Inspection on 22/02/06 for 290 Dyke Road

This inspection was carried out on 22nd February 2006.

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

Other inspections for this house

290 Dyke Road 11/09/08

290 Dyke Road 17/11/06

290 Dyke Road 13/07/05

290 Dyke Road 15/02/05

290 Dyke Road 27/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 290 Dyke Road Hove East Sussex BN1 5BA Lead Inspector Jennie Williams Unannounced Inspection 22nd February 2006 10:20 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 290 Dyke Road Address Hove East Sussex BN1 5BA 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) 01273 552069 Care Management Group Limited Louise Davie Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of service users to be accommodated is five (5). That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. That service users to be accommodated have a learning disability, or a physical disability. 13th July 2005 Date of last inspection Brief Description of the Service: 290 Dyke Road is one of many homes owned by Care Management Group Ltd (CMG). 290 Dyke Road is registered to provide accommodation for five residents with learning disabilities. Residents at 290 Dyke Road have profound learning and physical disabilities. The home is a converted bungalow. All rooms are for single occupancy. There are suitable bathing facilities at the home to meet the needs of the residents. The home is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and access to public transport. There is no parking available at the home, but parking is permitted on the street. The home has access to its own transport. Residents are provided with an opportunity to attend a day centre provided through the use of the organisations development centre. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 290 Dyke Road will be referred to as ‘residents’. This unannounced inspection took place over six and half hours on the 22 February 2006. Staff files, care plans, medication procedures and residents’ personal allowances were inspected. Some policies and procedures were spotchecked. The environment and some individual rooms were spot-checked. Staff and residents were spoken with throughout the inspection process. Due to the disability of the residents, the Inspector had limited verbal communication with them. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection report of 13 July 2005. There were five residents living at the home on the day of the inspection. What the service does well: What has improved since the last inspection? The home has undertaken work to meet the requirements and recommendations made at the last inspection. The Statement of Purpose has been amended to reflect changes from the building works. Care plans are being reviewed at least six monthly and pre assessment forms are being signed and dated. The home has locally amended some policies and procedures and is awaiting an update from CMG head office. Risk assessments have been undertaken for residents travelling in the bus. The provision of meals has improved and the home now undertakes in house cooking. The information required to be kept of staff has improved. The recording procedures for resident’s personal allowances have improved and safety measures have been implemented. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. EVIDENCE: The Statement of Purpose has been amended, as required form the last inspection, to reflect changes in room occupancy and communal space. A copy of this document was forwarded to CSCI following the inspection. The Statement of Purpose incorporates the use of pictures throughout the document. It was confirmed that the Service User Guide has been amended and the home is currently awaiting the printed document from head office of CMG. A copy of the amended Service User Guide is to be forwarded to CSCI when available. The organisation has a central assessment team based in Wimbledon who undertakes the initial assessment of prospective residents. There has been one new admission to the home since the last inspection. This resident was transferred from another home within the CMG organisation. The home has good support systems in place through use of the organisation’s specialist health professionals eg. speech and language therapists. CMG is currently in the process of employing a new physiotherapist. Prospective residents/representatives are encouraged to visit the home prior to moving in. Due to the disability of the residents, admissions are generally well 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 9 planned and the home will not take any emergency referrals or short-term admissions. There was evidence that the home had undertaken their own pre assessment prior to the new resident being admitted. There was evidence that a good transitional programme was undertaken which included visiting for tea and an overnight visit. On one visit, this new resident was assisted in making a new sign for their room door. Contracts are negotiated between head office of CMG and the purchasing authorities. It has been required that the home ensures that they have copies of all residents contracts/terms and conditions available for inspection. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 & 10 Residents’ needs are being met by the information contained in the care plans. Due to the profound disabilities of the residents, limited risk taking can be initiated. EVIDENCE: The home has comprehensive care plans titled ‘all about me’. These are developed and reviewed with input from relatives, if applicable. Residents are involved in the process but are unable to comprehend a lot of the information. The ‘all about me’ are very detailed and include photos of the residents’ preferred position. All residents have daily diaries that are kept with the individual. None of these were read on the day of the inspection. It was confirmed that the daily routine and any changes in the individuals’ health is recorded in these diaries. Keeping these diaries with the individual encourages good communication between the home care staff and the day centre staff and promotes continuity of care. The registered manager has implemented a review sheet for staff to sign and date when reviewing care plans. There is evidence that care plans are being reviewed six monthly or earlier if the needs of an individual changes, as required at the last inspection. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 11 CMG have developed a new Health Booklet that will include all relevant information about an individual. It was confirmed that they contain comprehensive information on an individual’s health needs. The registered manager has received training on using these new documents and will provide this training for the staff. These booklets condense all the information regarding an individual and will assist in providing clear accessible information if a resident requires admission to hospital. Residents have complex needs and verbal communication is limited. Staff working at the home are able to interpret an individual’s subtle level of communication and will include residents in the daily routines of the home wherever possible. Residents require supervision in all activities they participate in, so taking risks is very limited. Risk assessments need to be implemented for door locks on individual rooms. Personal information is kept confidentially at the home. This has been promoted with the provision of a small office for the registered manager. This office has limited working space, but sufficient room to store confidential information. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15, 16 & 17 Residents are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. EVIDENCE: Residents are provided with a range of activities they are able to participate in. The development centre provided by the organisation provides opportunities for residents to engage in informative and creative activities should they wish. One resident attends a day centre. The home has its own bus and there is a full time driver available. One resident attends college one day a week and participates in a gardening course. There is currently no one involved in employment. All residents have a daily routine. These routines are flexible, but due to the complex needs of the individuals’, residents respond better when there is a familiar routine in place. Visitors are welcomed at the home. Residents may see visitors in their own rooms if they wish. There is a visitor’s book kept at the entrance of the home that all people must sign when entering and leaving the home. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 13 The home has reviewed the system for the provision of meals. It was previously prepared at another establishment and transferred to the home, limiting the level of choice and diversity for the residents. This had been outstanding for the past two inspections. The home now undertakes in house cooking. The registered manager confirmed that this has been beneficial for the residents. The registered manager is purchasing a pictorial menu planning pack that will provide residents with further opportunities to input into the menu planning. Meal times have been adjusted for the benefit of the residents. It was noted in the information of an individual that they had an allergy with a certain food. It is required that a list of residents likes/dislikes/allergies be placed in the kitchen as guidelines for staff preparing and cooking the meals. All residents are weighed monthly and specialist advice is sought when required. All residents’ weights are recorded in a book. It is recommended that individual records be maintained to promote confidentiality. Residents are provided with an opportunity to participate in the preparing of meals. It is required that risk assessments be undertaken for the tasks undertaken when working in the kitchen. The kitchen is small and only one resident is able to assist a staff member at any given time. It is recommended that consideration be given to having the kitchen updated and being made more user friendly and accessible for wheelchair users. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 & 21 Resident’s needs are being met by the numbers of staff on duty and support network of health professionals within the CMG organisation. EVIDENCE: Throughout the ‘all about me’ there are clear instructions on the preferred way an individual receives personal support. Clear photos on the preferred position an individual should be placed when in bed etc support this. All residents require full personal care due to their complex needs. The home does not provide nursing care. District nurses will visit the home if an individual requires nursing input. Due to the complex needs of residents, staff are required to have a clear understanding of all needs. Health needs are also met with the good support network throughout the organisation. CMG is currently employing a new physiotherapist. It is anticipated that this person will commence work in April 2006. It was confirmed that the previous physiotherapist gave a thorough handover of all individual physiotherapy programmes. Residents’ postural management programmes are still being undertaken. Staff administering medication have received appropriate training for this role. There was medication training being undertaken on the day of the inspection. MAR charts inspected demonstrated that medication is being signed for at the 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 15 time of administration. There was a prescribed medication for an individual found in a communal area. This has not been reflected as a requirement as this was addressed on the day of the inspection. Some MAR charts did not provide clear guidance. One MAR chart still had a prescription on that was no longer in use. One prescription had instructions to use following GP directions. No record of the GP’s initial instructions could be located. Issues identified were discussed with the registered manager who will liaise with the supplying pharmacist. It is required that prescriptions on MAR charts are kept up to date. The registered manager confirmed that they have continued to work towards obtaining an individual’s wishes following death, as recommended at the last inspection. It was confirmed that the home is awaiting information from one resident’s care manager. This has not been reflected as an outstanding recommendation. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents/representatives are provided with opportunities to air their views. Clear written policies will provide staff with clearer guidance on adult protection procedures. EVIDENCE: There is a complaints procedure available at the home. This has been amended locally to include the contact details of the local CSCI as required at the last inspection. There is a pictorial complaints procedure that residents have access to. There have been no complaints made to the home or directly to CSCI since the last inspection. It remains an outstanding requirement that the Protection of Vulnerable Adults (POVA) policy and procedure needs to clearly state that all allegations of abuse must be referred to social services, who are the lead agency. Information regarding the POVA list needs to be included in this policy. It was discussed with the registered manager that the home amends this policy locally until an update is provided from the CMG head office. There have been no POVA investigations since the last inspection. The whistle blowing policy has been amended locally as required from the last inspection. The home is still waiting for this amended document to be forwarded from the CMG head office. There is one person within CMG who is the designated appointee for residents’ finances. The home holds personal allowance securely at the home. Personal monies spot-checked demonstrated that there are suitable procedures in place for handling residents’ personal allowance. Receipts are kept of all financial transactions. The recording procedures have improved as required from the 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 17 last inspection. Resident’s monies are double checked and handed over when there is a change of staff on duty. It was noted that a resident was given a cheque from a relative in midDecember. This cheque, to date, has not been placed within the individuals’ bank account. Action must be taken to ensure that this cheque is placed into the residents account before it expires. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 & 30 Residents live in a homely environment. Recent completed building works provide residents with good-sized single rooms. There is better communal space available to residents. EVIDENCE: The home is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and access to public transport. There is no parking available at the home, but parking is permitted on the street. There have been recent building works completed to provide all rooms for single occupancy and to provide suitable space for wheelchair users. A conservatory has been added to expand the communal space for residents. The registered manager has been provided with a small office area as part of these alterations. Rooms spot-checked were seen to be personalised to reflect the individuals’ choice and character. Thermostatic valves have been installed at hot water outlets in residents’ rooms, as required from the last three inspections. It was made an Immediate Requirement that a risk assessment be put in place for the shower in the bathroom that is delivering hot water in excess of 43°C, until a pre set valve is installed. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 19 Risk assessments need to be undertaken for door locks on individual rooms. Rooms have been provided with overhead tracking hoists. These were noted to be positioned in an unobtrusive way. The registered manager has identified a need for a mobile hoist. This was noted when a resident had a pressure area and had to remain out of their chair. This individual had to spend periods of time in their room on the bed, as the home did not have a mobile hoist to allow this resident to join in group activities or be positioned in the communal areas. It is required that advice regarding the need for additional equipment be sought from an Occupational Therapist. The Inspector noted that a carer had difficulty in manoeuvring a wheelchair through a communal doorway. It took them several attempts to get the wheelchair through. It is required that a risk assessment be undertaken for this doorway to establish if an assessment by an Occupational Therapist is required. There were some boxes noted to be in the lounge room. It was discussed with the registered manager that priority be given to store these in an area that does not impact on the residents’ communal space and provide a more homely environment. There is a cleaner employed at the home. The home was clean and free from offensive odours on the day of the inspection. There was a bin for clinical waste noted to be stored with no covering. It is required that all bins having clinical waste are provided with a lid. It is recommended that the cleaning of extractor fans are implemented into the cleaning schedule. The flooring in the staff toilet and bathroom needed replacing. This has not been reflected as a requirement as it was confirmed that this is being addressed. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 35 Residents needs are being met with the numbers of staff on duty at all times. Residents are safeguarded by the recruitment procedures in place. EVIDENCE: There has been one new member of staff employed since the last inspection. This staff member transferred from another CMG establishment. There were some shortfalls in the documentation. These were discussed with the registered manager who confirmed that she will address these shortfalls. It is recommended that the mental health status of a prospective employee be expanded. Staff spoken with confirmed that there are sufficient numbers of staff on duty at all times. The home currently has a vacancy for a part time care worker. There are clear roles and responsibilities for staff. The registered manager confirmed that the key worker system is improving and assisting in providing clear roles and responsibilities for staff. There is no carer with NVQ level 2 qualifications. There are five staff who commenced this training two weeks ago. One carer is undertaking an apprenticeship, which will incorporate NVQ training. It is required that the home continues towards meeting the 50 ratio of staff with NVQ level 2 qualifications. CMG is providing an incentive for staff to complete their NVQ training. A prize is given to the individual who completes the most units within a month. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 21 A staff member spoken to confirmed that they are provided with a lot of opportunities to undertake training relevant to their roles. Some training certificates were noted to be out of date. The registered manager confirmed that staff have received updated training, but head office of CMG have not forwarded on the training certificates. There were no records kept at the home to confirm that training has been undertaken. It is required that evidence be kept at the home of staff training. A staff member spoken with confirmed that they received a good induction when commenced work at the home. There was evidence that staff have undertaken an induction programme. All staff receive a copy of the GSCC code of conduct and practice. A copy of this is kept by the visitors’ book. The home employs some foreign staff and should be commended on obtaining this document in the native language for these staff members. It was confirmed that all staff preparing and cooking meals have not all had Food and Hygiene training. This is to be arranged through the head office of CMG. The provision of night staff has improved since the last inspection. There is one waking staff member and a sleep in staff member. The new procedures for night staff promote their safety, as required at the last inspection. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40 & 42 Residents and staff benefit from clear leadership within the home. Residents and staff will be safeguarded better if prompt action is taken to address identified shortfalls in the health, safety and welfare. EVIDENCE: The registered manager is registered with the CSCI. She has not commenced the Registered Manager Award (RMA). This has been delayed by the head office of CMG. The registered manager has located a distance learning RMA through a college and will be requesting head office of CMG to finance these studies. There are currently no plans to undertake NVQ level 4 in care or equivalent. Priority must be given to ensure the registered manager is provided with support and assistance to obtain the required qualifications. The registered manager has qualifications, which she confirmed is equivalent to NVQ level 3 in childcare. The registered manager confirmed that she has received some managerial training through CMG. This included: Managing a team, supervision, managing stress and budget workshops etc. Staff spoken with were complimentary about the management at the home. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 23 Not all policies and procedures were inspected. Any shortfalls in policies and procedures have been highlighted in the relevant section of the report. The home receives policies and procedures from the head office of CMG. A quick reference guide to policies and procedures has been implemented as recommended at the last inspection. It was confirmed that there may not be a trained first aider on every shift at the home, but there would be one within all CMG homes that are located within the same area. The home must work towards ensuring there is a qualified first aider on duty at all times. This remains an outstanding requirement. It was confirmed that an additional two staff are undertaking this training in March 2006. The home undertakes monthly health and safety checks of communal areas. Fire safety records inspected demonstrated that regular fire drills are undertaken. Fire testing is completed every week. It was noted that problems identified during this test were recorded, but action taken to address the shortfall was documented. There were fire doors noted not to be closing. There was evidence that the home had notified head office of CMG in November 2005. No action had been taken to address this. It was made an Immediate Requirement that all fire doors close effectively. Windows were noted to be unrestricted. It is required that window restrictors be installed. This is to promote the security for staff and residents, working and residing at the home. The laundry is kept unlocked and there were hazardous substances noted to be stored on shelves. It was discussed with the registered manager that consideration be given to keeping this door locked at all times. A risk assessment needs to be put in place to identify if there is a risk to residents/visitors and further action be taken if identified. The recording of accidents has been improved as required at the last inspection. It was confirmed that key workers are currently updating residents’ inventories following the Christmas period. There is suitable insurance in place. 290 Dyke Road is one of many homes within a growing organisation. The home has given no cause of concern regarding financial viability to date. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 1 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 290 Dyke Road Score 3 X 2 2 Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X 1 X DS0000060764.V267166.R01.S.doc Version 5.0 Page 25 YES 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. 2. Standard YA1 YA5 Regulation 4&5 17 Requirement That a copy of the amended Service User Guide be forwarded to CSCI upon completion. That the home has a copy of each individual’s contract/terms and conditions available for inspection. That risk assessments are implemented for the tasks undertaken when working in the kitchen and for individual door locks. That there is a list made available in the kitchen of service users’ likes/dislikes/allergies with food. That prescriptions on MAR charts are kept up to date. That the adult protection policy clearly states that all allegations of abuse must be referred to social services. Information about the POVA list needs to be included. (Timescale 30/09/05 not met) That prompt action is taken to ensure cheques given to service users are placed within the individual’s account. Timescale for action 31/03/06 30/04/06 3. YA9 13(4) 31/03/06 4. YA17 16.2(h&i) 31/03/06 5. 6. YA20 YA23 13(2) 13(6) 15/04/06 31/03/06 7. YA23 13(2)(l) 31/03/06 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 26 8. YA24 23(2)(a) 9. YA27 13(4) 10. YA29 13(5) 11. YA32 18 12. 13. YA35 YA37 18(1)(c) 9 14. 15. 16. 18. 19. YA42 YA42 YA42 YA42 YA42 13.4(a) 13.4(a) 23(4) 13(4) 13(4) That a risk assessment be undertaken for the narrow doorway to establish if an assessment by an Occupational Therapist is required. That a risk assessment be implemented for the shower in the bathroom that is delivering water in excess of 43°C. (Immediate Requirement) That advice regarding the need for additional equipment be sought from an Occupational Therapist. That the home continues working towards the 50 ratio of care staff with NVQ level 2 or equivalent qualifications. (Timescale 31.12.05 not met) That evidence be kept at the home of staff training. That the registered manager obtains the relevant managerial qualifications in care and management. That a pre set valve be installed for the shower. (Immediate Requirement) That windows be restricted. That all fire doors close effectively. (Immediate Requirement) That there is a qualified first aider on duty at all times. (Timescale 30.09.05 not met) That a risk assessment be undertaken regarding the storage of hazardous substances and further action taken if identified. 15/04/06 23/02/06 30/04/06 30/09/06 31/03/06 30/09/07 01/03/06 30/04/06 27/02/06 15/05/06 31/05/06 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA17 YA17 YA24 YA30 YA34 YA42 Good Practice Recommendations That individual records be maintained of service users weight to promote confidentiality. That consideration be given to having the kitchen updated and being made more user friendly and accessible for wheelchair users. That items are not stored in communal areas. That the cleaning of extractor fans be implemented into the cleaning schedule. That information regarding a prospective employees mental health status be expanded. That action taken to address shortfalls noted in the health and safety checks is documented. 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 290 Dyke Road DS0000060764.V267166.R01.S.doc Version 5.0 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. 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!