Inspection on 08/09/05 for Chandos Road, 91

This inspection was carried out on 8th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 17/01/06

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 8 September 2005 at 2.30 pm th 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 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 Stationary 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 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Consensa Care Ltd Address 91 Chandos Road, Stratford, London, E15 1TT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8552 8818 020 8471 9225 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 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection None 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. 91 Chandos Road is newly registered, and this was the first inspection under National Minimum Standards. There are at present two female service users living at the home. 91 Chandos Road is a three bedded terraced house in a residential area. The accommodation comprises a communal lounge, kitchen diner, smoking lounge, downstairs wc, shower room, bath room 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 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over the course of an afternoon and evening. Service user files and staff files were sampled, as were the homes policies and procedures and other relevant documentation. The Inspector interviewed one support worker and had discussions with the deputy manager as the inspection drew to a close. In addition the Inspector spoke with one service user and was shown their room. What the service does well: What has improved since the last inspection? What they could do better: The home should revise its statement of purpose to include all the elements required by National Minimum Standards. The contract with service users should be revised to include information on the homes alcohol and smoking policies. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 6 All aspects of service users needs should be addressed by an individual plan, and these must be reviewed and updated as service users needs change. Risk assessments should include strategies to manage and minimize the risks identified. All confidential records, including service users personal files must be securely stored. Records of activities in which service users are involved should be kept up to date. The home should facilitate and record regular service user meetings, and service users should be consulted on the meals to be provided each week, and their preferences reflected in the menu offered. All staff must be aware of service users health care needs, including the frequency of blood sugar monitoring. The home should revise its medication policy to include controlled drugs. All medications including “as required (PRN)” medication must be listed on the Medication Administration Record (MAR). The MAR must clearly show whether a service user is self-medicating or not. Service users self-medication must occur within a risk assessment and management framework. All self-medicating service users must be provided with a suitable locking cabinet. The homes adult protection policy should be reviewed to include details of the local multi agency arrangements for adult protection. The home should also review the format in which complaints are recorded to include details of any investigation carried out. Minor revision is required to the recruitment policy, and several key policies need to be developed and implemented by the home. The home must ensure that all records required by regulation are kept up to date and in good order. Personnel records must be available for inspection and a recorded induction programme implemented for new staff. The home must urgently address outstanding maintenance issues and address health and safety issues including fire drills, food hygiene and legionella. 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 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5. The home has produced a statement of purpose and service user guide and facilitates “test drive” visits for prospective service users, all of which enables service users to make informed decisions about where they live. The home has evidenced that it gathers relevant information from a variety of sources as part of the assessment process, and completes its own preadmission assessment. The home has demonstrated that it is able to meet the needs of its current service users. EVIDENCE: The home has a produced a statement of purpose and service user guide which were reviewed by the Inspector. The statement of purpose requires minor revision as outlined in the requirements section of this report to meet National Minimum Standards. A summary of the statement of purpose is included in the service user guide. The service user guide was found to meet National Minimum Standards. The Inspector sampled the personal files of both service users living at the home. This evidenced that copies of relevant assessments had been obtained prior to admission. Documents located included an Occupational Therapy assessment, a discharge summary and Care Programme Approach documents including a multi disciplinary care plan. A pre admission assessment completed by the homes deputy manager was also found on each service users Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 9 personal file. The information collated indicated that the home has the capacity to meet individual service users needs. Detailed recording on both service users personal files evidenced that they had taken the opportunity to “test drive” the home on day and overnight visits prior to moving in. Each service users personal file included a contract that was signed and dated. Whilst the contracts were generally comprehensive, the Inspector noted that it did not contain information relating to the homes smoking and alcohol policies. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10. The home has not evidenced that individual plans are reviewed in line with service users changing needs. The home also needs to develop its risk management strategies and clearly identify actions to be taken to minimize risks to service users. Confidential records are not kept in a secure environment. EVIDENCE: Inspection of service users personal files evidenced that the home had developed with each service user a series of individual plans that identified service users needs, including personal, social and healthcare support and how the home will meet these. Whilst the individual plans viewed on file were generally broad ranging, the Inspector noted that there was no individual plan addressing education and occupational needs for one service user. Discussion with this service user indicated that they were being supported to locate a suitable college course. At the time of this inspection neither service user had been in residence sufficient time to warrant a six-month review of their care plans. Recording in Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 11 the personal file evidenced key working sessions and evaluations of the individual plan. The Inspector did however note that a risk indicator checklist completed after two diabetic hypo episodes in one week identified the need to increase blood sugar monitoring, and that the relevant individual plan had not been updated to reflect this. The individual plans evidenced that service users are supported to make decisions about their lives, including managing their own finances with appropriate support. Specific individual plans addressing budgeting were found on service users personal files. The Inspector viewed the minutes of service users meetings and spoke to staff and service users regarding these. Whilst a rota displayed in the staff office indicated that these meetings should be held monthly, other evidence did not support this. Minutes for these meetings indicated that the only meeting had been held on the 1st July 2005. The Inspector reviewed the risk indicator checklists for one service user in detail. Checklists had been completed on four occasions since admission to the home, each relating to a separate identified risk. The Inspector noted that a risk indicator completed on the 16th August was prompted when the service user sustained minor injuries after an incident of self-harm with a knife. Another risk indicator had been completed on the 6th July 2005 identifying risks associated with the service user lighting cigarettes from the cooker. The Inspector noted that these risk indicators did not include a strategy to manage or minimise risks associated with the incident being recorded. The Inspector viewed the homes absence without authority policy. This offers guidance to staff on conducting a missing person assessment and the procedures to follow to report a service user missing and their return. The Inspector noted that service users personal files are stored on an open shelf in the staff office, and that the staff office cannot be secured as the door window glass is missing. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16 & 17. Service users wellbeing is promoted through opportunities to develop skills and appropriate occupational and leisure activities. The home must ensure that it keeps up to date records of the menus offered, and that all service users have the opportunity to select meals for inclusion on the weekly menu plan. EVIDENCE: The Inspector viewed the homes records for service users activities. From the homes opening until 4th July 05 an activity log was completed. From July a “residents daily activity sheet” system had been introduced. The Inspector noted that these had not been completed since the 19th August 05 and that there was no recorded information available for recent weeks regarding activities. From these records, discussion with one service user and the deputy manager the Inspector established that service users are encouraged to develop and maintain independent living skills by being supported with domestic tasks around the home. For one service user this includes cleaning their own room Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 13 and being supported to prepare meals. This service user is also being supported to access local adult education courses that would support her longterm goal to work with children. The other service user has been supported to attend a trial visit for a local day service and has had outings with staff to a local pub. Both of the homes service users are involved in shopping for the houses weekly supplies. The home also arranges for service users to have meals out with staff or choose take always of their choice. The senior worker also advised that the consensa organisation hold regular barbeques and parties where service users have the opportunity to meet residents from other homes. One service user attends local leisure facilities for swimming sessions and the other service user has been supported to develop their interest in gardening. During the course of the inspection staff were observed to be interacting with service users and that service users had a choice when to be alone or in company and when not to join in an activity. Individual plans identified service users family and friends and how they preferred to maintain contact. The Inspector viewed the homes menu file. It appears that the home operates a rotating weekly menu sheet. As only one of the available sheets had a date recorded, it was not possible to establish the frequency with which the weekly menu sheets were rotated. The service user spoken to did not recall being asked to participate in the selection of dishes for the weekly menu sheets. During the course of the inspection the inspector observed one service user choosing a meal they would like to eat and preparing this with appropriate levels of staff support. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 & 21. The home appears to have addressed issues of illness and death in a sensitive way. Support to attend healthcare appointments and recording of their outcomes was clearly evidenced. However the home has failed to implement its own recommendations regarding the blood sugar monitoring needs of one diabetic service user following a series of diabetic hypo episodes. The homes medication policy requires revision. Current practises for the storage of medication are unacceptable. The home must develop its practise with regard to the recording and administration of medicines and ensure that self-medication occurs within a risk assessment and management framework. EVIDENCE: The Inspector was advised that the current service users are independent in their personal care. The Inspector viewed the homes appointments diary, service users appointments book and correspondence in service users personal files. This evidenced that the home supports service users to attend healthcare appointments and appropriately records the outcome of these including any treatments and follow on appointments. The Inspector viewed the current blood sugar monitoring charts and noted that these were not being recorded three times daily as identified in the risk Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 15 indicator dated 14th July 2005. The staff member on duty was also not aware that blood sugar monitoring should be occurring 3 times daily. The Inspector viewed the homes medication policy and noted that this includes procedures for service users who self medicate. To meet National Minimum Standards the Inspector is of the view that the policy should be revised to include procedures for controlled drugs and to explicitly state the minimum training required to be successfully completed by staff before they are able to dispense medicines. At the time of the inspection the home were transferring from a dossett box system to blister packs stored on racks. The Inspector noted that the new racks did not fit into the homes medication cupboard and were therefore being kept on the floor and in an unlocked draw. The Inspector checked the medication available loaded in the blister packs against that listed on the Medication Administration Record (MAR) and found that these matched. The Inspector did however note that “as required (PRN)” paracetomol was not listed on the MAR sheet and that a service users inhaler was also omitted from the MAR sheet. The Inspector noted that one service user is currently self-medicating. Whilst this was clearly identified in the relevant individual plan, the Inspector was unable to locate a risk assessment for this activity. The Inspector noted that for a period of one week during the changeover from dossett boxes to blister packs this service user was actually being administered their medication by staff, and the Inspector observed this occurring. The MAR did not reflect this and stated that the service user continued to self medicate. During discussions with the service user - who will be would be resuming selfmedication shortly - it was identified that whilst they have a lockable cabinet in their room, their preferred choice of drawer in which to store medication did not have a lock. From sampling of service users personal files the Inspector noted that service users wishes in respect of illness and death had been discussed and recorded. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23. The home aims to protect service users with its adult protection policy and training for staff. Their complaints policy aims to improve the service provided. EVIDENCE: The Inspector viewed the homes complaints procedure and noted that this includes guidance on how to make a complaint, gives a timescale of 28 days for dealing with complaints and gives contact details for the Commission for Social Care Inspection. The service user spoken to by the Inspector stated that they were aware of the homes complaints procedure and that they knew what to do if they wanted to make a complaint. The Inspector also viewed the homes complaints log. No complaints have been received to date. The Inspector noted that the current recording format within the complaints log does not explicitly include an investigation heading, and the home should review its recording format to include this. The Inspector was shown the homes adult protection policy. This includes a description of the different types of abuse service users may experience and makes reference to multi agency local adult protection procedures that must be followed. The homes whistle blowing policy is also referred to. Staff training records were not available in the managers’ absence. The member of care staff interviewed advised that they had completed the initial day of adult protection training and were scheduled to attend a follow up day. The staff member was able to identify several different types of abuse and potential abusers and was aware of the homes policy. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 17 Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24, 25, 26, 27, 28, 29 & 30. Service users have their own bedrooms that they can decorate and personalise to their own tastes. The home offers adequate shared and private accommodation for service users and their visitors. The communal lounge would benefit from developing a more homely atmosphere. It was of concern to the Inspector that such newly commissioned premises should have so many maintenance requirements and that despite staff reporting of these, works had yet to commence. EVIDENCE: The Inspector toured the communal areas of the home, the staff office and two of the bedrooms. The main communal lounge is off of the entrance hallway. It contains armchairs, a sofa, TV and stereo. There was not however a homely feel to the room, which seemed quite stark. The Inspector also noted that the lounge curtains were not properly hung and the homes registration certificates were prominently displayed on the lounge wall. A vacant service user bedroom is also on the ground floor as is the kitchen. The kitchen is extended and has ample room to accommodate the table and four chairs located at one end. The Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 19 kitchen has a range of units and the usual appliances including a cooker, microwave, toaster and kettle. The cupboard containing potentially hazardous cleaning materials has a broken lock. The door leading from the kitchen to the rear of the property had no glass in the window. A WC situated behind the kitchen had no toilet seat fitted and was blocked at the time of the inspection. The Inspector noted that it had continued to be used and was stained with faeces and urine. To the rear of the ground floor is a smoking lounge with access to the garden. This contained a sofa and a second TV and stereo. A laundry cupboard containing a washing machine and tumble dryer is located in this room. The first floor of the building accommodates two more bedrooms. The Inspector saw one of these. Furniture found in the room included a single bed, two wardrobes, and a chest of draws, bedside table and a shoe rack. The Inspector noted that the service user had personalised their room to reflect their own tastes and interests. One of the wardrobes was found to have a broken door. The staff office that is also located on the first floor also had the glass from its window missing. This level also houses a shower room that appeared in good order. The adjacent bathroom has a tub with mixer taps and a shower curtain, a hand basin and WC. A storage box in the bathroom was broken as was the door handle. The Inspector also noted that on the day of inspection the front door lock did not appear to be working properly. The inspector was shown the homes maintenance log that indicated that many of the faults identified as a result of this inspection had been reported two months previously on the 6th July, but repair works had yet to commence. The Inspector was shown a letter from the fire brigade regarding the homes fire assessment. This recommended replacing the under stairs cupboard door with a fire door and extending the battery back up system for the fire alarm. These works also remain outstanding. The Inspector was advised that none of the current service users require specialist mobility or transfer equipment. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36. The homes staff appear comfortable with and accessible to service users. The home must review its recruitment policy to ensure that service users are protected. Personnel records required by regulation must be available locally for inspection. The home must evidence that new members of staff receive appropriate induction training that is recorded in their personnel record. EVIDENCE: During the course of the inspection the Inspector observed that staff on duty were accessible to, approachable by and comfortable with service users. The Inspector viewed the homes recruitment policy and procedure. This requires a number of revisions to comply with National Minimum Standards, which are detailed in the requirements section of this report. The Inspector sampled the personnel record for one staff member. This contained a contract of employment and a completed application form. Two satisfactory references had been obtained has had copies of certificates and confirmation of immigration status and rights to employment. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 21 Written supervision records on file indicated that this was occurring on a four to six weekly basis. During our discussion the staff member confirmed that they always receive a copy of these minutes. The Inspector asked to view the personnel file of the most recently joined member of the staff team and was advised that these records were held at the organisations central personnel office and were yet to be copied to the home. The Inspector asked to see a copy of this staff members induction programme, and again this was not available. A current staff rota was displayed in the staff office and this indicated that the deputy manager is on site Monday to Friday between 9 am and 5 pm. In addition one staff member is in attendance on a day shift between 7 am and 7.15 pm and is then relieved by a staff member on a night shift from 7 pm until 7.15 am. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41 & 42. The home needs to develop its quality assurance processes and publish its findings. A number of key policies also need to developed and made available within the home. Significant shortcomings with the homes health and safety practises were identified during this inspection including those relating to fire safety, food handling and legionella. EVIDENCE: The deputy manager advised the Inspector that a service user feedback questionnaire had been completed in August 2005, and that the home was looking at ways to obtain feedback from family members and other professionals with whom the service has contact. The home has not published and made available results of the quality assurance process it has undertaken to date. During the course of the inspection the Inspector cross referenced the policies and procedures available with those required by National Minimum Standards Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 23 and was unable to locate a number of key policies and procedures. These include policy and procedure for emergency admissions, physical intervention and staff grievance and disciplinary action. The Inspector sampled a number of records kept by the home. The record of activities for service users was not up date. The Inspector viewed the homes fire record. This indicated that the kitchen fire alarm had not been working for over a month, and whilst this had been reported no maintenance had been carried out. No weekly record of fire alarm testing had been completed since the 19th August 2005. There was no record of a fire evacuation drill having taken place. The water temperatures record had only three entries recorded in it, the last being the 14th May 2005. The Inspector noted that an Enviromental Health Report to the home dated 20th June 2005 had advised the home that their current practises with regard to water temperatures and legionella risk control were not appropriate. Information was contained in this report on measures the home could utilise, but it was not evidenced that these had been implemented. The Enviromental Health Report had also advised the home to develop a Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) policy and an accident book, neither of which were made available during this inspection. The Inspector also viewed the homes incident book. This included recording for a recent missing person report for one service user. Valid portable appliance testing stickers were found on the kitchens microwave, toaster and kettle and a valid gas safety inspection report was seen. The log for recording fridge and freezer temperatures was seen. No record for temperatures had been recorded on the 9th and 10th April 2005. The Inspector also noted that on the 11th August a fridge temperature of 29 degrees had been recorded. An inspection of the homes fridge identified two items past their “use by” dates that were still in use, and one item being kept for over a week past the date indicated by the packaging storage instructions. As a result of outstanding maintenance issues potentially hazardous cleaning substances (COSHH) are not securely stored. Valid insurance certificates were displayed in the homes entrance hallway. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 2 1 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 N/A 1 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Consensa Care Ltd Score 3 2 1 3 Standard No 37 38 39 40 41 42 43 Score x x 2 2 2 1 3 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 25 N/A 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 1 Regulation 6& Schedule 1 Requirement Timescale for action 08/01/06 2. 6 15(1) & 15(2)(b) 3. 8 12(2) 4. 9 13(4)(c) 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. (ii) comprehensive information in addition to the visitors policy, on how service user will be supported to maintain contact with family and friends. The registered manager must 08/01/06 ensure that individual plans are (i) developed to address each area of personal, social and healthcare need (ii) reviewed and updated to reflect any changes in service users needs. The registered manager must 08/01/06 ensure that service users have opportunities (including regular service user meetings) to participate in the day to day running of the home and matters such as review of policies and staff recruitment. The responsible person must 08/01/06 ensure that the homes risk assessment framework is developed to include risk Version 1.40 Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Page 26 5. 6. 10 17 17(1)(b) 16(2)(i) & Schedule 4 - 13 7. 20 13(2) 8. 24 23(2)(b) & (d) & (h) 9. 24 management strategies including actions to be taken to minimize identifed risks and hazards. Service users individual records must be kept secure and confidential. Service users should be offered a choice of suitable menus that include their individual preferences. Records should be kept of the menu offered each week. The registered person must (i) revise the medication policy to include procedures for dealing with controlled drugs. (ii) Specifically identify in the medication policy the minimum training to be successfully completed by staff prior to their dispensing medications. (iii) Provide a suitable, lockable facility in which to store medication. (iv) Ensure all medication including PRN medication is listed on the MAR. (v) Ensure that a risk assessment is completed and regularly reviewed for all self medicating service users. (vi) Ensure that individual plans and MAR sheets accurately reflect the current arrangements for administering a service users medications. The home must (i) consult with service users to make the lounge a more homely area that also reflects the service users living there. (ii) Relocate its registration certificates from the lounge wall and properly hang the curtains. The home must urgently address the following outstanding maintenance works: (a) Repair the front door lock, (b) repair or 13/10/05 08/01/06 13/10/05 08/01/06 13/10/05 Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 27 10. 24 23(4) 11. 30 16(2)(k) & (f) 12. 34 7, 9, 19 & Schedule 2 13. 35 18(c)(i) 14. 19 12(1) & replace the lock on the cleaning materials cupboard in the kitchen, (c) replace the missing glass to the kitchen door, (d) unblock the downstairs toilet and replace the toilet seat, (e) repair or replace the broken storage box in the bathroom, (f) repair or replace the broken handle on the bathroom door, (g) repair or replace the broken wardrobe door in the service users bedroom. The registered person must implement the recommendations of the Fire assessment including: (i) replacing the understairs cupboard door with a fire door. (ii) Extend the mains powered battery back up to the fire alarm system. (i) The registered person must ensure that the home is kept clean, hygienic and free from offensive odours. (ii)The siting of the laundry facilities should be reviewed as at present all laundry is conveyed via the kitchen. 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. (ii) All staff must be subject to a 3 month probationary period. (iii) All gaps in the employment record should be explored. (iv) Personnel records required by National Minimum Standards must be available for inspection. The registered person must evidence that all staff receive structured induction training within six weeks of appointment. The registered person must 08/01/06 13/10/05 08/01/06 08/01/06 13/10/05 Page 28 Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 13(4)(c) 15. 39 24(2) & (3) 16. 40 Appendix 2 17. 41 17(3)(a) 18. 42 23(4) & (5), 23(2) (b), (c) & (d) & 13(4)(a) 19. 42 Schedule 4 - 12 and 13(4)(a) ensure that the health care needs of service users are assessed and recognised and that procedures are put in place to address these. Specifically, the registered person must ensure blood sugar monitoring occurs at the frequency recommended by the risk indicator checklist and that all staff are aware of this. Quality assurance processes should include the views of service users, their family members and other professionals and results should be published. The registered person must ensure that all policies and procedures required by National Minimum Standards are developed for the home. Records kept by the home must be kept up date and in good order. This specifically relates to records of activities undertaken by service users. 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. (ii) A fire evacuation drill must be carried out and recorded with evacuation times. (iii) Water temperatures must be recorded regularly. (iv) fridge and freezer temperatures must be accurate and recorded daily and appropriate action taken if the readings are outside of acceptable limits. (v) all accidents are recorded in an accident book that is available on site. The registered person must: (i) Obtain a legionella certificate. (ii) Develop and implement a RIDDOR policy for the home. (iii) 08/01/06 08/01/06 13/10/05 08/01/06 08/01/06 Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 29 Ensure safe food hygiene and handling practises are implemented in the home including disposing of food items past their use by dates. (iv) Ensure that COSHH substances must are securely stored. 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. 2. 3. 4. Refer to Standard 5 22 23 28 Good Practice Recommendations The homes contracts with service users should be revised to include information on it alcohol and smoking policy. The home should review the format it uses to record complaints to explicitly include details of any investigation undertaken. The homes adult protection policy should be reviewed to consider adding names and contact numbers for local adult protection officers. The home should consider purchasing an air purifier for use in the smoking lounge. Consensa Care Ltd G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Gredley House 1-11 Broadway 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 G57 G06 S62806 Consensa Care Ltd V248828 080905 Stage 4.doc Version 1.40 Page 31 - 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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