Inspection on 19/07/06 for 86 London Road

This inspection was carried out on 19th July 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

86 London Road 03/07/07

86 London Road 27/10/05

86 London Road 04/06/05

86 London Road 01/02/05

86 London Road 05/08/04

86 London Road 30/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 London Road (86) 86 London Road Wickford Essex SS12 0AR Lead Inspector Mrs Bernadette Little Key Unannounced Inspection 19th July 2006 10:00 London Road (86) DS0000018029.V304344.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 London Road (86) DS0000018029.V304344.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. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service London Road (86) Address 86 London Road Wickford Essex SS12 0AR 01268 562660 01268 562660 shcllondonroad@estuary.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Estuary Housing Association Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: 86 London Road offered care to four adults with learning disabilities. The house was detached and in a residential street near to Wickford town. There were four single bedrooms, one of which was on the ground floor. Residents have the use of a separate sitting and dining room. Upstairs there was a separate bathroom and a shower room. One room upstairs had been changed into a visitors room and a training room for staff. The garden was large, accessible and well maintained. The home had its own transport to facilitate access to the community for residents. Information on the actual cost of a place was not included in the pre-inspection questionnaire as requested. No information was provided in the questionnaire regarding any additional charges to residents. The weekly fee of £1,517. 52 was identified in the service users’ guide. There was no clarity as to what additional charges residents paid. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of 86 London Road and six hours were spent at the home. Four residents were living at the home at the time of the inspection. Four residents, two staff and the recently appointed manager were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for one resident were case tracked and were sampled for another resident. A pre-inspection questionnaire had been received from the home prior to the site visit and information from this document was also used to inform this report. Discussion of the inspection findings took place with the manager and staff during the inspection and guidance and advice was given. Four completed comment cards were received from a relative, GP, healthcare professional and care manager. Three confirmed that they were satisfied with the overall care provided to residents at the home. One advised that they were unable to comment due to a lack of contact. What the service does well: What has improved since the last inspection? Staff were more clearly aware of the role of the key worker and what this meant. Information and procedures on how to protect residents and what to do if a concern was raised were readily available to staff. A system had been put into place to ensure that agency staff were given an opportunity to read the resident care plans and they signed to confirm that they had done this. New vanity units had been fitted in residents bedrooms. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. London Road (86) DS0000018029.V304344.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 London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and other interested people were given information about the home so they could know whether it was right for them. Pre-admission assessment and trial visits had been undertaken to ensure the home could meet the resident’s needs. EVIDENCE: The service user guide was readily available. It was out of date as it contained information on the previous proposed manager. The newly appointed manager advised that this is being addressed. The statement of purpose was very recently revised. An updated copy of both documents must be sent to the Commission. The file for one service user indicated appropriate social worker referral and contained copies of the initial assessment undertaken by Estuary. A letter on file confirmed overnight stays as part of planned preadmission assessments and opportunity for a trial visit. The letter also confirms that based on the preadmission assessment, the home would be able to offer a placement. Despite the actual assessment, in light of the residents needs and those of the other resident in the home, it was not clear from the assessment that the resident was appropriately placed. Staff spoken with mentioned this also. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 9 A Licence to Occupy, signed by both the home and the resident, was on file. Staff were unclear as to why there was no pictorial statement of terms and conditions on the file, as is Estuarys usual policy. If this is based on the resident’s ability, then further information needs to be provided to the Licence to Occupy. London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The home’s system for recording residents individual care needs and opportunity to make choices/take risks needed greater detail in some areas to ensure consistent care for residents. EVIDENCE: On one file sampled a care plan was in place and dated as written the day the resident was admitted. Considering the residents abilities it was disappointing to note that they had not signed their care plan. The care plan contained relevant issues such as communication, contact with relatives, health action plan, medication, mental health and environment. Some had clear guidelines on how they were to be implemented. Others, for example, in relation to environment and boundaries did not inform how they were to be used in everyday practice. A care plan about the resident’s cooking and eating habits was not in place. A care plan was in place regarding one resident’s possible involvement in a sexual relationship, but not on anothers. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 11 Inspection of the care file tracked, and observation of practice, indicated that residents were supported to take varied risks, including going out alone, smoking, managing their own money, cooking with supervision and in relation to sleeping in the garden. A thirteen point risk and management plan was in place to support staff to consistently manage aggressive behaviour. A behaviour monitoring chart had been instigated and a multidisciplinary meeting planned for the near future. The last inspection all five of the permanent staff were attending training on positive responses. London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ access to leisure and community activities varied widely, and were limited for some residents. The home is aware of the need to increase social and leisure opportunities for residents. Residents were provided with a varied nutritional diet. EVIDENCE: A whiteboard in the office identifies what, if any, activities are planned for each resident of each day. Until recently one resident went to day services five days per week and another on one day a week. These services have now been withdrawn. Staff advised that residents have limited activities, as there is limited provision available. On one day per week, each resident changes their bed linen and tidies their bedroom. One resident has a specified laundry day and also is able to undertake their own ironing. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 13 One resident needs a two to one staffing ratio to go out. Once a week, additional staffing is put in place so that they to go with another resident to watch their horseriding, and then go out to lunch. The resident stated that they really enjoyed this outing. Additional opportunities and staffing need to be provided to ensure this resident has more opportunity for individual planned leisure and social outings each week. One resident attends a mixed craft group once a week and two go horseriding once a week. Some residents also help with the shopping, or go for a drive to head office, or go to the library to choose DVDs. Two residents attend a youth club one evening a week. One residents care plan sampled showed no structure of social activities and indicated that the resident was able to take themselves out as they pleased. This included to cafes, to go and visit family and for example to get a taxi back from the youth club in the evening, based on risk assessment. Staff advised that none of the residents have had a holiday this year, as most could not afford it. Estuary provided £300 towards the cost of a holiday, and residents have to pay all additional costs, including for staff. Observation of practice showed that residents chose whether to be alone or in company. Residents were confident to go in and out of the office to find staff. Staff advised that the planned menu is used as a suggestion or prompt and if service users do not want that meal, they are offered an alternative. This was identified in the record of meals served. This positively shows three meals plus snacks each day. Adequate food stocks were observed. On the day of the site visit three residents were having spaghetti Bolognese and one resident had chosen to have a chicken burger. This resident was being supported to undertake some of the cooking. Three residents spoken with said that they like the food that they had at the home. London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. There was an effective key worker system that supported consistent care for residents. Resident’s health care needs were met. Medication systems sampled protected residents. EVIDENCE: Staff confirmed the detail of the pre-inspection questionnaire that no resident required any specialist equipment and had no need for assistance with transfers. One resident is advised as needing assistance for bathing and would be able to say if they did not want a particular person with them at this time. The home operate a key worker system permanent staff group to assist with continuity of care. A clear policy and procedure on key working was available. Staff clearly identified key clients. Staff advised that they have had opportunity to build relationships with residents over the years and that the success of this and the key worker system this is reflected in the stability of residents’ behaviour. Following advice at the last inspection, as an additional support to consistency of care there were clear written instructions for agency staff to read the care plan and risk assessments. They are also required to sign to confirm that they London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 15 have carried out this instruction. This was observed in practice at the time the site visit. The care file tracked confirmed that the resident had been able to register with a local GP. Staff advised that a resident sees the GP alone as that is their choice, while others are supported as necessary. It was noted that antibiotics had recently been prescribed for the resident for a chest infection. No care plan was in place in relation to this. The resident had seen an optician and had a new prescription/glasses recently, although there was no reference to this in the care plan. Daily care notes identified that staff had taken appropriate action where a resident had asked for pain relief for toothache, and the resident confirmed that they had seen the dentist today. Senior staff advised that permanent staff and three of the regular agency staff who administer medication have an annual assessment in relation to medication competence. No record of this was available for one of the relevant staff, but the staff member did confirm that she had undertaken this some time previously. Medication Administration Recording (MAR) sheets sampled tallied with the medication in the monitor dosage system. Protocols were in place onto resident file sampled in relation to as required medications, which is good practice. Evidence of up to date training for identified staff in relation to the administration of rectal diazepam was not available. The medication policy and procedure was readily available. Staff identified that permission has to be obtained from a senior on-call person in Estuary prior to administering any as required medications. A current Medications Directory and copies of Patient Information Leaflets were also available on file. London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Information was provided to residents in a way that helped them to understand about making their views/complaints known. Policies and procedures generally safeguarded residents, with the exception of some aspects of the use of residents’ money and the charges made to them. EVIDENCE: The home had received no complaints since the last inspection. The Commission had received no complaints regarding the home. The customer services policy/complaint information was displayed. Information on the complaints procedure was contained in the statement of purpose and a pictorial format was also available in the service user guide. All comment cards confirmed that they had not received any complaints nor had to make any complaints about the home. One person stated that they were unaware of the homes complaints procedure. Booklets and guidelines for staff on the protection of vulnerable adults were readily available. Some staff were currently undertaking protection of vulnerable adult training. Staff spoken with were aware of how to identify different forms of abuse and what action to take to protect residents. Residents spoken with said that they would feel able to tell a member of staff if anything was worrying or upsetting them. Records were sampled for residents’ money. Estuary operates a system where residents’ money is kept in an individual current account and individual savings London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 17 accounts, which is positive. However, residents’ personal spending money is pooled in a weekly float and records maintained on individual sheets. Receipts are maintained in the home for only one week as they have to be returned to Estuary and therefore it is not always possible to fully audit the records. It was advised that three of the four residents pay for additional cable television stations. It was unclear who actually watches these channels, and why only three of the four residents are being charged for it. Information on this charge was not contained in the information on charges to residents referred to in the statement of terms and conditions and service user guide. Issues have been raised with Estuary previously about the use of residents money and clarity must be provided to protect staff and residents. Whilst the statement of terms and conditions/contract states that all food is included in the cost of the placement, records indicated that residents regularly pay for their lunch outside the home as an activity. Staff confirmed that residents do not pay for staff meals. London Road (86) DS0000018029.V304344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a comfortable and generally safe environment that met their needs. EVIDENCE: 86 London Road was clean, well maintained and generally safe. However, the cupboard in the laundry where hazardous substances were kept was seen to be open and so present a risk to residents. Additionally a resident had overridden the window restrictors in an upstairs bedroom. This presented a potential risk and a risk assessment/appropriate action was required. Residents’ bedrooms were personalised. A more recently admitted resident had chosen the paint colour for their room, which had been recently redecorated. New vanity units had been fitted in the bedrooms, although one had already been broken. New mirrors were needed in those rooms where this was the appropriate for individual residents. Communal rooms were comfortably furnished and pleasant. Staff were advised of the clear risk presented by the sitting of the ironing board being used by a resident. The garden was well maintained and obviously used by residents. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 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): 32, 33, 34, 35, 36 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to offer residents greater opportunities. The home could not provide access to staff recruitment files and so could not evidence that residents were protected. Training opportunities supported staff and residents. Staff were not provided with supervision. EVIDENCE: Rosters sampled indicated that the minimum staffing level of two staff during the day and one staff at night was being maintained. An additional member of staff was also on duty to assist one resident on their weekly leisure activity, as they require a two to one staff ratio. The newly appointed manager came to the home to participate in the site visit. 86 London Road continues to have staff vacancies. These are mainly covered by agency staff or the homes own staff working additional shifts through the agency. The home endeavour to use regular agency staff that know the residents and rosters indicate that they have been quite successful with this. The roster needs to record the actual hours worked by staff on an early or late shift. The rosters also indicate for example that staff work an early shift followed by an agency late shift, or an eleven and a half hour shift for the agency. There is a maximum limit of 60 hours per week. Staff spoken with said London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 20 they preferred to work these long shifts as residents preferred regular staff and it is less stressful and less of a workload if there are two regular staff on duty. While this is understood, working long days could put staff and residents at risk. Staff advised that three staff are currently undertaking the last module of NVQ level 3 training. Staff demonstrated that they were aware of resident’s individual needs and personalities. Staff and residents spoke to each other and good interaction was noted. Residents confirmed that the staff were friendly and that they liked the staff. Access to the staff recruitment files was required but unable to be given as neither the manager, nor the staff in charge of the home at the time of the site visit, had the key. All keys left in their charge were considered but none gave access to the staff training records. This was an identical situation to that at the last inspection. The report of that inspection stated clearly the concern this raised as Estuary had failed, and had been informed on numerous previous occasions, that this is a legal requirement and access must be available. Staff confirmed that all permanent staff had attended training on anger management since the last inspection in response to a residents need. This and fire training for five permanent staff were identified in the communication book, but no evidence of this had yet been received. Three staff were advised as also having undertaken first aid training in April but were also awaiting certificates. A list of current and planned training was provided. This indicated that the five permanent staff had current training in basic mandatory topics such as food hygiene, protection of vulnerable adults, medication administration and risk assessment. Updates for staff were identified or already booked. Two staff training files were sampled. Certificates were not available to support more current training and this confirmed the staff advice that Estuarys human resources department did not always provide staff with evidence of training. No evidence was available of training for agency staff. Staff confirmed that the home does not provide formal supervision to staff. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 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): The 37, 39, 41, 42 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the homes management could not be inspected as those in charge were unaware of, or unable to access required records and information. Estuary has not provided a suitable person to be registered as manager at this home for over five years. The home has no current system to regularly seek residents and their representatives’ views. Estuary has not regularly monitored the home, as required by regulation 26, to protect residents. EVIDENCE: 86 London Road has not had a registered manager for over five years. While managers have been appointed by Estuary or proposed for registration, they have for one reason or another not been suitable/completed the process. This is not an acceptable situation and Estuary need to propose a suitably experienced person to manage 86 London Road. A person has again very recently been appointed as manager of 86 London Road. He advised that he has no management experience. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 22 Estuary undertook a quality network review in April 2005 in which 86 London Road participated. There has been no further quality review at the home and staff had no further information on this subject. The monthly inspections and reports of these required to be undertaken by the registered person and send to the Commission, have not been undertaken for some months although it is advised that one occurred very recently. It is of concern that a home that does not have an experienced/registered manager in post has not been monitored and supported more closely by Estuary. A record of all the charges to residents, including additional charges, is required to be maintained. This was not available. Portable appliances were logged as recently tested. The emergency lighting was recently inspected. Fire drill records were maintained in different books and again did not identify that all staff had recently participated in a fire drill. Staff advised that a new health and safety officer had been appointed at Estuary who was going round to the homes undertaking specific fire training. The checks required by Estuary to be undertaken weekly, for example for fire equipment, extinguishers, fire alarm and fire doors were not always completed within their required timescale. The water temperature checks were tested and recorded only for hot water, which does not comply with Estuarys own risk assessment requirements. Much of the information or evidence required during the site visit was not readily available or known to staff present and much time had to be spent looking for them. This was difficult for the staff and obviously for the newly appointed manager, who advised he has not yet had time to familiarise himself with all the systems in the home, and the requirements of the National Minimum Standards and Regulation. London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 23 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 2 2 2 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 1 X 2 2 X London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4(2) & 5(2) Requirement A copy of the current statement of purpose and service user guide to be sent to the Commission in response to this report. Timescale for action 15/10/06 2. YA5 5 (1) Each resident to be provided 15/10/06 with a copy of the statement of terms and conditions and standard form of contract include the amount and method of payment of fees. The care plan for each resident must include all aspects of their health and welfare. The person registered must ensure that residents are enabled to engage in age and peer appropriate activities. The person registered must ensure that residents are enabled to engage in community activities. The person registered must ensure that residents are enabled to engage in appropriate DS0000018029.V304344.R01.S.doc 3. YA6 15(1) 15/10/06 4. YA12 16(2)m 15/10/06 5. YA13 16(2)m 15/10/06 6. YA14 16(2)m 15/10/06 London Road (86) Version 5.2 Page 25 social and leisure activities. 7. YA20 13(2) The person registered must 15/10/06 ensure that staff involved to in the administration of invasive procedures (rectal diazepam) are evidenced as trained and competent to undertake the procedure with regular updates. The person registered must 15/10/06 ensure the protection of residents by ensuring the appropriate use of their finances. (Previous timescale of 1.02.04 and 01/12/05 not met) This includes clarity regarding additional charges to residents. 9. YA24 13(2)(c) The person registered must 19/07/06 ensure that potential risks to residents are identified and as far as possible removed. This refers to the lock on the COSHH cupboard being used at all times. The person registered must ensure that potential risks to residents are identified and as far as possible removed. This refers to the opening upstairs windows. The person registered must ensure that there is clarity of roles and responsibilities, and support for all staff in the home, both internal and external, to ensure the best outcomes for residents welfare. (This is a requirement from a previous inspection not assessed at this inspection. Carried forward to a future inspection.) 12. YA33 18(1)a The person registered must provide additional staffing hours to support regular opportunities DS0000018029.V304344.R01.S.doc 8. YA23 13(6) 10. YA24 13(2)(c) 19/07/06 11. YA31 21(1) 19/07/06 15/10/06 London Road (86) Version 5.2 Page 26 for each of the residents to have for opportunities for a leisure activities and community presence. 13. YA34 17(2) & Schedule 4 The person registered must ensure that a system is in place to ensure that all required records relating to staff (including agency) are available for inspection, to evidence robust recruitment practices to protect residents (Previous timescale of 01/07/05 and 01/11/05 not met). Staff must be provided with regular supervision. The person registered must ensure effective management of the home, both internal and external and support the staff team to develop appropriate and effective communication. (This is outstanding from last inspection). The person registered must ensure is a system is in place for reviewing regularly and improving the quality of the care provided in the care home. The person registered must ensure that monthly inspections of the home are undertaken on its behalf and copies of these are sent to the Commission as required by Regulation. (Previous timescale of 01/07/05 and a 01/11/05 not met) The person registered must keep a record of the homes charges to service uses, including any extra amounts payable for additional services not covered by those DS0000018029.V304344.R01.S.doc 19/07/06 14. 15. YA36 YA37 18(2) 12(5)a 15/10/06 19/07/06 16. YA39 24 19/10/06 17. YA39 26 19/10/06 18. YA41 Sch 4(8) 15/10/06 London Road (86) Version 5.2 Page 27 charges, and the amounts paid by or in respect of each service user. A copy of the scale of charges to be sent to the Commission in response to this report. The duty roster must identify the hours worked by each person at the care home. The person registered must, after consultation with the fire authority, take adequate precautions against the risk of fire. This refers to the requirement for a fire risk assessment and maintenance of the fire doors/self closures. Not inspected on this occasion, carried to a future inspection. 21. YA42 23(4) The person registered must make arrangements for people working at the care home to receive suitable training in fire prevention and to be involved in fire drills and fire practices, with appropriate records kept. (Previous timescale of 01/11/05 not met) 19/07/06 19. YA41 Sch4 (7) 15/10/06 20. YA42 23(4) 19/07/06 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 YA2 Good Practice Recommendations The assessment process should evidence that it takes into account the compatibility of the prospective resident with that of existing residents. DS0000018029.V304344.R01.S.doc Version 5.2 Page 28 London Road (86) 2. YA23 The whistleblowing procedure should be written in clearer language. (This is an outstanding recommendation from the last two inspections.) At least 50 per cent of care staff should achieve NVQ training. Staff should not work excessive hours/long days. (This is an outstanding recommendation from previous inspections.) Staff should be provided with formal supervision at least six times each year (This is a recommendation carried from the previous inspection that had not been met) The person registered should ensure that all staff in the home have access to a range of appropriate policies and procedures. The person registered should ensure that the roster identifies who is in charge of the home. The home should comply with the actions required by its risk assessment in relation to the testing of cold water temperatures. It also refers to ensuring that all outlets are recorded as run regularly. 3. 4. YA32 YA33 5. YA36 6. YA40 7 S YA41 YA42 London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 London Road (86) DS0000018029.V304344.R01.S.doc Version 5.2 Page 30 - 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. 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