Inspection on 18/04/05 for Companion In Care

This inspection was carried out on 18th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Companion In Care 31/05/06

Companion In Care 20/12/05

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 Companion In Care 495 Barking Road Plaistow London E13 8PS Lead Inspector Lea Alexander Unannounced Inspection 18th April 2005 at 11:00am 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 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 Stationary 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. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Companion In Care Address 495 Barking Road, Plaistow, London, E13 8PS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8586 5712 020 8809 7044 Companion In Care Ltd Ms Monica Makoni Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4th August 2004 Brief Description of the Service: Companion in Care is a residential home for 3 service users diagnosed as having mental disorder. The home is staff over 24 hours with a sleeping night cover. In addition to the manager 2 support workers have recently been appointed and a regular bank support worker also covers shifts at the unit. The property comprises three bedrooms, a kitchen diner, a lounge, a bathroom, shower room and a staff office/sleeping area. There is a small yard to the rear of the property. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and occurred over one day on the 18th April 2005. Two Inspectors visited the home over the course of the day and met with one support worker, three service users, the registered manager and the responsible individual at different points during the day. The main focus of the inspection was to review progress regarding the 40 requirements made at the previous inspection in August 2004. 21 requirements were carried forward and are restated from the last inspection. An additional 27 requirements were made as a result of this inspection. The inspectors would like to thank service users and staff for their assistance with this inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 5. The home has made no progress since the last inspection in addressing its pre placement assessment procedure or revising the statement of purpose and service users guide. Individual care plans are not comprehensive and important elements are not included. EVIDENCE: Several inconsistencies and inaccuracies were identified in the statement of purpose and service user guide at the last inspection. These remain outstanding. The homes current service users have resided there for some years. In reviewing their pre placement assessments the previous inspection had required the home to develop their current tools. This remains outstanding. One of the current service users is in the process of moving on to more independent accommodation, which makes this requirement more pressing. The Inspector looked at the service users personal files. The individual plan format is brief, and the plans were not comprehensive. For example, one service user has been started on a programme to prepare for self-medication. There was no reference to this in the individual plan. The Inspector looked at the contracts section on one service users personal file. The contracts now being used have been revised since the last inspection and appear more tailored to the individual service users needs. However, the Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 8 Inspector found that although the contract between the service user and the home had been signed, several undated, un-initialled amendments had been made to the contract in pencil. A second contract relating to this service user between the home and placing authority had not been signed at all. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9. The home have reviewed individual care plans and risk assessments since the last inspection. Service users are not actively engaged in the day to running of the home and there appears to be no mechanism to consider their views when making decisions about the home which will directly impact upon them. EVIDENCE: At the last inspection the home was required to develop its individual planning procedures and ensure that these are comprehensive and regularly reviewed. From viewing service users personal files the Inspector found that individual plans had been reviewed since the last inspection. The plans currently in use however are not comprehensive care assessments that cover the full range of service users needs. This remains an outstanding requirement. One service users individual plan identifies “avoiding social isolation” as a need. The review of this element states “still trying at the moment, no success”. There is no reference to the type of work undertaken with the service user to address this issue, or record of how this has been monitored or reviewed. The individual plan must be developed to include clear, specific aims and objectives agreed with the service user and other professionals involved in their care. Methods to meet and implement them must be developed. This is an outstanding requirement from the previous inspection. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 10 The Inspector noted that the home do have a system of monthly reports which are completed by the key worker. These were informative and gave more of a flavour what was happening for service users at the time of writing. The home has reviewed service users risk assessments since the last inspection. However, these are not comprehensive and require further development. For example, one service users risk assessment identifies the potential for financial exploitation by drug abusing associates. The rest of the information completed with regard to this risk addresses the service users own drug abuse. These are two separate issues and need to be risk assessed separately. Another service users file had no risk assessment addressing his “programme leading to self medication”. At the last inspection it was noted that this service user has a brain injury and physical disability. The home was required to identify and address risks attendant to this such as bathing or showering. It was not evidenced that this had occurred. The home is regularly used as a placement for trainees completing a care assistant course. All of the homes service users fedback to the Inspector that they were not happy with this. One service user stated that he had frequently told staff that he did not like having students at the home. Another service said that he had complained last year when he suspected that a student had stolen DVD’s from his room. When discussed with the home manager, she advised that there is no consultation with service users regarding student placements, although service users are told in advance of their arrival. The home does not currently ensure that service users are offered opportunities to participate in the running of the home, and there is no process to take account of their views. There is also no mechanism in place at present to involve service users in a review of the homes policies and procedures. Posters regarding advocacy services were displayed in the communal hallway. During discussions with the Inspector two service users stated that they would like support from an advocate, but were unclear about how to access this service. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Service users are socially isolated and have limited opportunities for development or involvement in activities outside of the home. Opportunities for personal development are also limited. EVIDENCE: Service users plan and prepare their own meals with staff support. Mealtimes are flexible. At present the service users submit a shopping list to staff once per week. A bulk shop is then done and goods distributed to service users. Two service users complained to the Inspector regarding this process. One of them is in the process of moving to a hostel, and would like support in developing his budgeting and shopping skills. He has requested that staff support him to do his own weekly shop. This has not yet happened. Another service user told the inspector that he felt frustrated that food items he has asked for, that reflect his own cultural background are often not provided. This service user also wanted more individual support in developing his budgeting and shopping skills. Issues regarding bulk shopping for service users were identified as needing attention at the last inspection. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 12 The Inspector viewed the contents of the fridge and noted that there was a choice of items. Some foods in the fridge were date labelled, but did not have any other information such as “opened” or “use by”. Some items in the freezer were in bags with no labels at all. At present none of the service users are involved in any community based activities. One service user had been attending a computer class and day centre until recently. The manager was unaware as to why he had stopped attending. The previous inspection report had identified that service users were socially isolated. There was little evidence of systematic work being done by staff to address this issue. For example, the service user whose care plan identifies concerns regarding social isolation has not been invited to participate in the activities the home offers since 28th January 2005. Another service user of white British heritage had asked for support in joining a local pool club. Staff had referred him to an afro carribean service who had declined the referral and explained to staff why this was not appropriate. The previous inspection report had identified that staff may need additional support and training to assist them to address service users needs in this area. During this inspection the registered provided told the Inspector that he had not agreed with this view, and is of the opinion that staff are able to motivate and encourage service users without the need for additional support or training. The Inspectors view is that service users remain socially isolated. Since the last inspection the home has instigated an activities rota, but take up of many of the items is limited to one service user. Service users also fedback to the Inspector that the stereo in the lounge area does not work, and a stolen video player has not been replaced. The TV has no remote control. Two of the service users told the Inspector that these things encouraged them use their own TV and stereo in their rooms, and that this limited opportunities to come together as a service user group in an informal way. One service user told the Inspector that he had recently gone for a coffee with a staff member during a key working session and had enjoyed this. The homes activities log indicates that one service user accompanied a staff member to a photographic exhibition. The service user was enthusiastic in his feedback to the Inspectors regarding this visit. However this had occurred in November 2004 and no subsequent trips to similar events had been arranged. Service users stated that they were all able to maintain relationships with family members, most of who live outside of Newham. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. The homes current medication policies do not support service users self medicating, or embarking upon a programme leading to self-medication. The home also needs to develop it practise in supporting service users with physical disabilities, by making sure that the necessary assessments for aids and adaptions are carried out. EVIDENCE: Service users appear to be fairly independent. Each service user has an allocated keyworker, and they are each aware of who this is. One service user is recorded in the Medication record as self-medicating. Discussion with the manager and service user indicated that this is not the case. The agreement is that this service user will come and ask staff for his medication which is then administered in the usual way. The service user reports feeling very frustrated by this process. He is unclear how it is reviewed and his progress monitored. The current medication policy does not adequately address self-medication. This manager described this service user as being on programme leading to self-medication. There was no reference to this in any policy or procedure, in his care plan, individual plan or risk assessment. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 14 At present the Medication Administration Record (MAR) is being used to list all medication, including depot injections. The MAR sheets were accurately completed. As previously stated, one service user has a brain injury and physical disability. This service user has lived at the home for a number of years. There has been no assessment of aids or adaptions he might need around the home during this time. The last inspection report advised risk assessment with regard to activities such as showering. This has not occurred. Service users personal files contain records of all recent appointments with professionals and details of any treatments, medications or follow on appointments. Whilst some service users wishes regarding death were recorded in their personal files, the home as yet to develop a protocol regarding ageing, illness and death that can be utilised in key working sessions as appropriate. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has a complaints procedure and service users are aware of this. There is evidence to suggest however that the procedure is not always followed when a complaint is made. EVIDENCE: The Inspector reviewed the homes complaints folder. No complaints were recorded within it. The Inspector noted that one service user had complained in October 2004 of a theft from their room. Whilst the home had informed the Commission for Social Care Inspection of the incident, neither the complaint or any subsequent investigation or outcome had been recorded in the complaints file. The Inspector reviewed the home’s “Management of service users money and financial affairs” policy. The previous inspection had identified that this needed review and update to include current practises within the home. There was no evidence to suggest that this had occurred. The Inspector viewed the homes “Whistleblowing policy”. This had not been reviewed as required by the previous inspection to include up to date contact details for the Commission for Social Care Inspection. During discussion with service users all had knowledge of the homes complaint procedure and had a copy of the complaints form. All service users were aware of the Commission for Social Care Inspection and had some awareness of its role as a regulatory body. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 16 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 standard(s) 24, 26, 27, 28, 29 and 30. The home is poorly maintained and the communal areas are not homely or reflective of the service users living there. Service users have had the opportunity to personalise their own rooms. EVIDENCE: The home environment remains shabby. Two of the service users spoke to the Inspectors of there unhappiness regarding the maintenance and upkeep of the home and the length of time elapsing between repairs being identified and work carried out. Some redecoration has been carried out, but this is generally of a poor standard. Paint spillages have been left on the bathroom floor tiles. It would appear in many rooms the ceilings have not been painted during the redecoration programme. The lounge in particular would benefit from redecoration as the ceiling is dirty and many marks and patches are present on the walls. In the kitchen repairs had been undertaken to the unit kickboards and to the boiler. The facing board used to mask off the pipes underneath the boiler remains unfixed since the last inspection. All matters identified at the previous Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 17 inspection relating to the boiler and electrical wiring appear to have been dealt with appropriately. Service users have had the opportunity to personalise their own rooms. The communal area’s of the house, particularly the lounge are not homely and do not reflect the service users living there. Additionally, the carpets in the lounge area are badly stained and need replacement. The curtain rail in the lounge is broken and the curtains fitted to it are not large enough to cover the window area. The storage cabinet in the lounge has had its front edging broken off and this has not been repaired. The bridging strip between the lounge carpet and hallway laminated flooring is missing, and this poses a potential trip hazard. The entrance hall contains a cabinet with photographs of service users, however this is rather overshadowed by many posters including A3 size posters for manual handling and control of substances hazardous to health. These are not appropriate in the service users communal area and those required by staff should be moved to a more appropriate area, as should the health and safety executive poster in the kitchen diner. The homes hallway should be less institutional and more reflective of a small care home environment. The carpet on the stairwell is badly fitted and rucked in some places. Two service users identified this as a potential trip hazard. There is also damage to the underlying floorboards on one landing this also presents a trip hazard. The stairway carpet is badly stained. One service user has laid a rug over the carpet in his room. This prevents the door from opening properly. In another service users room the built in wardrobes lack sufficient depth to be able to hang items properly. Although the cupboard appears large, only a few items, which have to be hung at an angle can be stored. The cupboard over this wardrobe is too high for the service user to access. Lampshades in one service users room and on the landing still have their plastic wrapping. This poses a potential fire hazard. The small rear yard has a leaking drain. Some furniture and cleaning items have been stored here. The home has a downstairs bathroom. This includes a WC, handbasin and bath with shower over. The wall along the side of the bath is bowed and tiles are no longer properly secured to the wall. Many tiles are cracked. The registered provider states that these problems arise from a leak in the neighbours adjoining property. He further stated that they are negotiating with the neighbour to fix the underlying problem. The grouting and sealant around the bath was badly stained and discoloured. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 18 There is a shower room on the upper level. This contains a WC, small handbasin and shower cubicle. Space is very restricted in this area, and two of the service users told the Inspector that they did not use the shower as the door to the room has to be left open to get in and out of the shower enclosure. The kitchen diner area was well laid out, but cluttered with separate tables for a phone and answer machine. The homes old cooker and new garden furniture were also being stored in the dining area. The Inspector noted that the home was generally clean and free from odours. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35. All of the homes permanent staff has joined in the last year. A programme of staff training has been devised and started. The homes recruitment policy and procedure is inadequate and does not state how service users will be involved. EVIDENCE: The manager showed the inspector a job description that has been drawn up for support workers. The manager states that all staff has been given a copy of this. In addition to the manager, two permanent support workers are employed within the home and a regular bank support worker also covers shifts. Staff working within the home are usually there as singleton workers. The manager states that a handover meeting occurs at the start of each workers shift. The service users told the Inspector that there are “always new faces” in the staff group. The manager has been in post for one year, and the two permanent support workers started in November and December 2004. The manager has been registered with the Commission for Social Care Inspection since August 2004. The manager showed the inspector training records for the permanent support staff. This indicated that whilst both had completed first aid training fire Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 20 training and food hygiene training had not yet occurred. The manager showed the Inspector a list of training courses that had been identified for staff to attend. She stated that a rolling programme of training to attend these courses has started. The previous inspection identified the need for a review of staffing to ensure that staff resources were sufficient to cover all tasks and duties including the management and supervision of students. The manager advised that this had not occurred, but that if extra staff is needed bank staff can be used. The Inspector reviewed the minutes of staff meetings. These would appear to indicate that four staff meetings were held last year. One set of minutes had no date for the meeting. The minutes seen indicate that two staff meetings have been held to date this year. Minutes of meetings should indicate who has written them. The Inspector discussed with the registered provider arrangements regarding Criminal Record Bureau (CRB) checks for students on placement. He advises that all students are cleared prior to starting their placement. He further stated that copies of the CRB are not kept at the home, but are kept centrally and shredded when the student completes their placement. The Inspector was not to confirm this information but did see a list that identified students who had received a CRB check. The Inspector looked at the homes recruitment policy and procedure. This contained a number of errors and omissions. The current policy does not include a guidance procedure on how staff will be recruited, or how service users will be involved. The registered provided and manager state that a service user was involved in the recent recruitment of support staff. The service user could not recall this and there was no documentary evidence available to show the Inspector to support their assertion. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41 and 42. Service users views do not appear to be central to the running of the home. Many policies and procedures still require revision and update. Contact with service users placing authorities is variable, but generally poor. EVIDENCE: The Inspector was not able to view the responsible individuals monthly visit reports. She was advised that they were presently not at the home. All service users are placed at the home by out of borough services. The level of contact with professionals responsible for their placement is variable, as are the regularity and recording of Care Programme Approach meetings when everyone involved with the service user meets with them to review progress and need. The home must work to develop links with placing mental health services to ensure that service users needs are addressed. The Inspector was unable to evidence that effective quality assurance and monitoring systems based on seeking the views of service users are in place. Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 22 One service user described the atmosphere in the home as “us and them” in referring to service users and staff. Another service user reported that he was frightened and felt intimidated by another service user living at the home and felt unsupported by staff when he spoke about this. It would appear that policies and procedures have not been reviewed and updated as required by the previous inspection. The home needs to improve the quality of the records it keeps, as identified in other parts of this report. The last inspection resulted in a requirement for the home to send to the Commission for Social Care Inspection copies of fire inspections and other health and safety reports to be kept in the home. This remains outstanding. The manager showed the Inspector a report that indicated all electrical appliances and fixtures within the home had been tested and passed as fit. SCORING OF OUTCOMES Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 1 2 3 Standard No 11 12 13 14 15 16 17 1 1 1 1 3 2 2 Standard No 31 32 33 34 35 36 Score 3 3 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 2 Standard No 37 38 39 40 41 42 43 Score 3 1 2 2 2 2 x Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 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 1 Regulation 4, 5 & 6 Schedule 1 Requirement Both the statement of purpose and service user guide must be amended to fulfil the requirements of the regulations and to reflect the real situation in the home. This is a restated requirement. Comprehensive needs assessments of new service users must be properly carried out. This is a restated requirement. The manager and provider must demonstrate by clearly laid out individual care plans on service users files how their needs are being reviewed and met. This is a restated requirement. Contracts must be signed and any changes made signed and initialled by both parties. All individual care plans and risk assessments must be thorough, up to date and reviewed at least every six months. This is a restated requirement. Service users must be involved in the review of the homes policies and procedures. This is a restated requirement. The manager must ensure that Timescale for action 18/07/05 2. 2 14(1) 18/07/05 3. 3 14(2) 15(2) 18/07/05 4. 5. 5 6 14(1)d 14(2) 15(2) 18/07/05 18/07/05 6. 8 12(2) & 5 18/07/05 7. 9 14(2) 18/07/05 Page 25 Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 8. 11 13(1)(b), 16(1), 16(2)(m) 9. 12 12(1), 16 (2)(n) 10. 13 12(1) 11. 14 16(2)(m) & (n) 12. 16 12(1), (2) & (3) 13. 17 16(2)(i) 14. 18 14(2) clear and comprehensive risk assessments are completed and are held on file for each service user. This is a restated requirement. The manager and staff must, along with mental health services, evaluate how to more proactively intervene to meet service users social, emotional, communication and independent living skills needs. This is a restated requirement. The manager, with appropriate local appropriate service providers, should consider how best to improve the motivation of service users. This is a restated requirement. The manager and staff must, along with mental health services, evaluate how to more proactively intervene to meet service users needs to participate in the local community. This is a restated requirement. The manager should ensure that staff review service users awareness of local services and entitlements as part of the planned review of care plans. This is a restated requirement. The manager must review how service users can be encouraged in their independence . Practices and procedures that may undermine independence should be changed to facilitate it. This is a restated requirement. The manager must ensure that all food is stored and handled in a safe manner, and that all staff are aware of food hygiene guidelines. This is a restated requirement. The manager must ensure that reviews are carried out regularly 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 Page 26 Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 15. 21 12(3) 16. 23 15(1) 17. 23 13(6) 18. 24 23(2)(d) 19. 34 17(2) Schedule 2 20. 39 26 21. 41 17 with providers and commissioners and that the home then works together with them to meet service users needs. This is a restated requirement. The manager must develop a procedure to explore service users wishes and feelings around both death and the consequences of ageing. This is a restated requirement. The manager must ensure that all care plans reflect the recorded assessed needs and risks and written plan for action is made. This is a restated requirement. The proprietor must ensure that the whistleblowing policy is amended to include details of the Commission for Social Care Inspection. This is a restated requirement. The proprietor must ensure that all areas of the home are decorated and maintained to a reasonable standard. This is a restated requirement. The registered person must demonstrate that the home operates a thorough recruitment procedure based on equal opportunities and ensures the protection of service users. This is a restated requirement. Regular and comprehensive monthly unannounced visits by the responsible individual must be carried out and records sent to the home and the Commission for Social Care Inspection within 2 weeks of each visit. This is a restated requirement. The manager must ensure that where records are required to be held by the home, these are maintained and made available 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 18/07/05 Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 27 22. 23. 6 18 22(2) 14(1)a 24. 20 17(1)a Schedule 3, 3 (m) 17(1)a Schedule 3, i3 (m) 17(1)a Schedule 3, 3 (m) 17(2) Schedule 4, item 11 23(2)a 25. 20 26. 20 27. 28. 22 24 29. 30. 31. 32. 33. 34. 35. 24 24 24 24 24 24 24 16(2)c, 23(2)(m) 13(4)a 16 (2) c 13(4)a 16(2)c, 23(2)(m) 16(2)c 14(4)c for inspection. This is a restated requirement. Service users must be supported to access advocacy services. The service user who has a brain injury and physical disability must be assessed by appropriate professionals regarding aids and adaptions and risk assessments completed as appropriate. The current medication policy must be reviewed and revised to adequately cover self medication. Any service user who is self medicating or in a process leading to self medication must have this adequately included in their care plan. Any service user who is self medication or in a process leading to self medication must this adequately risk assessed and recorded. All complaints must be recorded along with details of any investigation and action taken. Posters in the hallway and kitchen diner area should reflect the homes ambience and purpose. Information posters for staff should be removed from this area. The Lounge carpet must be replaced. The loose floorboard on the upper landing must be repaired. The stairway carpet must be replaced. The missing threshold strip between the lounge and hallway must be replaced. Suitable curtains and fixings must be provided in the lounge. Broken furniture should be properly repaired or replaced. The kitchen diner area must not 18/09/05 18/09/05 18/09/05 18/09/05 18/09/95 18/09/05 18/09/05 18/09/05 18/09/05 18/09/05 18/09/05 18/09/05 18/09/05 18/09/05 Page 28 Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 be used to store items. 36. 37. 38. 27 33 33 23(2)j 18(1)a 18(1)a Service users must be able to use the upstairs shower with the door to the room closed. The staff team should reflect the cultural composition of service users. Staffing levels must be sufficent to ensure uninterrupted work with service users, completion of administration and organisational duties, the day to day running of the home and management of emergencies. Staffing levels must be regularly reviewed to reflect service users changing needs. Plastic wrapping around lampshades must be removed. The manager must ensure that the service user with a rug in his room can open his door properly. The manager must review the storage arrangements in service users rooms in view of the fact that wardrobes are not sufficently deep to hang clothes. The manager must ensure that service users rights to make decisions is limited only through an assessed process and is recorded in the individual service user plan The home must provide comfortable shared spaces for service users. Refer to requirement listed under standard 18. The management of the home must create an open, positive and inclusive enviroment. Policies and procedures must comply with current legislation and recognised professional standards. Recent fire inspections, general risk assessments and any other 18/09/05 18/09/05 18/07/05 39. 40. 41. 42. 33 24 24 26 18(1)a 13(4) c 13(4) c 16(2)c, 23(2)(m) 18/07/05 18/06/05 18/06/05 18/09/05 43. 7 15(1) 18/07/05 44. 45. 46. 47. 28 29 38 40 16(2)c, 23(2)(e) (g) 14(1)(a) 12(5)(a) 12(1)(a) (b) 23(4)(5) 18/09/05 18/09/05 18/09/05 18/09/05 48. 42 18/07/05 Page 29 Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 health and safety reports must be kept in the home and copies forwarded to the Commission for Social Care Inspection. This is a restated requirement. 49. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard Good Practice Recommendations Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 30 Commission for Social Care Inspection 4th Floor, Gredley House 1-11 Broadway, Stratford London E15 4BQ 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. Extracts may not be used or reproduced without the express permission of CSCI Companion In Care G56 G06 S43729 Companion In Care V221239 180405 Stage 4.doc Version 1.20 Page 31 - 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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