Inspection on 07/01/08 for Chandos Road, 91

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 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 16/01/07

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 Rob Cole Unannounced Inspection 7th January 2008 09:30 Chandos Road, 91 DS0000062806.V357254.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.V357254.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.V357254.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 info@consenscare.com 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 Nicola Jane Rabey Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 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 garden area to the rear of the property. Parking is available to the front of the property and local shops and buses are within walking distance. The current range of fees for the home is between £1218.80 and £1244 per week. Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place on the 7/1/08 and was unannounced. The inspector had the opportunity of speaking with service users from the home, along with care staff. The homes manager was present for part of the inspection. The inspection also included an observation of the care and support provided by staff, and a tour of the premisis. The inspector was able to check various policies, records and other documents. The home completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection, at the request of the CSCI, and this formed part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still a number of issues that must be addressed, and a total of eleven requirements have been made, along with one good practice recommendation. In particular, the home must ensure that all medications within the home are stored securely, and that risk assessments carried out by the home are fully implemented and subject to regular review. The home must also ensure that comprehensive pre admission assessments are carried out for all prospective service users, and that monthly Regulation 26 visits take place. Please contact the provider for advice of actions taken in response to this Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 6 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.V357254.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.V357254.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): 1,2,3,4 and 5. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are able to visit the home prior to them moving in. However, in order to ensure that placements are appropriate, pre admission assessments must be carried out on any prospective service users. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statements says “We aim to provide therapeutic and supportive accommodation within a safe environment for residents who are experiencing long term mental health problems.” The Statement includes details of the aims and objectives of the home, and since the previous inspection it now includes details of the registered manager and of the organisational structure of the home. The Service Users Guide contains details of the services and facilities provided and a description of the physical environment, and was in line with the National Minimum Standards (NMS). All service users are provided with their Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 9 own copy of the Service User Guide. There was evidence that both the Guide and the Statement of Purpose have been subject to review. All service users are provided with a written contract/statement of terms and conditions. These have been signed by the service user and a representative of the home. Contracts include details of the facilities and services provided, and of the rules of the home. The contracts state that fees are agreed prior to admission and that they are individual for the needs of each service user. The contracts go on to say that the fees breakdown is included in Appendix A of the contract. However, for the most recent admission to the home this information was not in place. It is required that service users contracts clearly state the fees payable, what these fees cover and what is not included by the fees, so that both staff and service users are clear about what service users may have to pay for out of their own finances. The home has an admissions procedure in place. This states that any prospective service users will be given the opportunity of visiting the home prior to making a decision as to move in or not. The AQAA supplied by the home also stated this, and service users spoken to confirmed that this was indeed the case. One service user has moved into the home since the previous inspection. The inspector was disappointed to note that the home had not carried out a pre admission assessment on this person prior to them moving into the home. In order to help verify and demonstrate that the home is a suitable placement, and that it is able to meet the needs of any prospective service users, a comprehensive pre admission assessment of their needs must be carried out. Chandos Road, 91 DS0000062806.V357254.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 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users have a large measure of control over their daily lives. However, to help ensure the safety of service users and others, the home must implement its own risk assessments, and make sure that they are subject to regular review. EVIDENCE: Individual care plans are in place for all service users, and of a good standard. Plans are drawn up with the involvement of the service user, their keyworker and management staff from the home. Plans are clear and comprehensive and subject to regular review. Care plans cover needs around mental health issues, medication and social and leisure needs. Plans also cover needs around equalities and diversity issues such as service users needs around religion and culture. Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 11 Risk assessments are in place for all service users. Although assessments identify any potential risks, and include strategies to manage and reduce these risks, there was evidence that the home does not fully implement these strategies. For example, the risk assessment for one service user stated that they should be supported at all times when accessing the community, yet it was observed on the day of inspection that they went out to the local shops without any staff support. The assessment for another service user identified that they were at a high risk of contracting a sexually transmitted disease, and that consequently they should have regular blood tests. This was dated June 2006, but there was no evidence that any blood tests have been arranged since that date, although the manager informed the inspector that this was still a risk to the service user. It was also noted that this assessment had not been reviewed since June 2006. In order to promote the health, safety and welfare of service users and others, it is required that the home implements its own risk assessments, and that these assessments are subject to regular review, at least once every six months. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. Service users informed the inspector that they are able to get up and go to bed at a time of their choosing, likewise they have a choice over meals and mealtimes. Service users are able to move freely around the homes communal areas, and to access the community. However, service users have not been offered keys to either their own bedrooms or to the homes front door. A risk assessment is in place for one service user around this issue, but not for the other two. In order to promote service users privacy, dignity and independence, service users must be offered keys to the front door and their bedrooms, subject to the completion of satisfactory risk assessments. Service users are involved in the day to day running of the home, for example with menu planning. Service users have regular one to one meetings with their keyworkers, which gives them the opportunity to discuss any issues of concern to them. Occasional service user meetings are held, however, the most recent of these was in July 2007. The homes manager informed the inspector that these should be happening at least once every two months, and this is recommended. Service users are able to participate in choosing new décor for the home, for example the homes sitting room has recently been decorated, and service users were able to choose the colour scheme. Service users are involved in the day to day routines of the home, such as helping to keep their bedrooms tidy and food preparation. The home has a confidentiality policy in place. This makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Confidential records are stored securely, and staff and service users can access their confidential records as appropriate. Chandos Road, 91 DS0000062806.V357254.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): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home supports service users to live valued and fulfilling lives. Service users have routine access to the community, and food was of a good standard within the home. EVIDENCE: No service users are currently involved in any employment, although one is exploring the possibility of doing some work through the Community Mental Health Team. The home is also looking into the possibility of service users attending local colleges. All service users attend a day service for adults with mental health needs, which helps to meet their needs around equality and diversity issues. The day service operates as a drop in centre, which gives the opportunity to develop Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 13 and maintain relationships. The service also runs an art workshop and film club. There was evidence that service users have routine access to community facilities. Service users go swimming, to the library, shops, markets, post offices and hairdressers. One service user regularly attends an AfricanCaribbean hairdressers, thus helping to meet their needs around equalities and diversity issues. Service users access public transport, including buses and trains, and the home has access to an unmarked vehicle service users can use to access the local community. Service users have access to a variety of social and leisure activities. In house service users have access to satellite television, DVD’s and music. The home arranges occasional parties, for instance to celebrate birthdays. Service users visit local restaurants, for example they recently went to a Greek restaurant for a meal. The home arranges occasional day trips, recently there was a day trip to Clacton. Visitors are welcome at any reasonable time, service users can see visitors in private if they so wish. Service users are able to visit friends and relatives, including for overnight stays. Service users were observed to be given their own mail to open on the day of inspection, and they have access to a telephone that they can use in private. Records are maintained of menus. These indicated that service users are offered a varied, balanced and nutritious diet. Service users are able to plan their own individual menus, and are heavily involved in food preparation. The kitchen was clean and tidy, records are maintained of fridge and freezer temperatures. Mealtimes were observed to be relaxed and unhurried. The home helps to meet service users equality and diversity needs through food, for example by the provision of Caribbean food. Chandos Road, 91 DS0000062806.V357254.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 and 21. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is meeting the personal care needs of service users. However, to ensure that it is also meeting their health care needs, the home must ensure that medications are stored, recorded and administered appropriately. EVIDENCE: All service users are able to manage their own personal care, although the home will offer support and encouragement to service users, for example around dressing appropriately for the weather. The home has sought the views of service users on their wishes on the arrangements to be made in the event of their death. The manager informed the inspector that service users could remain in the home with a terminal illness, so long as the home could meet the medical needs of service users. Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 15 All service users are registered with a GP. Since the previous inspection the home now maintains records of all medical appointments, including details of any follow up action required. However, the home could not evidence that service users have routine access to all relevant health care professionals as appropriate, for example there was no evidence that two of the three service users have had any access to dental care within the past year. In order to ensure that the health needs of service users are been met, it is required that service users have access to all relevant health care professionals as appropriate, including dental care. The home has a medication procedure in place, and all staff undertake training before they administer any medications. No service users are currently on any controlled drugs, or self medicate. Medications still in use are stored in a locked cabinet or a locked fridge within the office. Temperatures are checked of the medication fridge on a daily basis. However, medications that are due to be returned to the pharmacist are stored in an unlocked free standing container within the office, and it is required that all medications within the home are stored securely. Records are maintained of any medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record charts are maintained, those seen by the inspector were accurate and up to date. The homes medication procedure states that guidelines should be in place for the administration of any medications prescribed on an as required basis. Two service users are currently prescribed ZOPICLONE on an as required basis, but there are no guidelines or protocols in place around when this should be administered, and this must be addressed to help ensure that medications are always administered appropriately. Chandos Road, 91 DS0000062806.V357254.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 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints procedure. A copy of this was on display within the home, and all service users are given their own copy. The procedure makes reference to the CSCI, and includes timescales for responding to any complaints received. The home also maintains a complaints log, which indicated that complaints are investigated and recorded as appropriate. The home has a copy of the Local Authorities adult protection procedure, and also its own policy and procedure on adult protection. This appeared to be in line with current legislation. All staff have undertaken training in adult protection issues. The home holds money on behalf of service users in a locked cabinet inside the office. Records and receipts are maintained of financial transactions involving service users monies. Those checked by the inspector were satisfactory. Service users sign to evidence whenever they receive any money. Chandos Road, 91 DS0000062806.V357254.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): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet its stated purpose with regard to the physical environment. Service users are provided with adequate communal and private space, and the home was generally well maintained. EVIDENCE: The home is situated in the Stratford area of the London Borough of Newham. The home is in a quiet residential area, and is in keeping with other homes in the vicinity. The home is close to shops, transport networks and other local amenities. The homes communal areas consist of a sitting room, kitchen/dinning room, lounge/smoking room and a garden with garden furniture. However, at the Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 18 time of the inspection there was a discarded washing machine in the rear garden, and this must be removed. The home was generally well maintained, both internally and externally. As mentioned, the sitting room has been decorated since the previous inspection, and décor throughout the home was of a satisfactory standard. Furniture and fittings in the home were well maintained and domestic in character. However, the kitchen floor covering was uneven, and torn in several places, and this must be replaced. All service users have their own bedrooms, which contain a hand basin. Bedrooms contained adequate furniture, including table, chair, chest of draws and a wardrobe. Carpets, curtains and bedding were well maintained and domestic in character. Service users have been able to personalise their rooms to their own individual tastes, for example with photographs and televisions. Bedrooms meet NMS on size requirements. All bedrooms contain central heating, and radiators are appropriately boxed in. Bedrooms contain adequate natural light. The home has one bathroom/toilet, one shower room and one toilet on its own. The inspector was satisfied that these are sufficient in number to meet the needs of service users. Bathrooms were clean, tidy and free from offensive odour. Bathrooms and toilets had working locks fitted, which included an emergency override device. The home has laundry facilities which are appropriate in scale for the service users. Hand washing facilities are situated around the home, and staff are provided with protective clothing such as gloves and aprons. COSHH products are stored securely. None of the current service users require any adaptations to help with their mobility. Chandos Road, 91 DS0000062806.V357254.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): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home is staffed in sufficient numbers to meet the needs of service users, and that staff are suitably qualified and experienced to carry out their duties. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. Staffing levels have been reviewed since the last inspection, and are flexible, depending on the needs of service users. There was a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. However, the rota did not record the hours worked in the home by the manager. To ensure that service users and staff know when the manager will next be in the home, and to help demonstrate that the manager spends sufficient time in the home to effectively manage the service, it is required that the staffing rota clearly indicates the times when the manager is working at the home. Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 20 Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and that they have built up good relations with individual service users. Staff were seen to interact with service users in a friendly and respectful manner. The home has various employment related policies in place, including on recruitment and selection and equal opportunities. The inspector was pleased to note that CRB checks are now in place for all staff since the last inspection. Other employment checks including proof of ID and references were also in place. All staff undertake a structured induction programme on commencing work at the home. This includes issues around service users, and the aims and objectives of the home. Staff undertake regular training, recent training has included food hygiene, fire safety and understanding mental health. Over 50 of care staff working at the home have achieved an NVQ Level 2 in Care or equivalent qualification. Chandos Road, 91 DS0000062806.V357254.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): 37,38,39,40,41,42 and 43. People who use this service experience adequate in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the homes manager is suitably qualified and experienced, the home must ensure that all necessary health and safety checks and quality assurances processes are carried out as appropriate. EVIDENCE: Since the last inspection the home now has a registered manager in place. They are also the registered manager for another care home run by the same organisation, and share their time between the two homes. They are supported in their management duties by a deputy manager at 91 Chandos Road. The registered manager has twelve years experience of working in the mental Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 22 health field, including six years in a managerial capacity. Staff and service users were seen to interact with the manager in a relaxed manner. The manager has achieved an NVQ Level 4 in Care, and the Registered Managers Award. Care plan reviews and staff meetings contribute to the quality assurance within the home, and copies of previous inspection reports are available to view. An audit timetable was been developed by the home at the time of the inspection. Surveys are issued to service users, completed surveys seen by the inspector contained generally positive feedback. However, there was no evidence of any Regulation 26 visits been carried out in the home since March 2007. To help develop quality assurance within the home, it is required that monthly unannounced Regulation 26 visits take place, and that a copy of the reports of these visits is kept within the home for the purposes of inspection. Fire extinguishers were situated around the home, these were last serviced in March 2007. Fire alarms were last serviced in June 2007, but they had not been tested by the home since the 3/12/07, five weeks prior to the date of this inspection. In order to ensure that fire alarms are in full working order, the home must test them at least once a week. The home has a comprehensive fire risk assessment in place. Hot water and fridge/freezer temperatures are checked regularly, and COSHH products are stored securely. The home has in date safety certificates for gas safety, PAT testing and electrical installation. The home has in date employer’s liability insurance cover in place. Chandos Road, 91 DS0000062806.V357254.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 3 2 2 3 3 4 3 5 2 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 2 X X 2 3 Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 24 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 26 Requirement The registered person must ensure that the monthly person in charge Regulation 26 visits are made to the home and reports completed and made available for inspection. (This is a repeat requirement from the previous inspection, and the timescale of the 31/07/07 has not been met.) The registered person must ensure that comprehensive pre admission assessments are carried out for al prospective service users prior to them moving in to the home. The registered person must ensure that all service users are provided with a written contract/statement of terms and conditions, which includes details of fees payable, what these fees cover, and what they do not include. The registered person must ensure that all service users are offered keys to their bedrooms and the homes front door, subject to the completion of a satisfactory risk assessment. DS0000062806.V357254.R01.S.doc Timescale for action 29/02/08 2. YA2 14 29/02/08 3. YA5 16 29/02/08 4. YA7 12 31/03/08 Chandos Road, 91 Version 5.2 Page 25 5. YA9 13 6. YA19 13 7. YA20 13 8. YA20 13 9. YA24 23 The registered person must ensure that risk assessments for service users are appropriately implemented, and that they are subject to regular review. The registered person must ensure that all service users have access to appropriate health care professionals, including dental care. The registered person must ensure that all medications kept within the home are stored securely. The registered person must ensure that clear protocols and guidelines are in place around the administration of any mediations prescribed on an as required basis. The registered person must ensure that the discarded washing machine in the homes garden is removed. The registered person must ensure that the damaged floor covering in the kitchen is replaced. The registered person must ensure that the staffing rota clearly records the hours worked in the home by all staff, including the homes manager. The registered person must ensure that the homes fire alarms are tested at least once a week. 29/02/08 29/02/08 31/01/08 31/01/08 31/03/08 10. YA33 17 29/02/08 11. YA42 13 and 23 31/01/08 Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 26 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 YA8 Good Practice Recommendations It is recommended that the home holds regular service user meetings, at least once every two months. Chandos Road, 91 DS0000062806.V357254.R01.S.doc Version 5.2 Page 27 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.V357254.R01.S.doc Version 5.2 Page 28 - 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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