Inspection on 14/05/07 for 27 Wontner Road

This inspection was carried out on 14th May 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 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Wontner Road 17/05/06

27 Wontner Road 10/08/05

27 Wontner Road 17/02/05

27 Wontner Road 06/09/04

27 Wontner Road 10/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 27, Wontner Road London SW17 9LH Lead Inspector Sandy Patrick Unannounced Inspection 14th May 2007 10:00 27, Wontner Road DS0000010239.V336419.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 27, Wontner Road DS0000010239.V336419.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. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27, Wontner Road Address London SW17 9LH 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) 020 8767 1621 020 8947 4898 www.odyssey-csft.org Odyssey Care Solutions for Today Gladys Otudeko-Odulake Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Agreement to admit one named female service user over the age of 65 years. The service users needs will be asessed at forthcoming inspections to ensure that the home can continue to meet her assessed needs. Date of last inspection Brief Description of the Service: Wontner Rd is a care home for 4 adults with a learning disability. The home is run by Odyssey Care Solutions for Today. The property is owned by Wandle Housing Association. The home is located in a residential area of Wandsworth, close to Wandsworth Common, shops, pubs and other amenities. The home is a three storey, large terraced house. The bedrooms are located on the 1st and 2nd floors. There is no lift access. There is a small garden to the rear of the property. The weekly fees are between £756.56 - £766.86 per week. Additional charges are made for some outings and holidays. There is a pictorial guide for the home which is available for people who are considering moving there. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection included an unannounced visit to the service on the 14th May 2007 and a telephone conversation to the Deputy Manager on the 21st May 2007. The Inspector met staff on duty during the visit. People who live at the home, their relatives, staff and other professionals were asked to complete surveys about their experiences of the home. The Deputy Manager and Area Manager completed a quality self assessment and evidence from this is used to help form some of the judgements in this report. The Inspector looked at a number of records held at the home and the environment. Three people were living at the home at the time of the inspection. The Registered Manager had been away from work since February 2007 and the Deputy Manager was managing the home in her absence. One person who lives at the home, two relatives and four members of staff completed surveys. They all spoke positively about the service. The person living at the home said that they were able to make decisions about their life, that they felt safe, liked the food and activities and knew who to speak to if they were unhappy about any aspect of their care. Both relatives felt that the needs of the residents were met and that the staff kept in contact with them as necessary. Some of the things which they wrote were: ‘My relative seems happy and well cared for.’ ‘I feel that the home does as much as possible to help my relative live their life to the full. They are very happy and settled.’ The staff described thorough recruitment procedures and said that they were well supported and trained. They acknowledged that vacancies in the permanent staff team had an effect on the way the house was run. They said that the team worked well together and supported residents well. What the service does well: 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 6 People living at the home are happy there. People pursue a wide range of different activities of their choice. The staff feel supported and work well as a team. What has improved since the last inspection? 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. 27, Wontner Road DS0000010239.V336419.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 27, Wontner Road DS0000010239.V336419.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. There is accessible information for people who are thinking about moving to the home. If more things were accessible the people living at the home would be better informed. There are suitable procedures for assessing people’s needs before they move to the home. EVIDENCE: There is a Statement of Purpose and Service User Guide for the home. Over the past year the staff have developed the Service User Guide so that information is now more accessible to the people who live at the home. The new guide includes photographs and pictures. Everyone living at the home has been given a copy of the new guide. No new people have moved to the home since the last inspection, although there is one vacancy. The person who lives at the home and returned a survey said that they had enough information to help them make a decision about moving to the home. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 9 There are appropriate procedures for the assessment of new people and people are able to visit the home before they make a decision to move there. Tenancy agreements are in place. But these are not accessible to residents. The staff should consider how the information from these could be recorded in an accessible format. 27, Wontner Road DS0000010239.V336419.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 adequate This judgement has been made using available evidence including a visit to this service. The people living at the home have been supported to record their wishes and needs in a way which they can understand. People have not been involved in assessing the risks which effect them and are sometimes unnecessarily restricted. Some of the general practices in the house restrict the freedom of the people living there. EVIDENCE: There is a series of guidelines informing staff of the support needed by each person. Person centred plans have not yet been developed although this is an area the Deputy Manager said the staff plan to work on throughout the year. Some of the information in residents’ files and care plans is muddled and needs to be sorted out so that information is clear for everyone. Since the last inspection the Deputy Manager has helped residents to create a ‘communication passport’. These are formed of photographs, symbols and 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 11 writing to help the people who work with the person to have a better understanding of their everyday needs and likes. Each person has two copies of their communication passport, so that they can take one with them when they go out of the home. These passports are very good and the Deputy Manager is commended for his work in this area. Some restrictions are placed on people without proper assessment. For example people’s clothes and toiletries are locked away. Some of these restrictions may be unnecessary and must be reviewed. People must not be restricted unless they or others will be placed at harm. Any decisions to make restrictions must be undertaken following multidisciplinary assessments. Risk assessments do not include the views of residents or other parties. Some of the risk assessments are old and have not been reviewed. The organisation must review risk assessments taking into account the wishes of the person they are about. They should also consider how people could be enabled to make more choices and take risks rather than be restricted. Some risk assessments stated procedures that were not always followed. For example one risk assessment regarding radiators said that staff tested the heating was at a reasonable level by touching radiators everyday. There was no procedure for this in the daily routines. Some of the radiators were burning to touch and this indicated that staff had not checked that they were at a safe level. Risk assessments must be accurate. The staff said that they felt people living at the home were central to decision making. The Deputy Manager said that they want to look at more ways to involve people in the running of the home. There were a number of areas where simple improvements would mean that people living at the home had more control. For example the pay phone for their use was situated by a fire extinguisher and there was no chair next to it making it hard to use. A clock in the kitchen told the wrong time and the pinboard in the kitchen contained information for staff not accessible information for residents. The fruit bowl, tea and coffee were all stored high up and were not easily accessible. 27, Wontner Road DS0000010239.V336419.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, 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. People who live at the home are given opportunities to take part in a wide range of activities at the home and in the community. They are supported to stay in contact with friends and families and to celebrate their culture and religion. EVIDENCE: The Deputy Manager and staff said that residents participate in a wide range of activities of their choice as a group and individually. In the past year people have joined the local library and Gateway club. People attend local resource centres and have a variety of regular groups they attend. Staff felt that people made a lot of choices at the weekends and took part in lots of different things of their choice. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 13 The staff on duty said that residents participated in household shopping. They do not cook or participate in household tasks. The staff should consider ways to support people to be more involved in the running of the home. Individual cultural needs and interests are recorded within the communication passports. Residents who wish to are supported to go to Church. People living at the home make good use of the local community and are supported to use public transport, leisure facilities and other places of interest. People are supported to stay in contact with friends and families. One person visits their family each weekend. Relatives completing surveys said that they were well informed and were made welcome at the home. The communication passports and other accessible information is good. The staff need to consider other ways they can support people with accessible information such as a pictorial menu, photographic staff rota and cleaning rotas. Information for staff emphasised the importance of showing residents respect. There were no residents at the home at the time of the inspection, so the Inspector was not able to observe interactions. However, all staff showed that they had a good understanding of the importance of showing respect and treating people well. The person completing the survey said that they liked the food at the home and were happy with the activities which they participated in. The menu is varied. The kitchen was well stocked with fresh food and meals are freshly prepared. 27, Wontner Road DS0000010239.V336419.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, 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at the home have their personal and health care needs met. Medication is generally managed safely but there needs to be some improvements to make sure procedures are followed. EVIDENCE: Personal care needs are recorded within guidelines. The staff said that same gender carers were provided where requested. All residents are registered with local GPs and other health care professionals as required. The Deputy Manager said that specialist health care professionals had offered individual support for people over the last year. There are no health action plans for people living at the home and the Deputy Manager said that they plan to create these in the near future. On arrival at the home the keys to the medication cabinet were left in the cabinet door and the door was unlocked. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 15 One person had run out of a supply of medication on the day of the inspection. The Deputy Manager explained that the medication was due for review with the GP the following day. However, the staff should make sure people do not actually run out of medication. People’s allergies were not recorded on medication administration records and should be. There should be a list of staff signatures and initials so that the person who has signed the administration record can be easily identified. The care plan for one person records that they use a medicated cream. However, there was no record of this on the administration record. There was a packet of pain killers but no record of these and no record of any pain killers which had been administered. There was no record of staff training in medication or first aid. 27, Wontner Road DS0000010239.V336419.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 adequate This judgement has been made using available evidence including a visit to this service. The people who live at the home are informed about how to make a complaint. The procedures at the home do not adequately protect people and they may be at risk. EVIDENCE: The Service User Guide includes a complaints procedure which is designed to be easier for people to understand. The resident who completed the survey said that they knew who to speak to if they were unhappy about anything. The record of complaints and concerns could not be located at the inspection. The Deputy Manager must make sure this is accessible and up to date. The home has adopted the local authority protection of vulnerable adults procedure and the organisation has its own procedures in abuse and whistle blowing. There was no record of staff training in abuse. None of the people living at the home are signatories for their own bank accounts. The current system is that the Manager is the only person to have access to these bank accounts. The Manager has been away from work since February and this has caused problems. People who are able must be given the opportunity to sign for their own accounts and be in control of the money they withdraw. The situation where the Manager is the signatory for their accounts must cease as this system is open to abuse and has caused 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 17 inconvenience for the residents who have not been able to access their own money for several months. The staff hold small amounts of the residents’ money. This is held in a locked cabinet, but individual tins were not locked and should be. Records of the money were seen to be accurate. The staff make checks on this money when they change over. 27, Wontner Road DS0000010239.V336419.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 poor This judgement has been made using available evidence including a visit to this service. Areas of the home are homely and personalised however some rooms are not. The home is not well maintained or clean. EVIDENCE: Areas of the home were homely and nicely laid out for the people living there. A number of cards were on display in the lounge following a recent birthday. There were pictures and a range of games, puzzles and books for residents. However, other areas looked less personalised and homely. A large amount of the residents’ communal area was taken up with staff records, lockers and electrical equipment. Some rooms did not have curtains. Bathrooms were not personalised or made pleasant. The staff should think of ways to make the home seem more attractive and personal for the people who live there. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 19 Since the last inspection the lounge flooring has been replaced and some new furniture has been purchased. The Deputy Manager said that there are plans to buy some new garden furniture. Areas of the building are showing wear and tear and a number of environmental repairs need to be attended to. These include: The hall and stair carpet is badly stained and should be replaced. Some paintwork throughout the home is chipped, worn and stained. Some doorframes were cracked. One bathroom door did not lock. There was no plug in one bath. Some of the toilet roll holders were broken. Some overhead lights did not have lampshades. One bedroom window was jammed so that it could not be opened or closed. There was no curtains or alternatives on some windows. There was no shower curtain for one shower. There were drips of dried paint on window pains. Some tiles in bathrooms were cracked. A drawer handle was missing from one resident’s chest of drawers. The floor between one resident’s room and the hallway was uneven and was a trip hazard. Laminate flooring was coming up in some places. The kitchen floor needs replacing. The oven door had fallen off and there was no handle. There was not a warning sign on this piece of equipment whilst parts were being ordered and there needs to be. The seal around the taps in the kitchen needs replacing. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 20 There has been problems with some of the windows for some time and these need replacing. The front of the house needs repainting. The Deputy Manager said that the Housing Association have not attended to this work despite repeated requests over the last two years and a requirement made at the last inspection. Some areas of the house were dirty and good infection control procedures were not always followed. The concerns noted below must be addressed and procedures must be put in place to make sure that cleanliness is maintained and the risk of infection minimised. Skirting boards were dirty and dusty. There was no soap or paper towels in two bathrooms and toilets. Plug holes in baths and sinks were filthy and contained hair and scum. Some lampshades, light switches, televisions, behind doors, on shelves and radiators were dusty. Extractor fans were dusty and dirty. There was a large amount of rubbish in cupboards under sinks in bathrooms and the kitchen. Blue tac was left on walls where pictures used to be. Used disposable gloves were left in the laundry room. The insides of food cupboards were sticky, dirty and had crumbs. There was a note in the kitchen asking staff to put open packets in appropriate containers. However, this was not happening and there were open packets and bottles which were unlabelled. These included a knotted plastic bag of yellow powder, which had not been labelled with the date or the product. Vegetable racks were dirty. There were cobwebs on the kitchen window and high on the walls. There was no lid on the kitchen dustbin. The sponge used for washing dishes needed to be replaced. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 21 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 adequate This judgement has been made using available evidence including a visit to this service. People living at the home are not supported by a full permanent staff team. The staff have been appropriately recruited and say that they are trained and supported but there is little evidence of this. EVIDENCE: The current staff team have worked at the home for some time and know the people living there well. They commented that they work well as a team and feel that they have good communication which each other. However, there were only four permanent members of staff, including the Manager, employed at the time of the inspection. This situation had been ongoing for some time and the Manager has not been at work for several months. The home has relied on temporary members of staff. Although they have tried to make sure the same regular temporary staff have worked at the home, this is not always possible. There is also a lack of continuity and consistency that only a full permanent staff team can bring. The organisation must recruit to the staff vacancies to make sure there is a quality service. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 22 The staff completing surveys said that they had good training and support. They described recruitment practices which were thorough and included preemployment checks. Some staff said that they had attended equality and diversity training. On the day of the inspection there were three members of staff on duty. There were no residents at home at the time of the visit. Throughout the four hour visit the staff did not attend to any work and sat as a group chatting and reading through the communication book and magazines. The television was on. This was discussed with the Deputy Manager. Although no residents were not at home, the staff should have found other tasks to attend to. The organisation should reassess whether such high staffing levels are necessary when no residents are at home. The staffing hours would be better deployed supporting people when they need it. All the staff are working towards NVQ Level 3 awards. Staff have not undertaken training in Autism or people who challenge. This is important for their roles and the Deputy Manager said that this training is planned in the next few months. The staff said that the training from the organisation was good. Records of staff training need to be improved so that there is evidence of when training took place and when updates are due. Records seen were out of date and did not show recent training or training in some key areas. The three members of staff on duty were all temporary staff. One person said that they worked at the home regularly. One person said that they had not worked there that much. They said that when they started work they were not shown any files, the communication passports or care plans but were only given a verbal handover about the residents. The staff must make sure any new or temporary workers are given an appropriate induction into the home. This must include using the communication passports and being shown correct procedures for the tasks they will be undertaking. 27, Wontner Road DS0000010239.V336419.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, 28, 39, 41 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Manager has been absent from the service for a number of months and improvements and developments have been difficult. There are some systems for quality assurance but these need to be improved to make sure people have an influence over developments. The procedures for health and safety are not always being followed and people are put at risk. EVIDENCE: The Registered Manager has a range of relevant experience and is undertaking her NVQ Level 4. However, she has not worked at the home since February 2007. The Deputy Manager has been managing the home in her absence. He was not sure when she would be returning to work. He said that the Area Manager had supported him. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 24 The organisation did not inform the CSCI of this prolonged absence and should have done. The organisation must confirm the arrangements of the management of the home and keep the CSCI informed of any changes, including the predicted and actual return of the Manager to the home. Some of the planned developments and improvements are hard to achieve without proper management and staff shortages. The Deputy Manager cannot take on all the responsibilities of the Manager, do his own job and still work as one of the support staff. Appropriate management arrangements are needed for staff to have regular supervision. The Deputy Manager said that the organisation plans to develop a survey for residents to find out what they think about the service. The Inspector saw a copy of a survey completed by another professional in a residents’ file. There was no evidence that information from the survey had been used for quality monitoring or planning. The organisation should continue to ask others, including residents, to complete surveys. But instead of storing this information in personal files, the results of the surveys should be recorded within a quality action plan which outlines where stakeholders think the service has done well and what needs to be improved. Many of the records at the home needed to be reorganised. Some information was out of date and needed to be archived. Recent and older information was muddled together. Some information contradicted other records. Some records were not dated or signed. The Deputy Manager said that work to sort out some records had started. However, this is slow because the Manager has not been at work and there is only a very small staff team. Further work needs to take place to make sure records are accessible, up to date and accurate and that old information is stored appropriately. The office space is limited and is also located on the second floor. For this reason some of the paperwork is stored in the lounge. There is also a computer in the lounge, which the staff said was for them to use and not residents. It is important that certain paperwork, especially the communication passports are accessible, and it is reasonable to store these downstairs. However, there may be some records which could be moved to the main office. The organisation of records stored in the lounge needs to be reviewed so that the room does not appear like a workplace. Any computer kept in the residents’ communal area should be accessible to them and used by them. There was a record of checks on equipment by appropriate professionals, including fire and electrical equipment. There was an appropriate record of all accidents and incidents. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 25 There are a number of regular health and safety checks made by staff and these are recorded. However, some of the information recorded is inaccurate. For example records show that monthly checks are made on first aid supplies and that there were no problems with these. On inspection, the first aid boxes were found to contain a number of out of date items, including some sterile dressings which were dirty and some which expired in 2003. The first aid supplies must be within date and regular checks must be made to make sure of this. Records for these checks must be accurate. The risk assessment for one person refers to risks with them having access to toiletries. However some household cleaning materials were left in bathrooms and were not locked away. The boiler cupboard was not locked. A drawer in the kitchen was marked as containing sharp knives. There was no risk assessment in place regarding this and the drawer was not locked. 27, Wontner Road DS0000010239.V336419.R01.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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 2 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 1 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X 2 1 X 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 27 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 YA9 Regulation 12 13 Requirement Timescale for action The Registered Person must 30/06/07 make sure people are not restricted unless they or others will be placed at harm. Any decisions to make restrictions must be undertaken following multidisciplinary assessments, which must be recorded. The Registered Person must 31/07/07 review risk assessments taking into account the wishes of the person they are about. They should also consider how people could be enabled to make more choices and take risks rather than be restricted. The Registered Person must 30/06/07 make sure risk assessments are accurate and that staff follow the agreed instructions which are recorded. The Registered Person must 30/06/07 make sure people are not at risk DS0000010239.V336419.R01.S.doc Version 5.2 Page 28 2. YA9 12 13 3. YA9 13 4. YA42 13 27, Wontner Road of scalding from radiator surface temperatures. 5. YA7 12 The Registered Person must 30/06/07 make sure people living at the home are not restricted in making choices and having control by in house procedures and practices. The Registered Person must 30/06/07 make sure medication is safely handled, including: The medication cabinet must be locked at all times. Residents must not run out of medication. There must be a record of all medication held and administration, including pain killers. There must be a list to identify staff signatures. Staff must be trained in medication and first aid and this must be recorded. The allergy section of administration records must be completed. There must be creams that administered. 7. YA22 22 a record of have been 6. YA20 13 The Registered Persons must 30/06/07 ensure that any complaints are logged in the complaints book as soon as they are received. 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 29 Previous 17/05/06 8. YA23 13 18 requirement The Registered Person must 31/07/07 make sure the staff are trained in protection of vulnerable adults and this is recorded. The Registered Person must 31/08/07 review the procedure for handling residents’ money so that: People who are able are the signatories for their own bank accounts and can withdraw money as they chose. The Manager is not the only signatory for any bank account belonging to a resident. 9. YA23 12 13 10. YA24 12 23 The Registered Person must 31/08/07 make sure the home is attractive and personalised for the people who live there. Staff records and equipment should be kept to a minimum and must be appropriately stored in residents’ communal areas. The Registered Person must 31/08/07 ensure that the premises are kept in a good state of repair both internally and externally. The premises work identified in Standard 24 must be addressed. Previous requirements 30/10/05 & 30/09/06 11. YA24 23 12. YA30 23 The Registered Person must 30/06/07 make sure the house is regularly cleaned and issues identified in DS0000010239.V336419.R01.S.doc Version 5.2 Page 30 27, Wontner Road the report are attended to on a regular basis. There must be procedures to minimise the risk of infection. 13. YA33 18 The Registered Person must 31/08/07 recruit permanent staff to the staff vacancies. The Registered Person must 31/07/07 make sure staffing levels reflect the needs of the residents and staff are actively deployed for the benefit of the home. The Registered Person must 31/08/07 make sure that staff have a training and development plan which includes updates of refresher training. Previous 30/09/06 16. YA35 YA31 18 requirement 14. YA33 18 15. YA35 18 The Registered Person must 30/06/07 make sure all new and temporary staff are given a full induction into the home. The Registered Person must 30/06/07 confirm the arrangements for the management of the home and keep the CSCI informed of any changes, including the predicted and actual return of the Manager to the home. The Registered Person must 30/06/07 notify the CSCI of any event that affects the wellbeing of people who live at the home. 17. YA37 8 10 18. YA37 37 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 31 19. YA41 17 The Registered Person must 31/07/07 make sure records are accurate, complete, kept up to date and stored appropriately. The Registered Person must 30/06/07 make sure first aid supplies are within date and regular checks must be made to make sure of this. Records for these checks must be accurate. The Registered Person must 30/06/07 make sure people living at the home are kept safe by COSHH products being locked away and appropriate assessments being made on dangerous equipment and materials. 20. YA42 13 21. YA42 13 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. Refer to Standard YA5 Good Practice Recommendations The Registered Person should consider how the tenancy agreements can be recorded in a more accessible format so that the people who live at the home can understand them. The Registered Person needs to support people living at the home to create their own person centred plans. Information in the current care plans needs to be sorted out so that it is clearer and makes more sense. 2. YA6 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 32 3. YA11 The staff should consider ways to support people to be more involved in the running of the home. The staff need to consider other ways they can support people with accessible information such as a pictorial menu, photographic staff rota and cleaning rotas. The staff need to make sure tins used for storing residents’ money are locked. The Registered Person needs to consider how best to gather the views of residents and other stakeholders and how these can be recorded in a meaningful action plan for the development of the service. 4. YA7 5. YA23 6. YA39 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 27, Wontner Road DS0000010239.V336419.R01.S.doc Version 5.2 Page 34 - 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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