Inspection on 31/07/07 for Banyard Road, 40

This inspection was carried out on 31st July 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Banyard Road, 40 07/06/06

Banyard Road, 40 01/03/06

Banyard Road, 40 26/09/05

Banyard Road, 40 08/02/05

Banyard Road, 40 31/08/04

Banyard Road, 40 03/03/04

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 Banyard Road, 40 Bermondsey London SE16 2YA Lead Inspector Ms Alison Pritchard Unannounced Inspection 31st July 2007 2:30pm Banyard Road, 40 DS0000007108.V316836.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 Banyard Road, 40 DS0000007108.V316836.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. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Banyard Road, 40 Address Bermondsey London SE16 2YA 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) 0207 231 4774 0207 261 4148 choicesupport@choicesupport.org.uk www.choicesupport.org.uk Choice Support See standard 37 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2006 Brief Description of the Service: The home is registered to provide care for three people who have learning disabilities. The home is managed by a ‘not for profit’ organisation called Choice Support (Southwark) which manages a significant number of care homes for people with learning disabilities in the borough of Southwark and elsewhere. The home is in a cul-de-sac in Bermondsey, close to Southwark Park where parking is available during daylight hours. It is indistinguishable as a care home. Other local facilities include a shopping centre, market, pubs, cafés and churches. The home is close to public transport routes. The home provides a statement of purpose, detailing what the service offers and provides. It also lists what people can expect in terms of their rights, the service and terms and conditions. They provide a service brochure, which gives details of the accommodation, local area and staffing support provided. At the last inspection the manager stated that the Statement of Purpose and Service Brochure inform people of how they can obtain of all reports on the home. The residents make financial contribution towards the cost of their placements. The weekly contribution towards rent is £34.55 and towards food costs is £29.40. The remaining cost of placements is paid for by the placing authority. At the time of the inspection there were no vacancies. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over an afternoon and early evening in late July. The inspection methods included observation of care practice; discussion with the manager; inspection of residents’ files and a range of records and policy documents. Involved professionals and relatives were sent survey forms so that they could contribute to the inspection process. Feedback was received from two relatives. The inspector is grateful for their views. The CSCI also has access to information gathered through notifications from the home. A pre-inspection questionnaire was completed by the previous Manager of the home in advance of the inspection and returned it to the inspector. All of this information has been taken into account in compiling this report. What the service does well: What has improved since the last inspection? Several of the requirements made at the last inspection of the home have been met. This has meant that the following improvements have taken place: o The bathroom has been re-tiled and redecorated and this makes the room more attractive and homely. o The cleaning products which could present risks to residents are sfely locked away o All of the staff have received training on how to keep residents safe. o A permanent manager has been appointed to the home. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Banyard Road, 40 DS0000007108.V316836.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 Banyard Road, 40 DS0000007108.V316836.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, 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission policy and practice takes into account the need to gather information about the potential service user’s needs. The information to be provided for anyone thinking of coming to live at the home is out of date and is currently being reviewed. EVIDENCE: The admission policy of Choice Support includes provision for introductory visits to take place and for social work assessments to be obtained prior to admission. Placements are subject to a twelve week trial period. An assessment of need carried out under the Community Care Act by a social worker was seen on the file of a resident who came to live at the home in April 2007. The admission of this person was made in circumstances which were outside of the organisation’s usual procedure. This was in the best interests of the resident and the CSCI was properly informed about the process. The new resident and a relative were provided with a service user guide for the home. On the files of the two residents who have lived at the home for some years were incomplete documents called service user guides. These documents were not yet complete. They are being written using plain English and pictures. The information seen is clear, easy to understand and would give anyone thinking of going to live at the home a good idea of what it is like. The Manager has confirmed that the service user guide is under review. A copy of a ‘statement of purpose’ seen was out of date and is also in need of review. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 9 It is required that copies of the reviewed documents be sent to the CSCI when the process is complete. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has been active in arranging assessments for a resident the further action is needed to create a care plan based on their knowledge of her needs. Risk assessments are being reviewed. There are good arrangements to ensure that residents’ views contribute to the running of the home and the managing organisation. EVIDENCE: The two residents who have lived at the home for a long time had recently had their placements and care plans reviewed. The residents, their advocate and relatives were invited to the meetings and the placing authority was involved in the process. Choice Support has introduced a care planning system which is based on the person centred model. This home has not yet fully implemented the new system. However the recent review meeting provided a useful forum for discussion of these residents’ plans and new goals were identified for them. There are some guidelines in place for the provision of care, but many of these are in need of review. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 11 In the case of the most recent resident, who was admitted to the home in an emergency situation, there is an interim care plan in place which was written by the placing social worker at the time of admission. Assessments are underway so that the home has accurate and specialist information about the range of the resident’s needs. It is intended that from these assessments a full care plan will be drawn up. The home has gathered a range of useful information from their own observations and experience of the residents’ needs. It is required that a care planning meeting be held to draw together all of the information currently available and produce a care plan. It is likely that as more information arises from the assessments that this will need review at frequent intervals, but this should not delay further the plan being put in place. The residents met with a member of staff and the Manager in mid July 2007, it is intended that the meetings be held monthly. The purpose of the meeting was to seek the residents’ views about aspects of life in the home. Matters discussed included the menu and ideas for day trips. Minutes of the meeting were made and arrangements are being made for them to be printed in an accessible format using plain English and pictures. This shows a commitment to residents having opportunities to participate in aspects of life in the home. The managing organisation has links with a service called ‘Customer Watch’ which is a forum through which people with learning disabilities can express their views on the services provided through Choice Support (Southwark). This ensures that the opinions of service users generally are included in the overall planning of the organisation. Risk assessments were on file for the two longest standing residents, none was seen for the third resident. All of the risk assessments seen were drawn up a long time ago and were in need of review. The Manager has confirmed that this process is underway. Residents’ personal information is stored with due regard for confidentiality. Choice Support is registered under the Data Protection Act and there is a confidentiality policy to ensure that staff handle residents’ personal information with care. The policy is included in the staff handbook. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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 this service. All of the residents are assisted to lead active lives, using local facilities and resources appropriate to their needs, interests and cultures. Residents are supported to maintain relationships important to them. The meals in the home are good and staff are aware of the need to consider cultural and nutritional needs as well as residents’ preferences. EVIDENCE: All of the residents are involved in activities away from the home. These include attendance at an art project, going to an evening art group, going to the Pop In social club, and ten-pin bowling. They go shopping and use local facilities such as the hairdressers and cafes in the local area. The activities were discussed at the recent reviews and new activities added to the programmes of two residents. They were also discussed with residents at their recent residents’ meeting. There was information that previous staff shortages had resulted in a reduction in the activities that residents had been able to follow. An agreement was achieved at the reviews that residents’ opportunities to keep in touch with people important to them and lead interesting lives will be protected. Outings had been arranged, including to a City Farm and to Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 13 Margate. During the inspection all three of the residents went out to a local park accompanied by staff. The residents are assisted to bake and cook meals. They watch television and listen to the radio. One of the residents has sensory items in her room, including a water bed. Two of the residents have reflexology sessions at the home. At the time of the inspection the inspector’s observation was that residents would benefit from more resources being available for activities in the home. Since the inspection the home’s manager has stated that over the next month residents are going to be assisted to choose items to use. All of the activities in which the residents take part are appropriate to their ages and their cultures. A comment made about the care provided in advance of the inspection was that the home ‘supports ethnic background, regularly takes [my relative] to Caribbean restaurant.’ Another person said that they felt the home was good at encouraging and supporting their relative to be part of the local community. Relatives said that the residents are helped to keep in touch with them and they are informed about matters of importance. One person commented that the home ‘encourages family links’. Residents make and receive visits to and from family members and friends. It was decided at a review meeting recently that a resident will be supported to renew a friendship with someone with whom she had lost touch. The routines of the home are flexible and based around the residents’ activities and needs. Staff spoke to and about residents with warmth and respect. Residents can choose when to spend time alone. There are no unnecessary or unreasonable restrictions on the residents’ movement about the home and garden. Menus are planned with residents to meet their nutritional needs and their preferences. Discussions are underway about the best way to meet the religious and cultural needs of one resident in relation to her diet. As noted above a comment was made that these issues are already well addressed in relation to another member of the resident group. Food stocks and menu records showed that the meals are varied and include fresh items. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 this service. Residents benefit from effective arrangements for contact with health care professionals and an understanding of their emotional needs. Some improvements to the management of medication are required. EVIDENCE: Each resident has a key worker who is familiar with her needs. The staff team is all female, as is the resident group, and this allows for appropriate care to be provided. Discussion with the manager showed appreciation of and sensitivity to the emotional impact that coming to live at the home might have. There are good relationships with health care professional from the multidisciplinary team specialising in the health care needs of people with learning disabilities. There was information to confirm good liaison with health care professionals, appropriate referrals had been made and assessments were underway. On going monitoring of residents’ weight is carried out as necessary. None of the residents look after their own medication. The medication administration record showed that staff are giving the regular medication properly. However there were some issues that needed attention – these were: Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 15 o The medication administration record for one resident had not been completed correctly. o Homely remedies lists should be agreed by the GP annually, two seen were signed by the GP on 30.8.05. o Some of the medication in stock needed disposal – o One item had expired on 1.7.07 o A bottle of eardrops was not labelled with the date of opening, they were issued on 23.4.07 and had the instructions that they should be disposed of 28 days after opening. The Manager was informed of these issues at the time of the inspection. She confirmed in a letter of 7th August 2007 that action had been taken to address these issues. A requirement is made to ensure safe medication systems. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and adult abuse policies and procedures contribute to the safety of residents. EVIDENCE: The complaints procedure meets the legal requirements and is included in the information given to residents at the time of their admission. One complaint had been made in the last twelve months. It was not upheld. The information kept about the matter showed that it had been investigated fully. Relatives confirmed that they are aware of the complaints procedure and expressed confidence in the home’s ability to deal with concerns about residents’ care. The Annual Report issued by Choice Support includes information that the organisation has conducted a thorough review of their policies, procedures and training to ensure that they are aimed at the protection of people who use their range of services. Choice Support introduced a new ‘safeguarding adults policy and procedure’ in March 2007. The judgement of the CSCI is that this is a thorough document, which is clearly written, and links all the aspects of safeguarding. The policy also introduces a new initiative of an internal protection committee. Staff receive training in adult protection as part of their induction to Choice Support and there is an on-going training programme in these issues. It is judged that this demonstrates that Choice Support is actively working to improve processes and practice. Choice Support has procedures to make sure that residents’ finances and valuables are kept safe. Checks of the financial records are carried out by the Manager. Banyard Road, 40 DS0000007108.V316836.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, 25, 27, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and provides a pleasant safe and relaxing environment for residents. It was clean and hygienic throughout. EVIDENCE: The home is situated on two floors with a large communal sitting room and kitchen/diner area on the ground floor. A left allows access to the first floor for people with mobility problems. These and the hallway are all decorated to a good standard and were pleasant and homely. There are patio doors leading from the dining area to a ramp leading down to an attractive garden with a paved area and raised flowerbeds. The garden is fully wheelchair accessible. There is a lift to the upper floors. Residents’ bedrooms are suitable for their needs, large and pleasantly furnished. One bedroom needs more personal items to be added and a lampshade to be fitted. The manager said that there are plans for these matters to be addressed. A walk in shower on the ground floor is presently not used. Residents use the bathroom on the first floor. The bathroom has been redecorated and this has significantly improved the appearance of the room. The building was clean and hygienic, laundry facilities are suitable for the needs of the home. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff to meet residents’ needs. This has been achieved through some use of bank staff although recruitment is currently underway and efforts are made to ensure that consistent care is provided. The staff are well supported. Less than 50 of the team is appropriately qualified is working towards a qualification. EVIDENCE: At the time of the inspection the staff team consisted of, in addition to the Manager, four permanent, full time support workers. Staff recruitment is underway and the manager expects the vacant posts to be filled in the near future. The vacancies are currently filled by a member of bank staff who works on a long term contract at the home and by members of the permanent staff team working additional hours. Despite the staff vacancies this allows for consistent care to be provided. There are two members of staff on duty at all times between 8am and 10pm. T night time one member of staff sleeps in the home and is available to assist residents. Additional help is available from managers through the on-call system. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 19 Two staff members have left the home since the last inspection. Several members of the staff team have worked at the home for several years and are familiar to the residents and with their needs. There are currently two members of staff who are working towards NVQ, one to NVQ2, the other to NVQ 3. This is less than the numbers of qualified staff required by the National Minimum Standards which specifies that 50 of the staff team should be appropriately qualified or working towards such a qualification. Three of the team hold a current first aid certificate. Choice Support provide staff with a minimum of five days a year training. When the staff recruitment records were last checked at the managing organisation’s head office they were in good order. As the records are kept centrally the home should ensure that a checklist confirming that appropriate checks and references have been taken up is kept in the home and available for inspection. There is a ‘debriefing’ service which staff may call if they are involved in dealing with difficult incidents. Staff receive regular supervision and attend staff meetings, systems which support them to do their jobs well. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. After a considerable period of instability at management level the home now has a permanent manager. However an application for registration has not yet been submitted to the CSCI, nor has the appropriate notification about the appointment been made. The home carries out quality assurance monitoring and the home’s procedures promote residents’ health and safely. EVIDENCE: The home has not had a registered manager since January 2004. At the last inspection (in June 2006) the deputy manager was acting up into the manager’s post and had been doing so since 2004. The assessment procedure for registration under the Care Standards Act had begun although the managing organisation then withdrew the application. A new manager of the home was appointed in May 2007. Choice Support has not yet submitted the application for registration under the Care Standards Act, although it is understood that the manager has begun to gather the appropriate documentation necessary to include in an application. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 21 Choice Support should have made a written notification of the management arrangements to the CSCI. This has not been received. new Visits from other managers take place as required by regulation. The visit reports confirm that discussions with residents and staff are included as part of their assessment of the standard of service. There are some requirements from the previous inspection which have not been met despite the gap of thirteen months between inspections. Some of these requirements had been outstanding for a significant length of time. This may be as a result of there being no permanent manager at the home and the management being covered by a series of interim arrangements. It is essential that the new manager is given sufficient office based time to address the outstanding issues and the new requirements that have been made as a result of this inspection. The managing organisation, Choice Support, has a business plan with identified objectives. These are centred on the further involvement of the residents in the running of the organisation, for example through Customer Watch and through taking part in staff recruitment. The Directors, Managers and Trustees of Choice Support meet regularly with representatives of service users who sit on a ‘service user forum’. They are involved with reviews of policies and procedures and two people with learning disabilities are part of the organisation’s Quality Assurance sub-committee. There are safe systems in place for health and safety matters and records of checks are maintained and were up to date at the inspection. The most recent fire drill took place in June 2007, the safety of the gas system was checked in the same month and the lift was serviced in May 2007. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 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 3 3 2 X 2 X 2 X X 3 X Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA37 Regulation 8 Requirement The Registered Provider must ensure that an application of a manager for the registration under the Care Standards Act 2000 is submitted to CSCI. This requirement was made in a report of the Inspection of August 2004 and has been repeated at subsequent inspections. Consideration will be given to legal action if compliance is not achieved. 2 YA32 18(1)(c)(i) The managing organisation must 01/04/08 ensure that a minimum of 50 of the care staff are either on or have completed their NVQ 2 in care. The previous timescale for action was 10/09/06. This is not met, a new date is set. 3 YA9 13(4)(c) The Registered Provider must 01/11/07 ensure that risk assessments are reviewed. Timescale for action 01/10/07 Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 24 4 YA1 4(2) 5(2) The previous timescale for action was 10/09/06. This is not met, a new date is set. The Registered Provider must 01/11/07 send to the CSCI copies of the reviewed service user guide and the statement of purpose when the process is complete. The Registered Provider must 01/10/07 ensure that all of the residents have a care plan in place which identifies how the residents’ needs with regard to their health and welfare will be met. The Registered Provider must 01/11/07 ensure that guidelines for the provision of care, are reviewed. The Registered Provider must 01/09/07 make sure that the management of medication is improved by making sure that: o medication administration records are completed correctly. o Homely remedies lists are reviewed by the GP annually, o Eye drops are dated the day of opening and they are disposed of as instructed. The Registered Provider must 01/11/07 ensure that residents are protected by the recruitment procedure by keeping in the home a checklist confirming the take up of required recruitment checks and references. The Registered Provider must 01/10/07 ensure that the appropriate notification of the new management arrangements is made as required to the CSCI. DS0000007108.V316836.R01.S.doc Version 5.2 Page 25 5 YA6 15(1) 6 YA6 15(2)(b) 7 YA20 13(2) 8 YA34 17(2)sch4 para6 9 YA37 39(a)(b) Banyard Road, 40 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations The Registered Provider should ensure that the new manager is given sufficient office based time to address the outstanding issues and the new requirements that have been made as a result of this inspection. Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Banyard Road, 40 DS0000007108.V316836.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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