Inspection on 04/11/05 for 6 Honister Gardens

This inspection was carried out on 4th November 2005.

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

Other inspections for this house

6 Honister Gardens 04/11/09

6 Honister Gardens 14/10/08

6 Honister Gardens 14/08/07

6 Honister Gardens 23/05/06

6 Honister Gardens 28/02/06

6 Honister Gardens 17/03/05

6 Honister Gardens 07/09/04

6 Honister Gardens 26/02/04

6 Honister Gardens 06/01/04

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 6 Honister Gardens 6 Honister Gardens Stanmore Middlesex HA7 2EH Lead Inspector Andreas Schwarz Unannounced Inspection 08:00 4th November 2005 & 7 November 2005 th 6 Honister Gardens DS0000017582.V264100.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 6 Honister Gardens DS0000017582.V264100.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. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 6 Honister Gardens Address 6 Honister Gardens Stanmore Middlesex HA7 2EH 020 8907 0709 020 8907 0709 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) Striving For Independence Group Homes Miss Deborah Alderlyne Pinnock Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2005 Brief Description of the Service: 6 Honister Gardens is a care home providing personal care and accommodation for up to five people who have a learning disability. There was one vacancy in the home at the time of the inspection. The home is owned and run by the Striving For Independence organisation, a local private and independent care service provider. The home has 24-hour staffing, including one waking-night staff and a sleepover staff. The home is located within a residential area on the edge of both Stanmore and Belmont, in the borough of Harrow. It is a few minutes from bus links, and around ten minutes’ walk from local shops. Parking restrictions do not apply on the road outside the home. The drive has space for two cars. The premises are a two-storey building in keeping with other homes in the street. All bedrooms are single rooms, fully furnished, and with built-in sinks, both upstairs and downstairs. One has an en-suite toilet. The home has one bathroom with adapted shower facility upstairs, and a shower room downstairs. The home has a kitchen, a lounge leading into a dining area, a spacious activities room, and a garden. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in November 2005. Three inspectors visited all care homes managed by SFI on the 4th November 2005 and spend three hours at the homes. The inspector returned Honister Gardens on the 7th November and spent an additional five hours at the home. During the two days the inspector spoke to Mrs Whittick (Registered Manager), Mrs Pinnock (Registered Individual), two members of staff and three residents living at the home. The inspector viewed care plans, risk assessments and other records made available to him. The inspector would like to take the opportunity thanking everybody who was so helpful during this inspection. What the service does well: What has improved since the last inspection? What they could do better: 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 6 The inspector made a number of requirements during this inspection, the Registerd manager is required to up date finance procedures in relation to service users finances. The home must also ensure that all staff employed by the home has had all relevant checks prior starting employment. Outstanding requirements made by the pharmacy inspector of the Commission for Social Care Inspection must be complied with. The manager must ensure staff is trained in dementia care and physical intervention. The registered manager must give clear instruction to staff in how to care appropriately for residents with type 2 Diabetes. 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. 6 Honister Gardens DS0000017582.V264100.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 6 Honister Gardens DS0000017582.V264100.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): 2; 3 Prospective residents are assessed appropriately and residents are offered the opportunity to test drive the home before permanently moving in. The home is currently meeting residents needs, but staff must receive more specialist training. EVIDENCE: The home has a very detailed assessment and referral policy in place. The home manager and proprietor assess new prospective residents. Assessment records viewed by the inspector confirmed this. Residents’ assessment records are not openly available to staff and have been locked away in the office during the first day of this unannounced inspection. [The registered manager informed the inspector during the second day of this inspection, “that it is not SFI’s policy for staff to have access to all of the service users records. However there are records that are stored in a locked staff cupboard and are readily available to staff such as care plans, medication, immediate medical and health records, and family contact details and petty cash information. Records that are stored in the office are like bank statements and historical information. These records are stored for the service users protection, to protect their rights to confidentiality, and to prevent the service user from being stereotyped based on previous reports. This information is available to key workers, staff and professional agencies upon request and on a need to know basis.”] The inspector was however satisfied that needs addressed during the assessment have been incorporated within the care planning process. The registered manager informed the inspector that the home accepts emergency 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 9 placements and offers respite beds. Policies and procedures in relation to this have been implemented. The previous inspection to the home required for staff to receive dementia training, this has not been met. The manager informed the inspector having contacted Harrow Learning Disability Team, but was unable finding anybody providing dementia training to the staff team. The inspector suggested to the manager contacting other agencies for training provision. 6 Honister Gardens DS0000017582.V264100.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 All residents have individual programme plans and are involved within the review processes. The home assesses residents risk in detail and residents are encouraged taking part in the review of these. EVIDENCE: The inspector viewed during the first day of the inspection residents individual programme plans, the folder however was very unorganised and it was difficult finding records relating to one individual. Staff was not fully aware where residents care plan files are kept, but told the inspector that they may be in the office. The office however was locked during the first inspection day and staff was not able accessing residents care plan folders. During the second day of this inspection, the inspector was able viewing the care plan folders and judged them as appropriate. The manager informed the inspector that the main files are kept in the office due to confidentiality, which is good practice. The care plan files hold a number of very important information, which may be important to know when caring for residents, the inspector therefore requires that care plan files are accessible to staff at all times. [The registered manager informed the inspector “As previously mentioned care plan files are available in the staff cupboard down stairs. The folder may have 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 11 been disorganised due to regular use, but it contained all four care plans for the residents in the home. Therefore care plans are available to staff at all times. Relevant information contained in the previous historical reports is included in the current care plan. There is however a master file in the office and when the manager is not in the home the office is locked. Information contained in the master file is available to key workers, staff and professional agencies on request and a on a need to know basis.”] The inspector suggests keeping care plan files in the lockable cupboard in the hallway. One of the individual programme plans viewed by the inspector had an excellent positive behaviour intervention plan attached. This document refers to physical intervention as the last resort; staff however was not clear what techniques are agreed by the home, which raises concern. The registered manager must ensure that all staff receives physical intervention training and one agreed technique is used if there is a need to hold or restrain residents. [The registered manager informed the inspector, “that SFI Group Homes staff have received the following training: (i) Introduction to Challenging Behaviour (by Elaine Rudy HLDT) and (ii) Risk and Conflict Management (by Bryan Shewry HLDT). The staff in question has informed the registered manager that she had received physical intervention training from a previous care home. The staff member did state that she was very nervous, felt intimidated and didn’t quite understand what the inspector was asking her. It is SFI Group Home Policy to ensure that staff are trained to SFI Group Homes standard and are therefore advised not to use physical intervention unless they are trained by SFI Group Homes to do so. SFI Group Homes Training Department do plan to schedule two courses early next year (i) Risk and Conflict Management and (ii) Physical Intervention Training.”] Another resident has diabetes, this has been addressed in the residents care plan and in the staff meeting, and the inspector was concerned to see that the resident had a large English breakfast on the morning of the first inspection day. The inspector therefore informed the manager that all staff must be made aware of how to care for residents with Type 2 Diabetes and the manager must ensure that all staff read staff meeting minutes. The inspector viewed a number of excellent risk assessments and the registered manager complied with requirements regarding assessing the risk of one resident who spends time on his own at the home. The home however has not complied with the need of assessing the risk for having a key to their room/ front door for three other residents living at the home; this is required. Risk assessments are reviewed annually during service users care plan reviews or when needs have changed. 6 Honister Gardens DS0000017582.V264100.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): 12; 17 Residents living at the home are offered appropriate activities in-house or in day centres. The home is providing a healthy, wholesome and varied diet to the residents EVIDENCE: The manager informed the inspector that residents either go to day centre run by the organisation or staff is provided if service users decide to stay at home. In Addition to this one resident accesses the community independent and the manager informed the inspector, that he is going to Harrow, Brent Cross, etc. The resident chooses what he wants to do independently and told the inspector of being happy with this arrangement. Another resident who is within the autistic spectrum is attending a day service run by the National Autistic Society in Acton. The inspector viewed a record of achievement file of this individual, which was judged exemplary and of high standard. The inspector however found that day service participation was not recorded for all residents to the same standard; which is required. The inspector viewed the homes menu and observed breakfast on two occasions. The home provides two cooked meals every day, previous inspections required to record fruit and vegetables on menus, which has been 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 13 complied with. Staff record menu choices made by residents separately. The breakfast observed on both occasions was cooked. The inspector informed the manager, that he observed one resident with Type 2 Diabetes having a cooked full English breakfast; this has been addressed in standard 6 in this report. A fruit bowl was openly available during this inspection and residents were observed of going in and out of the kitchen and helping themselves to food. Residents informed the inspector of being very happy with food at the home. The inspector recommended taking the meal choice for lunch of the menu. Residents don’t eat their lunch at the home during the week, except on Saturday and Sunday or if they decide not to attend the day centre in Petchgrove, which is run by the organisation. Menus are planned together with the residents during residents meetings. 6 Honister Gardens DS0000017582.V264100.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): 20 Residents are protected by the homes’ medication procedure. EVIDENCE: The pharmacy inspector of the Commission for Social Care Inspection visited the home in September 2005. The inspector assessed all requirements made by the inspector, the home however did not comply with all requirements made during this inspection by the pharmacy inspection and the inspector informed the registered manager that she must comply with all requirements to meet National Minimum Standards. [The registered manager informed the inspector, “ staff at Honister Gardens had attended a certified Medication Administration Training Course with Alpha Care in September 2005.”] 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 15 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’ views are listened to and supported to make complaints with the help of a complaints policy. The inspector did not assess standard 23 fully; financial records of residents however have been assessed. EVIDENCE: The inspector viewed the homes’ complaints procedure, which is judged as being detailed and compliant with National Minimum Standards. The home records compliments and complaints and the inspector viewed these records. The home has a service user-friendly complaints policy, which is available in the service user guide. The inspector informed the registered manager that it is good practice to display the complaints policy on the notice board for staff and service users to access. The home has followed up a complaint by a neighbour appropriately and is currently waiting of receiving the outcome of this complaint from the court. The manager however informed the inspector that the allegations made have been of malicious nature and the court will not pursue the complaint any further. The inspector asked the home forwarding this to the Commission for Social Care Inspection once received the judgement in writing. The inspector viewed and audited financial records. Residents’ families act as their appointee and provide the home with money to be given to residents on their request. Records of this have been viewed and assessed. The home has different places for money to be kept. All residents have individual tins, which can be accessed by support workers; records viewed by the inspector were in order. The manager informed the inspector that staff is giving one resident money on his request, but the service user does not sign records; this should be considered in the future. In addition to this the home has money locked 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 16 away in a safe, the manager can only access the safe, records of these were incorrect and did not tally. The inspector informed the manager of this and informed her that the records must be put in order. [The registered manager informed the inspector, “that the petty cash records were in the process of being logged onto the computer. The inspector was shown a work request sheet dated 27 October 2005 in addition to this the inspector was shown computer records of one of the residents and was informed that some information had been inputted onto the computer as previously requested, but this information had yet to be checked by the manager.”] There was no evidence of regular auditing by the manager or a finance person, the inspector informed the manager of this and explained that regular audits of financial records are required. [The registered manager informed the inspector, “that she regularly audits the finances however there were no records to verify this. The manager showed the inspector a folder containing clients’ petty cash receipts and explained the SFI finance office receives, checks and collates all clients’ petty cash and receipts. SFI office is currently arranging a general audit for the organisation via an external agency.”] 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 17 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 The home provides a homely and comfortable environment for residents. EVIDENCE: A member of the support staff showed the inspector around the home. The home is nicely decorated and was clean and free of any offensive odours during this inspection. The home has a through the floor passenger lift, which has been serviced and records have been viewed by the inspector the registered manager informed the inspector, that she is still waiting for a certificate from the company responsible for the service. In addition to this the inspector found when using the lift that the alarm bell was not working and informed the registered manager that the lift requires additional servicing. During a tour of the building the inspector made the following requirements. Two floor tiles in the kitchen were found to be cracked and one was loose, the doorknob to a corner kitchen cupboard was missing and a screw was exposed, which could lead to injuries. The carpet in the dining area to the edge of the floor hatch was found to be slightly lifted up; this must be repaired. A number of radiator covers around the home were broken and residents could scald themselves, a maintenance man started to repair the radiator covers during this inspection. The light switch in the hallway between room 2 and room 3 was found to be broken and must be repaired. The sky light above the door leading to the garden is leaking, the manager informed the inspector that a 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 18 builder has attempted to repair the leak, but the issue was not fully remedied during this inspection. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 19 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): 33; 34 A sufficient number of staff is supporting residents on a 24-hour rota basis. The home must review their recruitment practices to achieve full compliance with standard 34. EVIDENCE: A staffing rota was available during this inspection; it was evident that waking night staff works between 9pm and 9am, along with one staff sleeping-over. Two additional staff are rostered to work during the day, this means that at all time two staff support residents living at the home. This is judged as adequate taking the current number of residents living at the home into consideration. The home did not use agency staff since January 2005. There was no duty rota available for the following week, the inspector spoke to staff who informed him that they will call the proprietor to find out what shifts they are working the following week. Staff informed the inspector that usually rotas are available in advance, but due to the registered manager being on holiday this was not the case during the first day of this inspection. The inspector did not judge this as appropriate practice in particular to one resident studying the duty roster regularly. It is therefore required for the registered manager to provide duty rosters in advance. Staff work in all three care homes managed by the organisation. There is no record on each of the rotas of the total hours worked per week by members of staff. The registered manager is required to take immediate action to address the issue identified and to ensure the safety of all persons in the service. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 20 Two other Regulation Inspectors visited the head office on Friday the 4 November 2005 and assessed staffing files. The two inspectors have assessed all staffing records for all care staff employed by the organisation. The inspectors made the following requirements during this assessment. Five staff files did not contain an enhanced CRB disclosure, 3 staff files contained a CRB disclosure that had been obtained during employment prior to working at S.F.I., 3 files did not contain evidence of 2 satisfactory references, 8 files did not contain evidence of proof of ID, 5 files did not contain evidence of the member of staff’s right to work in the UK, 2 files contained information about student status without information about the number of hours that they are allowed to work, 1 file contained information about visitor status without information about whether they were allowed to work, 1 file contained a work permit that had expired and one file contained information about a work permit being refused. The registered manager is required to take immediate action to address the issue identified and to ensure the safety of all persons in the service. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 21 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): 42 The overall health, safety and welfare are protected by appropriate procedures and policies. EVIDENCE: The inspector viewed Health and Safety certificates and the following issues have been addressed with the registered manager. The gas safety certificate has expired; the Registerd manager must forward a valid gas safety inspection certificate to the Commission for Social Care Inspection. Portable Appliance Certificate is valid and current. The electrical installation certificate has been done, but it is not clear when the certificate expires, the inspector informed the Registerd manager that she must contact the engineer and obtain a certificate with an expiry date. Fire records viewed by the inspector have been of good standards with the exception of weekly fire point tests; the registered manager was informed of this and the inspector explained that this is required. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 22 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 X 3 2 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 Honister Gardens Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000017582.V264100.R01.S.doc Version 5.0 Page 23 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 Standard YA3 Regulation 18(1)(c) Requirement The manager must ensure that staff is provided with appropriate dementia awareness training to complement the skills needed to support one service user’s needs. (Expired 01/08/05) Care plan folders must be made available to staff at all times. The registered manager must ensure that all staff receives physical intervention training and only one agreed technique must be used. All staff must receive diabetes training and must be made aware of what food is appropriate when caring for residents with Type 2 diabetes. The registered manager must ensure that all staff read information relating to residents The manager must add to the service user risk assessments in respect of whether or not each service user is considered capable of holding house and bedroom keys, and in terms of any service users locking themselves in any rooms. DS0000017582.V264100.R01.S.doc Timescale for action 31/12/05 2 3 YA6 YA6 17(3)(b) 18(1)(c)(i) 13(7) 30/11/05 31/12/05 4 YA6 18(1)(c)(i) 31/12/05 5 6 YA6 YA9 18(1)(a) 12(4) 13(4) 30/11/05 15/12/05 6 Honister Gardens Version 5.0 Page 24 (Expired 01/08/05) 7 YA12 12(1)(b) 15(1) The registered manager must ensure that day service participation is recorded for all residents. 13(2) The home must have an additional procedure for accepting medication for respite service users. (Expired 01/11/05) 13(2) The home must have a list of signatures and initials of staff trained in the safe handling of medication. (Expired 01/10/05) 16(2)(l) Financial records, which were found to be incorrect must be corrected and evidence of this must be, send to the Commission for Social Care Inspection. 16(2)(l) The registered manager must ensure that service users financial records are audited regularly. 23(2)(c) The registered manager must LOLER;Reg send a copy of the lift inspection certificate to the Commission for Social Care Inspection. (Expired 01/07/05) 23(2)(c) The registered manager must LOLER;Reg ensure that a suitably qualified lift engineer repairs the alarm bell of the passenger lift. 23(2)(b) The cracked and loose tiles in 13(4)(a) the kitchen must be repaired. 23(2)(d) The missing door knob on the 13(4)(a) kitchen cupboard door must be replaced 23(2)(b) The ripped carpet in the dining 13(4)(a) room must be repaired or replaced. 23(2)(b) The broken radiator covers 13(4)(a) around the home must be repaired. 23(2)(b) The broken light switch in the 13(4)(a) hallway must be repaired. DS0000017582.V264100.R01.S.doc 30/11/05 8 YA20 31/12/05 9 YA20 30/11/05 10 YA23 30/11/05 11 YA23 30/11/05 12 YA24 15/12/05 13 YA24 30/11/05 14 15 16 17 18 YA24 YA24 YA24 YA24 YA24 15/12/05 30/11/05 15/12/05 30/11/05 30/11/05 6 Honister Gardens Version 5.0 Page 25 19 20 YA24 YA33 23(2)(b) 18(1)(a) Sch4(7) 18(1)(a) Sch4(7) 19 Sch2 Para1to7 21 22 YA33 YA34 The leaking skylight in front of the patio door must be repaired. Each home’s rota must record the total number of hours worked per week across all of the S.F.I. care homes The registered manager must ensure that the duty rosters are planned in advance at all times. Enhanced CRB disclosure application forms must be completed and submitted to the Commission for Social Care Inspection for the 5 members of staff who did not have a CRB disclosure and for the 3 members of staff who have provided CRB disclosures obtained prior to their employment with S.F.I. All files for members of staff employed since 1st April 2002 must contain 2 satisfactory references. All staff files must contain proof of ID. 30/11/05 14/11/05 30/11/05 20/11/05 23 YA34 19 Sch2 Para1to7 19 Sch2 Para1to7 19 Sch2 Para1to7 06/12/05 24 25 YA35 YA34 06/12/05 All files of members of staff who 06/12/05 do not hold a UK or EU passport must have evidence of their right to work in the UK and that the right to work is valid and has not expired. All files of members of staff who 06/12/05 have student or visitor status must contain information confirming right to work and any restrictions on this e.g. number of hours per week. A copy of a valid gas safety certificate must be forwarded to the Commission for Social Care Inspection. The registered manager must contact the electrical engineer DS0000017582.V264100.R01.S.doc 26 YA34 19 Sch2 Para1to7 27 YA42 13(4)(a) 30/11/05 28 YA42 13(4)(a) 30/11/05 Page 26 6 Honister Gardens Version 5.0 29 YA42 23(4)(a) who has done the electrical installation test and obtain a certificate with an expiry date The home must undertake and record weekly fire point tests. 30/11/05 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 7 Refer to Standard YA3 YA6 YA17 YA20 YA22 YA22 YA23 Good Practice Recommendations The inspector recommends contacting other training providers for dementia training. Care plan folders could be stored in the lockable cupboard in the hallway. The inspector recommends removing the lunch meal choice from the menu. If the home wishes to store and use homely remedies, then the policy should be expanded and agreed and signed by the GP. The manager should inform the Commission for Social Care Inspection in writing of the outcome of the complaints investigation. The home should display the homes’ complaints procedure on the notice board. If money is given to a resident a signature should be obtained. 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 6 Honister Gardens DS0000017582.V264100.R01.S.doc Version 5.0 Page 28 - 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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