Inspection on 09/02/07 for Cassland Road (1)

This inspection was carried out on 9th February 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) 21/11/07

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 9th February 2007 12:30p 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.V321700.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.V321700.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 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.V321700.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. 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 reside at the home. 8th December 2005 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 of these two people under the age of 65 to reside at the home, alongside two who are 69 and 70. The two people under 65 are aged 60 and now 56 - the age span, therefore being just fourteen years from youngest to oldest. 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 new 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 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 plasma 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.V321700.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 12.30pm throughout the afternoon, the inspector spending time with both the proprietor and the people who use the service themselves. Lunch was just being served on the inspector’s arrival, and supper was due soon after his departure (~5.45pm). In the interim, Mrs Boodnah (known as ‘Sheila’ to the people who use the service and their relatives) was able to assist the inspector with the paperwork and to review documentation. The inspector is grateful to the proprietor and her husband for their honesty and cooperation, and to the people who live at the home for their welcome, contact and hospitality. Feedback from people directly using the service and their relatives has recently been received, and continue to be very positive about the service (see below). What the service does well: The service provides a safe and secure environment for older people who have the need for security and a good standard of accommodation provided in a non-threatening and gently encouraging way. Although just off the bustling High Street of Thornton Heath, the house is a relative ‘oasis’ of calm - and the standard of the premises and facilities is very high. Food is freshly prepared and appreciated, this aspect being to a very high standard. The house is generally a ‘quiet’ house with a low-key, calm atmosphere. People living at Cassland Road actively use their own private space as well as the home’s communal facilities, expressing their individuality and preferences through engaging (or not - as per choice) with the local community - and organising their own lifestyles. Feedback from people who use the service included positive testimonials especially for the proprietor, Sheila, from respondents: “most helpful and very caring” wrote one - with all saying that they knew they could approach ‘Sheila’ if they had any concerns or wished to make a complaint. The service also obviously provides a generally good and reliable input: “always around when you need them.” “I would recommend a friend or relative to the House.” “The home is kept fresh and clean and spotless. I am grateful for this.” Comments in writing from current relatives (which indicated generally global satisfaction) included: “[My relative] is treated with the utmost respect” and “I find the home spotlessly clean - friendly to the extreme.” Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 6 A care management respondent - reflecting a positive overview of the service stated: “very high standard of care is maintained throughout the home.” The GP used by the home also reported back an overarchingly positive response. What has improved since the last inspection? 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.V321700.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.V321700.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): 3, 5 & 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user placed at the home can be sure that the multi-disciplinary CPA devised for them is used as a blueprint for their care 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: All service users have some need of support due to mental ill health, past or present; some were in long-term institutional care - and now live a pleasant ‘community’ life in the middle of this bustling Thornton Heath environment. The home provides a service focused on providing a long-term, low-key care to the people who stay there; all generally have a chronic condition, and so expecting to live at the home for some considerable time. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 9 All service users were found to have a professionally created ‘enhanced Care Programme Approach (CPA) Assessment’ completed by their referring social worker / care manager. In some cases (see next section) these documents were the sole lead guidance for the home’s caring practices. The London Borough of Croydon, predominantly, supports placements at the home, the current scale of charges made by the home ranging from approx. £450 - £600 per week. People living at the home confirmed both informally, and in their questionnaire responses, 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’. The person most recently admitted to the home spent a ‘trial’ night at Cassland Road a fortnight prior to their admission. Interviewees stated that they also had been provided with enough information about the home prior to moving in. Cassland Road (1) DS0000028101.V321700.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 adequate. 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 Care Planned Approach documentation, covering their medical, social and emotional needs - though the home must ensure more detailed care plan records are kept for each individual in order to fully support each person - to inform assessments and reviews, and should ensure more frequent in-house reviews. Service users can expect their health needs to be met through the home supporting and encouraging appropriate engagement with health care professionals. Assistance with medication regimes can also 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.V321700.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspector found that one person new to the service had not had a full care plan put in place by the manager - despite being in the home for a full six weeks, and despite there being a Care Programme Approach document already provided by the placement officer. There were also no day-to-day notes available to comment on the first four weeks of this person’s stay (whilst notes were, in fact, available for the three longer-term residents) - thus making it very difficult - save for subjective comment - to base a care plan on accurate observation. The manager stated that the notes must have been ‘lost’ - but on questioning, could not confirm to the inspector at the time that they had, in fact, been recorded in the first place. The guidance on care planning held in the home clearly committed the service to speedy assessment and the creation of a ‘room action plan’ (seemingly the title of the home’s principal care plan) by the end of the first week - to daily diary details - and also subsequent reviews. The care plans for two other of the three people using the service had also not been regularly reviewed - as they had been previously; this also indicating a break-down in the effective recording and ‘mapping’ of each individual’s case. The proprietor realised that there were significant deficits in the recording systems maintained by her in the home - commenting on this situation to the inspector she stated: “O dear, I’m dead meat.” With regard to medical and pharmacy interventions, however, the home was maintaining good records in relation to health care needs - and people who use the service reported that any physical / medical complaints or concerns they or the manager had - would be actively reported to the GP, and that an appointment for that person to see the GP would be made by the manager, without delay - with support provided to attend the appointment. Medication records inspected showed that all in this sector of recording was also in good order. All records were found to be up-to-date, with the medication store cupboard tidy and well ordered - including the records for the newest person using the service. Dental services are accessed locally; some service users have dentures. One service user sees a Community Psychiatric Nurse on a monthly basis and district nursing services, when necessary, are also used via the GP’s surgery. Personal hygiene is encouraged to a high standard at the home; all the people observed at this unannounced visit were well groomed and dressed, and it is clear that Mrs Boodnah encourages a sense of pride and individual dignity in each of them. Each service user has a separate bedroom, and bathing facilities are provided on a ratio of 2:1. Cassland Road (1) DS0000028101.V321700.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 local contacts, friends and relatives is encouraged, and a warm 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 clearly expressed 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.V321700.R01.S.doc Version 5.2 Page 13 EVIDENCE: People at the home have 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. All service users commented about life in the home either personally or via the Commission’s questionnaire and reflected a positive response to questions about their lifestyles at the home. One person was again very clear that 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. 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 vast plasma TV screen provides vivid engagement for films, documentaries, the news, and other televisual items. One ex-service user’s family friend regularly continues to visit the home, and supports by telephone the people, specifically, whom they had got to know whilst visiting their family friend at the home. The dining room remains attractive, and food is served either here or in a person’s room if requested. Crockery / cutlery were pleasant and condiments and sauces were openly available. A variety of cold drinks were available on the table to meet differing needs. Service users confirmed that they were very pleased with the food provided - choice of menu is provided, and snacks and special diets can be catered for. Service users are able to use the kitchen to make drinks - though most rely on the regular ‘service’ provided by the manager. Mrs Boodnah is clearly a good cook; food provided at the home is highly complimented; one person indicated in his feedback that he is supported to maintain a reducing diet - at the same time saying positively: “They cook pancakes for me when I want to have some!” Another comment positively noted: “All the meals are very tasty - we get a cooked breakfast and a cooked lunch.” All four people seen appeared well-fed, and confirmed that their weight is monitored regularly. The evening meal is served at about 7.00pm. Cassland Road (1) DS0000028101.V321700.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 home has a clear complaints procedure – which is displayed within the home and also in the Statement of Purpose. The proprietor has received no complaints about the service in the last year. The home 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 had to invoke any adult protection proceedings in the previous year. People at the home have again indicated in the Commission’s questionnaire responses that they feel ‘safe’ in the home, being well treated by staff, knowing who to speak to if they wish to comment on the service. Cassland Road (1) DS0000028101.V321700.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: The above judgement statement is as in the last inspection report - the entire set of standards being found ‘met’. During the inspector’s tour of the house and examination of premises - nothing was found to contradict the inspector’s opinions previously formulated - namely that the premises met all the key and supplementary standards. The house was immaculately kept - including the well-planted spring flower garden / patio area to the rear. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 16 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 adequate. 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: Mrs Boodnah runs this service, with her husband’s background support, on a day-to-day basis - effectively single-handedly. She supports each of the four men who are resident at the home, though all four can express themselves independently - being generally physically fit to undertake their own personal care - so the care ‘loading’ on the proprietor is relatively light in this regard, leaving her to ensure that the psychological and housekeeping needs are met. There is always at least one person on site at the house available to the people who use the service. Mrs Boodnah employs her sister, principally, and another relative, to cover her absences from the home. Both have provided this ‘cover’ for many years and are qualified to a suitable level: the former as a Registered Nurse, and the latter as a qualified Care Assistant. Both are familiar with the house, and have got to know the people who live there well - through informal ‘family’ contact - and therefore induction and foundation programmes are inappropriate to them. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 17 ‘Staff files’ are now maintained in line with the regulatory requirements as expressed in revised Schedule 2 of the Care Homes Regulations 2001. It is again advised that a ‘checklist’ against these Regulations be used as an index for each staff file; this will enable ease of file creation in the future - for new members of staff. Criminal Records Bureau checks for all staff are now quite ‘old’ (extending back to a time of portability) - and it was agreed with the manager / proprietor that all staff members who come into contact with service users - even occasionally - would have their CRB checks renewed (via a registered ‘umbrella’ body) at the enhanced check Level - with the attendant Protection of Vulnerable Adults (PoVA) checks also being undertaken - to ensure a regular and consistent check on their status and suitability to work with vulnerable people. Supervision is also an area where the staffing being provided on a very on a 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.V321700.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by a proprietor who has a clear 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, with precautions in place to guarantee safety and evidence best practice. Policies and procedures at the home generally support the service in handling issues arising now and in the future. Health and safety issues at the home are generally well covered, excepting one minor outstanding issue (PAT testing) - that is planned to be implemented by the proprietor within a short timescale. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home is run as a ‘family business’ with Mrs Boodnah in charge, generally assisted in the background by her husband, and assisted by her sister and another relative in personal care matters and management at times when Mrs Boodnah is not available. Generally Mrs Boodnah only takes one break - of a couple of weeks - off a year - for her annual holiday. Mrs Boodnah is undertaking her Registered Manager Award (RMA) with ‘DCL Consulting’, based in Crystal Palace SE19; and she evidenced - by letter shown to the inspector - that she has submitted her final two units for assessment, and for subsequent internal and external verification. The letter from the NVQ Assessor shows that DCL has experienced some delay in organising external verification - hence the delay in being able to confirm certification for previously completed units. It is sincerely hoped that the verification is completed soon, to release Mrs Boodnah from the strain / anxiety of awaiting a result, and hence being qualified to the level now required by the National Minimum Standards. Mrs Boodnah has now also undertaken the necessary First Aid training identified under Standard 38. Two people at Cassland Road fully handle their own financial affairs; the others have family / care management assisting - with the proprietor acting as Appointee to one service user. In this latter case, the money is paid directly to her, and she then passes on the weekly personal allowance amount to the service user. Records are being suitably kept of payments to this service user. The home has a generally comprehensive set of policies and procedures; the Commission’s policies and procedures list in the pre-inspection questionnaire was signed off except for a few appropriately identified as ‘not applicable’. The concerns about care planning and the apparent loss of documentation from the home have caused the inspector to indicate that standard 37 is found wanting at this visit. One health & safety issue raised was the need for the home to ensure that the Portable Appliance Testing (PAT) checks were completed for all the home’s and service users’ - items of electrical equipment. This appeared to have lapsed. No other health & safety issues were noted and all records of servicing and maintenance measures to ensure a safe environment for those living with Mrs & Br Boodnah were in place. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 20 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 14 & 15 Requirement Care plans should be more regularly updated / reviewed / revisited; the ‘OP’ standard of a monthly frequency of reviews may be reduced to a full 6monthly audit (in line with younger adults standard); however, this is the absolute minimum. The new care planning system (‘purple folders’) must now be fully adopted and implemented. Issue outstanding since deadline of 31/01/06. CRB checks at the enhanced level - including PoVA checks must be resubmitted to CRB to ensure the ongoing safety of the vulnerable people who use the service. ‘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. Timescale for action 30/05/07 2. OP29 19 30/05/07 3. OP30 18 30/05/07 Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 22 4. OP37 17 Records held at the home must be kept carefully, and be stored appropriately - to ensure that all necessary documentation can be called upon to evidence the correct conduct of the home. Portable Appliance Testing is outstanding at the time of the inspection visit; such tests must be undertaken on a yearly cycle to ensure the safety of service users and staff within the home. 12/02/07 5. OP38 13(4) 30/05/07 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 revised Schedule 2 of the Care Homes Regulations 2001 should be used as a ‘checklist’ for staff file contents - for both current staff and any future recruits, thus ensuring all statutory documentation is fully and competently kept. Cassland Road (1) DS0000028101.V321700.R01.S.doc Version 5.2 Page 23 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. 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