Inspection on 20/12/05 for Companion In Care

This inspection was carried out on 20th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Companion In Care 31/05/06

Companion In Care 18/04/05

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 11:20 20 December 2005 th Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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 Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Companion In Care Address 495 Barking Road Plaistow London E13 8PS 0208 586 5712 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) companionincare@hotmail.com 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 DS0000043729.V261322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2005 Brief Description of the Service: Companion in Care is a residential home for 3 service users diagnosed as having mental disorder. The home is 24 hour staffed, with sleeping night cover. In addition to the manager 2 support workers are in post 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 DS0000043729.V261322.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over the course of a day. The Inspector met with the homes registered manager, the parent organisations area manager and spoke privately with 2 service users. In addition the Inspector sampled service users personal files and other relevant documentation. The focus of this inspection was to review progress with regard to the 48 requirements made at an inspection on the 18th April 2005. What the service does well: What has improved since the last inspection? The home has made progress in addressing many of the requirements made at the previous inspection. The home has responded to service users views and students are no longer placed within the home. The home has reviewed and developed its practises in carrying out the homes weekly shop. There have also been developments in the activities offered, and engaged in by service users. The homes whistle blowing and recruitment policies have been revised and standards of record keeping have improved. Standards of food hygiene and food labelling have also improved. Service users have been made aware of local advocacy services and the responsible individual visits the home regularly and makes written reports. The majority of maintenance issues identified at the last inspection have been addressed, including the refurbishment of both bathrooms and WC’s. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 6 Progress has been made in creating a more open, positive and inclusive atmosphere within the home. 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. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. The home has developed a service users guide and statement of purpose that require further revision. EVIDENCE: The Inspector reviewed the homes statement of purpose and service user guide and found that these had been updated and revised since the last inspection. However, the Inspector noted that the statement of purpose states that “at least two leisure activities per month” such as bowling or a meal out will be arranged for service users. The Inspector viewed the homes log of leisure activities and found that this statement was not evidenced. The Inspector also noted that the home is described as having “multi channel TV” and twice-annual day trips outside of the locality at least twice yearly. Again these were not supported by the Inspectors findings. The Inspector also noted that the costing for placements is quoted at different rates between the statement of purpose and service users guide. The previous requirement to revise these documents to reflect the situation within the home is therefore restated. There have been no new admissions to the home since the last inspection; the previous inspection had identified a need for the home to develop its assessment processes for future admissions and it was not evidenced that this had occurred. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 9 The Inspector viewed the individual plans developed for each service user that identifies their care needs and how the care the home intends to meet these. The previous inspection had concluded that these plans required further development. The Inspector sampled plans for all three of the current service users and found some improvement, however, this remains an area for ongoing development. One service user is identified as requiring support to avoid social isolation. Whilst the individual plan identifies that this service user will require encouragement to engage in activities outside of the home there is no information about what activities this service user might be interested in or bars to their engagement that will need to be overcome and how the support worker might address these. The Inspector sampled the homes contracts with service users and found that up to date copies had been signed by all parties and are kept on the service users personal file. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. The individual plans and risk assessments developed for each service user should address do not address all areas of need and are not regularly reviewed. Service users benefit from regular key working sessions and monthly reports. EVIDENCE: Sampling of service users personal files evidenced that each service user has their own individual care and activities plans. Service users are offered key working sessions to review their needs and current situation on a monthly basis. Monthly reports giving an overview of the service users current situation are completed and held on file. One service user has commenced a self-medication programme and whilst comprehensive information relating to this is contained in several different sections of the personal file, there is no accurate but concise detailing of this programme or its review in the individual plan. The risk assessment for this service user was annotated as being reviewed in September 2004 and June 2005, but did not include the self medication Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 11 programme. A planning and review schedule recorded in the personal file indicated that an individual care plan was devised in October 2004, reviewed in April 2005 and a new plan drawn up in June 2005 which was scheduled for review in January 2006. The Inspector requested to see the October 2004 plan but the home manager was unable to locate this. A second service users personal file sampled by the Inspector did evidence the development and review of care plans in accordance with a similar schedule. The Inspector noted that this service users individual plan included concerns that they may be discarding some of their medication. The attendant risk assessment states, “encourage (him) to become medication compliant” and refer for review if not. It was not evidenced that concerns about this service user discarding medication had been evidentially recorded or referred back to the Community Mental Health Team for review. The Inspector sampled the minutes of service users meetings. These are recorded as occurring on at least a monthly basis and indicate that issues around maintenance and the general day to day running of the home are discussed. It was not evidenced that these meetings included the review and development of policy and procedure and the home should consider how service users could best be involved in this process. The Inspector was shown information relating to local advocacy services, and each service user had signed to indicate that they had seen and understood this information. The Inspector noted that in response to service users views elicited at the last inspection, the homes practise of offering student placements within the home has been suspended with no plans to resume in the immediate future. The homes manager advised that service users are in receipt of benefits and manage these independently. Staffs are able to offer support with budgeting with service users agreement. One service user currently receives staff support to make regular savings deposits. Key standard 7 was not inspected on this occasion. It was inspected on the 18th April 2005 and assessed as met. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 & 17. The home has made some progress since the last inspection in supporting service users to engage in meaningful activities. EVIDENCE: The Inspector viewed the homes activity log; sampled individual service users activity plans and spoke with two service users and the homes manager. Service users continue to submit a weekly shopping list but are now able to accompany staff on the weekly shopping trip. One service user has been supported to join and attend a local gym. The activities log indicates that a social evening of meal and drinks has taken place at local venues in October, November and December 2005. The area manager reported that discussions had taken place with one service users care manager regarding a request for them to have their own shopping budget. The care manager is reported to have felt that this was not appropriate. This discussion and its outcome were not however appropriately recorded within the service users personal file. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 13 The Inspector noted that over successive house meetings service users had requested and been refused a digital TV box. This was on the grounds that an earlier one had been stolen. It was not evidenced that there had been exploration of ways to minimise the loss of a replacement box. The home has implemented a programme of activities in the communal areas of the home such as playing cards or other games. The Inspector noted that at a service users meeting in July 2005 two of the service users had clearly stated that this was of no interest to them. Further discussion of activities later that month in which all three-service users rejected a trip to the cinema suggests that discussion around activities is staff led and does not reflect service users interests. One service user has repeatedly stated their interest in identifying local snooker facilities but it was not evidenced that staff had followed this up. The activities log indicates that over the last two months the only activity this service user has engaged in are service users meetings. Their activity plan states that they will receive a 1:1 session with staff each week, but it was not evidenced that this is occurring. A second service user attends service users meetings, accompanies staff on the weekly shop, goes out for monthly community meal, attends a local gym and enjoys going for walks by himself. The Inspector noted that this service user is repeatedly offered a cooking skills group that they have clearly stated they are no longer interested in pursuing. The third service user attends house meetings, accompanies staff shopping, attends house meetings and likes to visit a local park. The Inspector noted that this service user’s activity plan includes attendance at a local day service that they have refused to attend for over a year. The records of key working sessions indicated that staff has attempted to discuss issues regarding community based activities with two of the current service user group in recent months. Service users report that they have opportunities to plan and prepare their own choice of meals and can ask for staff supervision if required. The Inspector noted that one-service users individual plan identified the risk of their leaving the kitchen whilst cooking food and identified strategies to manage this and minimise identified risks. Two service users would like more individualised support in developing their independent living skills, particularly planning and carrying their own weekly shopping. The home must consider how it can further develop its practise in this area. The Inspector noted that service users individual activity plans include support to maintain their environment. Key standard 15 was not inspected on this occasion. It was inspected on the 18th April 2005 and assessed as met. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 & 21. The home has not made suitable arrangements for an occupational therapy assessment for one service user. The homes policy regarding self-medication does not include adequate safe guards and a protocol for exploring death and ageing has not been developed. EVIDENCE: Sampling of service users personal files indicated that a record is kept of each occasion a member of the community mental health team has contact with the service user with a brief summary of the issues discussed. It was also evidenced that the home supports service users to attend review meetings with their community mental health team and that staff contribute to discussions at these meetings. The Inspector noted that one service user had been minuted as stating in a service users meeting that the current shower facilities did not meet his needs. The Inspector noted that this service user has a brain injury and associated physical disability. The previous inspection had required the home to obtain appropriate professional assessments to identify any necessary aids or adaptations. A copy letter on this service users personal file indicated that the home had requested an Occupational Therapy assessment in May 2005. It was not evidenced that this had occurred. There was no record of any Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 15 subsequent actions taken by the home, although the area manager advised that phone calls to chase the referral had been made without result. The Inspector viewed the homes medication policy. The Inspector noted that this does now include information relating to self-medication as required by the previous inspection. However, the policy states that it is the responsibility of the member of staff on duty to record that medication is taken. This is not consistent with a programme of self-medication. The policy makes no mention of the requirement to manage self-medication within a risk assessment framework. The home has yet to develop a procedure to support staff to explore service users wishes and feelings around death and the consequences of ageing. A previous requirement regarding this is therefore restated. Key standards 19 and 20 were not inspected on this occasion. They were inspected on the 18th April 2005 and assessed as met. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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 & 23. The home has a robust complaints recording practise that protects service users. EVIDENCE: The Inspector viewed the homes complaints log and noted that this is completed to include verbal complaints. Three complaints had been recorded as having been made since July 2005. One of these was an allegation of a staff member shouting at a service user. The Inspector noted that the investigation recorded included separate interviews with the staff member and service user and detailed the outcome of the investigation and action taken. The Inspector reviewed the homes Whistle blowing policy and noted that this had been revised as required to include contact details for the Commission for Social Care Inspection. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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, 26, 27, 28, 29 & 30. Progress has been made in addressing maintenance issues around the home. The communal areas are not reflective of the personalities of service users. EVIDENCE: The Inspector toured the homes communal and spaces and two service users bedrooms. A number of the maintenance requirements identified at the last inspection had been completed to a good standard, including the refurbishment of WC’s and bathrooms, however some maintenance issues remain outstanding and are identified in the requirements section of this report. The accommodation consists of an entrance porch and hallway, communal lounge with a range of comfortable seating and a TV. On a lower mezzanine level there is a bathroom with WC, bath and separate shower cubicle. A large kitchen diner is also located on this level. The basement houses the staff office and sleep in room. Each service user has their own bedroom located on the first and second floors that they are able to personalise with their own belongings. A second WC and hand basin is located on the upper floor. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 18 The Inspector noted that service users meeting minutes recorded that on several occasions service users had requested items such as cushions to personalise the lounge, but that these had not been readily provided. Discussion with one service user highlighted their view that the communal lounge does not reflect the personalities of the service users and is therefore not used by them. The Inspector found the premises to be of a good standard of hygiene and free from offensive odours. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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, 33, 34 & 36. It was not evidenced that service users benefit from appropriate staffing levels with sufficient flexibility to meet their needs. EVIDENCE: The home employs a manager; two support workers and a bank support worker. Staffing cover is provided over a 24-hour period and the current shift pattern worked is 7am to 3pm, 3pm with sleepover until 3pm the next day and management cover from 12 noon to 7 pm. The previous inspection had queried whether current staffing levels are sufficient to support service users, particularly with regard to engaging in community-based activities. The Inspector noted that this had not occurred. All staff working in the home are from a black African and Caribbean heritage, the previous inspection had required the home to develop its practise to work towards the staff group reflecting the cultural composition of the service users group. Two of the support workers have successfully completed NVQ level 2, a third support worker has yet to enrol on a course. The Inspector viewed the homes recruitment policy and noted that this had been revised as required by the previous inspection. The policy includes information on including service users in the selection process, and clearly states that two written references and an enhanced level Criminal Records Bureau check must be obtained prior to new employees taking up post. The Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 20 Inspector noted that there has been no external recruitment within the home since the last inspection. A support worker from the parent organisation transferred has transferred into a vacancy occurring since the last inspection. The Inspector viewed the minutes of staff meeting minutes and noted that these are held on a regular basis and include senior management. Key standard 35 was not inspected on this occasion. It was inspected on the 18th April 2005 and assessed as met. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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, 38, 39, 40, 41 & 42. Progress has been made in developing positive, open relationships between staff and service users. EVIDENCE: The registered manager is a Registered Nurse (RMN), but has not completed or enrolled on NVQ level 4 to develop and evidence their management skills. At the previous inspection service users had described “a them and us” situation with staff, and the home was required to develop an open, inclusive and positive environment. The Inspector spoke with two service users and one of these commented that “things had got better” since the last inspection. The Inspector noted that the introduction of a monthly meal and social night had improved relations, but not all service users had attended. The Inspector recognises that some improvements in this area have been made, but further development in this area is required. For example, service users feedback questionnaires indicated that one service user felt “sort of” consulted with regard to the running of the home. By sampling minutes of service users Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 22 meetings the Inspector noted that many requests from service users such as purchasing cushions for the lounge are referred to senior management based outside the home, which can prove time consuming and leave service users feeling frustrated. Inspection of the homes fridge and freezer contents indicated that processed and prepared foods had been appropriately labelled with start and end dates. Copies of visit reports by the responsible individual were available for inspection within the home and the Inspector noted that these had occurred on a monthly basis. The Inspector noted that generally more of the information required by regulation was available within the home and that the standard of these records had improved. It was evidenced that the policies and procedures had been revised since the last inspection, however, further required revisions have been identified in other sections of this report. The Inspector asked to view the homes fire risk assessment, the development of which had been required by the previous inspection. The manager advised that one was not available. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 3 2 3 3 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Companion In Care Score 3 X 2 2 Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 3 2 X DS0000043729.V261322.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4,5, 6 & Sch 1 Requirement Both the Statement of purpose and service users 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. The most recent target of the 18/07/05 was not met. 2. YA2 14(1) The home must develop its processes to ensure that assessments of new service users are properly carried out. 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. The previous target of the 18/07/05 was not met. 30/06/06 Timescale for action 01/06/06 3. YA3 14 & 15 01/06/06 Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 25 4. YA6 14 & 15 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. The previous target of the 18/07/05 was not met. 01/06/06 5. YA8 12 & 5 Service users must be involved in the review of the homes policies and procedures. This is a restated requirement. The previous target of the 18/07/05 was not met. 01/06/06 6. YA9 14 01/06/06 The manager must ensure that clear and comprehensive risk assessments are completed and are held on file for each service user. This is a restated requirement. The previous target of the 18/07/05 was not met. 7. YA11 13 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 previous target of the 18/07/05 was not met. 01/06/06 8. YA12 12 & 16 The manager, with appropriate local appropriate DS0000043729.V261322.R01.S.doc 01/06/06 Companion In Care Version 5.0 Page 26 service providers, should consider how best to improve the motivation of service users. This is a restated requirement. The previous target of the 18/07/05 was not met. 9. YA13 12(1) 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 previous target of the 18/07/05 was not met. 10. YA14 16(2) The manager should ensure that staffs review service users awareness of local services and entitlements as part of the planned review of care plans. This is a restated requirement. The previous target of the 18/07/05 was not met. 11. YA16 12 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 previous target of the 18/07/05 was not met. Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 27 01/06/06 01/06/06 01/06/06 12. YA18 14(1) Appropriate professionals regarding aids and adaptations must assess the service user who has a brain injury and physical disability, and risk assessments completed. This is a restated requirement. The previous target of the 19/09/05 was not met. 01/06/06 13. YA20 17 & Sch 3 The current medication policy must be reviewed and revised to adequately cover selfmedication. Any service user who is self medicating or in a process leading to self-medication must have this adequately risk assessed and recorded. These are restated requirements. The previous targets of the 18/09/05 were not met. 01/06/06 14. YA21 12(3) 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 previous target of the 18/05/05 was not met. 01/06/06 15. YA24 13 & 16 The communal lounge would benefit from redecoration. The loose floorboard on the upper landing must be repaired. This is a restated requirement the previous target of the 18/09/05 was 01/06/06 Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 28 not met. Suitable curtains and fixings must be provided in the lounge. This is a restated requirement the previous target of the 18/09/05 was not met. The manager must ensure that the service user with a rug in his room can open his door properly. This is a restated requirement the previous target of the 18/06/05 was not met. 16. YA26 16 & 23 The manager must review the 01/06/06 storage arrangements in service users rooms in view of the fact that wardrobes are not sufficiently deep to hang clothes. This is a restated requirement. The previous target of the 18/09/05 was not met. 17. YA28 16 & 23 The home must provide comfortable shared spaces for service users. This is a restated requirement. The previous target of the 18/09/05 was not met. Shared spaces should reflect the personality of service users. 18. YA33 18(1)a The staff team should reflect the cultural composition of service users. This is a restated requirement the previous target of the 18/09/05 was not met. DS0000043729.V261322.R01.S.doc 01/06/06 01/06/06 Companion In Care Version 5.0 Page 29 Staffing levels must be sufficient 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. This is a restated requirement the previous target of the 18/07/05 was not met. Staffing levels must be regularly reviewed to reflect service users changing needs. This is a restated requirement the previous target of the 18/07/05 was not met. 19. YA37 9(2)(b) The registered manager must commence an NVQ level 4 courses or equivalent in management. 01/06/06 20. YA38 12(5)(a) The management of the home 01/06/06 must create an open, positive and inclusive environment. This is a restated requirement. 21. YA40 12(1) Policies and procedures must comply with current legislation and recognised professional standards. This is a restated requirement. The previous target of the 18/09/05 was not met. 01/06/06 22. YA42 23(4)(5) Recent fire inspections, 01/06/06 general risk assessments and any other health and safety reports must be kept in the home and copies forwarded to DS0000043729.V261322.R01.S.doc Version 5.0 Page 30 Companion In Care the Commission for Social Care Inspection. This is a restated requirement. The previous target of the 18/07/05 was not met. 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 Companion In Care DS0000043729.V261322.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection East London Area Office 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 DS0000043729.V261322.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!