Inspection on 21/02/07 for 145 Kingsley Road

This inspection was carried out on 21st February 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

145 Kingsley Road 05/09/07

145 Kingsley Road 29/11/05

145 Kingsley Road 07/06/05

145 Kingsley Road 08/09/04

145 Kingsley Road 20/04/04

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

CARE HOME ADULTS 18-65 145 Kingsley Road Milton Portsmouth Hampshire PO4 8HN Lead Inspector Clare Hall Key Unannounced Inspection 21st February 2007 10:00 145 Kingsley Road DS0000012048.V331350.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 145 Kingsley Road DS0000012048.V331350.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. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 145 Kingsley Road Address Milton Portsmouth Hampshire PO4 8HN 023 9229 4649 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) www.mencap.org.uk Royal Mencap Society Ms Janet Ann Herwig Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users are not to be admitted under 18 years of age Date of last inspection 29th November 2005 Brief Description of the Service: 145 Kingsley Road is a residential home providing care and accommodation for up to eight adults and older persons who have a learning disability. The registered provider is the Royal Society of Mentally Handicapped Children and Adults (Mencap). The property is owned by Portsmouth City Council who lease it to New Era Housing Association, who have financial responsibility for the maintenance of the majority of the physical environment. The home is located in the Milton area of Portsmouth and is close to shops, a post office and other community facilities such as a public house. The sea front, including a promenade and beach, is within walking distance of the home. All bedrooms are single. The home has one lounge and a dining room. In the view of the inspector, the home is well laid out offering service users and staff space to undertake activities. The client contribution is £62.35/£94.45 weekly. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit to Kingsley Road took place on 21st February 2007 and was undertaken by one inspector in the late afternoon through to early evening. Throughout the visit the support staff were available and all eight of the residents assisted the inspector in general. The judgements made in this report were made from information gathered pre-inspection from previous reports, the service history, Regulation 37 notices received and reports sent to the CSCI by the provider. Also considered were correspondence with the home, contact sheets, reports and feedback relayed to the commission by staff, family members and residents. During the visit all residents were either spoken with in groups and or individually. The inspector did not have returned the care staff surveys sent to the home so these could not be used to inform this report. The manager did assist the audit process by handing out relevant comment cards to the residents, other stakeholders and health and social care professionals. The management team completed the pre inspection evidence and this was also used to inform the inspection process and report. Two residents kindly offered to show the inspector around their home and invited the inspector to join them for tea. As a result of this process 6 requirements have been raised. What the service does well: Health and social care professionals reported that the home communicates clearly and that there is always a senior member of staff on duty to confer with. They also said that staff demonstrate a clear undertstanding of the care needs of residents and that any specialist advice given is incorporated into the service users care plan. All health care professionls were satisfied with the overall care in the home. All residents were met and discussions held. It was unanimous that residents felt they were kept informed of all important matters and felt consulted and empowered to make decisions. The residents were observed going about their usual daily living and there was a happy atmosphere. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 6 The support worker interacted with all the residents in a caring, respectful and supportive manner. The overall evidence would suggest residents are treated with dignity and their choices respected. They are also encouraged to maintain their independence and have a good quality of life. Only one relative stated they didn’t always feel involved in decisions made but stated they did not have any complaints and were happy with the overall care. What has improved since the last inspection? What they could do better: The registered person must address the poor staffing levels as this is having a direct impact on the safety, health and welfare of the residents. There are times in the day when the residents do require more supervision and support. The lack of staff also contributes to the lack of opportunities to go out at weekends and in the evenings for some residents. It was also recognised that the staff office /sleep in room is accessible to everyone. Personal records, staff recruitment files and other confidential information is freely accessible to all. When the inspector was trying to audit records, policies and other documents they were hard to find and audit, as there is no clear indexing of files or their order or their contents. The MENCAP policy and procedures manual was found but most of the policies were dated as last reviewed in 2002. The inspector couldn’t find an up to date infection control procedure or fire risk assessment. The only member of staff on duty reported she hadn’t received any training in the last year and was waiting for a fire update. It was also established she hadn’t received any supervision. Her recruitment file was not held on the premises and therefore could not be audited. The back office, situated away from the main building was left with the door open and the computer switched on. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 7 When the residents showed the inspector their home they described their back garden as “messy.” This area is in need of tidying up and improvement. The staff sleep in room and combined office needs cleaning up and the substances hazardous to health removed and stored more appropriately. Once the policies have been updated the manager needs to look at the way she is managing infection control and fire safety in the home. 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. 145 Kingsley Road DS0000012048.V331350.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 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel informed and empowered by the choices they make about where they live. EVIDENCE: The relatives of the residents of Kingsley Road informed the inspector by survey that: 145 is a pleasan,t loving home where xxx has been very happy for many years. “The staff treat her with respect and I am perfectly happy with all aspects of care given.” “I have found Kingsley Road to be a warm friendly environment for my cousin to live in. She is loved, cared and nutured to achieve things beyond her wildest dreams. Thank you to all the staff.” One friend of a resident stated, we are very statisfied with our friends care, she is very well looked after.” 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 10 Service users informed the inspector that they received a tenancy agreement and that they received enough information about this home before they moved in so they could decide if it was the right place to live. One comment was, I choose to live at Kingsley Road. Another resident said she was not sure what the CSCI meant by a contract but sad she had received a tenancy and Mencap agreement . She further reported that, I came to visit and stay several times and then moved in on a temporary basis and decided I wanted to stay. I like it here the staff are nice. The information provided to the commission by staff indicated there have not been any new admissions in the last twelve months and this was confimred during the visit. The pre inspection information also identified that all service handle their own affairs and they all have bank/building society accounts.This was confirmed during the visit. The MENCAP organisation does have a service user selection and assessment policy and procedure, which explains all aspectsof needs assessments, meeting needs, introductory visits, the statement of terms and conditions,contract, contact with the community and policy on the day of the move for new residents. This also states there will be continuing monitoring and review of some one who has moved in.The information and assesment details are very detailed. The provided statement of purpose could be improved to a more service user friendly format but sepite this it is informative 145 Kingsley Road DS0000012048.V331350.R01.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): 6,7,8,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are given the opportunity to make everyday life decisions and are offered the support to do so but the staff must ensure their independence is supported in a safe environment and all hazards are minimized. Inadequate staffing levels have a detrimental impact on the lives of the service users. Confidential records are not stored in locked cupboards. Personal information is accessible by all staff and residents. EVIDENCE: Residents’ feedback indicated that they felt they received the care and support they needed and that the staff listen and act on what they say. They also reported that staff are always available when they need them. One service user sat with the inspector and talked about his personal care profile records and care plan. It was clearly evident that service users know 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 12 their assessed needs and have been involved when identifying what they feel their support needs are. These have been regularly reviewed. Residents also shared information with the inspector about their key workers and showed the inspector who they were through photos and pictures. During the visit residents were observed making choices about all aspects of their daily living and these were respected and sought by the support staff member. Service users were also observed taking risks when undertaking kitchen and household tasks independently. The records identified that the residents are assessed prior to being supported with their daily living activities through adequate risk assessments. The inspector was concerned when she observed that two hot frying pans full of frying meat and a pan of boiling vegetables were left unattended in the kitchen when the support staff went to get some money for another service user. Service users were left alone in the kichen at this time. Later two service users were trying to work the kettle and make a hot drink while another service user was making a sandwich. The inspector noted there were not enough staff to safely supervise all service users at this time and ensure that any hazards and associated risks in relation to their activities in the kitchen were being adequately minimized. This will be discussed further in the staffing section. The inspector was given a tour of the premises by two service users.Through the back door of the building there is an office, garage and laundry.Doors to the office were open and the computer was on. This is an unsupervised area and open to anyone who may come into the back garden area. In the main lounge area of the home there is a door leading to the staff sleep in room.This was open at all times and so were the cupboards within. Service users freely walked in and out while getting crisps and biscuits for their packed lunches. In one open cupboard with the crisps and biscuits were the service users files and a box of cleaning substances including substances hazardous to health on the bottom shelf. These liquids are unsafe to be stored with food. Next to this was the filing cabimet which holds all the staff files which was also open.This could lead to breaches of data protection and confidentiality. 145 Kingsley Road DS0000012048.V331350.R01.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel they live fulfilling lives but would benefit from having more staff on duty, as they can’t all go out on their own. Otherwise they said they were very happy with their lifestyle. EVIDENCE: Residents of 145 Kingsley Road completed questionnaires about the service for the inspector. They reported that there were activities arranged by the home that they can take part in. One service user reported, I like coach trips and eating out. I do this a lot. The inspector discussed with the service users forthcoming holidays they were planning and ones they had recently been on. Pictures were shared and residents were delighted about opportunities coming up to go to the cinema 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 14 and meet with friends. One resident talked about his new hobbies of archery and sailing. The inspector was invited to join the residents for tea and everone was served a fantastic home made cottage pie and vegetables. All residents said the meals were good and that the staff were great cooks. Residents explained how they had a rota to keep the house clean and tidy.One resident said the house is always fresh and clean and that she, likes to keep the house clean. One resident reported that they have super cooks at Kingsley road and another resident reported he had been at Kingsley road for many years andloves it here. Another resident said he likes to go out alone as much as he can and he also reported that, the girls are good cooks and we all share cooking the meals with their help and I dont mind cooking. Another resident stated, if I dont like something like curry I can choose anything else, the staff help me with this.” One other resident reported, I like it here, its my home. My friends are nice and the staff are good to me. I want to stay here always. The PIQ indicates that there are usual times for meals but these can be flexible to the service users plans and wishes. During the evening meal four residents stated they have their own front door keys and can have one for their room if they choose. One resident reported in a survey, The staff are very busy as there’s usually only one of them but they always try to help me when I need it. When talking with the support worker it was established that service users need to say in advance if they would like to go out so extra staff can be arranged because it is not possible if there is only one person on duty. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents say their healthcare needs are supported and that they were involved in recording what they felt those needs were. EVIDENCE: Residents responded positively when describing the help they receive from staff. One resident came in unwell and was disappointed she had missed her doctor’s appointment due to a late bus. The support staff member discussed the arrangements for making another appointment. During the evening meal service users explained how and when they had their optical check up and how they are supported to visit the dentist. During a group discussion residents described how staff knock before entering their rooms and respected their personal space. One resident visited was supported to self medicate through prompting within a risk assessment framework. Others were supported by records which included information regarding the medications taken, what they were for, 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 16 what if any of the complications they may cause and any interactions. It also clearly described how the resident likes to be supported when taking medicines. This is considered good practice. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were well informed with regards to the complaints procedure. They felt comfortable about reporting any poor practice should it occur. EVIDENCE: The feedback from the residents’ surveys indicated that they know who to speak to if they are unhappy and know how to make a complaint. One resident explained the procedure of writing it on a complaints form and that there was a procedure for it. One resident said she was aware that people must not swear at her and this must be reported, but that this had never happened. In a group discussion residents identified what was considered poor support and stated they would report anyone who didnt treat them nicely. Some relatives of service users stated in their surveys that they did not know the homes complaints procedure and this will need to be addressed by the manager. 145 Kingsley Road DS0000012048.V331350.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): 24,25,26,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the residents were very happy with the standard of the accommodation but felt let down with the state of the back garden. Regular audit of the premises by the manager will address the issues raised and this should be done. EVIDENCE: One resident told the inspector in a survey, I like Kingsley Road and want to stay here. The pre inspection information (PIQ) received by the commission states there have been no changes to the premises since the last inspection except for some bedrooms which have been redecorated. During a tour of the premises given by two residents, it was noted that the downstairs bathroom needed redecorating and the back garden needs tidying up as it was described by a resident as messy. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 19 A door upstairs which was clearly labelled as a Fire door keep locked, was open. The manager needs to ensure doors which have signs to keep locked are done so. There was a general lack of hand towels in areas considered high infection control risk areas i.e. kitchen, toilets and the laundry. The suitability of fabric towels will need to be looked at by the manager in relation to recent guidance and best practice recommendations. The residents were very proud of and happy with their accomodation. They said that they had chosen the wall paper and had made their rooms their own with their personal items and soft furnishings. Residents were also observed respecting other service users rooms and did not open their doors without seeking their permission. The residents said they liked the furnishings and these were all in a good state of repair. When the residents were asked if anything was broken or if they needed anything the unanimous response was no. 145 Kingsley Road DS0000012048.V331350.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): 31,32,33,34,35,36, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents speak with fondness about the staff and know who is the manager. The percentage of support workers with a care qualification is below 50 . Despite this permanent staff are given a lot of opportunities to attend other service specific training. The team mates (bank staff) that are employed in the home are not receiving the same level of opportunities for training or having regular supervision. The organisation has failed to meet a repeated requirement made regarding employing appropriate numbers of staff in the home and this has a detrimental impact on the service users. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 21 EVIDENCE: One resident told the inspector , I like all the staff, another said, the girls (support staff) are lovely. One resident reported in a survey,The staff are very busy as there’s usually only one of them, but they always try to help me when I need it. The homes duty rota and training record indicates there are 7 care staff of which only two currently hold an NVQ (with one pending). The inspector arrived at 3.30pm when residents had started to return to their home. The house was being staffed by one bank staff support worker who had worked there just twice before. The support staff was trying to cook a large cottage pie and vegetables for eight residents, meeting and greeting and supporting each of them and arranging and handing out pocket money. One service user came in unwell with a sore throat, ear pain and headache and very much needed some one to one support as she was quite upset at having missed her doctors appointment. Later two service users were talking together and trying to make a hot drink , one was doing her washing and another was shouting out to the support worker that she couldnt do her packed lunch on her own. These support needs continued for up to three hours which was overwhelming for a single care staff worker and considering everthing she remained good humoured, sensitive and caring to people needs. The staffing rota would also indicate that this level of staffing happens regularly in the week and sometimes at the weekend. Out of eight residents currently accomodated only four can go out safely alone, therefore due to low staffing at times four residents cannot go out if they so wish. This concern over the levels of support staff provided in the home has been raised on two previous occasions. On both occasions a requirement has been raised. As this has not improved this will be addressed through issuing a statutory requirement notice. There appears to be a good level of training provided by MENCAP for their permanent staff. The pre inspection information would indicate that in the last twelve months training has been provided in respect of fire ,food hygiene, moving and handling , medication, care planning, first aid, protect and respond, autism, bi polar disorders, person centred planning, infection and 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 22 control, national vocational qualification, loss and breavement, positive enabling and conflict resolution. This was confirmed when tracking one support workers file during the visit. The support worker on duty explained that she worked for MENCAP as a team mate, bank staff member. The inspector could not track her recruitment and training because the file was not on the premises. Basic information should be available for all staff and this was not available. It was established that the team mates regularly support the staff team at Kingsley Road. The pre inspection care staff surveys were not completed or received by the commission. It would appear through discussion that the regular care staff have good training,robust recruitment and support with regular supervision and performance appraisals but this is inconsistent for the team mate members employed by MENCAP who also support clients.The organisation will need to look at how it ensures the standards for training, supervision and performance are as good as those provided for permanent staff. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 23 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, 40, 41 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes monitoring of residents and stakeholders satisfaction needs to be developed so that it reflects a continuous process of audit showing outcomes and actions. A reorganisation of the homes administrative records is needed and the organisations policies and procedures are in need of review and update in lines with recent and changing legislation. EVIDENCE: The information provided pre inspection and seen at the time of the visit indicates that the service undertake an annual quality assurance survey. When looking at this during the visit it could not be established how the information was collated and used to make any necessary improvements as there wasnt any records to identify this in the file. 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 24 The manager did state pre visit that the organisation has a business and continual improvement plan which can be seen on request and that this is mainly concerned with training ,environmental issues and improvements, quality improvement, holidays, the garden and many other issues but this could not be found. Records did indicate that checks in respect of fire and the maintenance of equipment had been undertaken, but throughout the visit the inspector and the support worker were hindered when trying to locate information by the disorganisation of the homes files and information. There was no clear arrangements for policies and procedures and the files were full of other old information. All these records are in need of a good reorganisation. When asked, support staff could not locate some documents. The organisations policies and procedures are also in need of up dating and review to ensure they reflect current and changing legislation. The fire policy and risk assessment were not in date nor reflective of the recent changes regarding ‘ infection control in care homes’ released by the Department of Health, 2006 or for the changes in Fire Legislation regarding risk assessments (2006) The MENCAP policy and procedure file indexed policies written in 2002 and there was no indication of update orreview. Overall the storage of records and documents were really very poor and not in line with data protection and aspects of confidentiality. The manager must address this lack of review and disorganisation. The homes cats’ basket was placed in front of a fire door, which had a self closure linked to the alarm. In case of fire this would have prevented the door from closing. The cat basket was moved but the staff must make themselves more aware of checking these aspects of fire safety. Despite this residents explained the fire procedure and confirmed they had received instruction. Equipment checks had been undertaken and staff trained in fire safety. 145 Kingsley Road DS0000012048.V331350.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 3 2 3 3 3 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 2 25 3 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 2 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 X 1 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 2 2 X X 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 26 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 12(1) Requirement Residents must not be exposed to high risks such as leaving hot cooking food in frying pans under their sole supervision. Residents records and support workers personal files must be stored in lines with data protection and confidentiality guidelines and not in open cupboards and cabinets. The registered person must inform the commission how they intend to ensure that team mates have the necessary training (NVQ) and development as the permanent staff they employ. Team mates who are regularly employed must have the necessary supervision and appraisal of their practice. The organisations policies and procedures must be reviewed and ensure they have been updated and reflect recent changes in legislation and best practice especially in respect of Fire and Infection control. Staff must then be informed of the DS0000012048.V331350.R01.S.doc Timescale for action 07/03/07 2 YA10 17(1) b 10/03/07 4 YA32 18(1) 10/03/07 5 YA36 18(2) 10/03/07 6 YA40 12(1) b 10/06/07 145 Kingsley Road Version 5.2 Page 27 changes in organisational policy. 7 YA42 12 (1) Substances hazardous to health must not be stored in the same open cupboard as residents food and personal files as this could place them at risk of serious injury. 10/03/07 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 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 145 Kingsley Road DS0000012048.V331350.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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