Inspection on 04/04/08 for Community Resettlement Project

This inspection was carried out on 4th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Community Resettlement Project 10/08/07

Community Resettlement Project 10/07/06

Community Resettlement Project 01/12/05

Community Resettlement Project 02/04/05

Community Resettlement Project 01/11/04

Community Resettlement Project 15/04/04

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 Community Resettlement Project 24-28 Argyle Street Kings Cross London WC1H 8EG Lead Inspector Pearlet Storrod Unannounced Inspection 4th April 2008 10:00 Community Resettlement Project DS0000010342.V361294.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 Community Resettlement Project DS0000010342.V361294.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. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Community Resettlement Project Address 24-28 Argyle Street Kings Cross London WC1H 8EG 020 7278 3629 020 7813 9776 mkumah@onehousinggroup.co.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) Community Housing Association Mercy Owusuah Kumah Support Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2007 Brief Description of the Service: Community Housing Association manages the Community Resettlement Project (CRP). This organisation has considerable experience in the housing sector and provide a wide range of support and support services. The home itself provides support and support to adults with mental health needs. It is situated in a residential/commercial street very close to Kings Cross Station. The property is three adjoining houses. House number 24 is registered to accommodate five women; house number 26 is the office-cum-staff area and house number 28 is registered to accommodate thirteen male service users. The houses are interconnected. Accommodation for service users is provided in single rooms, each is furnished with a fridge and a wash hand basin. Communal facilities include toilets, bathrooms, kitchens and lounges. There are two gardens to the rear of the premises. The houses are not suitable for service users with mobility problems and as they are listed buildings, alterations and adaptations are unlikely. The focus of the CRP is on rehabilitation and resettlement. Residents are to be motivated to be able to cook and undertake cleaning and laundry or improve these skills. An average stay is twenty-two months although residents can be there for longer. The fee charged for the service is £534.93 Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took six hours to complete and I spoke with three people who use the service and three members of staff and the manager. Six surveys were returned duly completed; three from staff and four from people who use the service. Information from the (AQAA) Annual Quality Assurance Assessment was used to complete the report. All the key standards were inspected. I toured the building inside and externally and examined records and files for people who use the service. The manager and three staff members were on site. What the service does well: The service supports people who use services to live as independently as possible and to access appropriate activities including work experience. It is clear from discussion with staff that they understand the needs of the people using the service. Engagement between staff and people using the service, and an ex client who visited on the inspection day, demonstrated mutual respect from everyone involved in dialogue. Key workers have regular contacts with the people that they support; house meetings occur regularly and the Responsible Individual oversees the service via monthly monitoring visits. The meetings and visit provides and opportunity for people who use the service to voice a concern or to express their views about the running of the service. A person who uses this service commented in a survey, “information and brochures etc received.” Another person who use the service said, “I was not sure, but now I have moved here it is a very nice clean place to be here and a safe place too. I think it is a very good idea that the men are separated from women which makes it a safe place”. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A good number of requirements are still outstanding to be addressed and it is good to learn that the funding has been increased, which would go towards improving the service. I understand that the provider proposes to renovate the building to provide en-suite accommodation in the future and this would no doubt enhance the standards. In the meantime some requirements must be attended to, to protect and safeguard the health and wellbeing of people who use the service, staff and visitors. These relate to ensuring that the staircases are made safe to walk and their appearances improved, ventilation is installed in a bathroom on the ground floor, loose handrails in the rear garden to be fixed. The situation regarding lack of bathroom ventilation, gloomy bathrooms and loose handrails has the potential to prohibit the autonomy of people who use the service. A survey returned by a person using the service commented, “the handyman isn’t around, logged reports are not received.” And another individual said, “I think it would be nice if we had our own shower and toilet in our own rooms”. The service is required to provide a more practical approach to support people with planning their nutritional meal plans to give an indication as to whether the dietary and nutritious needs of people who use the service are being met. Monitoring of the records held at each inspection would evidence this. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 7 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. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 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 Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A statement of purpose and service user guide is now available for the service, which meet the National Minimum Standards. Assessments of needs remain satisfactory. EVIDENCE: The statement of purpose and service user guide has been reviewed and this now appears to meet the National Minimum Standards. Four files for people who use services were examined. The placing authority prior to admission to the service conducts an initial assessment of needs. An allocated support worker conducts an induction of the person being placed and the key worker and individual discuss issues about the placement. Further information is generated which is used to generate a support plan. A person who uses this service commented in a survey, “information and brochures etc received.” Another person who use the service said, “I was not sure, but now I have moved here it is a very nice clean place to be here and a safe place too. I think it is a very good idea that the men are separated from women which makes it a safe place”. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 10 Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support plans have been improved to be more person centred and the support staff continues to encourage and support people to make decisions for themselves. There is evidence of social inclusion in the plans of support and risk assessments have also been improved. EVIDENCE: The support plans are updated six monthly or sooner if the need arise and are person centred. Individuals’ personal goals are reflected in their support plans. There is evidence of equality and diversity in the support plans. Key work sessions occur regularly between client and key worker; at these meetings events about day-to-day events and other matters are discussed and recorded. The support plans also indicated social inclusion and participation, reflecting the views and thoughts of people who use the service in all aspects of their individual health and wellbeing and of their progress with timescales for set goals to be achieved. Review dates are reflected in the support plans. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 12 Of the four files for people who use the service it was noted in one support plan that an individual was reluctant to attend a day centre; this individual’s first language is not English and staff were making attempts to have an interpreter to help them to improve communication between them and the individual but this resource was proving difficult to achieve. Support staff understands the need for people to make decisions for themselves and they are encouraged and supported to do so, particularly as the service focus on an independent and rehabilitative approach. Risk assessments had improved. They are now more robust and each tailored to accordingly to the specific needs of people who use the service. Risk managements plans were up to date. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. Staff continues to encourage people who use the service to have links and make use of community services and to maintain family contacts. Rights and responsibilities are respected. An individual needs more practical support with planning their meals. EVIDENCE: People who use services continue to receive encouragement and support from staff about the ways to access and make use of community services. The changing needs of people who use the service are identified in the support plans. Individuals are persuaded to enhance their skills and to develop new ones for example, attending college and undertaking work experience. People who use the service are asked to bring their individual thoughts to their keyworking sessions. An individual is successfully employed in a restaurant run by people with a learning disability. Several groups have been set up within which people who use the service take the lead with support from staff. This Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 14 set up helps to boost the confidence of individuals and increase their independence and determination. People are encouraged to maintain family contacts. They decide whether to have their families involved and notified of events that affect them. The need to respect the rights and responsibilities of people who use the service is enshrined in the statement of purpose and within the support plans. People rights and freedom to use the garden area was restricted at the time of this visit because of unsafe handrails. Refer to Environmental outcomes. During the visit an ex service user that I met at the previous inspection visited the home to meet up with other people at the service; this demonstrates clearly that people who use the service are maintain contact with their friends. An individual from ethnic minority background confirmed that he is supported by his family and attend cultural events as and when he desires. The previous report mentioned the proposal to establish a group to deals with issues about healthy living, which would take the cultural needs of people into account. People who use the service would take the lead once set up; this group has not progressed and the manager reported that they are experiencing difficulty in identifying a suitable cook to assist with this project. It was unclear whether the dietary and cultural needs of people who use the service are being met, as no records are available to demonstrate this, which continues to be an outstanding requirement. When the manager took up her post last year she introduced a healthy lifestyle group, which looks at healthy eating and dietary needs. There was no evidence available to demonstrate that the dietary needs of the people who use this service are being met. Each person has responsibility to shop, prepare their meals and cook for him or herself. I spoke with an individual that I met at the previous inspection. I was given permission to look in their refrigerator, which is in their room; it contained 6 eggs and a packet of bread. It was 3 pm and they had not eaten as yet because they got up late. I asked what they intended to eat and they indicated that a staff member had gone to buy them some chicken and rice for cooking. They explained, “Everything was okay, I sometimes visit my family and eat there.” The support plan for this individual did not reflect assistance with the planning of their meals. Staff stated that food is discussed at key-work or contact sessions and that the information is not recorded. Staff also accepted that this individual above would benefit from more planning in this area. A policy and procedure in respect to food safety and nutritional must be developed and a nutrition plan must be put in place for each person who uses the service. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 15 Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service does not provide personal support; individuals are supported as necessary with emotional health needs. Improvement has been made in respect to the management of medication. EVIDENCE: Personal support is not provided at this service. From observation of the support plans these are reviewed regularly with people who use the service. Daily reports are informative and where necessary changes are discussed with individuals and recorded. Records demonstrate that appropriate medical professionals involved assess physical and emotional needs regularly. I saw Community Practice Nurse assessments on files and records of GP appointments. There is evidence to suggest that key personnel i.e. social worker or medical professional are notified immediately when concern arise. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 17 The service is now in the process of admitting people with dual diagnosis. Some individuals have other support needs such as drug and alcohol. The home is equipping themselves for the various challenges ahead of them. The service has an appropriate medication policy in place; staff reported that they have recently changed the pharmacist that they have acquired certificates to demonstrate their competence in medication administration. Two named individuals have responsibility for medication management and this appears to be managed well. I looked at the records for four people who self medicate, each of who are at differing stages as evidenced from the support planning and reviews. There are set goals with timescales for proposed achievements on record and from observation, one person who currently manages their own medication is due to move into semi independent living accommodation shortly. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 18 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. Improvement has been made to the complaint protocol following the previous inspection and an appropriate policy and procedure in respect to the protection of vulnerable adults is available. EVIDENCE: There is a clear system in place for staff to follow in the event that a complaint is made. Previously an informal process to combat the need for complainants to have to wait and exhaust the various stages in the process before an outcome is reached. With the inclusion of the informal process concerns that are not of a serious nature could now be resolved at the home. The manager confirmed that she has received the necessary training in this regard. There were no recorded complaints evidenced since the last inspection. The home has an adult protection policy in place. Discussion with staff indicated that all staff have now received POVA training. Members of staff were able to describe accurately the procedure that would be followed if an allegation or complaint were made in relation to adult protection are not of a serious nature could now be resolved at the home. The manager confirmed that she has received the necessary training in this regard. There were no recorded complaints evidenced since the last inspection. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 19 The home has an adult protection policy in place. Discussion with staff indicated that all staff have now received POVA training. Members of staff were able to describe accurately the procedure that would be followed if an allegation or complaint were made in relation to adult protection. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 20 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, and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not operate in a person centred way with regards to the environment. People who use the service have to “make do” with a standardised and poor environment in which to live. EVIDENCE: The majority of the surveys returned from stand and person who use the service demonstrate concerns about poor environmental conditions. A person who uses the service commented, “the handyman isn’t around, logged reports are not received.” The perception given is that the provider is not proactive when maintaining and repairing works that are reported for action. I toured the building and was given the permission of an individual that I met at the last inspection. I noted that their carpet remained in a poor state they said the same as words as they previously did, “It was like that when I moved in.” Staff repeated the same message, “the carpet has been changed.” There was no evidence to suggest that the carpet was in better condition when the individual moved in or that the carpet has been replaced Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 21 since the last inspection. The room was in a poor state at the time of this visit. The occupant reveal that they would vacuum the carpet and as they will soon be moving to independent living accommodation soon, they are no longer bothered about the condition of the carpet. The fact that no action has been taken to clean or replace the carpet in the room of this individual demonstrates a lack of dignity and respect. A person who use the service said, “I think it would be nice if we had our own shower and toilet in our own rooms”. The missing pieces of carpet on the staircases have not been remedied and more importantly, the half landing on each staircase poses a problem. The areas decline as you put your weight on the steps. It was slightly a frightening feel when the steps declined with my weight. Furthermore, one bathroom had the extractor fan removed and a new one has not been installed, there is no window and this means that there is no ventilation to the room. The carpet in the room on the ground floor outside the office needs to be removed and replaced with durable floor covering; again to enhance the appearance. The bathrooms and kitchens are all in need of improvement For example, the kitchen cupboards have been identified for replacement; some of the doors to the base cupboards in particular are missing or warped. The bathrooms are dark and gloomy; the main lounge in both blocks also need attention in respect to the replacement of carpets and furniture and decoration to enhance the appearance of the home. Discussion with staff confirmed this. The views about whether the home was comfortable to live in was sought from a person using the service; their response was, “the living room is gloomy, it could do with some pictures and ornaments and general improvement.” Staff echoes this view. The rear garden also poses a problem for staff, people using the service and visitors, as the handrails along the steps in the garden are loose. It should be said that staff with the participation of people who use the service tidied the garden; they asserted that a company has been contracted to maintain the garden and to be responsible for cleaning the communal areas of the home. In the meantime however, the areas identified that are hazardous must be addressed as soon as possible to prevent injuries to people using the service. The handrails were installed for ease of access and to help to protect people from harm. Currently they present a danger to people using the garden. It was pleasing to note that matters relating to the boiler and general heating and hot and cold water supply have been satisfactorily addressed along with the installation of new industrial washing machines. The lounge, bathroom and kitchen areas used by the women were in a poor state at the time of this inspection. Attempts are generally made by staff to ensure that the communal areas of the home are clean and hygienic and Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 22 domestic staff is employed to undertake this task though there was no evidence of this staff member during the inspection. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 23 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, 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. A trained and competent staff group supports people who use the service. A review in the number of permanent staff is necessary. The previous report required a review of the recruitment and selection protocol. EVIDENCE: Some staff have already achieved their NVQ level 3 qualifications and others are undergoing training to accomplish this. I met and spoke with three staff members and the manager. I was told that they have all had their training needs identified and that some of them have already attended training in various disciplines like first aid, drug and alcohol, medication management, substance misuse, diagnostic behaviour therapy, personality disorder, POVA and health and safety and others. From observation of practice and discussion with the manager, staff and two people who use the service it emanated that staff are aware of the needs of people using the service and interaction with them were noted as positive and respectful. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 24 Staff commented in the returned surveys that, “the service could benefit from adding one more staff to the staff team;” some indicated that someone with experience in substance misuse would be suitably employed. All surveys demonstrated concerns about the environment. We discussed the matter of sufficiency of staff and the manager declared that they now use bank staff as opposed to agency workers to make up the shortfall as and when necessary. She said that bank staff working in this service are interviewed by her and have to undergo induction training and staff shadowing for continuity in practice. This also ensures consistency and costing is reduced. The manager indicated that they have not been successful in obtaining clearance for an additional staff but that the service would benefit from specialist input such as drug and alcohol to work effectively with people diagnosed with both mental health and drug and alcohol problems. Examination of the recruitment protocol was not undertaken as part of this inspection process as this was undertaken previously. Staff spoken with confirmed that they have been asked to complete applications to have their Criminal Records Bureau disclosures updated and the manager acknowledged this and this was further confirmed in a staff survey. She explained that staff photographs have not as yet been put on their individual files but that this is in the process of being done within the next week or two. Regular supervision is received by all staff as confirmed by staff and evidenced at inspection. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 25 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff continues to make strong efforts to manage this home well; People who use the service are not adequately protected or safe in this home. EVIDENCE: The manager of the service has now had their registration as support manager approved by the Commission. The manager is in the process of completing the Registered Managers Award and NVQ 4 in Health and Social Care. Registration certificate and insurance document are displayed conspicuously. The views of people who use services are regularly sought in a variety of ways. They participate in the assessment and support planning process and at regular key work or contact sessions. People who use services also make their views known at the house meetings and the minutes indicate that people who use services make contributions, which are acted upon. Monthly monitoring visits are carried out and these provide an opportunity for people who use Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 26 services to share any concern or complaint they may have. The reports are informative and they reflect how the service is being run and any shortfalls. Health and safety documents were examined and these showed that regular monitoring occur, weekly and monthly checks of equipment takes place. Inspection in respect to gas was carried out on 24/01/2008. A number of requirements remain outstanding, some of which have the potential to cause risk of harm to staff, people who use the service and visitors. At the inspection I was told of a proposed plan to carry out some renovation works to the service, which would include development of en suite facilities. It is imperative that a realistic timescale is given to the Commission in writing for the proposed redevelopment works to be effected to prevent enforcement action being instituted for continuous failings to bring the home up to a suitable standard which would reduce the potential for risk of harm and injury and at the same time increase independence and quality of life for those using the service. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 1 27 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHSUPPORT SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 28 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 Support Standards Act 2000, Support Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation Requirement Timescale for action 06/05/08 2. YA24 Key workers must support service users with nutritional planning of their meals and to monitor and record these. This is to ensure that service users are eating healthy and nutritious meals regularly. Restated: 10/12/07 13 (4)(a),(b),(c)23(2)(a) The registered 04/07/08 (b)(c)(p), 16 (2) (f)(h) provider must ensure that the ventilation systems together with other items listed for repair and improvements i.e. decoration in the previous reports. They must also carry out the repairs and maintenance outlined on a schedule held in the home dated 05/07/07. The DS0000010342.V361294.R01.S.doc Version 5.2 Community Resettlement Project Page 29 3 YA42 registered provider must ensure that the ventilation systems together with other items listed for repair and improvements i.e. decoration in the previous reports. They must also carry out the repairs and maintenance outlined on a schedule held in the home. The outstanding requirements inhibit clients autonomy 12(3) and 13(4) a, b and The registered 20/07/08 c provider must carry out appropriate maintenance - repair and refurbishment to the premises, to enhance people’s quality of life. Restated: 20/12/07 A plan for the proposed renovation must be developed and a copy issued to the Commission. An improvement plan is attached to this report and to be returned by 24/05/2008 Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 30 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 YA40 Good Practice Recommendations The registered provider should ensure that a policy and procedures for food safety and nutrition is developed so that support workers appropriately guided on how to assist individuals with nutritional plans. Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 31 Commission for Social Support Inspection London Regional Contact Team Caledonia House 223 Pentonville Road London N1 9NG 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 Support Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Community Resettlement Project DS0000010342.V361294.R01.S.doc Version 5.2 Page 32 - 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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