Inspection on 06/04/06 for Colham Road, 3

This inspection was carried out on 6th April 2006.

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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colham Road, 3 15/08/07

Colham Road, 3 12/10/06

Colham Road, 3 01/11/05

Colham Road, 3 16/05/05

Colham Road, 3 21/10/04

Colham Road, 3 10/06/04

Colham Road, 3 19/01/04

Colham Road, 3 10/12/02

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 Colham Road, 3 Hillingdon Middlesex UB8 3UR Lead Inspector Robert Bond Unannounced Inspection 6th April 2006 10:00 Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Colham Road, 3 Address Hillingdon Middlesex UB8 3UR 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) 01895 271 245 01895 236 588 London Borough of Hillingdon Mr Robin Wemyss Inglis Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to care for no more than 13 adults with a learning disability. Of those 13 adults, no more than three may be accommodated on a respite basis. 1st November 2005 Date of last inspection Brief Description of the Service: 3 Colham Road is managed by the London Borough of Hillingdon and owned by the Health Authority. It provides residential care for ten permanent and three respite care service users. The service users have profound multiple learning, sensory and physical disabilities. All are non-verbal and two require PEG (pecutaneous endoscopic gastronomy) feeding. The home was purpose built in 1987 and is set on one floor, divided into four units: North, South, East and West Lodges. Each lodge is designed for three or four service users and leads out to an attractive central courtyard, laid out with paved sitting areas and fringed with shrubs and trees. Each lodge is self - contained with a lounge, kitchen/diner, bathroom with toilet facilities and single bedrooms for each service user. All the bedrooms are attractively decorated with individual colour schemes and furnishings. Seven of the bedrooms do not meet the National Minimum Standard of 12 square meters for service users needing to use a wheelchair within their bedroom. All except one service user attends day centres, for which London Borough of Hillingdon provide a special minibus. Service users attend medical appointments and use the homes specially adapted transport for this. The home is set in its own large grounds near Hillingdon Hospital and is about three miles from central Uxbridge. The home has ample parking facilities and is easily accessed by public transport. The staff team consists of one Manager Designate, four full-time seniors, seventeen residential workers, including five night workers, one domestic, one full time administrative officer and one part time handy person. The home is currently regularly using a large number of agency staff to support the permanent staff team. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) are currently undertaking a ‘key inspection’ of all services that are registered under the Care Standards Act 2000. This key inspection of 3 Colham Road looked at all the identified key standards of the National Minimum Standards (NMS) for care homes for younger adults, as published by the Department of Health. The Inspector was at the home from 9.30 am to 4.00 pm. The Inspector interviewed the Manager Designate and one of the senior residential workers, spoke to two other staff, observed the care being provided to four service users, and examined a variety of records including ‘case-tracking’ three care files. The Inspector made arrangements for CSCI questionnaires to be sent to 20 relatives of current service users. On the day of the inspection, the home had one long term service user vacancy. Of the eight staff on duty during the day, five were agency staff. The Manager Designate reported that there were in total 12 vacant residential worker posts at the home and no recruitment drive currently under way. Seven of the bedrooms currently in use are under the minimum size allowed by the NMS. The London Borough of Hillingdon who operate the home are aware of this major shortcoming and plans were to be drawn up to refurbish the home to a modern standard. However the Manager Designate reported to the Inspector that these plans had been put on hold. The Registered Manager of the home has recently left his employment. The Manager Designate has a six month contract for the post, and is intending to seek Registered Manager status from the CSCI. Ten out of 15 of the requirements from the previous inspection have been met, and 5 out of 6 of the recommendations. The Inspector assessed the home this time against 25 of the NMS and found that 9 of the expected outcomes were fully met, 15 were only partly met, and 1 was not met. The Inspector made 16 requirements, 5 of which are restated from the previous inspection report as they were not achieved within the timescale set. The Inspector also made 4 recommendations. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? Care files and care plans have been improved for the long-term service users. Risk assessments on service users and the building have been undertaken. Care staff have received training in the proper completion of care plans, care plans are now routinely typed instead of being handwritten. Full address details of next of kin are now being maintained. Staff have been trained in ‘person-centred planning’ and person-centred plans (PCPs) are being produced. New menus have been introduced and supper is always offered. The home’s complaints procedure has been improved. Additional staff have been trained in Hillingdon’s Protection of Vulnerable Adults policy (Safeguarding Adults). Staff training records kept in the home are now of a good standard. The provision of qualified or experienced temporary agency staff has improved, and a revised rota system ensures that sufficient permanent staff are on duty to work with the agency staff. Some staff are being recruited more quickly by the use of ‘POVA First’ procedures. The hot water heating system is being improved, with new boilers being installed in each unit. Some parts of the home have been redecorated. Refrigerators are now being correctly used and their temperatures correctly monitored and adjusted. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 7 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. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 8 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 Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Prospective users needs are not satisfactorily assessed and recorded in a systematic way. The existing statements of terms and conditions (placement agreements) do not explain the additional costs that service users may be expected to meet. EVIDENCE: NMS 2: Since the previous inspection, one long-term service user moved into the home by transfer from another Hillingdon home that was due to close. Unfortunately the service user was very unwell, spent a period in hospital prior to moving into Colham Road, and then shortly after the move, she died. The Inspector asked to see the assessment records on this service user but they were not available. The Manager Designate reported that the formal assessment documents had remained at the service user’s former home but that she had visited the service user in hospital and notes of this visit were on file at Colham Road. Requirement 1. NMS 5: The Inspector asked to see the Placement Agreement for the most recent service user to move in. The Manager Designate reported that one had not been prepared during the short period she was resident. She added that the placement agreement had not been modified to include additional expenditure. The Inspector did notice however that on the service user’s file there was the previous placement agreement from her previous home that did refer to specific charges being made as a contribution towards the cost of the Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 10 home’s transport. This is an example of what is required to be added into Colham Road’s placement agreements. Requirement 2. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Care plans for respite care users and the system for reviewing them are not satisfactory at present. Not all care plans satisfactorily identify who the key worker is. Records do not satisfactorily identify how often reviews are taking place. Service users are as involved as possible in decision making, and parents and advocates are also involved. Service users are so far as possible adequately supported to take risks as part of an independent lifestyle. Confidential information about service users is not in all instances adequately stored at the home. EVIDENCE: NMS6: The Inspector examined in detail (case-tracked) the care files, care plans and review documents for two long-term service users, and one respite care service user. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 12 The files and records of the long-term service users were neat, tidy and systematic. Those for the respite care users were less so. Recommendation1. One of the long-term care plans named a link worker but did not name a key worker. Recommendation 2. Both long-term care plans examined were dated 15th March 2006 and were typed. A formal review of one had taken place on 14th December 2005. The Manager Designate confirmed that formal reviews take place annually. The NMS require that reviews take place at least six monthly but there was no clear evidence on the files that even informal reviews do take place as frequently as this. Recommendation 3. Respite care service users have their reviews only undertaken as part of their day centre service review. This is not ideal as inadequate attention may be paid to the residential respite aspect and the need to review that residential care plan. The notes of the latest review undertaken on the service user casetracked were not on file at 3 Colham Road as the day centre had not yet produced the notes. See Requirement 3. NMS7: None of the service users are able to manage their own finances. Given the multiple high level needs of the service users, communication is difficult, hence the provision of choice and decision making is difficult. Records show that relatives attend care plan reviews and are involved in decision making, and their views are sought by questionnaires. The Manager Designate reported that one service user has an advocate, appointed via MENCAP. Person Centred Planning is being introduced. Recommendation 4. NMS9: A comprehensive system of risk assessments has largely been introduced. These include taking service users out. The Inspector found however that a key risk assessment on manual handling had not been undertaken on the respite care service user that he case-tracked. Requirement 4. NMS10: The Inspector observed in a corridor two boxes of old files that included the care plan of a former service user. The Manager Designate reported that the files were awaiting collection for archiving elsewhere. Requirement 5. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Services users are mostly able to take part in appropriate activities at day centres. Services users are adequately able to take part in community activities. Service users mostly have appropriate family relationships. Service users rights are adequately respected. Service users receive an adequately healthy diet at the correct times. EVIDENCE: NMS12: The Manager Designate reported that all service users except one attend day centres. This was confirmed by service user plans examined. One of the service users who requires PEG feeding is not yet able to return to a day centre. This matter has remained unresolved for many months. Requirement 6. NMS13: The Manager Designate informed the Inspector of the various community activities that service users are able to engage in. The Inspector verified this information by checking service users’ daily diary sheets. The Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 14 home has a mini-bus. The Manager Designate reported that a second vehicle is to be leased. NMS15: The Inspector noted from the service user plans examined that relatives do attend reviews and are consulted. NMS16: Service users are consulted so far as possible. Relatives’ views are sought by questionnaires and at review meetings. The Manager Designate reported that one service user has an advocate obtained via MENCAP. NMS17: The Inspector examined the new menus in place. The Manager Designate reported that food at supper time is now routinely offered. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Arrangements for the provision of personal care are satisfactory. Further work is necessary to ensure that service users’ physical care needs are being fully met. The homes procedures for dealing with medicines protect service users in a satisfactory manner. EVIDENCE: NMS18: The Inspector observed care and attention being given to service users in an appropriate and caring way that maximised their privacy and dignity. NMS19: Both the long term service user files that the Inspector case tracked contained Health Action Plans and Weight Charts. However the latter were designed to be completed monthly but during the last 12 months, four months (including March 2006) had been missed for both service users. Requirement 7. Both files contained a Handling Assessment but one was not signed or dated. Both files contained Skin Maps but some were not dated. Requirement 8. NMS20: None of the service users are able to manage their own medication. The Inspector examined the medication storage facilities and the records in two of the home’s units. No major shortcomings were identified. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The complaints procedure is satisfactory. The homes’ permanent staff are generally adequately trained in adult protection. The instruction of agency staff in this regard is not satisfactory. EVIDENCE: NMS22: The Inspector examined the home’s revised complaints procedure, and the record of complaints. No complaints had been recorded since before the last inspection, but two letters of compliment had been received. NMS23: The Manager Designate reported that all permanent staff had been trained in Adult Protection but an examination of training records showed that one of the new recruits had not yet received the training. He is due to commence NVQ training shortly which will cover the topic. The Manager Designate showed the Inspector a revised induction check list for new agency staff. It did not mention Adult Protection issues or Whistle Blowing. A requirement has been made that the induction checklist be extended to cover these essential elements. Requirement 9. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is not suitably designed in that seven bedroom that are used by physically disabled service users do not meet the minimum size requirements for people using wheelchairs. The hot water supply is too hot. Some areas of the home are not sufficiently domestic in style. The home is generally clean and hygienic but the absence of double sinks or dishwashers is a concern. EVIDENCE: The Inspector toured the whole home. As previously reported, seven bedrooms do not meet the minimum size requirements for physically disabled service users. The Manager Designate reported that plans for extending the bedrooms and refurbishing the kitchens have been put on hold. Requirement 10. The home is generally clean and hygienic but kitchenettes are in need of refurbishment as they are showing signs of wear and tear, do not contain dishwashers, nor double sinks. A member of staff pointed out that the same sink has to be used for washing dishes and for washing PEG feeding syringes. This is a potential environmental health issue as well as a health and safety one. Requirement 11. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 18 The Inspector found that a visiting community nurse was storing boxes of her equipment on the bedroom floor of a service user in the respite unit. A more appropriate storage place must be found in order to maintain a homely environment. Requirement 12. The Inspector found that some bedrooms, bathrooms, toilets and hallways were overly dark, and institutional in appearance, having no pictures or other decoration other than plain paint upon their walls. Requirement 13. Several instances were found where notices for staff were stuck on the walls of service users’ bedrooms. Some of these were removed in the presence of the Inspector. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35 Although the permanent staff are generally well qualified and competent, there is a high a percentage of staff who are unqualified agency employees. Service users are protected by the homes recruitment checks but the home is not currently enabled to recruit permanent staff, and long delays are occurring in the clearance of staff who have been provisionally appointed. A good percentage of the permanent staff are professionally qualified but many staff are agency employees. EVIDENCE: The Manager Designate reported that since the last inspection two care staff have retired and one has moved away. The Inspector examined the home’s records and determined that at the present time there are 17 permanent care staff on the books, and 12 vacant care posts that are filled as necessary by temporary agency staff. Management has taken steps to improve the calibre of agency staff provided by Hayes Recruitment with some success. The Manager Designate reported that rotas have also been adjusted to ensure that as many permanent and experienced staff as possible are rostered to be on duty with relatively inexperienced temporary staff. Nevertheless on the day of the inspection, temporary staff outnumbered permanent staff 5 to 3. Reliance on agency staff must not be allowed to have any adverse effect on the care standards provided within the home. The Inspector was told of two new staff who had been recruited in August 2005 but seven months later their CRB had Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 20 not yet come through and hence their posts were still being covered by agency staff. Recruitment and the CRB clearance of new staff must be addressed by the senior management of the London Borough of Hillingdon as a matter of urgency. Requirement 14. Three of the relatives who responded to the Inspector’s questionnaire complained about the high use of agency staff as this they say affects the standard and consistency of care provided. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The Manager Designate has not been in post sufficiently long for a judgement to be made on NMS 37. Quality Assurance questionnaires to ascertain relatives’ views are undertaken sufficiently often. Service users’ rights and financial interests are not adequately safeguarded by the homes’ policies. The health and safety and welfare of service users are not sufficiently well safeguarded. EVIDENCE: NMS37: The new Manager Designate had only recently taken up her post having been promoted from post of senior residential worker at the same home, for a period of six months. She informed the Inspector that she will apply to the CSCI to become the Registered Manager and that she is to undertake the NVQ level 4 in Care qualification. The Inspector examined minutes of a senior staff meeting. The Manager Designate reported that these Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 22 meetings, those of the staff team as a whole, and those held within the units, all take place monthly. NMS39: The Manager Designate reported that questionnaires are sent six monthly to the relatives of service users. NMS41: The Inspector examined a sample of the records kept on how service users’ personal allowance is spent by the home. The Manager Designate reported that following concern expressed by the Inspector at the last inspection, a new form had been introduced so that the manager had to authorise expenditure that a residential was wanting to make. However she reported that the London Borough of Hillingdon had not issued her with any further written guidance on what was and what was not appropriate expenditure. A check of the records showed that in January 2006 a service user’s funds had been spent on a new bed and mattress, and in February, a service user’s funds had been spent on a laundry basket. These first two items at least are items that the CSCI would expect the home to pay for as they are normal furnishings that one would expect to find in a care home, and are mentioned as requirements in the NMS. The London Borough of Hillingdon must produce a policy to guide staff on appropriate expenditure, and amend their Placement Agreement to cover additional charges. Requirement 15. NMS42: The Inspector found that the toilets and bathrooms in the home did not contain any towels. The Manager Designate reported that the previous manager had not ordered any at the end of the last financial year in order to save money but they had now been ordered. The towels arrived later on the day of the inspection. The Inspector noted that new hot water boilers were being installed in each unit. The Inspector tested the hot water temperature in two units and found it to be 44.6 and 46 degrees Centigrade. The acceptable temperature is 42 degrees Centigrade plus or minus 2 degrees. Requirement 16. The Inspector asked to see the home’s water treatment certificate regarding Legionella. The Manager Designate reported that the test had been done, but she did not have the certificate. She agreed to fax a copy to the Inspector. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 2 3 x 4 x 5 2 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 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 2 LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 x 3 x 2 2 x Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 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 YA2 Regulation 14 (1) (a & b) Requirement The registered person shall not provide accommodation unless the needs of the service user have been assessed and the registered person shall obtain a copy of that assessment. The registered person shall provide the service user with a copy of the agreement specifying the arrangements made, including charges to be levied. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT AS THE TIMESCALE SET HAS NOT BEEN MET. The registered person shall keep the service user’s plan under frequent review. In particular respite care service users must have a review of their respite service that is distinct from their day centre service review. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users (including risk assessments) The registered person shall ensure that the home is DS0000032552.V286806.R01.S.doc Timescale for action 01/05/06 2. YA5 5 (3) 01/08/06 3. YA6 15 (2) (b) 01/06/06 4 YA9 13 (5) 01/06/06 5 YA10 12 (4) (a) 01/05/06 Colham Road, 3 Version 5.1 Page 25 6 YA12 7. YA19 8. YA19 9. YA23 10. YA24 11. YA24 12. YA24 conducted in a manner to respect the privacy of the service users. 16 (2) (m The issue about whether one of & n) the service users who is PEG fed may return to a day centre must be resolved quickly. THIS IS A RESTATEMENT OF A REQUIREMENT MADE TWICE BEFORE THAT HAS NOT BEEN ACHIEVED WITHIN THE TIMESCALES SET. 12 (1) (b) Weight charts must be completed monthly so as to promote the health of service users 13 (1) (b) Assessments and skin maps must always be signed and dated so that service users receive the health care they need. 13 (6) The registered person shall make arrangements by training staff to prevent service users being placed at risk of harm or abuse. 12,13(4 As service users have physical 5)23(a,e,f) disabilities, the home will have to be registered for that category. In order to gain this registration, the registered person will have to consider how the home can be refurbished in order to increase the size of certain bedrooms. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT MADE TWICE BEFORE. 13 (4) (a) Kitchenettes must be properly maintained and equipped in order to provide a safe service for service users 23 (2) (l) Nursing equipment must not be stored in a service user’s bedroom. The registered person must make suitable storage provision for the purposes on the care home. DS0000032552.V286806.R01.S.doc 01/06/06 01/05/06 01/05/06 01/06/06 01/12/06 01/12/06 01/05/06 Colham Road, 3 Version 5.1 Page 26 13. YA24 14. YA33 15. YA41 16 YA42 23 (1) (a); The registered person must 23 (2) (p) make arrangements to keep the premises homely in line with meeting the aims and objectives of the statement of purpose. All areas must be sufficiently well lit. 18 (1) (a) The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers appropriate for the health and welfare of service users. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT. SUFFICIENT PERMANENT STAFF HAVE NOT BEEN RECRUITED WITHIN THE TIMESCALE SET. 13 (6) The registered person shall ensure that service users are not placed at risk of (financial) abuse by providing staff with the required guidance and policies on what is appropriate expenditure to charge to service users’ personal allowance accounts. THIS IS A RESTATEMENT OF A PREVIOUS REQUIREMENT AS THE TIMESCALES SET HAVE NOT BEEN MET. 13 (4) © The hot water available to service users must be maintained at 42 degrees Centigrade plus or minus 2 degrees. 01/08/06 01/09/06 01/08/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 27 1. 2. 3. 4. YA6 YA6 YA6 YA7 The care files and care plans for service users receiving respite care should be improved by bringing them in line with those for long term service users. The care files and care plans of all long-term service users should clearly show who the key worker is. All such service users should have a key worker. Long term service users should have their care plans reviewed internally, at least six monthly. Person Centred Planning should be fully introduced. Colham Road, 3 DS0000032552.V286806.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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