Inspection on 12/10/06 for Alnwick Road (4)

This inspection was carried out on 12th October 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alnwick Road (4) 25/07/08

Alnwick Road (4) 28/01/08

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 Alnwick Road (4) 4 Alnwick Road Canning Town London E16 3EX Lead Inspector Lea Alexander Unannounced Inspection 12th October 2006 1:00 Alnwick Road (4) DS0000066795.V314882.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 Alnwick Road (4) DS0000066795.V314882.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. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alnwick Road (4) Address 4 Alnwick Road Canning Town London E16 3EX 020 7511 4854 020 7511 4845 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.heritagecare.co.uk Heritage Care Mr Bertram Okeke Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A Brief Description of the Service: Alnwick Road is a care home for six adults with severe learning difficulties that first registered in 1994. Earlier in 2006 Heritage Care took over as the registered provider, this did not have an impact on the day to day running of the service as Heritage Care staff were already operating and managing the home. This is the homes first inspection under National Minimum Standards with Heritage Care as the Registered Provider. There are currently six service users residing at the home, five of who are non verbal in their communication skills and all of whom experience varying degrees of challenging behaviour. The home is divided into three self-contained flats, the largest of which also accommodates staff and administration offices. The exterior of the building is in keeping with the surrounding properties. The home is situated in Custom House, close to public transport and other amenities. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors fourth inspection of the home, and it was carried out over an afternoon and early evening. The Inspector met with the two support workers and the Registered Manager, and met privately with one service user, and spent time with two non-verbal service users. The Inspector also sampled service users personal files, staff personnel files and other relevant documentation. What the service does well: What has improved since the last inspection? What they could do better: Whilst this is the homes first inspection since registering under Heritage Care, the home continues to be run and managed by the same staff. This Inspector was disappointed to note that there had been little progress in addressing shortfalls that had been identified over several previous inspections. A total of fourteen requirements were made as a result of this inspection. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 6 The home must evidence that it carries out its own assessment on prospective new service users to ensure that it can meet their needs. Service users individual plans must be reviewed every six months, or as their needs change. Service users information must be kept confidential – personal files should only contain information that relates to them. The home must ensure that potentially hazardous activities identified in the individual plan are subject to a risk assessment. These assessments must be reviewed and updated as circumstances change. The home must maintain records of health and safety checks required by legislation, and personnel records required by regulation must be available for inspection. The home must develop its quality assurance systems to include the views of service uses and to collate and publish quality assurance outcomes. The balance recorded on service users financial transaction sheets must correspond with the monies actually available. Any discrepancies and their reason must be recorded. Service users must be supported to attend regular healthcare appointments including the GP, optician and dentist. Standardised records of the outcome of these appointments must be maintained and made available for inspection. The home must address shortfalls in its recording of medication administered, make sure it keeps lists of medication up to date, and stores and disposes of controlled drugs in accordance with its policy. The home must keep the Commission updated on any adult protection allegations and provide copies of any investigation it conducts. The home must attend to the list of maintenance issues identified in the requirements section of this report and address the smell of urine found in one service users bedroom. 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. Alnwick Road (4) DS0000066795.V314882.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 Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Potential service users are able to “test drive” the home prior to moving in. However, it was not evidenced that their needs are assessed by the home as part of this process. EVIDENCE: One service user has been admitted to the home since the last inspection, and the Inspector sampled their personal file. This evidenced that the home had obtained relevant background material from the service users previous placement. However, the Inspector was unable to find evidence of an assessment having been carried out by staff at Alnwick Road prior to their moving in. The Registered Manager advised the Inspector that the service user had had the opportunity to “test drive” the home on a number of occasions prior to their moving in. The service user confirmed this during their discussion with the Inspector. Alnwick Road (4) DS0000066795.V314882.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home develops comprehensive individual plans for each service user. However, the home must evidence that these plans are regularly reviewed. EVIDENCE: The Inspector sampled the personal files of two service users. One had recently moved into the home, and the other was a well-established resident. Both of the personal files sampled contained an individual service user plan that included information relating to the service users personal, healthcare and social needs. The format used for the individual plan included simple phrases and pictures to promote service users understanding. The plans sampled also included information on how service users prefer to be assisted, their likes and dislikes and information on their communication needs. The front sheet of each plan stated that they had been developed in consultation between the service user and their key worker. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 10 One of the service users sampled had been in placement for only a short period and their plan was not yet due for review. However, the other service users plan had not been dated and review sheets had not been completed. It was not therefore evidenced that this plan had been reviewed on at least a six monthly basis. The service users sampled both receive support in managing their finances, and this is reflected in their individual plans. Each service user has a logbook in which all monetary transactions are recorded and signed for by staff, and where able, the service user. Each service user has a wallet in which their cash is stored, and this is kept in the homes safe when not in use. The Inspector sampled the logbook and cash available for three service users. In each case the logbook was found to be in order, with the date, reason for transaction and a signature for each entry. However, two of the wallets sampled contained several pence more than had been recorded and signed for in the logbook. No note of the discrepancy or the possible reason for this had been recorded. By sampling service users personal files the Inspector evidenced that all correspondence relating to savings and income were appropriately retained. One of the service users case tracked by the Inspector lives alone in the one bed flat. They had been risk assessed as not requiring a regular nighttime carer. Instead an emergency alarm had been installed so that staff could be contacted. During the course of the inspection however it became apparent that this alarm is not working. The Registered Manager advised that this fault had been reported to the Engineer. However, it was not evidenced that the risk assessment had been reviewed and updated with an alternative risk management strategy whilst the alarm was out of use. This was the only risk assessment found on this service users file. A range of completed risk assessments was located on the other service users file, including community activities and bathing. Whilst sampling service users personal files, the Inspector was shown a file for each service user titled “Ideal week”. The Inspector noted that these breach service users confidentiality as they contained information relating to other service users living at the home. Alnwick Road (4) DS0000066795.V314882.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to engage in a range of meaningful activities both inside and outside of the home. EVIDENCE: Discussion with the Registered Manager, a service user and sampling of service users personal files evidenced that service users are engaged in a variety of activities. At the time of this inspection individual service users were supported to attend water therapy, Jacuzzi sessions and swimming. One service user attends a local day service. Another attends the local cinema and bowling alley. Other service users like to go on bus rides and walks in the locality including visits to parks and to shops. In addition an aroma therapist visits the home twice per week. Entertainment available in the home includes TV, stereo and video’s. Some service users also engage in puzzles or foot spas’ at the home or have structured activities such as using the sand pit. At the time of this inspection service users were being shown brochures as the first step to planning a holiday. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 12 Service users individual plans were noted to include information on family and friends. One of the service users sampled was evidenced as being supported to maintain a longstanding friendship outside of the home. During the course of the inspection the Inspector observed that service users choose when to be alone or join in an activity and that staff interact comfortably with service users. By sampling the minutes of service users meetings, the Inspector evidenced that by using pictures service users were able to identify meals that they would like included on the menu. The service user spoken to by the Inspector said that they were happy with the meals provided. Alnwick Road (4) DS0000066795.V314882.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home must support service users to attend healthcare appointments and maintain consistent records of these appointments and their outcome. Medication Administration Records must be correctly completed and controlled drugs must be handled in accordance with the homes policy at all times. EVIDENCE: The individual plans sampled by the Inspector evidenced that service users preferences are recognised and implemented when providing support with personal care. For example, one service users plan identifies that with prompting they are able to choose their own clothes and get dressed, but will need assistance with buttons. Other preferences, for example “I prefer to have a bath and soak for a while” are also recorded in service users plans. The support worker spoken to by the Inspector demonstrated a good understanding of promoting dignity and respect whilst providing personal care and described how they would ensure privacy by closing doors and windows, and always explain to the service user what they wanted to do and seek their permission before starting. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 14 The Inspector asked to see records for healthcare appointments attended by two service users. The Inspector was given a separate logbook, but was unable to find any healthcare appointments recorded in this for the recently admitted service user. The Inspector later found that their healthcare appointments had been recorded in their personal file. The Inspector attempted to locate records of health appointments for a second, longstanding service user in the logbook, and was able to find only one. No further information relating to their health care appointments could be located in the log or their personal file. The home implements a corporate Heritage Care Medicines Policy. This includes guidance on completing the Medication Administration Record (MAR), the storage and disposal of medicines and self-medication. At the time of this inspection none of the homes service users are self-medicating. The Inspector sampled the medication available for two service users and checked this against the current MAR sheet. The Inspector noted that on one service users MAR sheet medication had been signed as being given, but that a sticker had then been stuck over the top. It was not clear whether this medication had been administered or not. A discussion with the Registered Manager did not clarify this situation. The Inspector requested that this matter be investigated and fedback to the Inspector. The Registered Manager subsequently reported that the MAR sheet had been signed in error and that the medication had not been administered. The Registered Manager also fedback that steps were being taken to improve staff training in the administration of medication and monitor practise in this area. One service user was recorded on their MAR as receiving a controlled drug. The Inspector was however unable to locate this medication in the controlled drugs cupboard. During subsequent discussion with the Registered Manager the Inspector was advised that this medication had been discontinued, and that the medication was being kept in the Registered Managers desk draw whilst waiting to be disposed of. The MAR sheet had not been updated to reflect the discontinuation of this medication, and the controlled substance was not being stored in accordance with Heritage Care policy. The MAR sheet and medication available for a second service user were found to correspond and be in good order. Alnwick Road (4) DS0000066795.V314882.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 at least once during a 12 month period. 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 the service. The home protects service users from abuse. However the Responsible Individual must ensure that the Commission is kept informed of any strategy meetings and the outcome of any adult protection investigation. EVIDENCE: The home operates a corporate Heritage Care compliments and complaints procedure. This clearly states the timescales in which complaints will be dealt with. The home has produced local complaints information based on the corporate policy. The Inspector viewed the homes complaints log and noted that no entries have been made since November 2004. The home also operates a corporate Heritage Care Adult protection policy. This includes definitions of the types of abuse vulnerable adults may experience and outlines staff responsibilities should they have any concerns. The policy also makes appropriate reference to local multi agency adult protection protocols. The staff member spoken to by the Inspector demonstrated a good understanding of adult protection issues and their duties to report any concerns. Following on from an allegation made some months ago a staff member had been suspended for some time. A strategy meeting had been convened and Heritage Care had carried out an investigation as a result of this. The investigation had concluded that the allegations were unfounded. However, The Commission for Social Care Inspection had not been advised of the Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 16 strategy meeting and had not received a copy of the investigation and findings from Heritage Care. Alnwick Road (4) DS0000066795.V314882.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from comfortable accommodation with a range of shared and private spaces. A number of pressing maintenance issues require attention. EVIDENCE: The homes accommodation is arranged into three units comprising a three-bed house, a two bed flat and a one bed flat. Each service user has their own bedroom and each unit has its own kitchen, lounge/diner, bathroom and WC. The three-bed house also accommodates two staff offices, one of which doubles as a staff sleep in room. There is a good-sized garden to the rear of the property that is mainly laid to lawn. The premises have a comfortable, homely feel, but would benefit from some maintenance, details of which are detailed in the requirements section of this report. The Registered Manager advised that many of the maintenance issues identified had been reported and were awaiting works to commence, although no date had been fixed. The home was generally clean, however a strong smell of urine was noticed in one service users bedroom. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 18 Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from competent and qualified staff. However, staff must receive regular supervision and personnel records required by regulation must be available for inspection. EVIDENCE: Heritage Care operates a centralised personnel department who organise recruitment campaigns and carry out pre employment checks. A Local file is available on site that includes photocopies of pre-employment checks. The Inspector sampled two personnel files, one for a long serving member of staff and one for a member of staff who joined in March 2006. A copy of a job description was located on one of the staff files. Copies of two satisfactory references were also found on one file, although no references were found on the other. Photocopies of proofs of id and application forms were found on both files. It was also evidenced that Heritage Care had obtained Enhanced level Criminal Records Bureau checks for both staff. However, one of these was recorded as being obtained in June 2003, and it was not evidenced that a replacement had been requested upon its expiry in June 2006. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 20 The personnel file of the recently joined staff member included a completed record of induction training. The Registered Manager advised the Inspector that there is a rolling programme of training, with adult protection, fire and care planning training all having been provided in the previous two months. The Inspector was advised that as part of their aim to build partnerships with the London Borough of Newham Learning Difficulties Team a programme of challenging behaviour training is planned for the coming months. During discussions, the Registered Manager advised the Inspector that of the homes 13 permanent staff members all had obtained NVQ level 2 and that some staff members were currently studying for their NVQ level 3 and 4. The Inspector viewed the homes current staffing rota. This stated that four staff should be on duty at the time of the inspection, which corresponded to the situation found in the home. In addition to the Registered Manager, four care staff was on duty, with two based in the three-bed flat and one staff member in each of the other flats. Two members of staff are rostered on for night duty. The one bed flat is not staffed at night, and the service user has been supplied with an emergency alarm to use should they require assistance. During the course of the site inspection the service user of this flat advised the inspector that the alarm was not working. The Inspector raised this issue with the Registered Manager who advised that additional night staff cover would be put in place immediately to ensure the safety of this service user. The Inspector sampled supervision records for two staff members. This evidenced that one staff member had received two supervisions since joining in March 2006. A second staff member had received three supervisions since September 2005. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is excellent/good/adequate/poor. This judgement has been made using available evidence including a visit to the service. The home benefits from a qualified and experienced Registered Manager. However it must develop its quality assurance processes to include the views of service users and maintain all required health and safety records. EVIDENCE: The Registered Manager informed the Inspector that they had completed their NVQ level 4 studies and their Registered Managers Award. In addition they are an NVQ assessor and are undertaking post-graduate studies. The Registered Manager advised the Inspector that the home uses monthly visits by the Responsible Individual and staff meetings to monitor and develop the quality of the service. The Registered Manager also advised that the home is looking at using local advocacy services to develop service user input into the quality assurance process. The home does not currently collate or publish and quality assurance information. Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 22 The Inspector sampled a number of health and safety records required by legislation. These included the homes fire safety checklist. The entries seen by the Inspector evidenced that the necessary checks are not being completed on a weekly basis. A fire evacuation drill was recorded as having occurred in September 2006 and included information on the time taken to complete the evacuation. The Inspector also sampled the homes record of fridge and freezer temperatures. These are recorded as being within acceptable limits, however there were frequent dates in September 2006 when no temperature had been recorded. The Inspector also read a recent electrical inspection report that identified the need for urgent investigation and possible further works on two areas of the homes electrical circuit. It was not evidenced that any further action had been taken to address these shortfalls. During the Inspectors tour of the premises it was evidenced that some started processed foods had not been labelled with a start date, meaning that the food could not be stored for the appropriate period in accordance with the manufacturers instructions. In addition two items that had passed the use by date were found in the fridge of the one bed flat. Alnwick Road (4) DS0000066795.V314882.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 X 2 1 3 X 4 3 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 3 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 1 1 X 3 X 2 X X 2 X Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14 & S3 Requirement Timescale for action 30/01/07 2. YA6 15 3. YA7 16,20 & S4 4. YA9 13 New service users must only be admitted on the basis of a full assessment, undertaken by people competent to do so. The Registered Person must 30/01/07 evidence that service users individual plans are reviewed at least six monthly, or as their needs change. The balance recorded on 30/11/07 individual service users financial transaction sheets must correspond with the actual monies available and any discrepancies and their reason recorded. The home must ensure that 30/11/07 potential risks identified in the individual plan are subject to a risk assessment. Service users risk assessments must be reviewed and updated as circumstances change. Service users personal files should only contain information that relates to them. The Registered Person must ensure that all service users are supported to attend regular DS0000066795.V314882.R01.S.doc 5. 6. YA10 YA19 12 12 & 13 30/01/07 30/01/07 Alnwick Road (4) Version 5.2 Page 25 healthcare appointments including the GP, dental and optician checks and that a record of these appointments is maintained. The Registered Person must ensure that the home uses the same system to record healthcare appointments for all service users and that these are available for inspection. 12,13,17,S3 The Registered Person must ensure that MAR sheets are correctly completed, with any errors annotated in an agreed, standardised format. MAR sheets must be updated to include only current medications. All controlled drugs must be stored and disposed of in accordance with the homes policy. Staff must receive refresher medication training that should include an element of assessment of their capabilities to administer medication. The Registered Person must keep the Commission for Social Care Inspection updated of the progress of any adult protection allegations, including the dates of strategy meetings. Copies of the recent adult protection investigation carried out by Heritage Care along with its findings must be forwarded to the Commission. The following maintenance works must be carried out: (i) Alnwick Road (4) 7. YA20 30/01/07 8. YA23 13 & 21 30/01/07 9. YA24 23 30/01/07 The laminate Version 5.2 Page 26 DS0000066795.V314882.R01.S.doc flooring in the main hallway must be repaired or replaced. In the three bed house: (ii) The broken shower in the three bed house must be repaired or replaced. The broken chest of draws and shoe shelf in one service users bedroom must be repaired or replaced. The damaged kitchen work surface should be replaced. Cleaning of this kitchen should include cleaning the unit doors, cleaning the kitchen door and cleaning the lino to the edges, as all were noted to be soiled at this inspection. In the bathroom missing tiles and soiled grouting should be replaced. (iii) (iv) (v) (vi) In the one bed flat: (i) the broken shower hose should be repaired or replaced. The broken emergency alarm should also be repaired or replaced. Version 5.2 Page 27 (ii) Alnwick Road (4) DS0000066795.V314882.R01.S.doc In the two bed flat: damaged kitchen work tops should be replaced. (ii) The lino in the WC and bathroom should be replaced. (iii) The blocked bath should be repaired. (iv) The smell of urine in one service users bedroom should be attended to. Where essential pieces of 30/11/06 equipment (such as the emergency night alarm in the one bedded flat) are not working and are waiting to be repaired, the RM must ensure that staffing levels are reviewed to provide adequate support. 30/01/07 The Registered Person must ensure that current CRB checks are obtained for all staff. Two satisfactory references must be obtained prior to an appointment being made. All records required by regulation must be available for inspection. Staff must receive regular supervision sessions, at least six times per year. Effective quality assurance and quality monitoring systems based on seeking the views of service users must be developed. Outcomes from the homes quality assurance process should be collated and made available to interested parties. The Registered Manager must ensure that: DS0000066795.V314882.R01.S.doc (i) 10. YA33 18 & 19 11. YA34 19 & Sch2 12. 13. YA36 YA39 18 24 30/01/07 30/01/07 14. YA42 16 & 23 30/01/07 Alnwick Road (4) Version 5.2 Page 28 (i) (ii) (iii) (iv) (v) Weekly fire checks are carried out and recorded. Maintenance works to address shortfalls in the homes electrical wiring must be urgently addressed. Fridge and Freezer temperatures must be recorded on a daily basis. Started processed foods must be labelled with a start date in accordance with the manufacturers storage instructions. Food that has passed its use by date must be appropriately disposed of. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alnwick Road (4) DS0000066795.V314882.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!