Inspection on 17/01/06 for Chandos Road, 91

This inspection was carried out on 17th January 2006.

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 16 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 16/01/07

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 Consensa Care Ltd. 91 Chandos Road Stratford London E15 1TT Lead Inspector Lea Alexander Unannounced Inspection 17th January 2006 11:15 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Consensa Care Ltd. 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 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 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. There are at present two 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. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors second inspection at the home. The Inspector carried out this inspection over the course of a day, during which they met with the staff member on duty, the registered manager and spoke privately to both service users. In addition the Inspector toured the premises, viewed service users personal files and other relevant documentation. The main focus of the inspection was to check on the progress made with the 19 requirements and 4 recommendations made at a previous inspection on the 8th September 2005. What the service does well: What has improved since the last inspection? What they could do better: Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 6 Sixteen requirements were made as a result of this inspection, and ten of these were restated requirements identified at the previous inspection. The home should revise its statement of purpose and include its smoking policy in its contracts with service users. Individual plans should address all areas of need and be updated to reflect any changes. Any changes to specialist counselling should be driven by service users needs and wishes. Identified risks must be subject to an assessment and management strategy. Self-medication must also be risk assessed and managed, and medication that requires refrigeration must be appropriately stored. Service users should participate in the recruitment of staff and the development and revision of policies. An emergency admission policy, physical intervention policy and staff disciplinary and grievance policy must be developed and implemented. The home must also develop its quality assurance process. Minor issues with regard to the homes environment must be addressed. In addition fire equipment must be maintained and Fire Brigade recommendations fully acted upon. A fire evacuation drill should be conducted and the outcome recorded. Entries in the incident log should be reviewed and if appropriate investigated and notified to relevant parties. Accidents must be properly recorded. A legionella certificate must be obtained and food hygiene practises observed in labelling prepared or processed foods. Appropriate action should be taken when fridge temperatures fall outside of acceptable parameters. A manager for the home must be appointed and retained. Personnel information including induction records must be available for inspection. Regular “person in charge” visits must be made and their outcomes reported. 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. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 5. The home has produced a statement of purpose that requires further revision to accurately reflect the current situation. EVIDENCE: The Inspector viewed the homes statement of purpose. Whilst this had been amended in accordance with a requirement made at an earlier inspection, the Inspector formed the view that this requires further revision to clearly state the current number of care staff working in the home, and details of their actual qualifications and experience. The Inspector also noted that the statement of purpose says that service users will be supported to take up regular weekly outings to places of interest. The Inspector sampled the homes activity log and noted that this did not evidence these trips as occurring. The Inspector viewed service users personal files and evidenced that the home has completed up to date contracts with service users. Whilst these contain information relating to the homes alcohol policy, there is no information with regard to the homes smoking policy. One service user has now been living at the home for six months. They reported feeling very settled and said that they were “happy living here”. Standard 2 was not inspected on this occasion. It was inspected on the 8th September 2005 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9 & 10. Individual service users plans do not address all areas of need and some potential risk areas are not subject to a risk assessment or management strategy. EVIDENCE: The Inspector viewed the individual plans developed for each service user. The previous inspection had required that these are developed to address each area of need, and that the plans are updated to reflect any changes in service users needs. The Inspector sampled individual plans for both service users and assessed this requirement as unmet. One service users individual plans do not address their educational or occupational needs, and do not accurately reflect their current situation, or detail the support being provided to enable this service user to access training courses. The other service user has a risk assessment that indicates that as a result of hypoglycaemic episodes their blood sugar must be monitored at least three times daily by staff. Their care plan had not been updated to reflect this Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 10 change. The Inspector observed that individual plans for both service users had a review sheet attached that had been completed on a monthly basis. The Inspector viewed the minutes of service users meetings and noted that these had been held in September, November and December and that a further meeting was scheduled for late January 2006. The Inspector concluded that the minutes did not indicate that these meetings are used to involve service users in the selection of staff or to review the homes policy and procedures. The previous inspection had required the home to develop its risk management strategy to include the management of potential risks and strategies to minimize these. This particularly related to two risks identified for one service user associated with self harm with a knife and unsafe use of the cooker to light cigarettes. The risk assessments on file did not evidence that this requirement had been met. The Inspector also viewed the homes generic risk assessment file and found this to be empty. Since the previous inspection notes in service users personal files indicate that additional potential risks have been identified as one service user smokes in their room, and the other has recently been physically aggressive to support staff and service users. The Inspector was unable to locate risk assessments to identify and manage either of these potential risks. The Inspector noted that required maintenance to the homes office had been completed and confidential information was now securely stored. During discussion with one service user about how the home meets their needs, the service user stated that they found staff very helpful and thought of two staff in particular as “good friends”. Standard 7 was not inspected on this occasion. It was inspected on the 8th September 2005 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 & 17. The home has not demonstrated how an unplanned change in specialist counselling provision for one service user is in their best interests. EVIDENCE: Sampling of one service users personal file indicated that they had recently commenced a programme of counselling initiated and funded by the home. Commencement of this service was not reflected in the service users individual plan. The Inspector noted that reports from the counsellor indicated that the programme was to recommence in the New Year. Discussion with the service user involved identified that the registered manager had advised them that the programme would not be resuming. The registered manager confirmed that counselling with this organisation had ceased and would be transferred to another organisation. It was not evidenced from the records available what consideration had been given to the possible impact of a change of counsellor at this stage and how the change is in the best interest of the service user. The Inspector sampled the homes record of meals provided to service users, and this indicated a range of nutritious meals being offered. Service users are Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 12 able to choose the meals prepared within the home and are supported by staff to prepare these. Standards 12, 13, 15 and 16 were not inspected on this occasion they were inspected on the 8th September 2006 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20. The homes medication policy has been revised to address issues identified in the previous inspection, however it does not adequately address the management of controlled drugs. The current arrangements for storing refrigerated medication are not appropriate and must be addressed. EVIDENCE: The Inspector viewed the blood sugar monitoring sheets for a diabetic service user and noted that these are being completed at least three times daily in accordance with the homes risk assessment guidance. The Inspector viewed the homes medication policy and noted that this had been revised as required by the previous inspection. The policy now states that new staff members should be inducted into the homes medication procedures and observed practising these prior to administering medication by themselves. The policy now also clearly states that self-medication by service users must occur within a risk assessment framework. From sampling the personal file of the service user who is currently self-medicating, the Inspector was not able to evidence that this had been risk assessed. The policy has not been revised to include information with regard to the handling, storage and administration of controlled drugs, and this requirement is therefore restated. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 14 Medication in the staff office and in the self-medicating service users bedroom is stored in lockable cupboards. The homes Medication Administration Records (MAR) accurately reflect that one service user is self-medicating, and all of the medication for the other service user, including “as required” (PRN) medication was listed on the MAR. The MAR sheet appeared accurately completed and evidenced that medication was regularly administered in accordance with its prescription. The Inspector noted that the homes medication fridge in the staff office was currently not working. Insulin medication for one service user was being kept on an open shelf in the homes general fridge. The Inspector noted that this medication requires storage at between –2 to –8 degrees, and that the fridge temperature was significantly higher than this. When pointed out to the member of staff on duty they removed all food contents to a separate refrigerator and adjusted the thermostatic control. Standards 18 and 21 were not inspected on this occasion. They were inspected on the 8th September 2005 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Previous inspection has evidenced that the home listens to service users and protects them from abuse. EVIDENCE: These standards were inspected and assessed as met on the 8th September 2005. Recommendations with regard to the recording format for the complaints procedure and the availability of adult protection phone numbers were assessed as met on this occasion. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30. The home is generally well maintained and hygienic. However, health and safety requirement made by the London Fire Brigade remains outstanding. 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. 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. A vacant service users bedroom is also located on the ground floor. 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. Since the last inspection the homes registration certificates have been relocated to the hallway however, a copy of the complaints procedure is still prominently displayed and could be better sited on the hallway notice board. A wall clock and potted plant have been added to the lounge, but further Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 17 development is required to ensure that this is a homely environment that reflects the personalities of the service users who live there. Many of the repairs identified at the last inspection have been addressed, however the downstairs toilet seat needs to be secured. The Inspector noted that the seat and toilet pan were soiled. A previous requirement relating to recommendations by the London Fire Brigade and the homes fire alarm system remains outstanding. The Inspector noted that the home was generally clean, and free from offensive odours. Standards 25, 26 and 27 were not inspected on this occasion. They were inspected on the 8th September 2005 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 & 36. Personnel information required by inspection was not available for all staff. EVIDENCE: The Inspector viewed the homes recruitment policy and noted that this had not been revised as required by the previous inspection. The Inspector sampled the personnel records maintained by the home. The organisation operates a centralised personnel office where original documents are kept. A summary sheet containing information required by regulation is held within the home. The Inspector searched for a personnel summary sheet for one of the permanent staff members identified on the current staffing rota, but none was available. The member of staff on duty advised that they had been externally appointed to their post, and started duties in September 2005. The Inspector was unable to locate a completed induction programme for this staff member. The Inspector viewed the minutes of staff meetings and noted that some staff members had expressed frustration with the senior management of the organisation and felt that they were not being supported to undertake their work. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 19 Standards 32 and 33 were not inspected on this occasion. They were inspected on the 8th September 2005 and assessed as met. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 & 43. Repeated changes in acting manager, and the posts current vacancy mean that service users are not currently benefiting from a well run home. EVIDENCE: The current registered manager is also the responsible individual. They are also a director of the parent company and since registration two acting managers have been appointed and commenced the registration process. The first left in September 2005 and the second the day before the inspection. As an interim measure a manager from another care home within the company is providing phone cover and visiting the site daily. The Inspector noted that the high turnover of managers had impacted upon the homes ability to address requirements identified by inspection and was unsettling for both service users and staff within the home. The Inspector noted an occurrence recorded in the incident log on the 5th January 2006 when one service user had become verbally and physically aggressive. The record indicates that the support worker on duty phoned the acting manager and was told to ring the registered manager. The support Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 21 worker did this and was advised to phone the police. During the incident the support worker records that they intervened to prevent one service user hitting the other and were then subject to an assault themselves. The Inspector noted that no follow up investigation or action was recorded as having occurred and the Commission received no notification of the incident. The Inspector was advised that the homes telephone landline had all its incoming calls diverted to another home. The Inspector advised that this practise must cease immediately, and the diversion was removed. The Inspector viewed the homes quality assurance file and noted no development work had been undertaken in this area as required by the previous inspection. The previous inspection had identified that several policies relevant to the home and required by National Minimum Standards had not been developed. These include emergency admission, physical intervention and a staff disciplinary and grievance procedure. A policy addressing communicable diseases and infection control has been developed by the home. The Inspector noted that records required by regulation were generally of a good standard and up to date. The Inspector noted that daily completion of the homes activity log for service users had resumed. The Inspector sampled the homes records for fridge and freezer temperatures. Whilst temperatures are recorded on a daily basis, fridge temperatures were noted to be outside of acceptable limits on several concurrent dates with no record or evidence of appropriate action being taken. Water temperatures are being recorded daily and were found to be within acceptable limits. A weekly fire alarm test is being carried out at the home, however, the test on the 13th Jan 06 identified a faulty emergency light. There is no record in the fire alarm test book or maintenance log of action taken to report or repair this fault. There was no information in the homes fire record to evidence that an emergency evacuation drill has taken place. The inspector viewed the homes accident book and noted that the two entries in it were incomplete. No information about the actual accident was recorded for either, and on one occasion no date of time had been entered. The Inspector asked to view the homes legionella certificate and was advised that the Environmental Health Officer had visited in December 05 but had not yet issued their report. The Inspector viewed the contents of both of the homes fridges. Whilst prepared foods were appropriately labelled with start dates the Inspector noted Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 22 that some processed foods items had not been labelled with start and end dates in accordance with manufacturers storage instructions. The Inspector viewed the log of “person in charge” visits and reports on the home. These indicated that these visits have occurred on only two occasions, in August and September of 2005. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 1 3 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 1 X 2 2 3 2 2 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 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 registered person must ensure that the homes statement of purpose complies with regulations and includes: (i) the number, relevant qualifications and experience of staff. Timescale for action 31/03/06 This is a restated requirement. The previous target of the 08/01/06 was not met. (ii) The statement of purpose must accurately reflect the services and opportunities offered to service users. 31/03/06 2. YA6 15 The registered manager must ensure that individual plans are: (i) developed to address each area of personal, social and healthcare need. reviewed and updated to reflect (ii) Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 25 any changes in service users needs. This is a restated requirement. The previous target of the 08/01/06 was not met. 3. YA8 12 The registered manager must ensure that service users have opportunities to participate in the day to day running of the home and matters such as review of polices and staff recruitment. This is a restated requirement. The previous target of the 08/01/06 was not met. 4. YA9 13(4) All identified areas of risk must be assessed and a management and minimization strategy developed and implemented. Service users with complex multiple needs should be offered specialist interventions by appropriately trained staff and any changes to these services must be considered in the service users best interest. 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 were not met. Medication requiring refrigeration Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 26 31/03/06 31/03/06 5. YA11 12 & 15 31/03/06 6. YA20 13 31/03/06 must be stored in a lockable container and maintained at the correct temperature. 7. YA24 23 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 home should relocate the copy of the complaints procedure currently displayed in the lounge. The following maintenance issues must be addressed: (i) (ii) The downstairs toilet seat must be secured. The broken handle on the upstairs bathroom must be repaired or replaced. The mains powered battery back up fire alarm system must be modified according to LFEPA requirements. The upstairs emergency firelight must be repaired. 31/03/06 31/03/06 (iii) (iv) 8. YA30 16 The registered person must ensure that the downstairs toilet is cleaned and maintained to a good standard. 9. YA34 7, 9, 19 & Sch 2 The homes recruitment policy and procedure should be revised DS0000062806.V278806.R01.S.doc 31/03/06 Consensa Care Ltd. Version 5.1 Page 27 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 should be explored. Personnel records required by National Minimum Standards must be available for inspection. (ii) (iii) (iv) The previous target of the 08/01/06 was not met. 10. YA35 18 The registered person must evidence that all staff receive structured induction training within six weeks of appointment. The previous target of the 08/01/06 was not met. Supervision records must be available for inspection. The responsible individual must ensure that good relationships between management, staff and service users are promoted and that staffs receive the support they need to carry out their work. 12. YA37 9 & 39 The home must appoint and commence the registration process for a manager as a DS0000062806.V278806.R01.S.doc 31/03/06 11. YA36 12 & 18 31/03/06 31/03/06 Consensa Care Ltd. Version 5.1 Page 28 matter of urgency and appropriate interim measures must be identified and notified to the Commission for Social Care Inspection. 13. YA39 24 Quality assurances processes should include the views of service users, their family members and other professionals. Findings should be published and made available to interested parties. This is a restated requirement. The previous target of the 08/01/06 was not met. 14. YA40 App 2 The registered person must ensure that all policies and procedures required by National Minimum Standards are developed by the home. This is a restated requirement. The previous target of the 08/01/06 was not met. 15. YA42 13, 23 & 37 The registered person must ensure that: (i) a weekly test of fire alarms is carried out and recorded and any identified maintenance is undertaken promptly. A fire evacuation drill must be carried out and recorded with evacuation times. Fridge and freezer temperatures must be accurate and recorded daily and Version 5.1 Page 29 31/03/06 31/03/06 31/03/06 (ii) (iii) Consensa Care Ltd. DS0000062806.V278806.R01.S.doc appropriate action taken if the readings are outside of acceptable limits. (iv) All accidents are comprehensively recorded in the accident book. A legionella certificate is obtained for the home. (v) These are restated requirements. The previous targets of the 08/01/06 were not met. The registered person must also ensure that: (i) Opened processed foods are labelled with start and end dates in accordance with manufacturers storage instructions. 16. YA43 26 The registered person must notify the Commission for Social Care Inspection without delay of significant events within the home that affect service users. Monthly “person in charge” visits must be made to the home and reports completed and made available for inspection. (ii) 31/03/06 Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 30 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. 2. YA28 The home should purchase an air purifier for use in the smoking lounge. This is a restated recommendation. Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Consensa Care Ltd. DS0000062806.V278806.R01.S.doc Version 5.1 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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