Inspection on 22/06/07 for Alderney Street, 117

This inspection was carried out on 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alderney Street, 117 08/01/08

Alderney Street, 117 09/01/07

Alderney Street, 117 07/06/06

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 Alderney Street, 117 117 Alderney Street London SW1V 4HE Lead Inspector Ann Gavin and Tony Lawrence Unannounced Inspection 22nd June 2007 10:20 Alderney Street, 117 DS0000065866.V337742.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 Alderney Street, 117 DS0000065866.V337742.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. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alderney Street, 117 Address 117 Alderney Street London SW1V 4HE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7834 1161 020 7834 1161 info@outlookcare.org.uk Outlook Care Ms Shirley Kaydea Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2007 Brief Description of the Service: 117 Alderney Street is a residential care home for 4 people with a learning disability. At the time of this inspection there were two women and two men living in the home. Alderney Street is owned by Westminster Council who lease the property to New Dimensions Housing Group. The accommodation is in a large terraced house in Victoria, with wheel chair access and a lift serving all floors. Each resident their own room with communal areas. The care and staff are provided by Outlook Care, a voluntary organisation. The home is located between Pimlico and Victoria. There are local shops and other services close by. Transport links are very good with easy access to both tube and buses. There is a small paved garden leading from the dining room. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on 22nd June 2007 from 10.20 to 4.30pm. There was one resident and one member of staff on duty when the inspectors arrived. Another member of staff was shopping with a resident and two other residents were at a day centre till 1.30. The inspectors met all the residents and four staff. A tour of the communal areas of the home was led by one of the residents who also showed their bedroom. The care of two residents was tracked and a selection of records seen. The current acting manager was not in the home that day. The inspectors gave a feedback directly to the manager the following week. Whilst much work has been completed there remains much to do to create a culture of promoting independence and choice for the people who live in Alderney Street. The high number of requirements reflects this theme that has recurred in recent inspections. What the service does well: What has improved since the last inspection? What they could do better: There is an urgent need for a permanent manager and a review of the ways of supporting residents to make sure the focus is on their abilities and developing their choice and independence. The high number of requirements made following this inspection reflects the need for staff to take more responsibility in making sure residents are supported in a flexible way. They must make sure that there are a sufficient number of staff on to enable them to carry out planned one to one time and activities, also to meet planned health appointments. Residents need to be supported to achieve their set care plan goals and the monitoring forms to support this need to be completed. The daily notes need to reflect the residents goals. The manager must investigate and report on the use of residents’ monies on taxi’s. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 6 Staff must support people to voice their concerns creating an accessible way to do this. The staff must make sure that resident lifestyles are reflected in their home, and that the communal areas are made more ‘homely’. 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. Alderney Street, 117 DS0000065866.V337742.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 Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. It clearly sets out the objectives and philosophy of the service. Assessments are conducted professionally and sensitively and involve the individual, and their family or representative, where appropriate. EVIDENCE: During this visit, the Inspectors reviewed the care plan files of two people living in the home, including one person who was the most recent admission. One care plan file included a copy of the home’s Statement of Purpose. The Statement included all of the information needed to meet Standard 1 and is produced using photographs to make the information more accessible for residents. The file also included a detailed care needs assessment completed by a Placement Monitoring Officer from Westminster City Council before the person moved into the home. The file also included detailed assessments by a Community Nurse and Occupational Therapist that had been completed shortly after the resident moved into the home. One care plan file included a copy of the person’s Licence Agreement that detailed the terms and conditions of residence and the resident’s rights and responsibilities. The other care plan and statement of purpose was reviewed in July 2006, but the details for staff and other information were out of date. All details should be updated. Alderney Street, 117 DS0000065866.V337742.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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of risk is positive, addressing safety issues whilst aiming for better quality of life. Care plans are in place and are reviewed, but it is difficult to evidence that they are being carried out as it is not often reflected in the monthly summaries or daily logs. EVIDENCE: One care plan file included a person-centred care plan that had been reviewed in April 2007. There was evidence in the plan that the resident had been involved and the plan included some clear goals to develop the person’s cooking skills, provide more activities and monitor health issues. The Inspector also saw copies of monthly summaries of care that had been written by care staff in July and December 2006 and February and April 2007. The summaries gave a good overview of the care provided and there was some reference to goals identified in the care plan. One care plan file included risk assessments covering epilepsy, challenging behaviours, access to the local community and going on holiday. The assessments were well completed, included clear guidance for staff on how to minimise identified risks and some had been reviewed in February and March 2007. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 10 The second care plan, written in March 2007, had very good goals, set by the current manager. These were to help enhance the person’s daily life skills and to build up their self esteem. One goal was to encourage the person to go out to a local hairdresser rather than being reliant only on their key worker to cut their hair. The plan, described the various stages needed to arrive at the goal e.g. getting used to travelling there, becoming familiar with the surroundings and how things are done. It also had in place good monitoring forms to chart progress, but they were empty. Equally, neither the monthly reports, which were erratic, nor the daily logs, showed evidence of staff supporting residents to meet their goals. The planning book, whilst it had good descriptions and gave a good profile of how the person uses makaton and objects of reference, had no visual images to make it accessible to the person themselves. There is a need to link the daily notes to identified goals in the care plan. For example, one resident should be encouraged to drink more, or another person enjoys having their nails painted. One care needs assessment did include information that the person enjoyed swimming and ten-pin bowling. While the daily care notes did refer to a recent swimming trip, no mention was made of bowling, although other people living in the home regularly go bowling. Staff should make sure that summaries are completed every month to evidence that the care provided is as agreed in the care plan Alderney Street, 117 DS0000065866.V337742.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living in Alderney street are being involved in more activities. However a more person centred approach is needed to be sure that staff create opportunities for personal development. Staff must take on the responsibility of replacing key items if they are missing and not wait for a manager. Staff must make sure that there are sufficient staff on duty to allow for planned one to one time with residents. EVIDENCE: Speaking with the staff and reviewing residents’ monies demonstrated that people at Alderney Street are going out more and being more involved in the local community. There have been various trips by taxi to the cinema. These are quite expensive as the cinema used is in Brixton and normally involves two taxis to take everyone. Staff said that this is the most accessible cinema and that local ones did not have access for wheelchair users. It is recommended that the staff review using just one cinema. Looking into about using local cinemas and Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 12 public transport that is listed as one of the activities that all of the people enjoy. The pre inspection questionnaire, stated that the recreational activities accessed in the wider community as ‘going to the pub, shopping, partying, e.g., at the Octopus and Westsiders clubs, going to parks, Gateway club, swimming, holidays, London Eye, Aquarium, train ride and bus rides’ Within the home the activities were listed as ‘darts, Lego building, drawing, TV programmes, partying, reading papers, videos, watering the garden, looking at chart book’ As stated in previous reports it would be good to see peoples drawings displayed within the home. One drawing was displayed but there was little else of people’s own work or choices found in the communal areas. The inspectors were unable to switch off the television in the communal lounge. There was no remote and the TV cannot be altered manually. Staff explained that the TV remote had been lost for a week and so it was not possible to change the channel or switch it off unless at the wall socket. They said they would wait till the manager returned to buy a new one. It is unacceptable for residents not to be able to access the TV for a week. Staff must take on the responsibility of replacing key items if they are missing and not wait for a manager. One of the residents was out shopping with their key worker. They had then planned to have lunch out but the resident decided to eat in the kitchen as they were hungry. The key worker told the resident that they would still go out. This was repeated a number of times. The other member of staff on duty questioned how they would be able to do this as they finished their shift soon. The key worker said they would go at 1.30 and it would be fine. The resident was outside the office during this time. Sometime after 2pm the key worker left. The resident did not appear to be told that they would no longer be going out. Alderney Street, 117 DS0000065866.V337742.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): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents must be supported to go to all dental, optician or other service appointments. Staff must be mindful of upholding the dignity of people who use the service at all times. There is a lack of staff understanding of the safe handling of medication. EVIDENCE: When the inspectors arrived a resident was about to visit the health clinic to have a wound on their leg checked. Whilst the staff member was attentive to the needs of the resident, they were equally wanting the inspectors to look a t the wound which was neither necessary nor did it uphold the dignity of the resident. One care plan file checked by the Inspectors included a copy of the resident’s Health Action Plan (HAP) that had been reviewed in March 2007. The HAP was good evidence that staff from the home worked well with healthcare professionals, including the person’s GP, occupational therapist and physiotherapist. During this visit the Inspectors were concerned that a resident’s dental appointment was cancelled as not enough staff were on duty to support them to the surgery. The staff shortage was caused by the Manager’s illness and this was known to staff who should have made arrangements to cover the shift Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 14 and support the resident to their appointment. Managers and staff in the home must make sure that arrangements are in place to make sure that planned health care appointments are not missed. During this visit an Inspector checked the home’s systems for managing residents’ prescribed medication. All medication is securely stored in a lockable cupboard in the main office. The Inspector checked the Medication Administration Record (MAR) sheets for all four people living in the home. While the MAR sheets were generally well completed, the Inspector noted a discrepancy between the number of tablets recorded as in stock for one person and the actual number of tablets in the medication cupboard. There was also a container of cream in the cupboard that had been opened in October 2006, despite the home’s own guidance that creams should be disposed of 3 months after opening. The Manager must make sure that accurate records of medication are kept and the home’s policy regarding the disposal of medication is followed by staff. Alderney Street, 117 DS0000065866.V337742.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): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Alderney street has good links with Social Services and healthcare professionals. Staff however lack an understanding of safeguarding adults procedures. There is a good complaints system in place, but no complaints have ever been noted. Staff need to develop a culture of supporting residents to ‘voice’ their concerns or complaints. EVIDENCE: Staff on duty during this inspection told the Inspectors that there have been no formal complaints since the last inspection. The Inspectors felt that managers in the home and the service provider organisation should make sure that staff are aware of their role to support people living in the home to make complaints, if required. For example, the TV remote had been missing for a week, so the same channel was on all the time; one person missed a planned dental appointment and another person missed going out with staff as part of their one to one. Residents should be supported to make a complaint if they wish. During this visit the Inspectors checked two residents’ finance records. The records were generally well maintained, but there is a need to clarify the home’s policy for spending residents’ personal monies on taxis. In one case, a resident spent £174 in 2 months on taxis to appointments and social activities. The home should make sure that other transport options, including public transport, Dial-a-Ride and the Taxi card scheme are used before residents’ money is used. Reviewing one person’s care plan an incident was recorded from the day centre involving two of the residents resulting in a safeguarding adults meeting. The staff on duty did not feel they needed to inform the Commission as the incident Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 16 occurred outside of the home. The staff need to be familiar with and adhere to local safeguarding adults procedures and to inform the Commission of any incidents which adversely affect the well being of residents. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Alderney Street was clean and hygienic. Although there were more photographs around the home the communal areas still need to reflect more of the lives of the people living in Alderney Street and to gather a more ‘homely’ feel. This would be helped by staffs’ attention to detail by removing items such as a TV that has been broken and in the downstairs lounge for at least six months. EVIDENCE: One of the residents happily showed the Inspectors their room and the communal areas. Alderney Street was clean and hygienic. Since the last inspection, more photographs have been provided around the home and repairs to the stairway had been completed. There still is a need to promote a greater sense of the people who live in Alderney Street and make it a more comfortable environment. This need has been mentioned in previous inspection reports. The downstairs lounge / dining room is very sparse and unwelcoming with a large old TV which has been broken since the last inspection in January. Plastic bags of pads and gloves were hanging behind the door in the ground floor toilet and pads were also on show in other bathrooms. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 18 The recommendation of an occupational therapist assessment was to make some adaptations to one of the bathrooms to enable one resident to access it more easily. The home needs to advise the Commission of the timescale to complete these works. Alderney Street, 117 DS0000065866.V337742.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All of the permanent staff are NVQ (National Vocational Qualification) qualified and have good access to training. There is a need to help staff to promote the culture of independence and choice in supporting residents. Staff need to be sure that they plan their shift to ensure that residents’ needs and goals can be met through adequate staffing. EVIDENCE: There is a core group of staff that have been supporting the residents for a number of years. They all have an NVQ level 2 in care and have attended regular training. In the pre inspection questionnaire it stated that staff had completed mandatory training as well as training g disabilities and mental health and substance misuse. Planned training includes epilepsy and safeguarding vulnerable adults update. It is recommended that the safeguarding Adults update is completed with the local Social Services. There was a lack of shift planning during the inspection as noted in the missing of a dental appointment for one resident and another resident neither being Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 20 able to go out nor being told. These were both avoidable, as it was known from the week before that the manager would not be in the home that day. It has been noted in previous reports and in various discussions with staff that staff need to involve residents more in the life. Various ways of doing this have been discussed. The use of photos, developing each individual’s way of communicating and reflecting that in meetings in working together with residents. The current manager had a number of good ideas, but these need to be implemented by the staff team. The staff need to promote a culture of independence and choice with residents. They need to go at the residents’ pace and give time so that people can achieve the task themselves. This could be reflected in outings, for example the cinema. Given the time and space all of the residents could travel on public transport and enjoy it. The care plans and observation o f practise highlighted that staff appear to make the residents reliant on them rather than help further their development and become use to new ways of achieving tasks with other people. (See individual needs and choices –the unmet goals for resident in working towards going out to the hairdresser rather than their key worker being the only person they will allow to cut their hair) Staff need to take responsibility to follow things through when they are on duty to make sure that resident’s needs are fully met. The example of the TV remote being missing for a week, but no- one taking responsibility to replace it highlights this. Alderney Street, 117 DS0000065866.V337742.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. 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. Alderney Street has been without a registered manager for nine months. There is a need to clarify management cover arrangements and to appoint a permanent manager. EVIDENCE: The temporary manager is an experienced learning disabilities manager. She has put in place good ideas and goals, but has been unable to provide the level and time of support the home needs to promote the necessary change to a culture of promoting independence and choice. There has been no update of the managerial cover and the plans to appoint a permanent manager. The inspector has requested to have copies of the monthly monitoring visits made by the service manager. (Regulation 26 visits) this has not been done and the home diary noted that these visits were made sporadically. In March, then May. In April there was a visit to look at a quality assurance tool. These visits must be monthly and the reports forwarded to the Commission. Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 22 A tour of the home showed that fire doors were being propped open in the laundry and the downstairs dining area. The latter apparently is because a resident likes that door open. The staff must make arrangements for the door to be kept open in a way that meets the fire regulations and does not compromise the safety of the residents. A test of the fire points was made during the inspection and the book showed that it was up to date. Alderney Street, 117 DS0000065866.V337742.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 3 36 3 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 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 Requirement There is a need to link the daily notes to identify goals in the care plan. Staff should make sure that summaries are completed every month to evidence that the care provided is as agreed in the care plan. Staff must urgently replace the TV remote on the communal TV that cannot be changed manually. Staff must make sure that there are a sufficient number of staff on duty to enable them to carry out planned one to one time and activities. The accessible menu the staff have been working on for sometime must be finalised and used. Staff must be mindful of upholding the dignity of people who use the service at all times. It is not appropriate to insist that inspectors see a resident’s leg wound. Managers and staff in the home must make sure that arrangements are in place to make sure that planned health DS0000065866.V337742.R01.S.doc Timescale for action 31/08/07 2 YA14 16 31/07/07 3 YA14 18 31/08/07 4 YA17 12 31/08/07 5 YA18 12(4) 31/07/07 6 YA19 12 31/07/07 Alderney Street, 117 Version 5.2 Page 25 7 YA20 12 8 YA19 12 9. YA22 22 10 11 12 YA22 YA22 YA23 22 17 13 13 YA24 23 14 YA26 23 15 YA33 18 16 YA33 18 care appointments are not missed. The Manager must make sure that accurate records of medication are kept and that staff follow the home’s policy regarding the disposal of medication. Staff must make sure that all storage of pads are discreet and not displayed publicly to preserve people’s privacy. The manager must develop an accessible way for service users to express their views of the service. Repeat requirement. Original timescale of 31/07/07 not met. Staff must develop a culture of supporting residents to ‘voice’ their concerns or complaints. The staff must investigate and report on the use of residents’ monies on taxi’s The staff need to be familiar with and adhere to local safeguarding adults procedures and to inform the Commission of any incidents which adversely affect the well being of residents The large TV in the downstairs lounge which has been broken for at least the last six months must be removed. The home must inform the Commission of the timescale to complete plans to make the bathroom accessible to all residents. Staff need to be sure that they plan their shift to ensure that residents’ needs and goals can be met through adequate staffing. All new staff recruited should be able to promote residents’ culture and promote residents’ personal development. Repeat DS0000065866.V337742.R01.S.doc 31/07/07 31/07/07 31/08/07 31/08/07 31/08/07 31/08/07 31/07/07 31/08/07 31/08/07 31/07/07 Alderney Street, 117 Version 5.2 Page 26 17 YA37 8 18 YA39 26 19 YA43 23 Requirement. Original timescale of 28/02/07 not met. The providers must inform the Commission of the appointment of a manager and the details for management cover The manager must complete and forward to the Commission monthly monitoring visits as requested previously. The staff must ensure that no fire door is propped open to ensure the safety of the people in the home. 31/07/07 31/07/07 31/07/07 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 Refer to Standard YA5 YA14 Good Practice Recommendations All details of the statement of purpose for residents should be updated. It is recommended that the staff review using just one cinema. Looking into about using local cinemas and public transport that is listed as one of the activities that all of the people enjoy. It is recommended that the Safeguarding Adults update training is completed with the local Social Services. 3 YA32 Alderney Street, 117 DS0000065866.V337742.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Alderney Street, 117 DS0000065866.V337742.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. 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