist with the inspection. Discussion with residents and staff, inspection of the records, but mainly observation of practice confirmed clearly that residents are encouraged and supported to make decisions about their own lives. Residents also clearly participated in everyday life in the home including choosing menus, going shopping, or helping with the garden. Minutes of residents’ meetings show that residents’ views are listened to and acted upon. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 This judgement in this outcome group is excellent. This judgement has been made using available evidence including a visit to this service. The home worked hard to help each resident gain access to a wide range of activities that they were interested in and that were appropriate to their age group, so they could enjoy life. Residents were provided with a choice of nutritional foods. EVIDENCE: Two residents have a clearly identified weekly activity chart. The registered manager advised that this would also be completed for the newer resident once full and individual activities can be accessed and organised. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 14 An activity book is maintained for each resident, which records all activities they participate in. This was also well documented in the daily care notes and supported by inspection of the resident financial records. Residents spoken with said that they have lots of opportunities to go out and to do things that they want to do. This includes going to work, to the library, to the pub, swimming, visiting family, to the cinema, for bus rides, and playing games indoors. A resident told me that they now have satellite television, which they like, and also have tickets for West Ham football club. A member of staff came in early on the day of the inspection as arranged with a resident, to take them to an Internet cafe. This resident explained that they were now going to join the local community club where the other residents go in the evenings to play snooker etc. Records also showed that residents went to the local shop, for example to get bread and milk or a newspaper, or went out on their own for walks. Each of the residents has their own mobile phone. Residents were heard discussing the roster with staff, working out with them when staff might do longer shifts so they could plan particular activities for later in the week. Residents have also enrolled for some local college courses and further courses are being sought appropriate individual residents needs. A resident showed their certificates achieved in numeracy, which were displayed on the wall in their bedroom. A resident provided the homes photograph album of the activities they had participated in, including the recent holiday to Spain that two of the residents said they enjoyed. Care plans and discussion with residents confirmed that they have a choice in the time they go to bed and get up in the morning. Observation of practice and discussion with staff showed that residents are free to spend time alone or in the communal rooms of the house as they choose. A resident was having a birthday on the day following the inspection and had brought the cake they had shared with their family, when staying at the weekend, to share with the staff and other residents. Family members, chosen by the resident, were also invited to the planned tea party. Another resident regularly had a friend to visit. Residents said that they liked the food and can make choices. There is no formal planned menu, as residents choose the meals. Choice was confirmed in the nutrition record, which also showed a cooked breakfast on a weekend morning, as well as occasional take-away meals. Residents were involved in the preparation of lunch at individual times depending on their plans for the 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 15 day. They were also seen to be confident to get themselves drinks and snacks. Ample food stocks were available. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 16 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 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are met. There is an effective key worker system that supports consistent care for residents. Medication systems generally protected residents. EVIDENCE: All of the residents are mobile and none require any specific equipment. The provision of guidance and support for personal care, while encouraging independence and skills development, was identified in the care records and through discussion. Residents use community facilities such as the hairdressers. They were also appropriately dressed for their age and choose their own clothes. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 17 The home has an effective key worker system in place. A resident introduced me to their key worker when they came on duty and other residents clearly knew who their key worker was. Records demonstrated that residents had been registered with a local GP and had access to other appropriate health care professionals, such as consultant psychiatrist/medication reviews, optician etc. Charts were maintained of residents’ weight. The home user monitored dosage medication system. The medication administration recording sheets (MAR) contained a photograph of each resident and a record of the amount of medication checked in, with a date and signature. The record of medication administered tallied with the medication in the blister packs. A copy of the Royal Pharmaceutical Society Guidelines for the Control and Administration of Medication in Care Homes was included in the medication folder. The homes procedure for the administration of medication was also contained in the folder along with information on homely remedies. Confirmation/agreement should be obtained from the GP for the use of homely remedies for individual residents. A record of staff signatures was available. A protocol was seen to be available both in the medication folder and the care folder for one resident’s ‘as required’ medication. This was not available for another resident’s ‘as required’ medication and needs to be developed. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 18 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 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home’s policies/procedures and staff training/knowledge protected residents. EVIDENCE: The registered manager stated that no complaints had been received by the home since the last inspection. The Commission for Social Care Inspection has not received any complaints about the home. A complaints procedure was displayed in the hallway. Two residents spoken with said that they would feel able to tell their key worker or a member of staff/the manager if they were unhappy with, or worried about, anything. The home had a policy and procedure on protecting vulnerable people and the local authorities protocol/guidelines was also clearly displayed in the office. Two staff spoken with confirmed that they had had training on protection of vulnerable adults and were aware of appropriate actions to take should they have any concerns. The home’s training records indicated that the majority of staff have had recent training in the protection of vulnerable adults. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 19 Risk assessments were in place on residents care files that considered the vulnerability of residents and action plans to support/protect them. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 20 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, 30 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. 111 Mollands Lane provided a clean, safe and pleasant environment with premises and equipment that met residents’ needs. EVIDENCE: The premises were well maintained and homely. A resident and the registered manager advised that the cream-coloured carpet in the hall, office and dining room is too difficult to keep really clean and so new flooring is to be fitted shortly. The resident confirmed that they had helped to choose this. All three residents were spoken with and said they were happy with their own bedrooms and found them comfortable and to meet their needs. All bedrooms are single. The three currently occupied bedrooms have their own ensuite. The fourth bedroom is not ensuite but will have the use of the additional 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 21 bathroom. There is also a downstairs toilet for residents’ use and a separate shower and toilet facility for staff. Bedrooms were furnished with modern furniture, which was in good condition. Residents had personalised the rooms and had their own televisions or music etc. Doors were lockable but none of the rooms were locked, even when the resident was out. Permission was sought from the resident going to work to view their room and the other two residents assisted with viewing their bedrooms. Each bedroom is fitted with an electronic safe for the resident use. Residents have the use of a large lounge, a dining room, kitchen and an accessible and well-maintained garden. This has a covered patio area with seating, which is used for barbecues and by those who wish to smoke. The room planned to be an activity room now contains the staff lockers, a desk, photocopier and filing cabinets and does not present as a homely and available room to residents, even though the registered manager stated that it is. This room did have a computer, which is advised as being for the use of residents. The home was noted to be particularly clean. The washing machine is in one part of the kitchen. A procedure was in place that laundry is not to be undertaken while food is being prepared. A separate hand-washing sink was available. The registered manager advised that all staff are booked to attend infection control/health and safety training early next month. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 22 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): 31, 32, 33, 34, 35 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were satisfactory to meet the current needs of residents. Staff training and recruitment procedure protected residents. EVIDENCE: Staff spoken with were clear about the homes values and clearly had built relationships with the residents. Staff also showed that they knew the residents, their likes/dislikes and care plans well. The staff files sampled contained a job description. The registered manager confirmed that none of the staff have been issued with a contract of employment. While the home does not provide nursing care or nursing intervention, four of the staff are qualified nurses, this includes the responsible individual who also appears regularly on the care roster. In addition to this, one of the care staff has attained NVQ level 2 and is now undertaking level 3. The newest member of staff advised that she has completed NVQ level 2 and is awaiting her certificates. She advised that it has been discussed with the 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 23 registered manager that once in post six months, she can undertake NVQ level 3 and is looking forward to this. Discussion with staff and the registered manager and inspection of the roster confirmed that there has been an increase in staffing levels to two staff all day and one staff at night, with the increase in resident numbers. Staff spoken with confirmed that this was adequate and also allowed greater flexibility and choice for residents in going out and staying at home, including in the evenings. The file for a more recently appointed staff member demonstrated that all appropriate checks and references had been undertaken during the recruitment process. This included a record that a Povafirst check had been undertaken before work commenced and while a criminal record bureau check was awaited. Appropriate records were maintained including a photograph and evidence of identity. An induction Skills for Care package was available on this file. Copies of training records were provided by the registered manager. These indicated that the majority of staff had completed basic mandatory training, although two staff had not completed moving and handling training and one was in need of update. Records were available of regular staff meetings, which were detailed and which covered relevant topics. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 24 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, 41, 42, 43 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. 111 Mollands Lane is well-organised, safe and efficiently managed. Staff felt well-supported by the manager and were enabled to support residents. EVIDENCE: The registered manager has completed NVQ level 4, Registered Managers Award, and has previous experience in working with people with a learning disability. This report clearly identifies that the home is well organised and effectively run, with the majority of standards inspected being met or very nearly met. Both staff and residents stated that they felt able to approach the manager, who the staff said was very supportive. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 25 Evidence was available that regulation 26 reports have very recently been undertaken at the home. The format was detailed and contained appropriate information. The home had a file titled QA, on which were to questionnaires undertaken on admission by two residents. A questionnaire was being prepared for residents living at the home, now that it had been operational for some months. The registered manager advised that they were to have a quality assurance inspection by the local councils commissioning office later this week. A resident assisted with the inspection of their individual financial records. The records tallied with the amount of money available. Receipts were on file where appropriate for example the chiropodist, whom the resident confirmed came to do their feet regularly. Records evidenced that the resident signs for withdrawals of spending money from that held for them in the safe. Records evidenced individual savings and current accounts. They also confirmed a range of activities and leisure pursuits. Records inspected other than those already mentioned and found to be satisfactory included the accident records, visitors book and the registration certificate was displayed. Issues outstanding from the last inspection and relating to this standard mainly related to fire equipment safety checks. These were seen to have been undertaken for times in the last month. Fire drills had also been undertaken more recently, but need to include evidence that all staff participated, including night staff. The registered manager advised their waiting the results of their certificate from a recent legionella test. The risk assessment had limited information. The home had recorded the hot water temperatures but not the cold, which does not comply with their policy and procedure. Records also need to evidence that all outlets are checked regularly. Information can be obtained on the booklets “ Essential Information for providers of residential accommodation” and “A guide for employers” on 01787 881165 or at www.hsebooks.co.uk The current certificate of liability insurance was displayed. There was nothing to raise concerns that the home was anything other than financially viable. 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 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 x 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 2 x 3 2 3 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement The care plan for each resident must include all aspects of their health and welfare. Outstanding in part from the last inspection. 2. YA35 18 All staff should be provided with 01/11/06 the basic mandatory training. This refers for example to moving and handling/load management training. The home must have an effective 01/01/07 quality assurance system that includes routinely seeking the views of residents and significant others. The person registered must 01/10/06 ensure that all staff are involved in regular fire drills and practices. Outstanding in part from the last inspection Timescale for action 01/10/06 3. YA39 24 4. YA42 23(4) 111 Mollands Lane Project DS0000064863.V320387.R03.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 YA20 YA20 YA42 Good Practice Recommendations Agreement should be sought from the GP in relation to any homely remedies to be administered to residents. Protocols should be in place for all as required [PRN} medications. The risk assessment relating to the water system should include more detail and clear instructions on actions to be taken. This refers to complying with the homes own policy and procedure in relation to the testing of cold water temperatures. It also refers to ensuring that all outlets are recorded as run regularly. Staff should be provided with a contract of employment/ statement of terms and conditions. 4. YA31 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 111 Mollands Lane Project DS0000064863.V320387.R03.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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