Inspection on 21/11/07 for Cassland Road (1)

This inspection was carried out on 21st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Cassland Road (1) 09/02/07

Cassland Road (1) 08/12/05

Cassland Road (1) 20/09/05

Cassland Road (1) 17/03/05

Cassland Road (1) 11/10/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cassland Road (1) 1 Cassland Road Thornton Heath Croydon Surrey CR7 8RN Lead Inspector David Pennells Key Unannounced Inspection 21st November 2007 11:30 X10015.doc Version 1.40 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 Cassland Road (1) DS0000028101.V354394.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 Older People. 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. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cassland Road (1) Address 1 Cassland Road Thornton Heath Croydon Surrey CR7 8RN 020 8665 0074 020 8665 0074 sboodnah@yahoo.co.uk 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) Mrs Sevalacion Boodnah Mrs Sevalacion Boodnah Care Home 4 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (4) of places Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provision of care in the service known as 1 Cassland Road is restricted to the registered provider only. If at any time the registered provider is unable to manage the home, the registered provider will nominate a person who will be agreed with the Commission for Social Care Inspection. As agreed on the 9th August 2006, two named service users under the age of 65 years can be accommodated. The CSCI must be informed when either of these service users no longer resides at the home. 9th February 2007 2. Date of last inspection Brief Description of the Service: Cassland House is registered to provide care for up to four older (aged 65 ) people with a mental health problem (excluding learning disabilities and dementia). The home holds a variation currently to allow two people under the age of 65 to reside at the home, alongside two who are over that age. The average age is just about 65, therefore. The property itself is ideally situated just off Thornton Heath High Street, within a few yards of retail outlets of many and varying descriptions. Banks, Pubs and Medical Health Centres are also close by. The local authority Sports Centre - including swimming pool, fitness classes and gym facilities - is also just a few hundred yards away. Transport links are also excellent, with bus stops dotted along the High Street, and the local railway station about a five or ten minutes’ walk away. Local places of worship (Anglican, Methodist, Roman Catholic, Hindu) are also within about the same walking distance. The premises are immaculately kept - clean and well furnished, and provide a very pleasant, comfortable environment for the service users. It is a ‘nonsmoking’ home. One bedroom is located at the front of the house on the ground floor, and three upstairs. One upstairs bedroom has an ensuite facility. The proprietor also has a bedroom on the first floor - from which she is ‘on-call’ at nights. There is a shower room with toilet on the first floor, and a bath and toilet on the ground floor. The main communal area is a large open plan lounge (with large TV screen DVD) and dining area, with the kitchen off - facing out onto a well-planted rear patio area which has garden chairs and a table and parasol for enjoying the hotter weather. A remote-controlled awning also ensures that the lounge does not ‘overheat’ in the summer. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced, on an ordinary working day, and occurred from 11.30am and throughout the afternoon, the inspector spending time with both the proprietor and the people who use the service. Lunch was served during the visit. During times both before and after lunch, Mrs Boodnah (known as ‘Sheila’ to the people who use the service and their relatives) assisted the inspector to tour the home, and was able to provide the paperwork and to assist the inspector in a review of documentation. The inspector is grateful to the proprietor for her cooperation, and to the people who live at the home and Mrs Boodnah for the welcome and hospitality. Feedback from people directly using the service was sought, and comments received through direct interviews of three of the four living at the home continue to be very positive about the service (see below). What the service does well: What has improved since the last inspection? The inspection generally showed a well running establishment, with the proprietor continuing to address issues raised by the Commission in an appropriate way. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 6 New Care Plan formats have been adopted to make clearer the approach to individualised care. Portable appliance testing has been undertaken since the last inspection visit. Criminal record Bureau checks have been repeated for all staff at the home thus ensuring that Protection of Vulnerable Adult (PoVA) checks have been completed for each staff member and also the proprietor and her husband. Mrs Boodnah now has completed her NVQ Level 4 Registered Manager’s Award (RMA) - and the certification dated June 2007 is in her possession. The dorgard fire door holders are now checked regularly. 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. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person placed at the home can be sure that the multi-disciplinary CPA devised for them is used as a blueprint for their care routines used at the home, and that therefore their needs will be generally met. Intermediate care is not provided at this establishment (standard 6) and therefore this standard does not apply. EVIDENCE: One service user made it plain that they had positively chosen to live at Cassland House and that they would seriously reconsider their residency there if Mrs Boodnah was no longer running the home - such was his reliance on her ‘style’ of service. One person had left the home in December 2006 and one had joined the community in January 2007. The home has been consistently full with all four Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 9 places being used. Interviewees stated that they also had been provided with enough information about the home prior to moving in; there is a Statement of purpose /service user Guide available. The cross-section of people living at the home is currently four white British men - all stating they have a Christian background - though none actively practice their faith. The average age at the home is just under 65 - two of those living at the house are under 65, whilst two are just over. The blend of the characters of the men living at the home seems to work very well. All service users were found to have a professionally created ‘enhanced Care Programme Approach (eCPA) Assessment’ completed by their referring social worker / care manager. The home provides a service focused on a long-term, low-key care level to the people who stay there; all generally have a chronic condition, and so expecting to live at the home for some considerable time. The home has expressed the opinion that the new approach to care planning will have a direct impact on the provision of care at the home, through developing ‘life biographies’ - these identifying needs more accurately. People living at the home confirmed that they and their relatives / supporters had had the opportunity to visit the house, to spend time - even overnight stays - there, before they were required to decide whether to move in for the trial six-week / two-month period up to the first formal ‘review’. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect the home to provide an agreed programme of care in line with their agreed Care Planned Approach documentation, covering their medical, social and emotional needs and reviews of the plans lead to an update of the plan on a regular basis. Service users can expect their health needs to be met through the home supporting and encouraging appropriate engagement with local general, and specialist mental health, care professionals. Assistance with medication regimes can be relied upon, with all medication issues satisfactorily fully documented and in place, thus ensuring safe and consistent assistance with medication-related issues. Service users can expect their privacy and dignity to be upheld at all times. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 11 EVIDENCE: We found that local authorities (Merton and Croydon) fund three of the four people using the service and therefore regular reviews are required and completed. One review visit was due within a couple of weeks of the Commission’s visit to the home. The fourth person living at the home has regular reviews at the Tamworth Road Resource Centre, so reviews for all four are guaranteed on a regular basis. We found that the new care planning process (supported by advice and support from an external consultant) operated at the home clearly committed the service to full assessment and the creation of a plan - which connected to daily diary details - and then subsequent reviews. Recording was much improved on the previous inspection’s identified problems. Review documents reflected the ongoing style of care input the home is committed to. The home declared that levels of physical care / dependency are generally low, with just one person requiring some direct personal care assistance. Mental health / psychological support is also identified as a necessary component of the care provided. Individual personal hygiene is encouraged at the home; all the people observed at this unannounced visit were very well groomed and dressed; it is clear that Mrs Boodnah encourages a sense of individual pride and dignity in each of them. We looked at medication records and stores, which were found to be well organised and clearly recorded. People who use the service reported that any physical / medical complaints or concerns they had would be actively reported to the GP, with a Surgery appointment made by the manager without delay with support provided to attend the appointment, if necessary. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service expect to receive care and attention appropriate to their needs and wishes, whilst ongoing contact with friends, local contacts and relatives is encouraged, and a warm, positive welcome awaits such visitors. People can expect to assert their independence, whilst the home will ensure support and encourage is provided, as appropriate, to each individual. The home respects the rights of all individuals to be involved or to ‘watch from the sidelines’ - if this is their preference. People can expect to be encouraged to adopt a lifestyle involving choice and self-determination / control. The home can be relied on to provide a satisfying, nutritious and filling diet, meeting individually expressed needs and aiming to ensure the wellbeing of the people who live at Cassland Road. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 13 EVIDENCE: One person using the service had just left the home to do some shopping when the inspector arrived. Along with his own personal items, he was pleased to be able to assist with shopping for items needed by the home. Each person has their own particular ‘lifestyle’ – varying from one who is often ‘out and about’, both during the week and at weekends - the local Gym, Swimming Pool and a Snooker Club in Croydon are popular haunts for this particular service user - to another who has a regular routine of going for a regular ‘constitutional’ each morning. Another enjoys going out shopping – both to Tesco’s [the local supermarket] and to the local butchers shop, or the newsagents - shopping for one or everyone. Activities within the home tend to be tabletop games or listening to music / the radio or watching TV. A DVD and expansive TV screen provides vivid engagement for films, documentaries, the news, and other televisual items. People at the home have already previously positively indicated that they did not wish to be involved in greater decision-making about life at the home – but did value being informed of impending changes. One person was again very clear that organised ‘activities’ are not their preference; they prefer to sit quietly in their room, when not undertaking their own activities based on their own considered decision-making. The dining area remains attractive, and food is served either here or in a person’s room on request. Crockery / cutlery is pleasant and condiments and sauces were openly available during the meal observed. A variety of cold drinks were also available on the table to meet differing needs. Those asked confirmed that they were very happy with the food provided - a choice of menu is provided, and snacks and special diets can be catered for; a reducing diet being noted as an example. People using the service are able to use the kitchen to make drinks - though the majority rely on the regular ‘service’ provided by the manager. Mrs Boodnah is clearly a good cook; food provided at the home is highly complimented. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People resident at Cassland Road can be assured that complaints will be taken seriously and addressed swiftly and effectively by the proprietors. People can be assured that that the proprietor will act to safeguard them from discrimination, abuse or neglect. EVIDENCE: The owner had declared no complaints recorded nor safeguarding issues rose within the past twelve months - and this appeared to be the reality - with all present reporting a happy use of the service at the home. The home has a clear complaints procedure – which is displayed within the home and it also appears in the Statement of Purpose. Leaflets concerning advocacy organisations are openly displayed for those using the service to make contact with if it was their choice. The owner has both the local council’s Vulnerable Adult’s Policy in place, and also a local policy and procedure relating to such reports or allegations. The home has not invoked any safeguarding / adult protection proceedings in the previous year. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can expect to enjoy the facilities of a well-maintained, clean and pleasant environment in which to live, with privacy and dignity supported by all having single bedrooms, a good number of bathing and toilet facilities, and good communal facilities, both inside and out. EVIDENCE: We toured the home - and found that the same level of cleanliness and good order was evident throughout. The above judgement statement is, as in the last inspection report: the entire set of standards being found ‘met’. During the tour of the house and examination of premises - nothing was found to contradict the inspector’s opinions previously formulated - namely that the premises meet all the key and supplementary standards. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 16 The house is immaculately kept - including the well-planted flower garden, which was prepared with winter planting in the patio area to the rear. The sloped access to this back garden / patio has a handrail to assist anyone with impaired mobility to access this attractive area. All maintenance records seen were up to date and evidenced an on-going concern for the quality of the general environment. The one service user who smokes now has a table, chair and secure parasol under which to smoke on his first floor balcony extending from his bedroom to allow him to smoke outside the home, which is now all ‘non-smoking’. A formal planning request to the local authority for permission to install a weatherproof canopy over this balcony has, sadly, recently been refused. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the proprietor and staff members will ensure they are supported and protected at all times, through the provision of competent and informed care and employment practices. EVIDENCE: We found that the home has now adopted the ‘Skills for Care’ Induction Training Programme for any new staff working at the home. Mrs Boodnah runs this service, effectively single-handedly on a day-to-day basis, with her husband’s background support. Support is provided for each of the four men who are resident at the home, though all four can express themselves independently - most being generally physically fit to undertake their own personal care - so the ‘loading’ on the proprietor is relatively light in this regard, leaving her to ensure that the psychological and housekeeping needs are met. There is at least one person on site at the house available to the people who use the service. Mrs Boodnah employs her sister, principally, to cover her absences from the home - having provided this ‘cover’ for many years. She is qualified to a suitable level - being a Registered Nurse. She is familiar with the house, and knows the people who live there well through informal contact, so an induction and foundation programme are inappropriate to her. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 18 Staff files are generally maintained in line with the regulatory requirements as expressed in revised Schedule 2 of the Care Homes Regulations 2001. It is again recommended that a full ‘checklist’ against these Regulations be used as an index for each staff file; this will enable ease of file creation in the future for any new members of staff. Criminal Records Bureau checks for all current staff members have been renewed recently, this leading to them being checked against the Protection of Vulnerable Adults (PoVA) list - which the older declarations did not have. Supervision is also an area where the staffing being provided on a very ad-hoc part-time basis does not lend itself to the ongoing professional support process. It is essential, however that the proprietor maintains records of the covering of staff members’ competences - and must put in place a checklist similar to an induction process - to ensure, and for the visiting staff to confirm, that they have adequate information and knowledge / capacity to run the home in Mrs Boodnah’s absence. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a qualified proprietor who has a clearly open concern for the service users, and a determination to develop and maintain a high standard of service – resulting in an ongoing generally high standard of care. The home is clearly run to the benefit and best interests of service users, though attention to quality assurance could be better expressed through a thought-through development plan. Policies and procedures at the home generally support the service in handling issues arising now and in the future, though a few require development and implementation. Health and safety issues at the home are generally well covered, resulting in a safe environment for those using the service. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 20 EVIDENCE: ‘This is an excellent home - and it’s all down to Sheila - She’s so good I’d ask to move somewhere else if she left’. In such a small establishment, it is clear that the owner is very familiar with all four people who use the service. There are plans to put comment /communication booklets in each room to encourage feedback about the service. Mrs Boodnah now has completed her NVQ Level 4 Registered Manager’s Award (RMA) - and the certification dated June 2007 is in her possession. In Mrs Boodnah’s (holiday) absence, the Commission is notified about replacement management cover for the home - generally her sister (who is qualified in nursing care services) is left in charge - she is already very familiar with those living at the home and is obviously a trusted and reliable worker. Generally Mrs Boodnah only takes a single break of a couple of weeks - for her annual holiday. Finance records of sums held by the owner in safekeeping were seen and clearly recorded. ‘Quality Assurance’ processes in such a small establishment are more difficult to establish - the owner does consult those using the service through 1:1’s and also general discussion - however, she and the consultant are considering better ways of encouraging feedback. In 2005 / 06 Mrs Boodnah had established a ‘Development / Business Plan’ which was useful to ‘set the agenda’ for future developments at the house. It is important that this now be updated to show how the service is continuing to develop. Mrs Boodnah has started to seek the advice of a care home consultant to assist her in implementing the issues raised from inspection reports where necessary. This person visits on a roughly six-weekly basis to offer advice on policy and practice: i.e. she had recently assisted with completing the home’s bullying policy. A tranche of other policies were declared [on the AQAA] as absent by the proprietor - so there is a requirement in this report that they be put in place. They cover: Communicable diseases and infection control / Contact with families & friends / Discharge of service users / Emergencies and crises / Gifts to staff / Individual planning and review / Pressure relief / Racial harassment / Recruitment processes / Staff grievance & supervision. All maintenance records seen were up to date and evidenced an on-going concern for the quality of the environment and safety issues, using reputable local or national companies. The ‘dorgard’ fire door holders are now checked regularly. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 3 Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP30 Regulation 18 Requirement ‘Induction checklists’ - covering the salient points necessary for a staff member to run the home in Mrs Boodnah’s absence - must be put in place for all staff taking charge of the home. Carried forward from last inspection. The 2005 / 06 Home’s Annual Development Plan for quality assurance must be updated for the coming year, with a copy being sent to the Commission. Policies and procedures relating to the following must be devised and put in place: Communicable diseases and infection control; Contact with families & friends; Discharge of service users; Emergencies and crises; Gifts to staff; Individual planning and review; Pressure relief; Racial harassment; Recruitment processes; Staff grievance & supervision. Timescale for action 15/03/08 2. OP33 24(1)-(3) 15/03/08 3. OP37 12 & 18 15/03/08 Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 23 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 OP29 Good Practice Recommendations That a checklist - using the revised Schedule 2 of the Care Homes Regulations 2001 - should be used as an index for staff file contents, for both current staff and any future recruits, thus ensuring all statutory documentation is fully and competently kept for the purposes of inspection. Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cassland Road (1) DS0000028101.V354394.R01.S.doc Version 5.2 Page 25 - 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!