Inspection on 06/12/06 for Dimensions 49 Chichester Court

This inspection was carried out on 6th December 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 24 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dimensions 49 Chichester Court 07/05/08

Dimensions 49 Chichester Court 20/01/06

Similar services:

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

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

CARE HOME ADULTS 18-65 Adepta 49 Chichester Court 49 Chichester Court Stanmore Middlesex HA7 1DX Lead Inspector Andreas Schwarz Key Unannounced Inspection 6th December 2006 09:30 Adepta 49 Chichester Court DS0000062735.V321181.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 Adepta 49 Chichester Court DS0000062735.V321181.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. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta 49 Chichester Court Address 49 Chichester Court Stanmore Middlesex HA7 1DX 020 8905 0068 020 8343 8876 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) www.Adepta.org.uk Adepta Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 Brief Description of the Service: 49 Chichester Court is the largest of four houses in a purpose-built complex previously managed by Hillstream Care but now by Adepta (formerly known as PentaHact) following a merger during the late summer of 2004. Metropolitan Housing Association maintains the building. The home provides long-term care and accommodation for up to seven adults with learning, physical and sensory disabilities. There were two vacancies at the time of the inspection. All service users have their own bedrooms. Bedrooms are on the ground and first floors. There is a spacious lounge, two dining areas, and a large garden to the rear. The building is fully wheelchair accessible downstairs, and has an adapted bathroom. Access to the first floor is by stairs only. The home is quite close to shops, leisure facilities and local transport. It shares a mini-bus with three homes in the same complex. Unrestricted parking is available on the road leading to the house. Fees and charges can be obtained from the Homes Manager. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place in December 2006 and lasted the whole day. The manager was available during the whole day and the inspector spoke to the deputy manager and two members of staff. Residents living at the home are nonverbal, the inspector observed staff interacting and supporting service users. The inspector viewed case notes and other relevant documents to make a judgement of the quality of care given to residents living at the home. The inspector would like to thank residents, staff and manager for welcoming and assisting him during this key inspection. What the service does well: What has improved since the last inspection? The home has met four of the eight outstanding requirements made during the previous key inspection. The home has received a random inspection in May 2006 during which a large number of requirements have been complied with. The home has purchased a Parker bath, which is now fully operational. The organisation has employed a new permanent manager, which appears to be very experienced and eager to implement changes to the service. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Adepta 49 Chichester Court DS0000062735.V321181.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 Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New prospective service users receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet the needs of new prospective residents. EVIDENCE: The home has updated their statement of purpose and service users guide, which now reflects the changes of provider and organisation. The home has an admissions procedure and policy in place. The procedure states that new prospective service users are able to test-drive the home. The home has currently two vacancies and had no new admissions since the last key inspection. Previous admissions have been assessed appropriately. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are good standard and service users involvement is evident throughout. Residents can choose where to go, what to eat and evidence of this was observed during this inspection. The home has detailed risk assessments in place and service users are involved in the review process. EVIDENCE: The inspector assessed two care plans in detail during this key inspection. One care plan was of excellent standard, service users needs and care plan objectives have been reviewed regularly and in detail. The service user has an advocate; which is fully involved within the care planning process. Service users communication needs have been assessed and a list of gestures are recorded for staff to use when communicating with this individual. Care plans have been reviewed and service users family and representatives have been invited and involved within the review process. All residents have an allocated key worker. The inspector noted than both of the assessed care plans were not Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 10 of the same standard, this has been discussed with the manager and the home has been informed to monitor care plans regularly. Cultural issues are addressed in the care plan and are reviewed regularly, i.e. to visit the country of origin, cultural appropriate food, festivals, etc. The home has access to an advocacy project in Hertfordshire and some residents have an advocate allocated while other residents are currently on the waiting list. The inspector observed staff offering choices of what to eat or what to do during this visit. Service users choices are recorded and documented in care plans. The home supports residents with their finances and staff have supported residents to purchase Christmas presents, which have been stored in one of the spare bedrooms. One of the care plan objectives was to open a bank account, which has been actioned, but the manager informed the inspector that the home still has problems with sorting out the appointee ship. This is currently with the Department for Works and Pension and the home is waiting to be visited soon. The home has a wide range of risk assessments in place. Service users risk assessments are reviewed within the care planning process. The home has a detailed Health and Safety risk and fire risk assessment in place, which has not been reviewed since December 2005. The inspector viewed detailed challenging behaviour guidelines for staff, the reactive actions to minimise challenging behaviour in these guidelines is the use of “Proactive Strategies for Crisis Intervention and Prevention” (SCIP), the manager informed the inspector that only two staff have attended the training. The inspector informed the manager that all staff must receive SCIP training to be able to deal with challenging behaviour appropriately. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is supporting residents to live a full, culturally appropriate and stimulating life. Residents can choose where to go, what to do and what to eat and are involved in the planning of activities. EVIDENCE: All residents attend different day centres in Harrow and Brent. The home has just received additional funding for one resident and day service will be provided through the home and in the community. Due to the level of disability none of the residents living at the home are currently in any employment. Residents access the local community regularly and records showed that residents go swimming, have lunch in local pubs or café’s, go shopping, go to cinemas and access social clubs on weekly basis. The home is sharing a minibus with homes located closely. Staffing is well balanced during evenings Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 12 and weekends. Additional staff has been allocated on weekends to enable attending church services. The home is addressing relationships and sexuality within the care planning process and residents are encouraged to maintain relationships with families. The home has done a lot of work to establish relationships with family members and two residents have increased contact with their family. The home has a relationship policy in place. Families and representatives are regularly invited to parties and are involved within the quality assurance process. Residents have the opportunity to meet non-disabled people in pubs, café’s, swimming, etc. The inspector observed staff treating residents with respect and mail has been opened in front of residents. Staff did interact with residents throughout this visit and one service users receives one to one support as stated in his care plan. Residents can move around freely and the ground floor of the home is fully wheel chair accessible. Residents are involved in household activities and staff support residents around their laundry, cleaning of their bedroom, etc. The home has a menu displayed and the diet is varied and healthy. The home has involved a dietician for two residents and recommendations made by the dietician are reflected in the homes menu and have been observed by the inspector. The home is regularly assessing service users weight and it has been noted that service users look healthy and have lost some weight during the past year. Residents are involved in choosing their menu and the home has a large folder with pictures for residents to point on. Menus are prepared weekly and displayed in the kitchen. The inspector recommends displaying a picture of the meal instead of displaying a written menu. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health is managed appropriately and residents are encouraged to be as self-managing as possible. EVIDENCE: Staff observed demonstrated good knowledge of how to support service users around personal care and continence. Care plans have personal care guidelines in place and residents were dressed gender appropriate. Staff supports residents in purchasing new clothes. The home has purchased a ripple mattresses and cushion to protect one resident from pressure sores. The manager informed the inspector that the home is currently exploring if a ceiling hoist could be fitted in one of the residents rooms. Residents are visited weekly by a Physiotherapist and massage therapist, clinicians such as psychiatrist and psychologist can be accessed through Harrow and Brent Learning Disabilities Team. Speech and language therapy has been involved and recommended for staff to attended a two days communication course, which is still outstanding. The Occupational Therapist assessed two service Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 14 users in November 2005, but recommendations made are still not met as previously required. Residents are registered with their own GP and visits are recorded clearly. One resident with diabetes has been missing chiropodist appointments and the last appointment was on 27/04/06, considering the history and health issue this is not satisfactory and the home must ensure that service users receive regular chiropodist appointments. Dieticians are involved and a suitable diet is provided for residents who have difficulties with swallowing. The inspector viewed separate health records in service users files, but these were not filled out to the same standard, which must be addressed. The home has a medication procedure in place, which has been updated in December 2006. Medication is handed over in each shift and two members of staff have to sign. The home had four medication errors in the past year and staff has been trained by the manager in the correct administration of medication. The home is currently in the process to teach one resident to selfadminister, which must be risk assessed in detail. One of the residents is having insulin injections and the community nurse visits the home daily to draw up insulin. The inspector spoke to the community nurse during this visit and the possibility of the use of an EPI pen has been discussed. The manager should contact community nursing to find out about training for staff and resident. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and self-harm. EVIDENCE: The home has a complaints policy, which has been updated and includes the new managers details. The home has not received any complaints since the last inspection. Previous complaints have been recorded, but recommendations to summaries complaints, in terms of what the issue was, what actions were taken and what the outcome was, is still outstanding. The home has a Protection of Vulnerable Adults policy in place and local guidelines are available. The home had no Protection of Vulnerable Adults referrals since the last inspection. The Inspector noted that the home has a number of policies such as whistle blowing, violence and aggression, etc. in place. Protections of Vulnerable Adults training records were incomplete and the manager must ensure that all staff receives Protection of Vulnerable Adults training. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment, which is clean and free of any offensive odours. Service users are encouraged to bring their personal possessions. EVIDENCE: The manager showed the inspector around the building, overall the home is nicely decorated and the ground floor is suitable for service users who use a wheel chair. The following issues have been pointed out to the manager. The shower hose in the upstairs shower is broken and must be replaced. The plasterwork and damp patch in the upstairs hallway has been plastered over, but plaster has started to flake again. The blocked sink in Room 5 must be unblocked. Staff assists residents with the cleaning of their room, but the inspector pointed out that skirting boards were very dirty and haven’t been cleaned for a long time. A shoe rack in a service users room was broken and a replacement has been purchased. The wardrobe door in room 3 came of and Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 17 must be fixed. The extractor fan in the kitchen was very sticky and must be cleaned The home has sluicing facilities and the laundry room has a dryer and washing machine. The floor is of good condition and the wall can be cleaned. The hand washbasin was very dirty and must be cleaned. The home has a range of Health and Safety policies in place and COSSH products have been stored safely during this inspection. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Appropriate recruitment policies and procedures protect residents from unsuitable staff. Staff has received some training, but more training is required to fully meet National Minimum Standards. EVIDENCE: Records show that all but one staff has or are in the process of obtaining their National Vocational Qualification in Care qualifications. The inspector observed staff interacting with residents and was impressed how patient and sensitive staff responded to service users needs. The home does not employ staff under the age of 18. The inspector viewed staffing files, which did not include any recruitment records. It was agreed with Adepta and Commission for Social Care Inspection Providers Relationship Manager in September 2006, that staff records could be stored centrally in the Colchester or Finchley office. These records can be obtained if the inspector chooses to, but this was not done on this occasion. Previous inspections noted that recruitment standards have been judged as good. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 19 The inspector was not able to fully assess training records during this inspection. Training and Development plans were not available and staff training needs have not been analysed. The inspector found a number of certificates, but the majority of certificates were for staff that has left the home. Staff informed the inspector of being unhappy about not receiving training, which has been discussed and agreed in supervisions. The inspector viewed three staffing files one member of staff has started with the organisation in February 2006, but has not received any training up to date. Another member of staff informed the inspector of not having received any training apart from Health and Safety training since the last inspection. Staff told the inspector that this dampens the morale and leads to staff leaving and looking for a post somewhere else. Due to the lack of training records the inspector was unable to establish if staff have received challenging behaviour training as required previously. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced and qualified manager manages the home. Residents are regularly involved and consulted in the running of the home. Residents Health and Safety is not compromised and safe working practices are in place. EVIDENCE: The acting manager Mr Mansell has left and a new manager has been appointed, the Commission for Social Care Inspection has not been informed of this. The new manager Mrs Rupee Jassal has National Vocational Qualification in Care and Management Level 4; she is also a qualified National Vocational Qualification in Care assessor and Verifier. Mrs Jassal has been working in the learning disabilities field for a number of years and has been registered with Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 21 the Commission for Social Care Inspection in the past. The inspector received very positive feedback from staff regarding the new manager. The home has a good quality assurance procedure in place and service users, families and staff surveys have been send out. The manager informed the inspector that the home would meet with families and service users on 14/12/06 to discuss and analyse the feedback received. The home has regular recorded service users and staff meetings. The inspector viewed fire records, which have been all up too standard. The last fire drill was in November 2006, the fire system is serviced quarterly last service 12/11/06. The home has a detailed fire risk assessment in place. The home Landlords Gas Safety Certificate was done in June 06 and is valid for one year. The manager informed the inspector that the electrical wiring test has been undertaken, but no certificate was available for inspection. The home must send a copy of the electrical wiring certificate to the Commission for Social Care Inspection. The inspector noted the Portable Appliances Test has expired in June 2006 and must be renewed. Hoists and Parker bath are serviced every six months the last service was undertaken in June 2006. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 2 X Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 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. 2. Standard YA6 YA9 Regulation 15(2)(a) 18(1)(c)(i) Requirement Timescale for action 31/12/06 3. 4. YA9 YA18 14(2)(a) 13(1b), 23(2)(a, n) Care plans have to be monitored regularly by the manager. All staff must receive 31/03/07 Proactive Strategies for Crisis Intervention and Prevention (SCIP) training All risk assessments must be 31/12/06 reviewed in regular intervals. Actions from the occupational 31/01/07 therapists’ report must be addressed. (Previous Timescale of 01/05/06 & 15/07/06 not met) 5. YA18 18(1)(c)(i) 6. 7. YA19 YA19 12(1) 17(1)(a) 8. YA20 13(2) Staff must attend a two-day communication training as recommended by the Speech and Language Therapist during the last assessment. The manager must ensure that residents attend regular chiropodist appointments. The manager must ensure that all health records are maintained to similar standards. The home must provide DS0000062735.V321181.R01.S.doc 31/03/07 31/12/06 31/12/06 31/01/07 Page 24 Adepta 49 Chichester Court Version 5.2 9. 10. YA23 YA24 13(6) 23(2)(b, d) detailed risk assessments for service users who are taught to self-administer. All staff must receive Protection of Vulnerable Adults training. Redecoration work following a leak from an upstairs bathroom is needed. This includes: On the walls outside the bathroom due to flaking paint. (Timescale of 01/04/06 & 15/07/06 not met) 31/03/07 31/01/07 11. 12. 13. 14. 15. 16. 17. YA24 YA24 YA24 YA24 YA24 YA30 YA35 23(2)(b) 23(2)(c) 23(2)(c) 23(2)(d) 23(2)(d) 23(2)(d) 18(1)(c)(i) 18. 19. 20. YA35 YA35 YA35 18(1)(c)(i)(ii) 18(1)(c) 18(1)(c) The broken shower in the upstairs bathroom must be fixed The sink in room 5 must be unblocked The broken wardrobe door in room 3 must be repaired The extractor fan in the kitchen must be cleaned. Skirting boards in service users rooms must be cleaned thoroughly. The sink in the laundry room must be cleaned. All staff must have a training and development plan and detailed training needs analysis. All staff must receive at least five training days per year The manager must update staffs training files The manager must ensure that all staff will have received training in challenging behaviours. (Previous timescale of 01/07/06 not met) 31/01/07 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/01/07 31/03/07 31/01/07 31/01/07 Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 25 21. YA37 10(3), CSA s11, 12 The manager must ensure that she applies for registration with the CSCI. (Previous timescale of 1/9/05 & 15/03/06 & 31/07/06 not met.) 31/01/07 22. YA37 39(b) 23. YA42 24. YA42 The registered provider must 31/12/06 inform the Commission for Social Care Inspection of changes in management. 23(2)(c)&13(4) The manager must send a 22/12/06 copy of the electrical wiring certificate to the Commission for Social Care Inspection. 23(2)(c)&13(4) The home must renew their 31/12/06 Portable Appliances Test Certificate and send a copy of this to the Commission for Social Care Inspection. 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. Refer to Standard YA17 YA20 YA20 YA22 Good Practice Recommendations The inspector recommends displaying a picture of the meal instead of displaying a written menu. A record of the date of opening any liquid medications should be kept. The home should find out staff training around the use of an EPI pen for insulin injections. It is recommended that each complaint within the complaints file be clearly summarised, in terms of what the issue was, what actions were taken, and what the outcome was. DS0000062735.V321181.R01.S.doc Version 5.2 Page 26 Adepta 49 Chichester Court 5. YA35 The organisation should review the practice of not providing training as promised in supervisions and appraisals. Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Adepta 49 Chichester Court DS0000062735.V321181.R01.S.doc Version 5.2 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. 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!