Inspection on 15/05/07 for Chelsea House

This inspection was carried out on 15th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chelsea House 23/11/06

Chelsea House 27/02/06

Chelsea House 30/01/06

Chelsea House 24/02/05

Chelsea House 29/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Chelsea House 4 Winchelsea Road London N17 6XH Lead Inspector Caroline Mitchell Key Unannounced Inspection 15th May 2007 09:30 Chelsea House DS0000010823.V333342.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 Chelsea House DS0000010823.V333342.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. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelsea House Address 4 Winchelsea Road London N17 6XH 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) 020 8885 1898 Mr Wilhelm Dale Lewis Mr Wilhelm Dale Lewis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2006 Brief Description of the Service: Chelsea House is a small care home registered to provide accommodation and personal care for a maximum of three adults with learning disabilities. Mr Dale Lewis owns the home and is registered as the manager. Mr Lewis also provides a separate specialist outreach service for people with learning disabilities, under the umbrella name of Pashun Care Services. The home is a terraced house with three bedrooms. On the ground floor, there is a lounge, bedroom, toilet, kitchen and a separate dining room. On the first floor there is a bathroom with a toilet, two bedrooms and a small office. There is a small paved area at the front of the house and a back garden, which is accessible to people living in the homes. The house is located near the busy Philip Lane and close to a sports centre. There is easy access to shops, restaurants and transport facilities located along the high street at Seven Sisters. The stated aim of the home is to provide a holistic and high quality of care to people with learning disabilities. The home also aims to provide practical help for people and maximise their individual potential while adhering to the core values of showing respect for people, encouraging local community participation and promoting independence. Placements at the home costs between £3430 - £1099 for each person per week. People living in the homes are expected to pay separately for some items and activities, such as eating out. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to people living in the homes and other stakeholders. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis. However, because the service users usually attend day services and there is rarely anyone at home during the daytime, and to ensure that the inspector could gain access to certain written records, the registered person was given 24 hours notice of this inspection. The inspection was completed in 1 day. The inspector spoke in some depth with the registered person, the deputy manager and the quality assurance officer. The inspector was also able to spend some time with the 3 people who live in the home, in the afternoon when they returned from their day services. Because of the nature of their disabilities, it is difficult to gain the opinions of the people living in the home, but they appeared relaxed and the inspector noted several instances where staff encouraged them to make choices. The inspector reviewed a number of the policies and procedures in place in the home, the written records for the 3 people who live in the home and the written records for 5 staff. The information recently submitted by the registered person in the form of a pre-inspection questionnaire was also taken into account as part of this inspection. What the service does well: What has improved since the last inspection? What they could do better: In the context of there having been some changes in managers and staff recently, the areas that have been identified for improvement at this inspection are about formally recruiting a full time manager, and ensuring that they apply Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 6 for registration with the Commission. There is also room for improvement in providing staff with formal one to one supervision and support and forums to discuss practice issues and the welfare and effective communication with the people who live in the home more regularly as a whole staff team. Good practice recommendations are made in relation to tightening up the procedure around providing medication for people for times that they visit relatives and are away from the home overnight, keeping records of the assessment of competence that staff undertake prior to administering medication without supervision, team building because of the recent changes in the make-up of the team and ensuring that staff are familiar with the improvements that have been made to the policies and procedure in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chelsea House DS0000010823.V333342.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 Chelsea House DS0000010823.V333342.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. EVIDENCE: No one has been admitted to the home since September 2005. The inspector reviewed the written records of 1 person living in the home with regard to the admissions process. Records indicated that a very carefully planned admission took place for this particular person, who has some behaviour that can be challenging to live and work with. The home was fully aware of the needs and risks associated with their behaviour. The inspector also reviewed the policy regarding the introduction of potential residents, which was reviewed in May 2007. This was clear and set out the arrangements for visits, trial periods and admission case reviews. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. People are encouraged to make their own decisions and choices. The care plan is a working document reviewed regularly and kept up to date. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. The service is aware of current policy issues and good practice developments, and tries where possible to transfer this thinking into their daily work. EVIDENCE: At the last inspection the registered person was required to ensure that two people s’ plans are reviewed and updated and to ensure that people s’ risk assessments are dated, and that there is clearer evidence that they have been reviewed. At this inspection the inspector found that both of these issues had been addressed and that all three of the people living in the home had had reviews over the past 6 months. Each person’s plan sets out their needs and goals, and the tasks involved in meeting these goals. Other detail, supplementary guidance is in place for staff about how to work positively and effectively with each person. The inspector noted that there is evidence that Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 10 the risks that are relevant to each person are reviewed and reassessed on an ongoing basis. The inspector also reviewed the personal development policy, which was reviewed in May 2007 and provides guidance for staff around supporting the people who live in the home to maintain and develop their social, emotional, communication and independent living skills and to build their confidence. The inspector saw evidence in people’s day-to-day records that a lot of emphasis is placed on providing people with opportunities to make choices about their lives. This included choosing what clothes that they wished to wear and the activities that they wish to take part in. The inspector noted that the policy that is place clearly sets out people’s right to freedom of choice and how staff can provide choices on a day-to-day basis. One person has behaviour that is particularly challenging to live and work with. It was evident that the number of incidents of violence and aggression have reduced significantly since he was admitted to the home. The acting manager explained that the stability and consistency of approach has led to him being more settled, and that supporting him to communicate his feelings more effectively has been a key element of this approach. The registered person explained that his medication had been reduced since admission as a result in the improvement in his mood and behaviour. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a commitment to enabling people who use services to develop their skills, including social, emotional, communication, and independent living skills. People who use the service have the opportunity to develop and maintain important family relationships. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. Help with communication skills is given by the staff team, both within the service, to enable residents to fully participate in daily living activities. People who live in the home are involved in meaningful daytime activities according to their individual interests and capability. They can access and enjoy the opportunities available in their local community, e.g. using public transport, the local pub, and local leisure facilities. People are involved in the domestic routines of the home, keeping their own room nice, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector noted that the people living in the home are provided with access to a range of activities, both within the home and in the local community. Staffing is sufficient to ensure that their needs are met in terms of their behaviour so that that they can have a presence in their local community. The registered person also provides a separate specialist day service and all three of the people who live in the home attend on a daily basis. On weekdays they engage in activities such as bowling, swimming and horse riding during the daytime and daily living skills such as doing laundry, vacuuming and various other domestic activities in the evenings. One person has a massage. At weekends aromatherapy is provided regularly and people are encouraged to go out to the park, use the local leisure centre and have lunch out. There was also evidence that people are supported to maintain relationships with concerned relatives. One person visits his family regularly and another told the inspector that he is planning to go on holiday to the Caribbean in the future, with a relative. At the last inspection it was recommended that the people living in the home be provided with more opportunities to learn about their own and each other’s cultures. At this inspection the inspector found that this had been addressed. Emphasis is placed on maintaining people’s rights and records reflect that staff have had training around dealing with violence and aggression, control and restraint and breakaway techniques. There is a clear policy around restraint, which sets out the principles and boundaries regarding what is an acceptable level of physical intervention. A record is kept of what people actually eat in order to help monitor whether people are getting a balanced diet. The menu provides a good variety of meals and is flexible and people are encouraged to make their own choices within it. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence in people’s plans of health care treatment and intervention, and a record of general health care information. Staff encourage people to be as independent as possible in their personal hygiene. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Medication systems do need minor improvement around secondary dispensing. Staff generally think in a person centred way when considering an individual’s personal care needs. Staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care. EVIDENCE: The inspector noted that people’s needs, in terms of their personal care are set out in some detail in their written records. This ensures that staff maintain a consistent approach, and people are encouraged to maintain and develop their independence in as many areas as possible. At the last inspection the registered person was required to ensure that people s’ health action plans are dated, and that there is clearer evidence that they have been reviewed. At this inspection the inspector found that this had been Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 14 addressed. The inspector noted that the home keep monitoring records of people’s health care needs and when they have had health care appointments. The inspector reviewed the policy regarding ensuring that the people who live in the home have access to proper health care input. This provided guidance for staff about such issues as contacting GPs out of hours. The inspector reviewed the policy and procedure regarding the administration of medication. It has been reviewed and updated to include issues such as non-compliance and covert administration. At the last inspection the registered person was required to ensure that ensure that a written record is kept when weekend medication is dispensed, and that two staff sign to indicate that the correct medication has been dispensed. At this inspection the inspector found that, although efforts had been made to improve practice in this area there was still some work to be done to ensure that the home avoids the secondary dispensing of medication. A recommendation is made in respect of this. There was evidence that most staff had received training in the administration of medication and the acting manager told the inspector that he assesses their competence prior to them administering medication without supervision. However, no written evidence is kept and a recommendation is made in respect of this. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in the home. The home keeps a record of complaints and this includes details of the investigation and any actions taken. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. The home understands the procedures for Safeguarding Adults and will attend meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. Training of staff in the area of protection is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. EVIDENCE: As the people who live in the home have some behaviour that can be challenging to live and work with the inspector reviewed the policies regarding physical restraint, and dealing with aggression. These were reviewed in May 2007 and were clear and helpful. The inspector noted that the staff working in the home had received training regarding the protection of vulnerable adults, and as previously noted various other training regarding physical intervention. There was further guidance included in people’s risk assessments and plans regarding the particular approach to be used on an individual basis. As previously noted there has been a reduction in one person’s challenging Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 16 behaviour since they were admitted to the home. No issues regarding adult protection had arisen since the last inspection. The inspector noted that there is a clear complaints procedure in place and that no complaints had been recorded as being received in the home since the previous inspection. Chelsea House DS0000010823.V333342.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, 26, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The home is a very pleasant, safe place to live and people are encouraged to personalise their bedrooms. The shared areas provide a choice of communal space. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The home is on the scale of an ordinary family home and is generally well maintained, clean and homely. Each person has their own bedroom, and these are comfortable and reflect their personalities and interests. However, the registered person has told the inspector that he has a long term plan to find a larger property, as he wishes to provide more space for people. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 18 Since the last inspection a new tumble dryer has been provided and some plaster work repaired and re-painted. At the last inspection the registered person was required to ensure that the sealant between the bath and the tiles in the bathroom on the first floor is replaced ensure that there are hand towels available in the upstairs bathroom, the downstairs toilet and in the laundry room. At this inspection the inspector found that both of these issues had been addressed. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The registered person is aware where there are gaps in the training programme and deals with this. Staff are encouraged and supported in the pursuing of external qualifications such as NVQs. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. The procedure is followed in practice and there is accurate recording at all stages of the process. There is acceptable use of temporary staff that doesn’t adversely affect the quality of care. Because of some recent disruption in the day-to-day management of the home, there remains room for improvement in providing staff with one to one support and supervision. There is diversity in the staff team and its composition reflects to some extent, the culture and gender of people living in the home. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 20 EVIDENCE: The rota reflects that the home is well staffed, providing one to one support to the people who live there the majority of the time. The inspector reviewed the written records for 5 staff who were working in the home at the time of the inspection along with 2 applicants who had been offered posts, and were waiting for all the necessary pre-employment checks to be undertaken. The necessary pre-employment checks had been undertaken people had been provided with clear job descriptions to ensure that they were clear about their role and responsibilities. The inspector noted that the two staff who had been offered posts had previous experience in care and had provided evidence of a good level of previous relevant training. At the last inspection the registered person was required to ensure that the staff application form is revised to ensure that applicants provide a full employment history including a written explanation of any gaps in employment. At this inspection the inspector found that this had been addressed. The inspector noted that the staff who have been recruited since 2004 have two written references and the authenticity of these has been verified. The registered person does need to ensure that a recent photograph is included in each person’s written records and a requirement is made in respect of this. Additionally, the registered person has recently undertaken an exercise in ensuring that all staff have provided valid documentation in respect of their right to work in this country. Unfortunately, this did result in the loss of some staff from the team, as their documents did not prove to be valid. As there have been changes in the team, and new staff due to join in the near future, it is recommended that the registered person consider undertaking some form of team building work when the new starters join, in order to maintain the previous quality of the teamwork within the team, and ensure the consistency of approach that has previously been positive in meeting the needs of the people who live in the home. The registered person was also previously required to ensure that staff are provided with formal one-to-one supervision at least 6 times per year. This has not been achieved and this requirement is restated as part of this report. It was previously recommended that staff be provided with more opportunities to undertake NVQ training and that staff be provided with refresher training in infection control. At this inspection the inspector found that a good proportion of staff are now undertaking NVQ training at level 2, 3 and 4 and that some staff had received infection control training, although some staff still need to attend training in infection control. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. After a recent period of disruption in managing the home on a day-to-day basis, there is a need to ensure that a manager is appointed and applies to be registered with the Commission. Now that the staff team is becoming more stable, after a brief period of change, there is also a need for staff meetings to take place on a more regular basis. The service is planned to be user focused, to take account of equality and diversity issues, and generally works in partnership with families of people who use the service and professionals. The policies and procedures are being reviewed and updated to a better standard. The registered person is aware of the need to promote safeguarding and has developed a health and safety policy that meets health and safety requirements and legislation. EVIDENCE: Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 22 There has been a period of instability in respect of the day-to-day management of the home over the past year. The registered person is registered as the manager of the home, but as he has other commitments, he no longer manages the home on a day-to-day basis. Two managers have been recruited since last year but neither were in post for very long. The deputy manager from the existing staff team has been acting as manager most recently. He comes across as competent and knowledgeable about the needs of the people living in the home. A requirement is made for the registered person to ensure that he applies to the Commission for registration as manager of the home. This was discussed with the deputy manager at the time of this inspection. At the last inspection the registered person was required to ensure that the staff meetings take place at least 6 times per year. This has not been achieved and this requirement is restated as part of this report. It was also previously recommended that registered person review the homes policies and procedures in line with current legislation. The inspector found that real progress had been made in reviewing the policies and procedures in the home and that the quality of the policies that had been completed had been improved considerably. A recommendation is made for the registered person to ensure that all staff are familiar with the changes made to the policies and procedures. The registered person submitted information regarding the health and safety checks undertaken in the home as part of the per-inspection information provided to the Commission. These were acceptable. The inspector reviewed the records kept of the health and safety arrangements that are in place in the home at random. The records reflected all of the necessary environmental checks such as gas safety certificates and fire equipment checks were up to date and that staff have received the appropriate health and safety training. There were no heath and safety hazards identified at the time of the inspection. Chelsea House DS0000010823.V333342.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 X 2 3 3 X 4 X 5 X 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 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 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 3 2 X 2 X 2 2 2 3 X Chelsea House DS0000010823.V333342.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 YA34 Regulation 19 Schedule 2 Requirement The registered person must ensure that each person’s staff records include a recent photograph. 01/07/07 The registered person must ensure that staff are provided with formal one-to-one supervision at least 6 times per year. The given timescale of 31/12/06 was not met. 3. YA37 8 The registered person must ensure that a full time manager is confirmed in post and makes application to be registered by the Commission. 4. YA39 18(2) The registered person must ensure that the staff meetings take place at least 6 times per year. The given timescale of 31/12/06 was not met. 01/07/07 01/07/07 Timescale for action 01/07/07 2. YA36 18(2) Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 25 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 YA20 Good Practice Recommendations It is recommended that the registered person discuss with the pharmacist, safer methods of dispensing medication for people for when they go on home visits. 2. YA20 It is recommended that a written record be kept of the assessment process regarding staff’s competence in the administration of medication. 3. YA32 It is recommended that the registered person consider undertaking some team building exercises with the team as a whole, when the new starters are in post. 4. YA41 It is recommended that the registered person ensure that all staff are familiar with the changes made to the policies and procedures. Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Chelsea House DS0000010823.V333342.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!