Inspection on 12/06/07 for Colegrave Road, 77- 79

This inspection was carried out on 12th June 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colegrave Road, 77- 79 23/06/06

Colegrave Road, 77- 79 30/12/05

Colegrave Road, 77- 79 01/08/05

Colegrave Road, 77- 79 06/01/05

Colegrave Road, 77- 79 16/08/04

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 Colegrave Road, 77- 79 77-79 Colegrave Road Stratford London E15 1DZ Lead Inspector Lea Alexander Unannounced Inspection 12th June 2007 9.15 Colegrave Road, 77- 79 DS0000058207.V341916.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 Colegrave Road, 77- 79 DS0000058207.V341916.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. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colegrave Road, 77- 79 Address 77-79 Colegrave Road Stratford London E15 1DZ 0208 534 1101 0208 534 1153 dko@consensacare.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Consensa Care Limited Dana Kotoulekova Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2006 Brief Description of the Service: 77 to 79 Colegrave Road provides residential support and accommodation to male and female service users with enduring mental health needs. The building is situated in a residential area in Stratford and is close to public transport and other local amenities. The home is owned and managed by Consensa Care Limited who provides a range of residential care services in Newham. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors first inspection of this home; they carried out the inspection over the course of a day. The Inspector met privately with the Registered Manager, a support worker and people who use the service, and also viewed resident’s personal files, staff personnel files and other documentation relating to the running of the home. What the service does well: What has improved since the last inspection? What they could do better: Three requirements made at a previous inspection were restated, and a further sixteen requirements and three recommendations were made as a result of this inspection. The homes statement of purpose and contract with residents should accurately reflect the service provided. Resident’s diversity could be better represented in their individual plans, by making these more person centred and including life Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 6 story work. These plans should be reviewed at least every six months, and any limitations on choice should be appropriately documented. People who use the service should be supported to participate in the day-today running of the home and to integrate into community life. Residents should also be supported to continue with or re-engage with activities they pursued prior to their moving in. Personal records must be accurate and confidential and policies should be regularly reviewed and updated. The home should evidence that all staff are inducted into the home and that staff receive regular supervision. The Manager should commence NVQ level 4 studies. Identified maintenance issues should be promptly attended to, and all WC’s should be kept clean. Required health and safety tests must be carried out and recorded and quality assurance information that relates solely to this home must be collated. 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. Colegrave Road, 77- 79 DS0000058207.V341916.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 Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are given the opportunity to visit the home and are not admitted until their needs are assessed. However, the statement of purpose and contracts with residents do not accurately reflect the service currently provided. EVIDENCE: The Inspector viewed the homes Statement of Purpose and noted that this did not accurately reflect the current situation in the home. For example, the Registered Managers qualifications were incorrect and the document stated that there are weekly lunch trips and outings, which the Manager confirmed occur irregularly. The Inspector case tracked the available records for two people who use the service. These records evidenced that the home assessed each person prior to their moving in and gave each the opportunity to “test drive” the home by having day visits. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 9 The Inspector noted that the contract the home had entered into with one resident stated that weekly psychology sessions were included in the cost of the placement and would be provided by the home. The Inspector asked to view evidence that these sessions were occurring and was advised by the Registered Manager that the home did not have such facilities at the present time, and that any psychological input would need to be referred to the local Community Mental Health Team. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has an individual plan. However, these are not reviewed and updated regularly and could be developed to include more person centred information. EVIDENCE: The Inspector sampled the personal files of two people who currently use the service. It was evidenced that clearly laid out plans identifying a range of health, personal and social needs had been developed, and that these had been signed by residents to evidence their participation in the planning process. The plans for one of the sampled residents were dated July 2006 with no evidence of subsequent review. For the other resident their plan addressing blood sugar monitoring had not been updated to reflect the most recent guidance from the GP on the frequency of this monitoring. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 11 On one residents plan called “cultural and faith needs” this had been completed to read “none identified”. The Inspector is of the view that the home could develop its life story and person centred planning work to identify significant events or past interests that could appropriately identified and worked with in this area. Sampling of resident’s personal files evidenced that regular 1:1 key working sessions are conducted every 1 to 2 months, and that these sessions are used to discuss issues such as activities of daily living and maintenance of good mental health. Comprehensive risk assessment tools were evidenced as having been completed for both the residents sampled. This addressed a range of potential hazards including non-compliance with medication, access to the community, smoking and diabetes. However the Inspector noted that one of the risk assessment sheets had been completed using another residents name. The Registered Manager told the Inspector that staff try and give people who use the service information and support to make choices about their everyday lives. Several of the homes residents have agreements with the home around managing their smoking, and during the course of the inspection some residents fed back that they were unhappy with their current cigarette contracts and their implementation and felt that these were being used to “manipulate” their behaviour. During the course of the site inspection the Inspector noted that some kitchen cupboards containing foodstuffs had been locked, and raised this with the Registered Manager. They advised that this practise was already in place when they joined the service and were not clear why it had been instituted. There were no records of discussion with residents and agreement with this practise or risk assessments addressing this limitation on facilities and choice in order to prevent harm. People who use the service receive varying levels of support to manage their finances. Details of the nature of the required support were found in the individual plan. The Inspector also viewed the homes records of financial transactions from resident’s finances. Each resident has a security-sealed bag containing his or her money held by the home. Every time they withdraw money from this bag the transaction date, amount and balance is recorded and this is signed by the resident and a staff member and a new security tag fitted. The Inspector viewed the minutes of residents meetings and noted that these are not held regularly. The available minutes evidenced that meetings had been held in January 2006 and October 2005. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to maintain contact with family and friends. However, the home should develop its practise to ensure that resident’s individuality and personal preferences are considered when identifying occupational, community and leisure activities. EVIDENCE: The home accommodates a diverse group of residents, three men and three women currently live at the home and their ages range from 18 to 57. People who use the service are from range of cultural and religious backgrounds including Asian, African Caribbean and British. People who use the service experience mental health difficulties that can impact upon their motivation to participate in occupational and community Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 13 activities. At present residents activities are centred on activities of daily living, such as the cleaning rota within the home or assistance in preparing meals. Outside of the home the main activity identified was attendance at a local mental health day service. Residents are currently undertaking a range of courses at this day service including literacy and numeracy, relaxation and computing. The Inspector noted that individual plans were similar in their activities and is of the view that these should be more person centred. For example, during the course of the inspection one resident expressed an interest in writing music and another in learning beauty therapy skills. This was not reflected in their individual plans. By sampling residents individual plans the Inspector evidenced that the home had identified people who use the service who have specific religious beliefs and offered appropriate support for them to fulfil their spiritual needs. Several people who use the service advised the Inspector that they access the community independently to visit local shops. One resident told the Inspector that they “wished they had more day trips”. Discussions with residents and sampling of individual plans evidenced that the home supports residents to maintain contact with their families and friends. People who use the service can choose whom they see and when and can see visitors in their rooms in private. During the course of the Inspection the Inspector noted that staff were accessible to and interacted with residents and that people who use the service choose when to be alone or in company. The residents spoken to by the Inspector fedback that they were generally happy with the meals provided. One resident told the Inspector that they were provided with West Indian food items that they requested. The Inspector viewed the logs of meals provided and noted that it was not always evidenced that a halal or beef alternative had been offered to two service users with specific dietary requirements identified in their individual plans. Colegrave Road, 77- 79 DS0000058207.V341916.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports residents to access healthcare services and retains correspondence relating to appointments. However, there are gaps in the healthcare information recorded and no medication policy and procedure was available within the home. EVIDENCE: Discussion with people who use the service, the Registered Manager and care staff evidenced that residents choose their own clothes and hairstyle and that their appearance reflects their personality. The Inspector sampled the personal files for two people who use the service. Copies of correspondence relating to medical appointments were found within these. The Inspector queried where the home maintained a record of medical appointments attended and the outcome of these, and was advised that a note is made in the diary and in the daily record. There is at present no system for readily accessing information on what recent medical appointments have been Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 15 attended and their outcome, or identifying when annual checks such as dentist and optician are due. The Registered Manager advised the Inspector that there are currently no residents who are self-medicating or taking prescribed controlled drugs. The Inspector asked to view the homes medication policy and was advised by the Registered Manager that this was not available on site as it was being revised at head office. The Registered Manager also advised the Inspector that the home had recently switched to a pharmacist-loaded medication dispensing system. Large stocks of loose medication were found in the home, and these should be appropriately disposed of. The Inspector sampled the Medication Administration Record and noted that for one resident a discontinued medication still appeared on this. Colegrave Road, 77- 79 DS0000058207.V341916.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 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their views and concerns in a safe environment. There are clear, accessible procedures for making complaints and safeguarding residents. EVIDENCE: The Inspector viewed the homes complaints policy. This includes information on how to make a complaint and the timescales within which the home aims to deal with these. The Inspector noted that the contact details for the Commission for Social Care Inspection found in the policy were out of date. Two of the residents spoken to by the Inspector advised that they had previously made a complaint to the home, and both told the Inspector that they were “happy with how it was dealt with” and satisfied with the outcome. The Inspector also viewed the homes complaints log and noted that any complaints along with the date, investigation, findings and outcome are appropriately recorded. The Registered Manager advised the Inspector that there have been no adult protection allegations since the last inspection. The member of care staff spoken to by the Inspector demonstrated a good understanding of adult protection issues and their responsibilities should they have any adult protection concerns. The Inspector also sampled the homes adult protection policy. This includes definitions of the different types of abuse vulnerable Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 17 adults may experience and gives guidance to staff. The policy and procedure also makes appropriate reference to local multi agency adult protection protocols. Colegrave Road, 77- 79 DS0000058207.V341916.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean and tidy, and people who use the service can personalise their rooms. EVIDENCE: The home is made up of two Victorian terraced houses that are joined together through a communal lounge. House number 77 accommodates three male residents. It has one ground floor bedroom and three first floor bedrooms that are accessed via stairs. There is also a first floor bathroom that contains a bathtub with mixer tap and shower curtain, a hand basin and WC. A communal kitchen is located on the ground floor to the rear of the property and this has access to the garden. A large lounge and dining room joins the two houses. This has a range of comfortable seating a dining table and chairs Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 19 and a TV. The Inspector noted that the lounge is rather small to accommodate seven residents. House 79 accommodates three female service users. One bedroom is on the ground floor with a further two bedrooms located on the first floor and accessed via stairs. A staff office and a bathroom with tub, mixer tap, shower curtain, hand basin and WC are also located on the first floor. On the ground floor to the rear of the property there is a smoking lounge, laundry facilities and access to the rear garden. A number of maintenance issues were identified and these are listed in the requirements section of this report. Residents have their own bedroom that they are able to personalise with pictures and mementos. The home was found to be generally clean and hygienic and free from offensive odours. Colegrave Road, 77- 79 DS0000058207.V341916.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): 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 sufficient, competent staffs to meet the needs of residents. The service provides regular training and its recruitment process safeguards people who use the service. EVIDENCE: During the course of the inspection care staff were observed to be approachable by and comfortable with people who use the service. The home currently employs eight care staff and has one vacancy. Two staff has obtained NVQ level 2 and three staff is currently studying for NVQ level 3. Three staff is studying for professional nursing or social work qualifications. Consensa Care operates a centralised Human Resources Department that carries out pre employment checks. A summarised record sheet of these checks is held on site and is available for inspection. The Inspector viewed the summary sheets and other personnel information available for three care staff. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 21 This evidenced that two references, an enhanced Criminal Records Bureau (CRB) check and proofs of identity are obtained prior to staff starting work. The Registered Manager advised the Inspector that there is at present no process to involve residents in staff selection, but that staff are subject to a three-month probationary period. The Inspector viewed the training records for three care staff. These evidenced that a range of training had been provided since the last inspection including food hygiene, challenging behaviour, infection control, health and safety, adult protection, fire safety and medication. The Inspector also viewed supervision records for these three care staff. Two had joined the home earlier in 2007, one staff member had received supervision once since starting, and the other had received none. A long-standing member of staff was evidenced as having received two supervisions since the last inspection. The Inspector also examined the personnel records for the two most recently joined staff members to find a completed induction record. This was only located on one personnel file with no record available for the second staff member. Colegrave Road, 77- 79 DS0000058207.V341916.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, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are generally satisfied with the care they receive, and there is sufficient staffing. The home also recognises the importance of staff training. However, health and safety checks required by regulation must be routinely carried out and recorded. EVIDENCE: The current manager has been in post since July 2006 and successfully completed the registration process in February 2007. They advised that they have completed their NVQ level 3 and are awaiting the outcome. The Registered Manager has worked within Consensa Care for some years, and had Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 23 previously been a Deputy Manager within a different mental health residential care home. The Registered Manager advised that Consensa care conducts a corporate quality assurance process for all its services, and that this includes surveying residents, staff, families of people who use the service and other professionals. However, there is no specific information available for this home and no annual development plan. The Inspector viewed a range of health and safety records the home is required to maintain. This evidenced that fridge and freezer temperatures are not recorded on a daily basis and that weekly fire alarm tests are carried out irregularly. The Inspector also noted that weekly water temperature testing was not regularly conducted. The Inspector viewed the homes portable appliance-testing certificate and noted that this had expired in January 2007. The Inspector asked one of the care staff on duty to carry out a fire alarm test; they declined stating that they did not feel confident enough with the system to do this. A fire evacuation drill with timings was recorded as having taken place since the last inspection. The Inspector viewed the homes log of accidents and incidents and found this to be in order. Colegrave Road, 77- 79 DS0000058207.V341916.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 2 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 2 3 2 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5, & 7 Requirement To assist people who may be choosing a service, the home must update its statement of purpose to accurately reflect the current situation within the home. The contract the home develops and agrees with each person who uses the service should accurately reflect the service that will be provided. To accurately reflect the strengths and needs of people who use the service individual plans must be reviewed and updated at least every six months or as needs change. Timescale for action 30/09/07 2. YA5 5 & 14 30/09/07 3. YA6 15 30/10/07 4. YA7 Sch 3 Limitations on facilities or choice, 30/08/07 such as locking food cupboards, must occur within the context of preventing harm and should be appropriately documented. To promote residents choice, people who use the service must be offered opportunities to participate in the day-to-day DS0000058207.V341916.R01.S.doc 5. YA8 24 30/10/07 Colegrave Road, 77- 79 Version 5.2 Page 26 running of the home. 6. YA10 17 The individual records of people who use the service must be accurate and confidential. People who use the service should be supported to continue or re-engage in activities they pursued prior to moving into the home. The home should support service users to integrate into community life through the appropriate use of leisure facilities, cinema, cultural centres, libraries and pubs. People who use the service should be offered a choice of menu that meets their dietary and cultural needs. The home must ensure that appropriate procedures are in place to address and record recognised healthcare needs, including routine annual check ups. A medication policy and procedure must be available within the home at all times. The Medication Administration Record (MAR) must correspond with the medications actually being taken. Medications that are no longer required must be promptly and appropriately disposed of. 12. YA22 22 The homes complaints policy must be updated to include current contact details for the Commission for Social Care DS0000058207.V341916.R01.S.doc 30/08/07 7. YA12 16 30/10/07 8. YA13 16 30/10/07 9. YA17 Sch 3 & 4 30/08/07 10. YA19 12 30/10/07 11. YA20 13 & 17 30/08/07 30/08/07 Colegrave Road, 77- 79 Version 5.2 Page 27 Inspection. 13. YA24 13, 23 & 29 The following maintenance and repair issues must be attended to: (i) Peeling paintwork in the bathroom at house 77 must be made good. Soiled carpets in the hallways and landings must be cleaned or replaced. The loose toilet seat in house 77 must be repaired or replaced. The hallway and landing walls must be cleaned or painted. The communal lounge should be made more homely and reflective of the personalities of the people who live there. Resident’s bedroom furniture must be maintained to a good standard. 30/08/07 30/09/07 31/12/07 30/10/07 (ii) (iii) (iv) (v) (vi) 14. 15. 16. YA30 YA35 YA36 13 & 16 18 18 Toilets must be maintained to a good standard of cleanliness. All care staff must be evidenced as having received an induction. Care staff must receive regular supervision, a minimum of six sessions per year. This is a restated requirement. The previous target of the 31/08/06 was not met. 17. YA37 9 The Registered Manager should DS0000058207.V341916.R01.S.doc 30/10/07 Page 28 Colegrave Road, 77- 79 Version 5.2 commence NVQ level 4 studies. 18. YA39 24 The homes quality assurance 30/10/07 process must be developed to include collated feedback from service users, relatives and other professionals relating to this home only. The Registered Person must ensure that all the staffs receive fire-safety training that is appropriate for the home. They must know how the system operates and where the zones are. The Registered Person must ensure that fire-alarm tests are conducted on a weekly basis. These are restated requirements. The previous targets of 30/06/07 and 26/07/07 respectively were not met. The home must test and record daily fridge and freezer temperatures. The home must test and record weekly water temperatures. 30/09/07 19. YA42 23 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 YA7 Good Practice Recommendations Where the home has entered into contracts with residents to modify their behaviour and curtail individual choices they should consider reviewing these on a frequent basis. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 29 2. 3. YA34 YA42 The home should develop a process to involve residents in staff selection. The home must obtain a portable appliance-testing certificate. Colegrave Road, 77- 79 DS0000058207.V341916.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. 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