Inspection on 15/02/07 for Church Lane (12)

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Lane (12) 21/02/06

Church Lane (12) 26/05/05

Church Lane (12) 06/10/04

Church Lane (12) 26/05/04

Church Lane (12) 20/11/03

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 Church Lane (12) 12 Church Lane Walthamstow London E17 9RW Lead Inspector Rob Cole Unannounced Inspection 15th February 2007 10:00 Church Lane (12) DS0000007273.V310892.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 Church Lane (12) DS0000007273.V310892.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. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Lane (12) Address 12 Church Lane Walthamstow London E17 9RW 020 8520 0138 020 8520 0138 CSavill@outward.org.uk 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) Outward Christine Savill Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: 12 Church Lane is a purpose built house offering accommodation to six service users with learning disabilities. The home is located in a residential area of Walthamstow in the London Borough of Waltham Forest, close to shops and other local amenities, including transport networks. The home consists of six single bedrooms, one ensuite, and service users share a kitchen, a sitting room, a conservatory and a sensory room, as well as a garden. The home is operated and managed by Outward. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 15/2/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes deputy manager and manager. The inspection also included a tour of the premises, and an examination of records and documents. Overall, the inspector was satisfied that this is a well run home, and that service users receive high levels of care and support. Service users spoken to informed the inspector that they are happy living at the home, and with the support provided. There are however some areas that must be addressed, as highlighted within the report. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 6 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 Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 7 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that prospective service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English, and the Guide has also been produced in pictorial form, and all service users are given their own copy. The Statement of Purpose includes details of the services and facilities provided, the staff team, and of the organisational structure of the home. It is dated and subject to regular review. The Guide includes a summary of the Statement of Purpose and details of the physical environment. All service users are issued with a contract/statement of terms and conditions. Contract have been signed by the service user, and a representative of the home. Contracts include the rights and responsibilities of both parties, and details of fees payable. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 8 There has been one admission to the home since the previous inspection. The home has a written admissions procedure, and there was evidence that the service user was admitted to the home in line with this procedure. A pre admission assessment was carried out by the homes manager and deputy manager, this covered needs associated with health, personal care, mobility and social and leisure needs. There was a structured transition period, which included visiting the home for overnight stays. After moving in on an initial trial period, a placement review meeting was held. The service user informed the inspector that they were happy with their new home. Church Lane (12) DS0000007273.V310892.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): 6,7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users have control over their daily lives, and that they are involved in the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users. Care plans are clear and comprehensive, and drawn up with the involvement of the service user, their keyworker and the homes manager. Plans were dated and subject to regular review. Plans cover needs associated with social and leisure needs, personal care and cultural needs. Risk assessments are also in place for all service users, and as with care plans these are of a satisfactory standard, and are subject to regular review. Assessments identify any potential risks, and include strategies to manage and Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 10 reduce these risks. They include assessments on accessing the community, epilepsy and challenging behaviour. Where it has been identified that there is a risk from challenging behaviour, clear individual guidelines are in place around managing this. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. Service users are able to get up and go to bed as they choose, and choose their own clothes to wear etc. One service user has been risk assessed as safe to access the community without the support of staff, and they are free to come and go from the home as they wish. Some service users have been given keys to their bedrooms, but not all. One service user informed the inspector that they would like a key to their bedroom, the deputy manager informed the inspector that there was no reason why they should not be given a key, and it is required that all service users are offered a key to their bedroom, subject to the completion of a satisfactory risk assessment. The deputy manager informed the inspector that service users were routinely consulted over the running of the home, for example over menus and activities. Regular service user meetings are held, these are minuted, and the agenda is set jointly by staff and service users. The home has had some decoration work carried out since the previous inspection, service users were involved in choosing the new décor, and the new admission to the home was able to choose the new décor for their bedroom. The home has a confidentiality policy, and service users records were stored securely in a locked filing cabinet. The inspector was informed that service users can access them as appropriate. Staff demonstrated a good understanding of the issues around confidentiality, and when a confidence may need to be broken. Church Lane (12) DS0000007273.V310892.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued and fulfilling lives, with regular access to the community. However, the home must ensure that service users are offered a varied, balanced and nutritious diet. EVIDENCE: Service users are able to be involved and participate in the local community. Service users visit local shops, banks, markets, parks, hairdressers and post offices. A visiting library visits the home, supplying games, videos, books and CD’s. Three service users regularly attend church. Several service users attend day services provided by the organisation that runs the home, which provides the opportunity for service users to get involved with gardening, music, art and drama. One service user recently attended a course in multimedia at the University of East London. One service user attends a drop in centre, where Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 12 they have the opportunity of socialising and developing friendships. Service users have access to public transport, including buses and trains, and the home has its own unmarked vehicle, which service users use to access the community. Service users have access to a variety of social and leisure needs, both in house and in the community. In house the home has its own sensory room, and service users have access to TV and music. The home arranges occasional parties, for example to celebrate birthdays. The home recently held a party to celebrate the 80th birthday of a service user, where a professional entertainer was booked to attend. Service users spoken to informed the inspector that they enjoyed this very much. A beautician visits the home, providing various treatments for service users such as massages and manicures. In the community the home arranges various day trips, recent trips have included Southend and Buckingham Palace. Service users visit live music and theatre events, and visit pubs, restaurants and cafes. Service users also go swimming. All service users are offered a weeks annual holiday away from the home as part of their basic contract price, there are plans for holiday to France and Wales later this year, which service users have helped to choose. Service users are able to maintain contact with their family, and visitors are welcome at any reasonable hour. Service users are given their own mail to open, and have access to use a telephone in private if they so wish. Records are maintained of menus. However, this recording was of a poor standard, for example records did not always accurately reflect the actual food that was provided. There were supposed to be individual menu charts for each service user, but for one service user it was found that there name had been put on the chart of a previous service user who is now deceased (whose name had simply been crossed out). This chart said that any food provided should be pureed first, but this information referred to the deceased service user. It is required that accurate records are maintained of meals provided. The inspector was disappointed to note that lunch provided for staff on the day of inspection appeared to be more appetising and nutritious then the lunch provided for service users. Service users were seen to be offered a cold mini sausage roll along with a cold mini Cornish pasty. All service users were given the same, and none were offered any choice. Staff were seen to help themselves to a selection of filled rolls, made up with fresh salad vegetables and a variety of cooked meats. It is required that service users are offered a varied, balanced and nutritious diet, and are provided with a choice of meals, in line with their individual preferences. The home maintains records of fridge and freezer temperatures, and food was stored appropriately. The kitchen was clean and tidy. However, service users informed the inspector that they did not like the kitchen, and wanted a new Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 13 kitchen fitted. This issue has also been discussed in service user meetings, where again, service users have stated that they wanted a new kitchen fitted. Although the inspector found that the kitchen was in a reasonable state, it is recommended that the home give consideration to service users requests for a new kitchen to be fitted. Church Lane (12) DS0000007273.V310892.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home is meeting the personal care needs of service users, more must be done to ensure that their health care needs are also been met. In particular, the home must ensure that all medications are appropriately administered and recorded. EVIDENCE: Guidelines were in place on providing personal care to service users, and staff were observed to knock and wait before entering bedrooms. All service users need some support with personal care, but the guidelines indicated that staff encourage service users to do as much for themselves as possible. Service users informed the inspector that they choose what to wear, and on the day of inspection all were dressed appropriately. The home has sought and recorded the views of service users on their wishes in the event of their death. The deputy manager informed the inspector that Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 15 service users would be able to remain in the home with a terminal illness, as long as the home could meet their medical needs. All service users are registered with a GP. Records are maintained of medical appointments, including details of any follow up action required. Records indicated that service users have access to district nurses, physiotherapists and psychiatrists. However, as at the last inspection the home could not evidence that all staff have access to routine dental care, and this must be addressed. Used continence products in the home are disposed of appropriately. At the time of inspection one service user was in hospital, and the inspector was pleased to note that other service users have been able to visit them. The home has a comprehensive medication policy in place, and all staff undertake training before they administer any medications. No service users are on any controlled drugs, or self medicate at present. Medications are stored within individual locked cabinets inside service users bedrooms. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. However, the inspector had some serious concerns about medications within the home, namely: • • Correction fluid was found to me used on Medication Administration Record (MAR) charts. There were found to be some discrepancies between the information on the MAR charts and the information on the medication label, for instance one service user has been prescribed QUETIAPINE tablets, the MAR charts stated take one tablet in the morning, and two at night, while the medication label stated take two tablets two times a day. There were no guidelines in place around the administration of medications prescribed on an as required basis, for example one service user has been prescribed PIRITON on an as required basis, but there were no guidelines in place around when this was to be administered. MAR charts contained several unexplained gaps. • • All of this must be addressed. Church Lane (12) DS0000007273.V310892.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has taken reasonable steps to help ensure that service users are protected from the risk of abuse. EVIDENCE: The home maintains a complaints log, this evidenced that complaints received have been appropriately recorded and investigated. The home also has a written complaints procedure, which makes reference to the CSCI. However, this was not on display within the home, and it is recommended that it should be. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. This appeared to be in line with current legislation. All staff employed at the home have undertaken training in adult protection issues, and those spoken to demonstrated a good understanding of the issues involved with regard to adult protection. The home holds money on behalf of service users in a locked safe. Records and receipts are maintained of all transactions involving service users monies, those checked by the inspector appeared satisfactory. However, as at the last inspection, one service user cannot access their own bank account. They have a named appointee to the account, but this is a former manager of the home, Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 17 who has not worked there for the past four years. Although the inspector acknowledges that the organisation who run the home have made monies available to the individual service user, it is nevertheless required that service users have access to their own bank accounts, and any monies held therein. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users are provided with adequate private and communal space. EVIDENCE: The home is purpose built, and suitable to meet its stated purpose with regard to the physical environment. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, close to shops, transport links and other local amenities. The home was generally well maintained, both internally and externally, and on the day of inspection was clean and tidy. Fixtures and fittings were well maintained and domestic in character. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 19 The home’s communal areas consisted of an adapted sensory room, sitting room, kitchen, conservatory, and garden, with appropriate garden furniture. Service users were observed to move freely around communal areas, and the inspector was informed by both staff and service users that the sensory room is used regularly, and that staff have received training on how to use it. The home has one shower room and toilet, one bathroom and toilet, and a toilet on its own, and all service users have hand basins in their bedrooms. Both the shower and the bath are adapted and suitable for all service users. All bathrooms had locks on them, and on the day of inspection were clean, tidy and free from offensive odours. All service users have their own bedrooms, one of which is ensuite. On the day of inspection rooms were clean and tidy, however, one of the ground floor bedrooms had a strong offensive odour, and this must be addressed. The inspector was informed that service users are involved in maintaining their rooms, for example helping to keep them tidy. Bedrooms were personalised to service users individual tastes, with family photographs and personal items on display. Furniture was well maintained, and consisted of wardrobes, chest of draws, table and chairs. Bedrooms meet National Minimum Standards on size requirements, and all had adequate natural light and ventilation. Curtains and bedding were domestic in character and well maintained. The home was purpose built to accommodate people who make use of wheelchairs, with widened corridors and door frames, and all areas of the home are fully accessible to service users. The home has a lift operating between the two floors. There are handrails in place around the home, and grab rails in the toilets and bathrooms. Service users have their own hoists and there was evidence that these are regularly serviced. The home has a call point alarm system in place, which all service users have access to in their bedrooms. The home has a policy on infection control, and protective clothing is available such as disposable aprons and latex gloves. The laundry room is domestic in character, and all service users have their own clothes basket. Washing facilities are appropriate to meet service users needs. Hand washing facilities are situated near to the laundry facilities, and throughout the home. The home has a macerator to dispose of soiled incontinence products, and all COSHH products were stored appropriately. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 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 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is staffed in sufficient numbers to meet service users needs, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. There was a staffing rota on display within the home, this accurately reflected the staffing situation on the day of inspection. 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. During the course of the inspection, one service user was seen to become distressed, and staff were observed to deal with this situation in a sensitive and timely manner. All staff have been provided with a copy of their job description and of the General Social Care Council codes of conduct. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 21 The inspector was informed that of the ten care staff employed at the home, seven have achieved a relevant care qualification. All new staff to the home undertake a structured induction programme, this includes health and safety and service user issues. Records are kept of staff training, these evidenced recent training in epilepsy, communicating with adults with learning disabilities, care planning and food hygiene. All staff receive regular formal supervision. This is minuted, and staff get a copy of the minutes. Supervision covers performance, service user issues and training needs. The home has policies in place around equal opportunities and recruitment and selection. Staff employment records are not held in the home, but are held centrally by the organisation, this is in agreement with the CSCI. The home does have a sheet for each member of staff, which includes details of what employment checks have been carried out. These indicated that all required checks have indeed been carried out as appropriate, including CRB checks and employment references. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 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 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is well managed. Staff are given appropriate support, and suitable arrangements are in place to help safeguard the health and safety of service users and others. However, the home must ensure that monthly Regulation 26 visits take place. EVIDENCE: The homes manager has twelve years experience of working with adults with learning disabilities, including seven years in a managerial capacity. They have successfully completed the Registered Managers Award and an NVQ Level 4 in Care. Service users informed the inspector that they found the manager to be Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 23 approachable and accessible, and on the day of inspection staff were observed to interact with the manager in a relaxed manner. The home’s policies were clear and comprehensive. The inspector checked policies on adult protection, equal opportunities and recruitment and selection, and all appeared satisfactory. Records were stored in a locked filling cabinet; the inspector was informed that staff and service users can have access to them as appropriate. The home has polices in place on confidentiality. Service user meetings, staff meetings and care plan reviews all contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home. The home issues questionnaires to service users to gain their feedback on the running of the home. The home has a “listening book” in which service users can make comments or suggestions. For example, one service user stated in the book that they did not want night staff to do any vacuuming, as it was too noisy when service users were trying to sleep. There was evidence that the manager addressed this issue, and that vacuuming of the home is now done in the day time. The home has only had nine Regulation 26 visits within the past twelve months. It is a repeat requirement that these visits are carried out monthly, and that a report of the visit is kept in the home, available for inspection. The home has various health and safety policies in place, for instance around fire safety and COSHH. Staff receive health and safety training, including fire safety and manual handling. Fire extinguishers were situated around the home, these were last serviced in December 2006. Fire exits were free from obstruction. Fire alarms are tested weekly, and were last serviced on the 27/10/06. The home holds regular fire drills. The home tests fridge/freezer temperatures and hot water temperatures. The home had in date certificates for gas safety, electrical installation and PAT testing. The home had in date employer’s liability insurance cover in place. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 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 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 2 3 3 3 3 Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 13 Requirement The registered person must ensure that service users have access to health care as appropriate, including dental care. (Timescale 30/06/06 not met) The registered person must ensure that clear guidelines are in place for the administration of all medications prescribed on a PRN basis. (Timescale 30/06/06 not met) The registered person must ensure that all service users have full unrestricted access to any monies held in their bank accounts. (Timescale 30/06/06 not met) The registered person must ensure that monthly unannounced Regulation 26 visits are carried out, and that a copy of the report of these visits is kept in the home. (Timescale 30/06/06 not met) The registered person must ensure that all service users are offered keys to their bedrooms, subject to the completion of satisfactory risk assessments. DS0000007273.V310892.R01.S.doc Timescale for action 30/05/07 2. YA20 13 31/03/07 3. YA23 20 31/05/07 4. YA39 26 31/03/07 5. YA7 12 30/04/07 Church Lane (12) Version 5.2 Page 26 6. YA17 16 7. YA20 13 8. YA26 23 The registered person must 31/03/07 ensure that service users are offered a varied, balanced and nutritious diet, and that accurate records are maintained of all meals provided. The registered person must 31/03/07 ensure the following with regard to the storing, administration and recording of medications: • Correction fluid must not be used on medication records. • Medication Administration Record charts must be kept up to date and accurate. • Information on Medication Administration Charts must be consistent with information on medication labels, and both must be in line with the instructions of the medical practitioner who prescribed the medication. The registered person must 31/05/07 ensure that all bedrooms are free from offensive odour. 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. Refer to Standard YA24 YA22 Good Practice Recommendations It is recommended that the home gives consideration to fitting a new kitchen, in line with service users expressed wishes. It is recommended that a copy of the homes complaints procedure be left on display within the home. Church Lane (12) DS0000007273.V310892.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London 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 Church Lane (12) DS0000007273.V310892.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. 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