Inspection on 04/07/07 for 2 Central Avenue

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Central Avenue 02/12/08

2 Central Avenue 18/12/07

2 Central Avenue 01/08/06

2 Central Avenue 05/12/05

2 Central Avenue 20/07/05

2 Central Avenue 01/02/05

2 Central Avenue 20/07/04

2 Central Avenue 12/01/04

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 2 Central Avenue 2 Central Avenue Billericay Essex CM12 0QZ Lead Inspector Pauline Marshall Unannounced Inspection 4th July 2007 09:25 2 Central Avenue DS0000018072.V344108.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 2 Central Avenue DS0000018072.V344108.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. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Central Avenue Address 2 Central Avenue Billericay Essex CM12 0QZ 01277 655394 01277 655394 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) Estuary Housing Association Limited Mr Russell Neil Groves Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: Central Avenue is a Care Home for four service users with Learning Disabilities. It is situated between Billericay and Stock. The home is registered for service users up to and over 65 years of age. The premises comprise of a bungalow with four single bedrooms, a bathroom, a lounge, kitchen/dining room and a small conservatory area with access to a large garden to the rear of the premises. There is also a garage for the homes minibus. The laundry area is situated in a room behind the garage. The premises are in keeping with the local community. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. The weekly fee is £1719.53 and residents’ contributions range from £63.90 – £98.60 as advised by the acting manager at the site visit. Additional charges/costs are incurred by residents relating to chiropody, purchase of personal toiletries, bedroom furniture. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for five hours and fiftyfive minutes. The process included a tour the building discussions with the acting manager, the staff and residents and examination of a random sample of staff and residents files. As part of this inspection surveys were sent on 6th July 2007 to four residents, four relatives’ four health and social care professionals and eight care workers to obtain their views on the service the home provides. The home said that they had not received these surveys and that this may have been because the CSCI addressed them to the registered manager who was on long term leave. Twenty-five of the forty-three standards were inspected. What the service does well: What has improved since the last inspection? The homes pre-admission procedure has been improved upon. The care plans now show that more choices are offered to residents. Risk Assessments have been carried out on residents leaving the home unsupervised. The actions identified in the homes fire risk assessment have been carried out. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides prospective residents with sufficient information to enable them to make an informed choice about where to live. A thorough needs assessment is undertaken prior to admission to ensure that the home can meet their needs. Each resident is provided with a written contract of his or her terms and conditions. EVIDENCE: The homes Statement of Purpose and Service User Guide were reviewed in September 2006 and contain sufficient information for prospective residents and their representatives to make an informed choice of where they want to live. The Service User Guide provides pictorial and large print information on the homes complaints procedure, however some of the information provided is out of date (such as the gross cost of a bed space). The Service User Guide clearly documents any additional items that residents will need to pay for over and above their weekly contributions. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 9 The home has admitted one resident since the last inspection and a thorough pre-admission assessment was carried out by the home that included the input of other professionals. The assessment form was not signed or dated by the person undertaking the assessment. The care files examined contained a copy of the individuals terms and conditions, signed and dated by them and the manager. License agreements were kept on each of the care files examined and the files also contained copies of letters advising residents of their annual increase and details of their weekly contribution rate. 2 Central Avenue DS0000018072.V344108.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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans reflect residents assessed and changing needs. Residents are consulted on the running of the home and make decisions in all other aspects of their lives. The home has comprehensive risk assessments and management plans. EVIDENCE: Two care files were examined and contained a number of working practice instructions that were detailed and covered all areas of the residents needs and clearly took the residents wishes and preferences into account. Residents spoken with said that they help make their care plans. The acting manager said that the care plans are now in the new format and that staff discuss each plan individually with residents to ensure that they understood and agreed the contents. Care files are person-centred and contained good evidence of 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 11 individual residents input. Each of the care files examined contained a signed document in pictorial format confirming that staff had explained the care plan to the resident. The daily notes were well written and contained detailed information of the days events. Residents meetings have been held twice in 2006. The acting manager said that it is the homes intention to hold more regular residents meetings and that residents are consulted on a daily basis about all aspects of living at 2 Central Avenue. Residents spoken with told of how they were able to choose their food and what activities they wanted to do; pictorial notice boards are displayed around the home to assist residents in making their choices. The two care files examined contained many risk assessments all of which had clear management plans in place. The recommendation made at the last inspection that risk assessments are undertaken in relation to residents leaving the premises unsupervised has been carried out. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents participate in appropriate activities both in the home and in the local community. The home encourages residents to have appropriate relationships and ensures that their rights and responsibilities are recognised. Residents are offered a healthy balanced diet in pleasant surroundings. EVIDENCE: 2 Central Avenue provides residents with a good range of activities both in and out of the home. There is a people carrier which is used to access the local community and residents spoken with talked of going out to the pub, cinema, park, bowling and that they had been out for a meal to a Harvester in Langdon Hills this week. The acting manager said that the day centres had now closed but a small club is due to open in the tea rooms in the high street which will 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 13 enable residents to meet with their friends outside of the home environment. All of the homes permanent staff have the skills to drive the people carrier, however, at times there are two agency staff on duty of which neither are able to drive. Staff spoken with said that due to staff sickness and leave there has been a higher level of agency staff lately but that some of the agency staff are regular and are able to escort residents on foot to local amenities. The garage conversion is on-going and the acting manager said there would be changes made to the work that is already done as the worktops are too high and need to be lowered. The acting manager said that the whole of the garage area is being redeveloped so that it can be accessed through a separate door and used independently from the home. The aim is for computers to be installed and an area made for arts and crafts and various activities which other local service users will be able to use. Residents spoken with talked about how they helped clean their rooms, do the shopping and participated in other household tasks. The food cupboards were well stocked and residents said they enjoyed their meals. The residents chose what they wanted for lunch and appeared to enjoy the whole experience. The dining area was clean, fresh and bright. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and their emotional and physical health needs are met. Medication practice is poor. EVIDENCE: The care files examined contained details of the levels of support residents required and identified if physical or verbal prompting was necessary to carry out personal hygiene tasks. Residents spoken with said they were happy with the support that staff provided. It was evident that residents have a good relationship with staff and feel comfortable in their presence; one resident was observed in conversation with a staff member and was happy and was laughing and joking with them. All healthcare needs are identified in the care plan and the outcomes of all medical appointments were recorded and any follow-up requirements and appointments were actioned. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 15 There were several items of medication not signed for on the MARS (medication administration sheet); it was not possible to establish from the homes weekly audit whether or not the medication had in fact been give. The first audit on the medicern card was carried out two days after the start of the new card, this made it unclear how many tablets were in stock before a new supply was added. There was no evidence that the omissions had been investigated or that advice had been sought from either a GP or a pharmacy. The staff member delegated to carry out medication audits said that she had left messages for the staff to sign but that these were agency staff and were not always at the home. Any ommissions on the medication administration sheets must be investigated at the earliest opportunity and medical advice sought. There is a list of staff names that are trained to administer medication; not all staff names had been added to the list. It was unclear from agency staff training records whether staff administering medication had up to date training. All trained staff, including agency workers must be added to the list of names of staff trained to administer medication and they must sign and provide a sample of their initials that will be used on the administration records. On one of the medication files examined there was a photgraph of the residents medication in tablet form; the acting manager said that this was changed to a liquid form last year. This photograph is misleading and must either be replaced with one showing the correct form of medication or removed from the file. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The homes complaints records do not contain full details of the complaint and how it was resolved. The homes practices do not protect residents from possible abuse. EVIDENCE: The homes complaints procedure is clearly documented in the Statement of Purpose and Service User Guide which includes a large print, pictorial version. The acting manager said that one complaint had been received since the last inspection and was in regard to trees overhanging a neighbouring property. The complaint was written on a customer feedback form that described the nature of the complaint but did not contain any details of whether or not the complaint had been resolved. The staff member who entered this complaint was on duty and explained that the customer feedback forms are sent to Estuary and that they deal with it. The complaints records should contain full details of the complaint and how it was resolved. There is currently one on-going POVA (protection of vulnerable adults) issue; the acting manager was unsure as to what stage this was at. Estuary has a Protection of Vulnerable People From Abuse policy that is dated January 2006 and this policy states that the suspicion of abuse or the reporting of alleged 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 17 abuse will be via an abuse alert form and that the service manager will contact the appropriate social services office and raise the abuse alert. The home had not followed its own procedures and had completed an Estuary incident/accident form and notified the CSCI of the issue on a Regulation 37 notice. As a result of the Regulation 37 notification the CSCI contacted Estuary and informed them that the notice identified a POVA concern and that a POVA referral had to be made to the Local Authority without delay. The Responsible Individual confirmed that this would be done immediately and a copy of the referral forms were received by the CSCI on 16/4/07. Staff spoken with said they had been trained in POVA and that they were aware of the Local Authorities procedures, however when asked what actions they would take both staff felt that to report to their line manager or service manager was sufficient. The staff felt that POVA issues were investigated by management and were not aware of the need to refer to the Local Authority. An abuse alert must be raised for the suspicion of abuse and immediately referred to the Local Authority. Estuary holds residents monies and provides a rolling float of £100.00 per person; the home writes the details of income and expenditure on a group transaction sheet. This sheet identifies the resident and the amounts of income and expenditure for the individual; receipts are sent to Estuary with the group transaction sheet. The home keeps its own record of transactions in a hardback bound book. One resident is able to handle his own finances with support and they are escorted to the cash point and are able to withdraw cash from their account. The resident is the only person that knows the pin number to access the account but they give all of the receipts to staff and ask them to keep any monies in their locked cash box in the homes safe. The cash box contained several petty cash vouchers, some had amounts that were withdrawn on them and some had amounts that were spent on them, none of the vouchers tallied with the amount in the box. The acting manager said that no record was kept of the residents’ income and expenditure; a discussion took place around the importance of recording and signing for all cash transactions as the home has access to the residents money. The home must keep clear cash transaction records to prevent the risk of financial abuse. 2 Central Avenue DS0000018072.V344108.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, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment. There was no evidence available of when reported repairs to the home were carried out. The home is generally clean and tidy but would benefit from deeper cleaning. EVIDENCE: The home has a large lounge and kitchen, a comfortable dining area and a good sized neat and tidy garden. The acting manager said that she has worked together with residents and that they are growing their own tomatoes in the small green house in the back garden and that they intend to grow other vegetables also. Residents spoken with said that they enjoyed tending to the tomatoes and liked to watch them grow. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 19 The acting manager said that there were no maintenance issues outstanding on the day of the inspection and that after reporting faults to Estuary they are sent a yellow sheet detailing when the work will be done. The acting manager was unable to confirm that a record of the work carried out was kept. When a fault or repair requirement is reported to Estuary a record of the date reported and the date of the actual repair should be kept within the home to ensure that they are carried out in a timely manner; this was a requirement made at the last inspection. Residents spoken with said that they liked their rooms and the communal areas of the home. Care staff work together with the residents cleaning their bedrooms and all of the communal areas; the home does not employ any domestic staff. Residents spoken with said they enjoyed making their home look nice. The home was clean, pleasant and homely on the day of the inspection, however there were some areas in the home that could benefit from more deeper cleaning; this was identified at the last inspection and a requirement was made. 2 Central Avenue DS0000018072.V344108.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, 35, 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Competent and qualified staff supports residents when permanent staff are working. There was no evidence that the agency staff employed at the home is qualified or has the necessary skills. The homes recruitment practice has minor shortfalls but protects its residents. EVIDENCE: The home currently employs the manager and three full time and three part time support workers; both the manager and one full time support worker are on long term leave. The homes duty rota shows that a high level of agency staff are working at the home and over a two week period forty two shifts out of seventy have been and would be covered by agency staff. All but one of the permanent support staff have completed their NVQ qualification, however as the home uses a large amount of agency staff partcularly at week ends there are times when there are no NVQ qualified staff on a shift. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 21 All five permanent staff have the skills to drive the people carrier but none of the regular agency staff have attained these skills and therefore when two agency staff are on duty together this limits the residents opportunities to go out. The acting manager said that no new staff have been recruited recently; it is clear from the level of shifts that are covered by agency staff that the home needs to recruit more permanent staff. The home keeps a staff profile for its agency workers, this confirms that all the necessary checks have been carried out by the agency and it provides a list of the staffs training. Two staff files were examined and contained application forms, references and criminal records bureau checks. There was no evidence of staff fitness on either of the staff files examined. The home had drawn up a training plan for April 2006 to April 2007 and the acting manager confirmed that the training plan has been carried out with some small exceptions. There was evidence on the staff files examined that recent POVA training had taken place and staff spoken with confirmed this. The details of agency staffs training were not up to date and although the staff profiles identified that updates in training were required in 2007, there was no information to confirm if or when the updates had been carried out. Staff spoken with said that they had received supervision and records examined confirmed that it had taken place, however had not been carried out as regular as it should be. There were records of two staff meetings having taken place in 2006. 2 Central Avenue DS0000018072.V344108.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, 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home currently has shortfalls in its management and there is no access to the computer system for staff to acquire up to date policies and procedures. The homes quality assurance system has not been implemented since 2005. The health, safety and welfare of residents are not protected. EVIDENCE: The registered manager has been on leave since April 2007; the CSCI was appropriately notified of the absence and the arrangements made for managing the home until his return. The registered manager is qualified to NVQ level 4 in Care and the acting manager to NVQ level 3. The acting manager said that the registered manager is in the process of improving the 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 23 homes systems that monitor practice and that he is the only staff member with access to the computer system at the moment. The acting manager said there are plans to train other staff to use the computer system and that this will allow them to access up to date policies and procedures. The policy and procedure documents examined had various issue dates between May 2004 and January 2006. The acting manager said that there were possibly more updated versions on the system, however as stated previously she did not have access to the computer system. The acting manager provided a quality assurance folder for inspection which did not include any survey materials or reports; all it contained was copies of the homes policy. The registered manager has drawn up a document that is posted on the office wall, this describes how the home will undertake regular audits to ensure the quality of the service it provides. The last quality assurance audit was undertaken in 2005 and the report was dated 26/9/05. The last inspection identified that the registered provider had not regularly been undertaking the monthly visits required under Regulation 26 and a requirement was made for these to be carried out and copies of the report to be sent to the CSCI. The provider made visits to the home on 24/4/06, 15/6/06, 24/7/06, 31/8/06 and 4/10/06 and has visited this year on 14/2/07 and 20/6/07; there were copies of the reports in the home. All safety certificates were in place and up to date. The homes last fire drill was carried out on 24/6/07 and there was evidence that these are regularly undertaken. The acting manager said that all of the actions identified in the fire risk assessment have been carried out. The home was unable to locate its thermometor which is used for recording water temperatures. The record of weekly hot and cold water temperature checks contained thirteen entries for eleven different outlets and identified if a temperature control was fitted and what temperature required for each outlet. All of the entries for bedrooms one and two were 34.12 degrees and for bedrooms three and four 35.12 degrees. The bathroom bath and basin taps were recorded as 35.12 degrees and the kitchen and utility room sinks were recorded as 60.12 degrees in every entry. The temperature recorded for the hand basin in the kitchen was 35.12 degrees on all of the thirteen entries; the required value should be between 55-60 degrees. All of the values recorded with the exception of the kitchen and 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 24 utility sink were either at or below the required temperature and there was no evidence that this had been reported to Estuary. There was no evidence that the water storage system had been checked and cleaned to control the risk of Legionella and the acting manager said she was aware that the water storage system had been cleaned in the past. 2 Central Avenue DS0000018072.V344108.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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 1 X X 1 X 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA12 Regulation 16(2)(m) Requirement The registered person shall ensure that residents are enabled to engage in local, social and community activities. This refers to the use of all agency staff on shifts at the weekend that are unable to drive; this prevents residents from going out if they wish. Previous timescale of 01/08/06 not met. The registered person shall make 30/10/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines. This refers to the omissions on the MARS sheets, the medication audits, agency staff training records and the picture of medication that was in the wrong form (tablet) that is now prescribed in liquid form. The registered person shall 30/10/07 ensure that any complaint made under the complaints procedure is fully investigated. DS0000018072.V344108.R01.S.doc Version 5.2 Page 27 Timescale for action 30/10/07 2. YA20 13 (2) 3. YA22 22 (3) 2 Central Avenue 4. YA23 13 (6) This refers to the lack of recording the outcome of complaints. The registered person shall make 30/10/07 arrangements to prevent residents being harmed, or suffering abuse or being placed at risk of harm or abuse. This refers to the POVA procedures not being followed and the incorrect handling of one resident’s finances. Previous timescale of 01/08/06 not met. The registered person shall 30/10/07 ensure that the home is kept in a good state of repair externally and internally. This refers to the recording of the date that repairs are carried out to ensure they are done in a timely manner. Previous timescale of 01/08/06 not met. The registered person must ensure the home is kept clean. This refers to the need to carry out deep cleaning such as washing skirting boards and paintwork at regular intervals. Previous timescale of 01/08/06 not met. The registered person shall ensure that suitably qualified, competent and experienced persons are working at the home. This refers to unqualified agency staff working unsupervised at the weekends. 5. YA24 23(2)(b) 6. YA30 23(2)(d) 30/10/07 7. YA32 18 (1) (a) (b) (c) (i) 30/10/07 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 28 8. YA34 19 (1) (a) (i) Schedule 2 The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in schedule 2. This refers to evidence of staff fitness. The registered person shall ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. This refers to agency staffs training. Previous timescale of 01/08/06 not met. The registered provider shall undertake regular monthly visits to the home under Regulation 26 and prepare a written report on the conduct of the home and supply a copy to the CSCI. Previous timescale of 01/08/06 not met. The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. This refers to the water temperatures of all outlets being tested regularly and appropriate actions being taken to minimise any risks identified. This requirement also refers to the need for regular cleaning of the homes water storage system. 30/10/07 9. YA35 18(1) (i) 30/10/07 10. YA39 26 (2) (3) (4) (5) (c) 30/10/07 11. YA42 13 (4) (c) 30/10/07 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA36 YA37 Good Practice Recommendations Staff should have regular recorded supervision meetings at least six times a year. The acting manager (in the absence of the registered manager) should have access to the computer system to enable the staff team to be provided with up to date policies, procedures and information. 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 30 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 2 Central Avenue DS0000018072.V344108.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!