Inspection on 16/01/07 for Chandos Road, 91

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chandos Road, 91 03/07/08

Chandos Road, 91 07/01/08

Chandos Road, 91 17/01/06

Chandos Road, 91 08/09/05

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 HOME ADULTS 18-65 Chandos Road, 91 91 Chandos Road Stratford London E15 1TT Lead Inspector Lea Alexander Unannounced Inspection 16 January 2007 11:00 th Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chandos Road, 91 Address 91 Chandos Road Stratford London E15 1TT 020 8534 8222 020 8471 9225 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) Consensa Care Miss Renu Kumari Singh Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: 91 Chandos Road is a registered care home offering accommodation to a maximum of 3 adults with mental health difficulties. The home is one of several operated locally by the Consensa Care organisation. At the time of this inspection there were three female service users living at the home. The home is a terraced house in a residential area. The accommodation comprises a communal lounge, kitchen diner, smoking lounge, downstairs wc, shower room, bathroom and three bedrooms. A staff office is located on the first floor. There is a small garden area to the rear of the property. Unrestricted parking is available to the front of the property and local shops and buses are within walking distance. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors third inspection at the home. The Inspector carried out this unannounced inspection over the course of a day, during which they met with the staff member on duty, the deputy manager and registered manager. The Inspector also spoke privately with two service users. In addition the Inspector toured the premises, viewed service users personal files, staff personnel records and other relevant documentation. What the service does well: What has improved since the last inspection? The home has addressed a number of requirements identified at earlier inspections. These include the development of individual service users plans and the use of risk assessments. Service users have also been supported to access specialist healthcare services. The home has attended to minor maintenance issues and the toilets and bathrooms were maintained to a good standard of hygiene. A Registered Manager has been appointed and an induction procedure developed for new staff. Supervision records were also available for inspection. The home has developed a range of policies and procedures and Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 6 has carried out regular fire alarm tests. The home has also improved its food handling and storage practises and has promptly notified the Commission for Social Care Inspection of significant events within the home. 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. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses service users as part of the admission process. However, it must ensure that the service users guide and statement of purpose are updated, and that potential service users are given the opportunity to testdrive the home. EVIDENCE: The Inspector sampled the homes statement of purpose and service users guide and noted that these had been revised since the previous inspection, however they require further revision to include the details of the current RM and DM and the numbers of support staff. The Inspector also noted that the homes statement of purpose outlined several activities such as weekly outings, that it was not evidenced were occurring. The statement of purpose should be revised to accurately reflect the services and opportunities offered to service users. There has been one new admission to the home since the last inspection in January 2006. The Inspector sampled their personal file and found documentation evidencing that the home had obtained assessments from other professionals and carried out their own assessment as part of the admission Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 9 process. From the available documentation the Inspector was not able to evidence that the home had offered this service user the opportunity to testdrive the home prior to moving in. A previous inspection had recommended that the home include information on its smoking policy in its contract with service users and the Inspector noted that this had not been implemented. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan. However, the home must ensure that these are reviewed as service users needs change and that appropriate risk assessments are carried out. EVIDENCE: The Inspector sampled the personal files for two service users. These evidenced that individual plans are developed for each service user that address their health personal and social care needs. The plans sampled included information on family and support networks, mental health, daily living skills, social skills and budgeting. The plans were signed by the service user to evidence their participation in the planning process. Regular keyworking and review sessions evidenced that individual plans are reviewed at least every six months. However, sampling of one service users personal file evidenced a change in the administration of their finances that had not lead Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 11 to their plan being updated. The home must ensure that individual service users plans are reviewed and updated as their needs change. Sampling of individual plans evidenced that service users are encouraged and supported as much as possible to make their own decisions. The Inspector was advised that the home holds regular service users meetings to encourage service users to participate in the day-to-day running of the home. Sampling of the minutes of these meetings evidenced that these have occurred on a weekly basis since October 2006. Issues minuted as being discussed included college attendance, activities within the home and plans for the Christmas period. The Inspector noted that a range of risk assessments that identified potential hazards and the control in place to minimise this had been completed for both the sampled service users. Risks assessed included smoking, holding a front door key, mobility and mental health. These assessments were evidenced as having been reviewed in December 2006. However, one service user was identified as requiring support in administering their insulin. The precise nature of this support was not specified in the individual plan or risk assessment. Sampling of the homes policies and procedures evidenced that the home has a comprehensive policy and procedure for staff to follow should a service user have an unexplained absence. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to engage in appropriate community, leisure and occupational activities and to maintain contact with their families. EVIDENCE: From discussion with service users and staff, and sampling of records the Inspector was able to evidence that service users are supported to develop the daily living skills they will need in independent accommodation. Service users are also supported to enrol and attend computer access college courses and some have also been referred to the Shaw Trust for support in finding appropriate employment or work experience. Service users are also regularly supported to access the local library. Service users are encouraged to maintain contact with their family and friends and the nature of this support is detailed in the individual plan. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 13 During the course of the inspection the Inspector observed that staff talk to and interact with service users and that service users choose when to be alone or join in an activity. Discussion with service users evidenced that a variety of meals are provided to service users that meet their dietary requirements. During the course of the inspection the Inspector observed that mealtimes are relaxed, unrushed and flexible to suit service users activities and schedules. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appropriately supports service users to maintain their personal care. However the home must improve its practise in the recording of medical appointments and their outcome. The home should also address shortfalls in its medication recording and risk assessment practises. EVIDENCE: Service users individual plans were found to detail the nature of personal care required by service users and how they preferred to receive it. Service users choose their own clothes, make up and hairstyles, and these reflect their individual personalities. Sampling of service users personal files and other records maintained in the home evidenced that the home retains correspondence relating to medical appointments. However, there was no record available for individual service users of all medical appointments attended, their outcome and follow up. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 15 The Inspector sampled the homes medication policy. This is a fairly comprehensive document that includes guidance on the storage, administration and disposal of medicines and guidance relating to service users self-medication. The policy does not however contain guidance on the storage and administration of controlled drugs, and requires revision to address this. The Inspector sampled the actual medication available in the home and compared this with current Medication Administration Record. This evidenced that a service users “as required (PRN)” medication is not listed on the MAR. Sampling of another service users individual plan identified that they are self medicating with insulin. However, their current risk assessment did not accurately reflect or assess this activity. The Inspector noted that the fridge currently used to store insulin was not lockable and that no records of its temperature were maintained. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home protects service users, but must ensure that a record of all complaints is maintained. EVIDENCE: The Inspector viewed the homes complaints policy. This includes information on how to make a complaint, the timescales in which the home aims to deal with complaints and contact details for the Commission for Social Care Inspection. The Inspector asked to view the homes complaints log and was advised that there was not currently one in use. The Inspector also viewed the homes adult protection policy. This includes definitions of the types of abuse service users may experience and makes appropriate reference to local multi agency adult protection guidelines. A service user had made one adult protection allegation since the last inspection. The home had appropriately referred this matter to the local Adult Protection Officer and had agreed to undertake an investigation and feedback to the Adult Protection Officer to decide on any further action to be taken. The member of support staff spoken with by the Inspector demonstrated a good understanding of Adult Protection issues and their role and responsibilities. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable and generally well maintained home environment. EVIDENCE: The Inspector toured the homes premises. These comprise of an entrance hallway, a communal lounge furnished with a range of comfortable seating, a coffee table, TV and stereo. In the Inspectors view the lounge would benefit from being made more homely and reflecting the personalities of the service users who live there. There is a large kitchen with dining area and a downstairs WC. To the rear of the property there is a small smoking lounge with a sofa, TV and cassette radio player. A recommendation to provide an air purifier in the homes smoking lounge has not been implemented. One service users bedroom is also located on the ground floor. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 18 On the first floor there are two service users bedrooms, a communal bathroom with hand basin and WC and separate shower room. The staff office is also located on this level. The homes current registration and insurance certificates are prominently displayed in the hallway. The majority of the maintenance issues identified at the last inspection have been addressed. However, recommendations by the London Fire Brigade relating to the homes fire alarm system remain outstanding. The Inspector noted that the kitchen draw containing knives was locked, as was a cupboard containing sweet foods. The Inspector was advised that these measures were to protect service users, including one who has diabetes. However no risk assessments addressing these were available, and it was not evidenced that discussion and agreement with service users for these measures had been obtained. The Inspector noted that the home was generally clean, and free from offensive odours. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from competent, suitably qualified staff. However, the home must ensure that its recruitment practises safeguard service users and that staffs are regularly supervised. EVIDENCE: The home employs three full time and one part time support worker, and a full time Deputy Manager and part time Registered Manager. The Deputy Manager and two support staff have obtained NVQ level 2. Sampling of a service users individual plan identified a period of ongoing crisis that would benefit from 1:1 staffing. The Inspector noted that this would be difficult to achieve with current staffing levels, and during discussion the Registered Manager advised that staffing levels were currently under review. A previous inspection had required the home to revise its recruitment policy. The Inspector sampled this document and found this matter to be outstanding. Staff personnel files are held centrally at a personnel office, however a Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 20 summary sheet containing details of pre employment checks is available at the home. This evidenced that the home obtains proofs of identity and two references prior to staff commencing their employment. However, the Inspector noted that no information was available to evidence that the home had obtained a Criminal Records Bureau (CRB) check for one staff member, and for the other, the CRB date significantly predates their start date at the home. The Inspector was shown a master copy of the induction record and advised that this was completed by all staff and retained on the central personnel file. The Inspector also sampled the supervision records for two staff members. This evidenced that one staff member had received only two supervision sessions in the previous year and that a member of staff who joined in September 2006 had yet to be supervised. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 & 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appointed a Registered Manager who will be able to address a number of shortfalls in the management of the home. EVIDENCE: A part time Registered Manager has been appointed to the home since the last inspection. They have previous experience of managing a residential care home and have also obtained their NVQ level 4. The Registered Manager advised the Inspector that the home is developing its quality assurance processes. Staff and stakeholder questionnaires have been developed and service users questionnaires are in the process of being Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 22 developed. The home has developed a range of policies and procedures in line with National Minimum Standards. The Inspector sampled a range of records relating to health and safety within the home. These evidenced that weekly fire alarm tests are carried out and recorded and any maintenance issues with the system reported. There was no record of an evacuation drill being carried out. The home maintains a record of water temperatures within the home and these were found to be within acceptable limits. A previous inspection had required the home to obtain a legionella compliancy certificate. During this inspection the home evidenced that a legionella compliancy inspection had been conducted, however it was not evidenced that remedial works identified during this inspection had been carried out. The Inspector viewed the homes record of fridge and freezer temperatures and noted that whilst these are recorded on a daily basis there were two occasions when fridge temperatures fell outside of acceptable parameters, with no record of any action being taken. During the site inspection the Inspector viewed the contents of the fridge and freezer and found these to be appropriately stored and labelled. The Inspector also viewed the homes accident and incident books and found these to be in order. However, the Inspector noted that some recorded involved service users verbally or physically abusing staff and recommends that the home consider implementing a debriefing session for staff after such incidents. A previous inspection had required the home to have monthly “person in charge” visits from the Responsible Individual. The Inspector sampled the reports available on site and noted that it was last evidenced that such a visit occurred in August 2006. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 2 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 3 X 2 2 Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 6 & Sch 1 Requirement The statement of purpose must accurately reflect the services and opportunities offered to service users. This is a restated requirement. The previous target of the 31/03/06 was not met. The registered person must ensure that the homes statement of purpose and service users guide are updated to include details of the current Registered and Deputy Manager and the number of support workers. New service users should be offered the opportunity to “test drive” the home. The registered manager must ensure that individual plans are reviewed and updated to reflect any changes in service users needs. This is a restated requirement. The previous targets of the 08/01/06 and 31/03/06 were not met. Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 25 Timescale for action 31/03/07 2. 3. YA4 YA6 14 15 28/02/07 31/03/07 4. YA9 13 & 14 5. YA19 12 6. YA20 13 The nature of staff support in administering insulin must be explicitly stated and subject to a risk assessment. The home must maintain a record all healthcare appointments attended by service users along with the outcome and required follow up. The registered person must revise the medication policy to include procedures for dealing with controlled drugs. The registered person must ensure that a risk assessment is completed and regularly reviewed for all self-medicating service users. These are restated requirements. The previous targets of the 13/10/05 and 31/03/06 were not met. Medication requiring refrigeration must be stored in a lockable container and maintained at the correct temperature. This is a restated requirement. The previous target of the 31/03/06 was not met. A record of all complaints must be maintained by the home including the nature of the investigation, the action taken and the outcome. The home must consult with service users to make the lounge a more homely area that reflects the personalities of the service users living there. This is a restated requirement. The previous target of the 14/10/05 was not met. The following maintenance 28/02/07 31/03/07 31/03/07 7. YA22 22 31/03/07 8. YA24 23 31/03/07 Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 26 issues must be addressed: (i) The mains powered battery back up fire alarm system must be modified according to LFEPA requirements. This is a restated requirement. The previous target of the 31/03/06 was not met. Curtains in service users rooms must be properly hung. The ripped sofas in the lounge and smoking room must be replaced. (ii) (iii) 9. 10. YA33 YA34 18 18, 19 & Sch 2 The home must evidence that it has carried out appropriate risk assessments relating to the locked kitchen draw and cupboard and engaged in appropriate discussion with service users regarding these matters. The home must review current staffing levels in accordance with service users needs. The homes recruitment policy and procedure should be revised to include: (i) An explicit statement that a satisfactory POVA and Criminal Records Bureau check must be obtained prior to appointment. All staff must be subject to a 3-month probationary period. All gaps in the employment record 31/03/07 31/03/07 (ii) (iii) Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 27 (iv) should be explored. Personnel information required by National Minimum Standards must be available for inspection. Previous targets of the 08/01/06 and 31/03/06 were not met. The home must evidence that it undertakes CRB checks on all staff prior to their appointment. Staff must receive a minimum of six recorded supervision sessions each year. The home should implement its quality assurance process including a survey of service users to establish their views and the publishing of outcomes identified during the quality assurance process. The registered person must ensure that: (i) A fire evacuation drill must be carried out and recorded with evacuation times. Appropriate action must be taken, and recorded if fridge temperatures fall outside of acceptable limits. 11. 12. YA36 YA39 12 & 18 24 30/09/07 30/09/07 13. YA42 13, 23 & 37 31/07/07 (ii) These are restated requirements. The previous targets of the 08/01/06 and 31/03/06 were not met. The home must evidence that remedial works recommended during a routine legionella inspection have been carried out. Monthly person in charge visits 31/07/07 DS0000062806.V316080.R01.S.doc Version 5.2 Page 28 14. YA43 26 Chandos Road, 91 must be made to the home and reports completed and made available for inspection. This is a restated requirement. The previous target of the 31/03/06 was 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 YA5 Good Practice Recommendations The homes contract with service users should be revised to include information on its smoking policy. This is a restated recommendation. The home should purchase an air purifier for use in the smoking lounge. This is a restated recommendation. The home should consider developing its incident procedures to include a debriefing session for the staff involved. 2. YA28 3. YA42 Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Chandos Road, 91 DS0000062806.V316080.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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