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Inspection on 13/06/05 for Brighton Road (47-49)

Also see our care home review for Brighton Road (47-49) for more information

This inspection was carried out on 13th June 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home encourages service users to make decisions about all aspects of their lives; this includes what to eat, where to go on holiday, for days out, and what clothes to buy. Service users spoken too felt that the staff have built a good relationship with them. Comprehensive information about the home and the services offered are available, and potential service users (and their relatives) are encouraged to visit the home, enabling an informed choice regarding the suitability of the home to be made. Service user files contained appropriate assessments and care plans and that service users` care and support needs had been properly assessed these include their health, personal care and social needs. Service users are treated with respect by staff and have their privacy and dignity respected. Comments from service users were generally positive, with indication that staff is kind and helpful in meeting their care needs.

What has improved since the last inspection?

All staff have had training in how to prevent service user`s being harmed or suffering abuse or being placed at risk of harm and/or abuse. They also have received training in fire awareness, first aid, equal opportunities, race equality and anti-racism. The infection control training is on going.

What the care home could do better:

The homes Statement of Purpose needs to be reviewed to ensure it reflects the services offered in the home, also a copy of the latest inspection report is included in the Service User`s Guide. Service users contracts must be signed by all parties concerned, and accurate records of their monies must be kept. The complaints procedure must be reviewed to include the stages and timescales for response. It also needs amending to reflect the change in regulatory organisation to the Commission For Social Care Inspection. A number of environmental issues arose during this inspection such as the outside of the house must be repainted and maintained on a regular basis. The mid and top landings need decorating. The side gate and broken glass in the basement windows need replacing. There were rubbish and broken furniture left on the side of the building. This needs to be cleared as failure could results to serious repercussions to the health and welfare of service users. The garden also needs attention. Staff files must contain all relevant documentations including proof of identification, references and Criminal Record Checks. An annual development plan must be implemented for the home. A copy of which must be sent to the local office of the CSCI. A number of health and safety issues arose during this inspection. The two fire doors in the hallway were wedged open, the COSHH cupboard door was unlocked and food were left uncovered and not labelled in the fridge. Requirements have been made for these matters. The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection.

CARE HOME ADULTS 18-65 Brighton Road (47-49) 47-49 Brighton Road Purley Surrey CR8 2LR Lead Inspector Mohammad Peerbux Unannounced Inspection 13 & 17 June 2005 9:00am 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 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 Stationary 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. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brighton Road (47-49) Address 47-49 Brighton Road, Purley, Surrey, CR8 2LR Telephone number Fax number Email 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 8660 4078 thfcare@brightonroad.fsnet.co.uk THF Care Estates Ltd Ms Lorraine Bright Care Home 15 Category(ies) of Learning Disability (15) registration, with number of places Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 17 November 2004 Brief Description of the Service: 47/49 Brighton Road is owned, managed and staffed by THF Care Estates Limited. The property is registered with the Commission for Social Care Inspection (CSCI) to provide residential care for up to fifteen adults with moderate learning disabilities. The home provides residential care for younger adults aged between 18 and 65 the vast majority of whom have lived together for many years, with the result that they seem very comfortable in one another’s company. Mrs. Lorraine Bright as the registered manager has been in operational day-to-day control of the home for the past eleven years. The property is situated on a busy residential road close to the centre of Purley and is well placed for local shops and public transport links. Built over three-stories the homes comprises of thirteen single and one double bedroom, currently shared by a couple; two separate lounges; a dining area; kitchen; laundry; office; and numerous bathroom/toilet facilities located conveniently positioned throughout the house. There is ample space in the front garden for parking and the back garden, which has a patio area and large lawn, is extremely well maintained. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It took place over two days .The first day of the inspection was unannounced. Some times were spent looking at the policies and procedures, talking to staff and to some of service users. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. The second day was pre-arranged with the manager to check on staffs’ files and training. What the service does well: What has improved since the last inspection? All staff have had training in how to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. They also have Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 6 received training in fire awareness, first aid, equal opportunities, race equality and anti-racism. The infection control training is on going. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 9 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 standard(s) 1,2,3,4 and 5 It would difficult for prospective service users to be clear about the service the home provides to meet their needs, as all the information that needed to be in the Statement of Purpose are not in one document. The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. The necessary information and opportunity to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home to be made. To ensure that service users and their next of kin/advocates are aware of the services they should be receiving, all service users must have a signed copy of their contract with the home. EVIDENCE: All the information that need to be in the Statement of Purpose are not in one document so it will be difficult for prospective service users to have the information they need to make an informed choice. The Service User’s Guide also needs to review to include a copy of the latest inspection report or make reference where it can be found. The manager must ensure that all information are included in Statement of Purpose as per schedule1 of the Care Standard Act 2000 and that a copy of the latest inspection report is included in the Service User’s Guide. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 10 individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a very comprehensive needs assessment, which covers prospective service users known strengths, skills, interests, and ability to take positive risks as part of the admission process. It was clear from care plans sampled at random that service user’s needs are being met. Records revealed that service users are in regular contact with other health and social care professionals, including General Medical Practitioners, District Nurses and Care Managers, who regularly visit the home to check that assessed needs are being met. All prospective service users are offered the opportunity to visit the home before a place is offered. An introductory visit is followed by a review after six weeks and then three months. Any placement made follows the homes admission/’trial’ placement procedures. Arrangements made for dealing with reviews of service users on a ‘trial’ placement are included in the homes contract. Service users or their recognised representatives are provided with a costed contract/statement of terms and conditions of occupancy which are agreed between each prospective service user and/or representative and the home. However three copies of contract were sampled, they were not signed or dated by either the registered manager or the service user. The registered manager must ensure that all contracts are signed by all parties concerned. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 11 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 standard(s) 6,7 and 9 Care plans are comprehensive and include detailed information about service users’ needs, personal goals, wishes and risk assessments. Service users are involved in decision making about their lives, they participate and can take some risks so that they live as normal a life as possible. Service users are not always safeguarded from financial abuse, as the records are not appropriately maintained. EVIDENCE: Three service user care plans were sampled, it was noted that they were all up to date and well-maintained. Overall, the plans demonstrated a thorough needs assessment, which clearly set out how current and anticipated needs would be met. The plans checked established individualised procedures for service users likely to challenge the service, focusing on positive management strategies. The home reviews the care plan of the service user every six months. Documentary evidence was available to show that the annual review included the care manager and/or other professionals from the placing authority. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 12 The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. Where possible service users are actively encouraged to manage their own financial affairs and one service user in particular retains their own Bank Book, which they use to good effect to make withdrawals and deposit money as they wish. Service user’s financial records were in the main clear, accurate and appropriately maintained. However at the times of inspection the amount of money recorded did not match what was in the service users’ wallets. The staff explained that the service users have recently been on holiday and that they were waiting for the manager to come and adjust the service users’ monies. The manager must ensure that accurate records are kept as far as service users’ monies are concerned. One of the stated aims of the home is to enable service users to take responsible risks wherever possible. Potential risks are identified prior to a prospective service users admission covering all aspects of their daily living both inside and outside the home. The home was able to demonstrate that this standard was met as individualised care plans were in place for each service user that referred to action required to minimise identified risks and hazards. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 13 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 standard(s) 12,15,16 and 17 Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: All the homes service users attend Day Centres during the week, including Driscoll, Hazel Dean, Hallmead, and Tandridge Hill Farm that offer a wide variety of fulfilling educational and social activities. Staff support service users who wish to find out about and take up opportunities for paid work in the local community. At least four service users have paid jobs including two, who work at a local Hotel and the local Council respectively. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 14 Service users are actively encouraged to maintain links with their families and friends. The home has an ‘open’ visitor’s policy and simply recommends that visitor’s telephone to say they are coming to ensure there loved one will be available. It was clear from entries made in service users daily diary notes and the visitors book itself, that visitors are always welcome at the home and service users can choose whom they see and when. The manager advised that all the homes service users have their own bedroom and front door keys. Having examined a random sample of menus it was clear that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of meals. The staff stated that once a week service users are asked to choose the meals they want to eat in the forthcoming week before the food is purchased. Where the published menu option is not desired on the day alternatives are provided as service users wish. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 15 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 standard(s) 18,19 and 20 Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’ medication is also well managed to ensure maximised good health. EVIDENCE: The vast majority of the homes service users are very independent and require little or no assistance with personal care (e.g. washing/bathing, dressing/undressing and eating meals). Where needed staff offer service users guidance about personal care/hygiene and seemed to be mindful of the need to respect service users’ rights to privacy and dignity at all times. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 16 Most service users are registered with the one GP, and in keeping with good practice. Records checked indicate that GP’s and other community based medical/health care professionals are contacted on an as needed basis, including dentists, opticians, audiologists, chiropodists, and specialist nurses. Service users are offered regular health checks and potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. It was evident that records of all medical/health appointment/visits were being meticulously maintained. Service users who are willing and able to self-medicate are always encouraged to do so in accordance with good practice. They have risk assessments in place. In general, medication records, including medicines received, administered and returned were all being appropriately maintained. Medication profiles in respect of each service user were also available, and detailed all continued and discontinued medicines. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 17 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 standard(s) 22 and 23 The home’s policies and procedures that are in place to deal with concerns, complaints needs amending to include the stages and timescales for response to ensure that service users have confidence that their complaint will be dealt with promptly and efficiently. Also it needs to reflect the change in Regulatory body. Service users are protected from abuse and are living in a safe environment as the home has appropriate adult protection policies and procedures in place. EVIDENCE: Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 18 The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. However it does not give the stages and timescales for response. The manager is required to review the complaints procedure to include the stages and timescales for response. It will also require amendment to reflect the change in regulatory organisation to the Commission For Social Care Inspection. A record of complaints made about the operation of the home is appropriately maintained and includes details of any investigations, its outcome and action taken (if any). It was noted that since the previous inspection there have been one complaint, which has been successfully resolved by the manager. The home has a detailed adult protection procedure; the procedure states that any member of staff who is being investigated would be suspended pending the investigation. It was previously required that the registered person must make suitable arrangements by training staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. The manager stated that all staff have now attended the training and are aware on how to prevent and deal with abuse. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 19 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 standard(s) 24,26,28 and 30 Although the environment and furniture generally met the service users’ needs, parts of the environment and fabric of the building does not fully promote the service users well being and therefore do not ensure that they live in comfortable and pleasant surroundings. The home is generally hygienic, clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 20 Overall the home was decorated to a reasonably high standard throughout and appeared to be very comfortable, bright and warm. It was previously required that the external paintwork of the house and the mid and top landing be decorated and repaired. These remain outstanding therefore these requirements will be repeated. During this inspection it was noted the side gate was broken and there were broken glass in the basement windows. The manager must ensure that the gate and the broken glass are replaced. There were rubbish and broken furniture left on the side of the building. This needs to be cleared as failure could results to serious repercussions to the health and welfare of service users. The lawn needs cutting and the garden also needs to be properly maintained. The service users spoken to said they were happy in the home. The home is situated on a busy road near the centre of Purley the home is within easy walking distance of local shops and amenities, including public transport links. On the whole furnishings, fittings, adaptations and equipment are of good quality, domestic in scale and ‘ordinary’ as is compatible with fulfilling their purpose. Some of the bedrooms were checked. They were decorated to a very high standard. Service user said that they had personalised their rooms with their own things. This was confirmed as many of the rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. Several service users had televisions, music systems and all manner of electrical appliances available in their rooms for their own entertainment. There is ample space for all the homes service users to sit together in and were their said they received visitors in private in either one of the homes two lounges and the dinning room as they wish. In addition, the kitchen and laundry areas are clean and domestic in scale. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However the COSHH cupboard was left unlocked (see standard 42). Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,35 and 36 The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. EVIDENCE: The manager stated that all staff have a job description in place. The job descriptions contain the main purpose, tasks, including household and administrative tasks staff are expected to perform and be responsible for. The home arranges for a least two members of staff to be on duty at times throughout the day and for a third member of staff to work across the early and late shifts. Two staff sleep-in at night. Current staffing levels are consistent with minimum standards. As part of the inspection process staff records were sampled for references, criminal record checks, application forms and copies of identification. It was noticed that one staff file did not have any identification and another did not Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 22 have a photograph. The manager’s file was also examined, it was noted there was no original application form, no references, no evidence that the manager is physically and mentally fit for the purposes of her work. The registered provider must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. There is a staff training and development programme in place. The manager is very proactive in respect of staff training. All staff are offered a wide variety of training appropriate to the needs of the service users. It was previously required that the registered person must ensure that all staff receive equal opportunities training, race equality and anti-racism training. There was evidence that staff have attended these courses. The manager advised that all the homes care staff receive at least six supervisions a year covering good care practices and career development. It is recommended that the manager keeps a yearly record of staff supervision signed by both the supervisor and supervisee for easy monitoring. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42 and 43 The home is managed by an experienced and well-qualified manager who ensures a quality service. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. It also needs to have a business and financial plan to ensure the effectiveness, financial viability and accountability of the home. Although the health and welfare of the service users is generally prompted, parts of the environment do not fully facilitate the service users health and well being. EVIDENCE: Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 24 Throughout the course of the inspection the manager demonstrated a good competent management skills and appears to have created a skilled, positive and enthusiastic workforce. She has many years experience of working with this client group and displayed an insight into the relevant issues. She is not qualified to level 4 NVQ in Management, but is currently completing the NVQ Level 4 and CMS. Service users and their families are consulted about the conduct of the home and their views are regularly sought by means of the telephone, invitations to reviews, and for some, regular visits to the home, where relatives are able to meet and talk directly with care staff and the manager. However the home does not; as yet have an annual development plan. This was a requirement from the last inspection. The registered provider must ensure an annual development plan is implemented for the home. A copy of which must be sent to the local office of the CSCI. A number of health and safety issues arose during this inspection. The two fire doors in the hallway were wedged open, the COSHH cupboard door was unlocked and food were left uncovered and not labelled in the fridge. Requirements have been made for these matters. No business and financial plan was available at the time of inspection. The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection. This was a requirement from the previous inspection. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brighton Road (47-49) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 2 G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 26 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 1 Regulation 4 Requirement The registered Person must ensure that all information are included in Statement of Purpose as per schedule1 of the Care Standard Act 2000 . The home must ensure that a copy of the latest inspection report is included in the Service User’s Guide. The registered Person must ensure that all service users contracts are signed by all parties concerned. The registered Person must ensure that accurate records are kept as far as service users’ monies are concerned. The registered Person is required to review the complaints procedure to include the stages and timescales for response. The registered Person must amend the complaints procedure to reflect the change in regulatory organisation to the Commission For Social Care Inspection. The registered person must ensure the outside of the house is repainted and maintained on a regular basis. (Timescale of Timescale for action 30/09/05 2. 1 5 30/09/05 3. 5 17(2) 30/09/05 4. 7 17(2) 06/09/05 5. 22 22(4) 30/09/05 6. 22 22(7)(a) 30/09/05 7. 24 23(2)(b) 31/08/05 Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 27 30/09/04 and 31/05/05 not met) 8. 24 23(2)(b) The registered person must ensure that the mid and top landings are decorated.(Timescale of 31/03/05 not met) The registered person must ensure that the side gate is replaced. The registered person must ensure that the broken glasses in the basement windows are replaced. The registered person must ensure that the rubbish on the side of the building are cleared . The registered person must ensure that the lawn is cut and the garden is properly maintained. The registered person must ensure copies of Birth Certificates, Passports (if any); a recent photograph; enhanced CRB check and any other documents laid down in this standard or schedules are available for inspection in the home at all times in respect of all staff employed. The registered provider must ensure an annual development plan is implemented for the home. A copy of which must be sent to the local office of the CSCI. (Timescale of 30/09/04 and 3/05/05 not met) The registered Person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The registered Person must ensure that all hazardous materials are kept locked in accordance with Control of 30/09/05 9. 10. 24 24 23(2)(b) 23(2)(b) 30/09/05 30/09/05 11. 12. 24 24 23(2)(o) 23(2)(o) 30/09/05 30/09/05 13. 34 17(2) 30/09/05 14. 39 24(1) 30/09/05 15. 42 23(4)(c) 06/09/05 16. 42 13(4)(a) 06/09/05 Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 28 17. 42 18. 43 Substances Hazardous to Health Regulations.. 12(1)(a) The registered Person must 06/06/05 13(4)(c) ensure that food is cover and e appropriately labeled in the fridge. 25(2)(a)(c The registered Person must send 31/08/05 ) to the CSCI, local office a current business and financial plan and a copy of the annual accounts. (Timescale of 30/06/04 and 31/03/05 not met) 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 36 Good Practice Recommendations It is recommended that the manager keeps a yearly record of staff supervision signed by both the supervisor and supervisee for easy monitoring. Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 Page 29 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Brighton Road (47-49) G53 S28161 BrightonRoad47-49 V228157 130605 stage4.doc Version 1.30 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. 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