Inspection on 08/01/08 for Alderney Street, 117

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Alderney Street, 117 22/06/07

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 27/02/2009.

CARE HOME ADULTS 18-65 Alderney Street, 117 117 Alderney Street London SW1V 4HE Lead Inspector Ann Gavin and Tony Lawrence Key Unannounced Inspection 8th January 2008 11:10 Alderney Street, 117 DS0000065866.V355797.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.V355797.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.V355797.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.V355797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2007 Brief Description of the Service: 117 Alderney Street is a residential care home for 4 people with a learning disability and/or challenging behaviours. 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 Era Housing Group. The care and staff are provided by Outlook Care. 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. 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. There is a small paved garden leading from the dining room. Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection on 8th January 2008 from 11.10 to 4.10pm. There were two people who live in Alderney Street at home with one permanent member and one agency 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 the four people who live in the home, two permanent and one agency. 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 inspectors gave a feedback to the service manager as the manager was away from the service. There has been much input from Outlook Care since the last inspection and this needs to continue to arrive at an ever greater involvement and development of the people who live in the home. Eleven requirements were made two of which were repeated from the last inspection. Three recommendations were also made with one being repeated form the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 6 Staff to gain greater understanding of promoting independence and to ensure that residents are supported to take part in appropriate activities. Shift plans should be used to make sure that people living in Alderney Street have their care plan and personal goals met. Staff must be mindful of upholding peoples privacy and dignity and not display people personal care routine on their bedroom walls. The manager needs to complete their registration with the Commission. 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.V355797.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.V355797.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 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. They have clear processes to assess the needs and aspirations of prospective residents. EVIDENCE: There has been no new people move into the home since the last inspection. Outlook Care has clear systems to assess the needs of people wanting to move into Alderney Street. At the last inspection in June 2007 the Statement of Purpose was noted as needing to be updated. This is still being is still being worked on. As there is now a permanent manager in place it needs to be completed Alderney Street, 117 DS0000065866.V355797.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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service understands the right of individuals to take control of their lives and to make their own decisions and choices. However, this does not always happen in practice as staff have a limited understanding of how to do this effectively EVIDENCE: During this visit the Inspectors checked the care plans of two people living in the home. Each person’s Person Centred Plan (PCP) was reviewed in March 2007 and there was some evidence that the residents, their families and other significant people had been involved in the reviews. Both plans included a review form, but these were only partly completed and lacked detailed information about each person’s abilities, needs and aspirations and how these would be met in the home. One review form did not include an action plan and the second action plan lacked sufficient detail to enable staff to work meaningfully with the resident. One PCP included a goal to support the resident to travel by public transport and this included good guidance for staff working with this person, written in Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 10 November 2007. Another goal to promote healthy eating was agreed in March 2006. There was no guidance for staff on the care plan file and no evidence that the goal had been reviewed for almost 2 years. The second person’s PCP included some good goals that had been agreed in March 2006, but there was no evidence that these had been reviewed or updated since then. There was no evidence in daily care notes that staff were aware of agreed care plan goals or were using these to inform their daily work with residents. The financial records of the same two people were also looked at. Their cash tins both held over £150 and one of the staff on duty said that it was to enable people to have money to go to the sales. There was no evidence of any plans to go out to the sales since Christmas. The receipts for monies spent were seen. The receipts for taxis are shared among various people in the home though they do not state the other people’s names. All receipts need to identify whom the expenses are shared with. The Inspectors saw that risk assessments had been completed for each resident. Assessment covered a range of issues, including challenging behaviours, bathing, medication, holidays, use of the kitchen and self-harm. Some assessments had been completed March and November 2007, but most had been completed in November 2006 and there was no evidence that these had been reviewed. Managers and staff must make sure that care plans are working documents that are known to staff and used to inform their daily work with individual residents. Managers and staff must also make sure that care plans and risk assessments are regularly reviewed Alderney Street, 117 DS0000065866.V355797.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): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are aware of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills, although this commitment is sometimes difficult to evidence. EVIDENCE: Both people whose care was checked during this inspection attended day services provided by the local authority, one person for 5 days and the other for 3 days each week. Both people were at their day service when the Inspectors arrived, returning home after lunch. There was evidence that staff from day services were involved in the reviews of peoples’ care plans. Both PCP files included a weekly programme of activities, including day services and activities in the home and the local community. Daily care notes were evidence that residents go swimming each week and trips to the cinema, bowling and shopping were also mentioned. The Inspectors noted that for two weeks over the Christmas and New Year period, very few outings or activities were recorded in residents’ daily care notes. Staff must make sure that Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 12 residents are supported to take part in appropriate activities, especially at times when formal day services are not available. It was still not clear if staff had trialled using local cinemas via either taxis or public transport. Staff told the Inspectors that residents are able to spend time in their rooms if they choose. When one resident returned to the home from their day service, they chose to go to their room to watch a film and staff supported them to do this. A second resident also spent time in their room. While helping with this inspection, staff did also spend some time with two residents who were at home for the day. One person spent time in the office with the Inspectors and the other spent time in the lounge. Staff did offer this person opportunities to take part in activities, but this could have been better managed. For example, staff did put the resident’s choice of music on in the lounge, but he was left alone and the TV was also left switched on. The Inspectors also felt that some staff were not proactive in identifying and providing activities that were appropriate and stimulating for some residents. Residents who interact with staff received attention and support, but the Inspectors saw that those people who were not mobile or able to articulate their wishes and preferences were left with nothing to do by staff on some occasions. Details of residents’ families, friends and other significant people were clearly recorded as part of their care plans. Contact with relatives and friends was recorded in the daily care notes. During this visit the Inspectors saw that some people who lived in the home were able to choose to spend time with other people or on their own and staff respected these choices. The Inspectors felt that other residents did not always get the support they needed and were often left for long periods in communal areas with no staff support. There is a new excellent menu planning in place. The weekly menu is displayed with the picture of the person who chose the meal. The recipes, with photographs, were in a menu planning folder helping people choose easier. The menus seen were more varied reflecting the culture and likes of the people in the home, for example, Caribbean, Irish dishes. Staff did support residents to make choices about the food they ate at lunchtime. Alderney Street, 117 DS0000065866.V355797.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): 18,19,20,21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence in the care plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information Medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded EVIDENCE: The Inspectors saw that the personal care needs of one resident were recorded in their care plan, but more detail was needed with specific goals for the person to work towards with staff support. During this visit the Inspectors checked the health care records for one resident and medication records for each person living in the home. As with other records, there is a need to make sure that healthcare records are reviewed and updated regularly. The resident’s file checked by the Inspectors did include a good positive behaviour plan and guidance for staff, but these were dated November 2006 and there was no evidence that they had been reviewed. The person’s Health Action Plan was not dated or signed and included the wrong date of birth. The plan included some good goals but these Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 14 were not signed or dated. There was evidence that the resident did have a medication review with their GP in November 2007. The records also showed that the resident had missed a number of chiropody appointments. Staff were able to confirm that the person had seen the chiropodist in January 2008 but a healthcare appointment form had not been completed by staff for the person’s health file. The inspectors were concerned that one person who was attending a non urgent doctors appointment at 5.30pm was kept back from their day service the whole day. This did not appear to be necessary. Staff had not made any plans for an alternative engaging activity for this person. They were also concerned to find a detailed plan of how to carry out personal care for one resident was displayed on their wall, which does not uphold the privacy nor dignity of the person. The Inspectors checked the Medication Administration Record (MAR) sheets for all four people living in the home. The administration sheets were well completed and the Inspectors saw no errors or omissions. All prescribed medication is securely stored in a lockable metal cabinet. Staff training records were evidence that all staff working in the home completed an assessment of competence to manage residents’ medication in July 2007. The two Person Centred Plans (PCP) checked during this visit included details of each resident’s religion and how they chose to practise their faith. Both files also included details of each person’s funeral wishes and arrangements that had been discussed with the residents and members of their families. Alderney Street, 117 DS0000065866.V355797.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Alderney Street has a good accessible complaints policy, which all staff need to promote. Half of the staff team have attended local Social Services safeguarding training. EVIDENCE: ‘We have an advocate who visits the home regularly to meet with the service users’ Quote from Annual Quality Assurance Assessment (AQAA) The manager wrote in their AQAA that the introduction of more consistent visits from the advocate has helped support both the people who live in the house and the service in identifying any issues. Helping the people in the house to voice their views, is an area that the staff need to develop. However there was evidence that one of the staff had going through the complaints procedure in an accessible format with one of the people in the house. There was one complaint since the last inspection, which was made by a visiting professional. The service informed social services and followed the correct procedures. This complaint was dealt with under the safeguarding adults procedures. People had been left in the house with a new agency worker who had not received a handover or proper induction whilst the regular staff member had supported a person to the doctor. Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 16 The investigation has been concluded with recommendations to ensure health appointments are not made near to handovers, that all agency staff receive a full handover and induction. A new induction folder for agency staff was seen in the office that the staff on duty confirmed they use. Two of the staff have completed safeguarding training with Westminster Social Services. Alderney Street, 117 DS0000065866.V355797.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): 24,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good. The home was clean and fresh. Alderney Street is gathering a more ‘homely’ feel reflecting more the lives of the people who live there EVIDENCE: A tour of the shared areas of the home was made with one of the people who live in Alderney St. They also showed their room. Since the last inspection, the hallways and stairs have been decorated, the lighting on the stairs changed giving it an overall brighter effect. The downstairs lounge looked more welcoming with new curtains, pictures, settee and lamp. Throughout the home there were more photographs of the people who live in Alderney Street. The lounge on the ground floor has a new flat screen television. Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 18 The adaptations to the shower on the first floor have been completed. It is now accessible to all the people who live in the home. There were also new cupboards in the bathrooms. Alderney Street, 117 DS0000065866.V355797.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): 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. There is still 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 are met. EVIDENCE: There has been an introduction of a shift plan since the last inspection. It clearly states to complete the plan according to activities and transport times then practical tasks and health and safety. These plans, the staff said, are created from the diary and the communication book. Looking at the plans from the 23rd December through to the 5th January there were only the following activities planned • On the 23rd December one person had a family visit another person was going to church. • On the 27th December two people went on a one to one outing. • On the 29th December a note was made to support people out to lunch in the park the following day but this was not on the shift plan nor was there any evidence of it taking place. From the 30th December to the 5th January the only thing stated in the shift plan under activities was for the Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 20 • evening shift ‘support service users one to one’. There were no plans as to what this might involve and no details on the daily notes On the 1st January when indoor activities was written. The daily notes neither reflected any engaging activities for the people who live in the home. This is unacceptable practise, as although practical tasks were planned it shows no thought for how the people who live in the home might be supported to lead fulfilling and enjoyable lives. There was no evidence of staff using their shift patterns for the advantage of the people who live in the home. The staff have been supported to attend training. All attended a day’s training on diversity and equality, which was held in the home. Two of the staff attended safeguarding adults training run by Westminster Social Services and the rest of the staff will attend shortly. The staff spoken with said they found both training very good. The training records were not updated in the office files but may have been in the individual staff files. It was not possible to review staff files or supervision notes, as the manager was not available. The supervision rota displayed in the office was only until Septembers /October again it was not possible to evidence supervision notes as the files were appropriately locked away in the absence of the manager. Staff said they did receive supervision. The staff rotas were looked at. These were much clearer stating the name of the agency staff working. A team day was held in November 2007 where the service manager was also present. There were no notes available for this meeting and the last available staff meeting notes were from 25th September 20078. On the day of the inspection one staff member was working 7am till 11 pm. This was an exception due to the unavoidable absence of the manager and sickness of another staff member. This shift had been discussed with the service manager who had tried unsuccessfully to engage agency staff and no other solution could be found. The second member of staff on in the afternoon to evening shift was giving the staff member a break. The outcome for the people in the house would be that they would be unlikely to be able to go out. Alderney Street, 117 DS0000065866.V355797.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): 37,39,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Alderney Street has now appointed a new manager, though they still need to complete their registration with the Commission. Arrangements have been made for a new deputy manager to begin work by February 2008.A review of the homes record keeping systems for the people who live in Alderney Street could be beneficial. EVIDENCE: The manager of the home was not on duty during the inspection. They were away from the service. The manager has come from managing another home within Outlook Care. The Annual Quality Assurance Assessment (AQAA) completed by the manager states that they have five years managerial experience and have an NVQ 4 in Management and Care and the Registered Managers Award. They are also a positive response trainer. However they have not, as yet, made any contact with the Commission to register as the Alderney Street, 117 DS0000065866.V355797.R01.S.doc Version 5.2 Page 22 manager. The manager needs to complete their registration with the Commission. The home has been without a deputy manager since October. They have now been appointed and will be starting work in February. The deputy manager will be working 25 hours a week over four days. This reduction in hours for the deputy will enable the manager to to work supernumerary .As from April he will work three days supernumerary one week and four days supernumerary the following week. Outlook Care has a Quality Management System. The new manager and service manager plan to carry out audits and review work practices. The request, in the last inspection, to have copies of the monthly monitoring visits made by the service manager (Regulation 26 visits) has not been met. This needs to be done and copies of visits since October 2007 must be forwarded to the Commission. The inspector has requested to have copies of the monthly monitoring visits made by the service manager. (Regulation 26 visits) The system for recording information for the people who live in the house would benefit from being reviewed so that information is accessible, not duplicated and in a format which enables the shift plans to be relevant to the people living in Alderney Street. Alderney Street has new fire safety contractors. The fire records were up to date and there are now new safety door closures on the office and lounge doors. Alderney Street, 117 DS0000065866.V355797.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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 3 2 X 2 X 2 3 X Alderney Street, 117 DS0000065866.V355797.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 (2) Requirement To make sure that residents are receiving the care and support they need. Managers and staff must make sure that care plans are working documents that are known to staff and used to inform their daily work with individual residents. Daily care notes must reflect agreed care plan goals and guidance for staff on how these are to be met in the home. All receipts for residents’ monies must be detailed. When expenses are shared among residents it must be clearly written who and how many residents are involved. To make sure that residents are supported safely and appropriately, managers and staff must make sure that care plans and risk assessments are regularly reviewed. Staff must make sure that residents are supported to take part in appropriate activities, especially at times when formal DS0000065866.V355797.R01.S.doc Timescale for action 29/02/08 2. YA7 17(2) 29/02/08 3. YA9 13 (4) 29/02/08 4. YA13 16 (2) 29/02/08 Alderney Street, 117 Version 5.2 Page 25 day services are not available. 5. YA14 16 (2) Staff must be more proactive in identifying and providing activities that are appropriate and stimulating for some residents. People who are not mobile or able to articulate their wishes and preferences should not be left without support from staff for extended periods. To make sure that residents receive the health care they need, Managers and staff must review and update healthcare records regularly. All records must be signed and dated. Health Action Plans must be dated or signed and staff responsible for the person’s care must agree goals. Healthcare goals must also be signed and dated. Staff must not display a detailed plan of how to carry out personal care for a resident on their bedroom wall, as it does not uphold their privacy or dignity. Staff need to be sure that they plan their shift to ensure that residents’ needs and goals are met. Repeat requirement. Original timescale of 31/08/07 not met-shift plans in place but not used. The manager must register with the commission. The manager forward to the Commission monthly monitoring visits. Repeat requirement. Original timescale of 31/07/07 not met DS0000065866.V355797.R01.S.doc 29/02/08 6. YA18 13 (1) 29/02/08 7. YA18 13 29/02/08 8. YA18 12(4) 29/02/08 9. YA33 18 29/02/08 10 11 YA37 YA39 8 26 29/02/08 29/02/08 Alderney Street, 117 Version 5.2 Page 26 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 Good Practice Recommendations All details of the statement of purpose for residents should be updated. It is still 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. The system for recording information for the people who live in the house would benefit from being reviewed so that information is accessible, not duplicated and in a format which enables the shift plans to be relevant to the people living in Alderney Street. YA14 3 YA41 Alderney Street, 117 DS0000065866.V355797.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.V355797.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. 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