CARE HOME ADULTS 18-65
Companion In Care 495 Barking Road Plaistow London E13 8PS Lead Inspector
Lea Alexander Unannounced Inspection 31st May 2006 11:00 Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 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.V294155.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th December 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. There is unrestricted parking in a residential road to the rear of the property. The home is located on main road on the Plaistow/Canning Town border. There is easy access to local shops and local bus routes. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 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 two half days. The Inspector met with the homes Registered Manager, the Responsible Individual and spoke privately with one service user and two support workers. In addition the Inspector sampled service users personal files, staff personnel files and other documentation relevant to the running of the home. The focus of this inspection was to look at key standards and to establish the progress with the requirements from a previous inspection on the 20th December 2005. What the service does well:
The home develops an individual plan with each service user. Their signing of the plan evidences service users participation in its development. Each service user receives support to manage their finances in accordance with their individual plan, and some service users have managed to save from their incomes. Service users are supported to develop independent living skills and to identify and where possible, engage in appropriate community, leisure and occupational activities. Appropriate contact with family is supported and encouraged and service users are able to choose when to be alone or join in. A record is maintained of all healthcare appointments, and service users are supported to maintain their personal care where needed. Service users are supported to prepare individual meals of their choice. Each service user has his own bedroom, and there is a variety of communal space including a lounge and kitchen diner. Service users fedback to the Inspector that they “get on well with staff” and that they get a “good response to what I ask for”. The home has an established staff team and a centralised training and development plan. Medication training has already been delivered to staff this year, and further training events for staff are planned. The home operates a complaints procedure that includes contact details for the Commission for Social Care Inspection and the timescales in which complaints will be dealt with. The home also maintains a complaints log that details the complaint and any action taken. There have been no adult protection concerns. The home operates equal opportunities and recruitment policies. The recruitment policy includes guidance on including service users in the recruitment process. The home obtains pre employment checks for new staff including a Criminal Records Bureau check, two satisfactory references, and photocopies of qualifications and proofs of identity. The home has developed an induction programme for new staff members to follow.
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 6 The homes manager has a background as a qualified nurse, and current registration and insurance certificates are appropriately displayed. Many of the health and safety records required by legislation and regulation are appropriately maintained, including fire records and food hygiene. The home has introduced a quality assurance process to obtain feedback from service users. What has improved since the last inspection? What they could do better:
As a result of this inspection seven requirements have been restated, some over more than one inspection. The most pressing of these is the requirement for an Occupational Therapy assessment for one service user. The home also needs to ensure that it attends promptly to minor repairs and implements a redecoration and refurbishment programme throughout the communal areas of the home. The Inspector was pleased to note that there has been an overall reduction in the number of requirements made at this inspection, and that shortfalls were of a mainly of a minor nature. However, unless the home continues to make improvements to the service provided it remains at risk of enforcement action by the Commission for Social Care Inspection. The home should revise its statement of purpose and service users guide to accurately reflect the situation within the home. Any partial or full programme of service users self-medication should be subject to a risk assessment. The homes medication policy should be further revised to adequately address selfmedication. The home must ensure that all lists of medicines correspond with the current prescription instructions. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 7 The home should review the range of entertainment available in the home, including the provision of digital TV and repair of the CD player. One service users culture and ethnicity is not reflected amongst the staff group or other service users, the home should consider how it meets their cultural needs. The homes communal spaces should reflect the personalities of the service users living there. A protocol regarding aging should be developed and the homes adult protection policy should be revised to include guidance for support staff. Adult protection training for staff should be a priority. The homes staffing levels should be regularly reviewed in line with service users needs. Minor revision is required to the homes recruitment policy, and the home must evidence that all staff have completed an induction. The home did not meet the target of 50 of care staff being qualified to NVQ level 2 standard by 2005. The home must evidence that all staff receive a minimum of six supervision sessions per year. The Registered Manager must commence NVQ level 4 studies. All records required by health and safety including a current portable electrical appliance testing certificate and a record of water temperatures must be available for inspection. The home should broaden its quality assurance process to include the views of service users families, professional visitors and other stakeholders. The outcome of the quality assurance process should be published and made available to interested parties. 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.V294155.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home assesses the needs of potential service users. It needs to make sure that its service users guide and statement of purpose are up to date. EVIDENCE: The Inspector sampled the homes statement of purpose and service users guide. These had not been revised as required by the previous inspection. The home has had no new admissions since the last inspection. The Inspector case tracked the documentation available for two service users. This evidenced that as part of the referral process the home completes its own assessment and obtains relevant background information from other professionals. Each of the service users personal files sampled evidenced that there is a clearly laid out individual plan that addresses how service users needs are to be met and dates for review. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are encouraged to participate in the day-to-day running of the home and benefit from individual plans detailing their care. These are regularly reviewed and associated risks identified. However, self-medication must be addressed in the risk assessment process. EVIDENCE: The Inspector sampled the personal files for two service users currently residing at the home. This evidenced that the home develops and agrees with service users an individual plan that describes the services to be offered. Area’s addressed in the individual plan include activities and personal care. One service user also had information relating to a programme leading to selfmedication. Individual plans are signed by service users, and were evidenced as being reviewed at least every six months. Service users are supported to manage their own finances, and details of the support required are detailed in their individual plan. One service user told the
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 11 Inspector that with support, they had been able to save several hundred pounds that they hoped to use in move on accommodation in the future. The home holds monthly service users meetings, and the Inspector sampled the minutes for the last three meetings. These evidenced that recent discussions had addressed activities the service users would like to be involved in including attending a party, having a meal and drink out with staff and other service users, possible day trips including the zoo or museum. There had also been discussion around accessing local advocacy services and how the home can support and monitor service users development of independent living skills. The Registered Manager advised the Inspector that any reviews of policy and procedure would be taken to service users meetings for discussion and cited the homes alcohol policy as a recent instance of this. Both of the service users personal files sampled contained fairly comprehensive risk assessments that had been reviewed in January 2006. Area’s addressed included drug misuse, self neglect, financial exploitation and potential for aggression towards others. However, the Inspector noted that there was no risk assessment for the service user who self medicates several days per week. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 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, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to identify and where possible, engage in, a range of community, leisure and occupational activities. EVIDENCE: Sampling of service users personal files evidenced that regular key working sessions are held approximately once per month. At these sessions a range of issues are discussed including activities inside and outside of the home such as outings, day centres and employment. Records of meetings with other professionals evidenced that service users have been referred to specialist counselling resources and to local training programmes. Minutes of service users meetings evidence ongoing discussions with service users regarding activities they may be interested in individually or as joint days out. Individual plans evidence that service users are supported to develop and maintain independent living skills, for example maintaining their own bedrooms. The home has reviewed and changed the way it purchases its
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 13 weekly shopping. Service users are now given the opportunity to join staff on these trips and assist in the purchase of items. Service users are currently involved in a range of activities including attendance at a gym and keep fit group, playing pool in a local club, attending a drug abstinence support group, contact with family, a meal and drink out with staff and other service users, assisting with the homes weekly shopping and purchasing their own personal items. The Inspector noted that some service users remain reluctant to take up activities, and that this had been appropriately addressed in key working sessions where issues relating to mental health had been identified as impacting upon the service user. The home has identified one to one staffing as a means of offering additional support to one service user to encourage them to follow up on community activities that they may be interested in. Key working sessions are also used as a forum to advise service users on local resources that they may be interested in. In the homes communal lounge a stereo and TV are available, however the Inspector was advised by one service user that they would like access to Digital TV and that the CD player did not work. Individual plans and discussion with one service user evidenced that visits to family and visits from family within the home are supported and encouraged by staff. Throughout the inspection the Inspector noted that service users are able to choose when to be alone or in company, and when to join in an activity. Service users choose the individual meals that they would like to eat, prepare a shopping list and then with staff support prepare the individual meal they would like to eat. The Inspector viewed the log of meals offered and noted that there is a variety of food and that service users have flexibility to choose the meal they would like to prepare. Service users are able to choose where and when to eat, and whether to eat alone or in company. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 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, 19, 20 & 21. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Service users are supported where needed with their personal care and a record is kept of all healthcare appointments. However, assessment by an Occupational Therapist for one service user remains outstanding, as does revision to the homes self-medication policy. EVIDENCE: By sampling service users individual plans the Inspector evidenced that support with personal hygiene, such as prompts to bath or shave are addressed. Previous inspections have identified the need for a service user with a brain injury and physical disability to be assessed by an occupational therapist for aids and adaptations to safely support them in activities of daily living. The Inspector was disappointed to note that this remains outstanding. Both of the service user personal files sampled by the Inspector contained a Health Appointment Record. This included details of recent optician, dental and GP appointments. The Inspector viewed the homes medication policy. This appropriately addresses procedures for staff to follow in the handling, administration and
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 15 recording of medicines. The previous inspection had required the home to revise the self-medication section of this policy. The Inspector noted that a section had been added to the end of the policy identifying the need for selfmedication to take place within a risk assessment framework. However the main section regarding self-medication had not been revised and still requires staff to record medication that is self-administered. From sampling the service users file that is partially self-medicating, the inspector evidenced that no risk assessment had been completed for this activity. The Inspector compared the available medication against that listed on the Medication Administration Record (MAR) for each service user. This was generally in order as all available medications were listed on the MAR. However, one service users medication had been altered by the GP to “as required (PRN)” and the MAR had not been amended to reflect this. The Registered Manager did amend this to PRN on the second day of the inspection. The Inspector was advised that medication is loaded into dossett boxes by the local pharmacy. Previous inspections have required the home to develop a protocol regarding the aging and death of service users. The Inspector noted that a key working session for one service user had included a discussion regarding their funeral wishes, however, the Inspector was unable to locate a protocol for these matters. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The home listens to and acts upon the views of service users. To protect service users the home should revise its adult protection policy and prioritise adult protection refresher training for staff. EVIDENCE: The Inspector viewed the homes complaints policy and procedure. This details a three-stage complaints process and a maximum 20-day timescale for complaints to be dealt with. The policy also includes contact details for the Commission for Social Care Inspection. The Inspector viewed the homes complaints log. The last complaint had been received in November 2005 when a service user had complained that a radiator was not working. Appropriate maintenance action was recorded as being taken as a result of the complaint. The complaints log-recording format includes details of the complaint received and action taken as a result. The Registered Manager advised the Inspector that there had been no adult protection issues since the last inspection. The Inspector viewed the homes adult protection policy. This includes definitions of the different types of abuse service users may experience and possible indicators staff should watch for. The policy includes guidance for the manager and includes reporting to the placing authority, the local adult protection officer and the Commission for Social Care Inspection. The policy also makes reference to the homes whistle blowing policy. The Inspector noted however that the policy does not include a procedure for staff to follow if they have adult protection concerns, or advise what staff should do if an allegation is made against the manager.
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 17 The Inspector spoke with a support worker on duty. Their personnel file did not evidence that they had received adult protection training since taking up post in 2003. The Inspector noted that heavy prompting was required for them to identify what “adult protection” means and the types of abuse service users may experience. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 & 30. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Service users benefit from having their own bedrooms and a range of communal spaces. However, the home should improve the length of time it takes to complete repairs and implement a redecoration program in communal areas. EVIDENCE: The Inspector toured the homes communal and spaces and one service users bedroom. The accommodation consists of an entrance porch and hallway, communal lounge with a range of comfortable seating, a TV and stereo system. 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.V294155.R01.S.doc Version 5.1 Page 19 The Inspector noted that communal areas such as the lounge do not reflect the personalities of the service users who live there and that one service user had previously commented that this was part of the reason that service users did not use them. A number of maintenance issues remain outstanding, including the redecoration of the lounge area and the repair of a loose floorboard on the landing outside of a service users bedroom. The Inspector identified that the hallway carpets and walls are stained and marked, as are the kitchen diner walls. The Registered Manager advised that there had been discussion with service users regarding the provision of storage in their rooms and service users had declined replacement wardrobes. The service user spoken to by the Inspector confirmed this. The Registered Manager also advised that one service user continued to have several rugs on their floor and there are ongoing discussions to address this issue as they impede the functioning of the fire door. The Inspector noted that the retaining wall in the front garden had fallen down in several places and had been balanced back in position creating a potential health and safety hazard. The Inspector viewed the homes maintenance and repair log. This included five routine maintenance items such as a repair to the bathroom door and supply TV booster that had been reported in March and April 2006 and remained outstanding. The Inspector found the premises cleaned to an acceptable hygiene level and free from offensive odours. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Service users are protected by the homes recruitment practices and benefit from a well-established staff group. However, all staff should be regularly supervised and thought given to meeting the cultural needs of all service users. EVIDENCE: The Registered Manager advised that there have been no permanent changes to the staff team since the last inspection. A regular member of bank staff has been covering a long-term absence by one support worker. The Inspector was advised that there has been no review of staffing needs since the last inspection. Two permanent support workers and one bank staff provide singleton 24-hour cover within the home. The current shift pattern is between 8 am and 3 pm and 2.45 pm and 8 am. The Registered Manager is additionally on duty during weekdays. One permanent support worker has successfully completed NVQ level 2 and the other staff members have started NVQ level 2 studies. At present the home accommodates one service user from a White British background. Their ethnic and cultural group is not currently represented within the homes staff or
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 21 other service users. The Registered Person should consider how this service users cultural needs can best be met. At the time of this inspection the Registered Manager advised that the home was in the process of developing its training plan for the coming year. The Inspector was advised that all staff had recently completed medication training. Training plans for the coming year include food hygiene, fire safety, disruptive behaviour, care planning and adult protection. The Registered Manager maintains a centralised training record with details of the training with dates that all staff has undertaken. The Inspector viewed the homes recruitment policy and procedure. This includes guidance on seeking service users views on the skills and experience required by new staff members and an invitation to participate in the selection process. The policy requires minor revision to state that Criminal Records Bureau (CRB) checks are not transferable, and that Companion in Care will need to obtain its own enhanced level CRB prior to a new staff member taking up their post. The home has a separate Equal Opportunities Policy that refers to recruitment and a policy to address potential racial harassment between staff, between service users, or by staff against service users or vice versa. The home has developed an induction programme for all new staff members, and a copy of this was made available to the Inspector. The Inspector sampled two staff personnel files. Both of these were evidenced to include a current enhanced level CRB obtained by Companion in Care, completed application forms and two satisfactory references. Photocopies of training certificates and proofs of identity were included in the personnel folder. One staff member was evidenced as having a completed induction checklist, whilst the member of bank staff did not. The Inspector sampled the Registered Managers supervision log. This evidenced that a permanent member of staff had received two supervision sessions this year with dates for a further four sessions set before December 06. The member of bank staff had not received supervision in the three months that they had been in post. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 & 42. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The home aims to provide an inclusive environment for service users and listens to their views. The majority of health and safety records required by regulation were available for inspection. However, the Manager needs to undertake NVQ level studies and further develop the homes quality assurance processes. EVIDENCE: The Registered Manager has a professional background as a qualified nurse. They have yet to start NVQ level 4 studies. The Registered Manager advised the Inspector that they aim to create an inclusive environment through service users meetings, group outings and the implementation of a range of equal opportunities policies within the home. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 23 As a result of this inspection the Inspector was able to evidence that a number of policies and procedures require further review and update, as identified in the requirements section of this report. The homes current registration and insurance certificates were appropriately displayed at the time of this inspection. Examination by the Inspector of a variety of health and safety records evidenced that fridge and freezer temperatures are recorded on a daily basis and are maintained within acceptable parameters. Fire alarm testing is conducted on a weekly basis and equipment is maintained in good order. A fire evacuation drill was recorded as having taken place in March 2006 and included the recording of individual evacuation times. Environmental health reports for 2003, 2004 and 2006 were seen by the Inspector and found to be in order. A current gas safety certificate dated August 2005 was also shown to the Inspector. The home also maintains accident and incident logs. The site inspection evidenced that the contents of the homes fridge and freezers are appropriately labelled and comply with food storage instructions. During the site inspection the Inspector noted that potentially hazardous cleaning materials were being stored in an unlocked cupboard under the kitchen sink. There was no record of water temperatures available, and the homes electrical portable appliance-testing certificate had expired in April 2005. The Inspector was shown the recent quality assurance exercise undertaken by the home. This occurred in May 2005 when the three service users were given survey. One declined to complete this and the results from the other service users indicated that they generally felt consulted about their views on the home and thought that the length of time repairs take could be improved. The home does not currently survey service users family members, professional visitors or other stakeholders. The outcomes of the quality assurance exercise had not been published or made available to other parties. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 2 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 2 2 2 3 2 2 X 2 X Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation 14 & 15 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. Previous targets of the 18/07/05 and 01/06/06 have not been met. Service users who are partially or fully self-medicating must do so within a risk assessment framework. The Registered Manager should review with service users the range of entertainment available in the home, including the provision of digital TV and the repair of the homes CD player. Appropriate professionals (Occupational Therapist) must assess the service user who has brain injury and physical disability, for aids and adaptations. This is a restated requirement. Previous targets of the 19/09/05 and 01/06/06 have not been
Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 26 Timescale for action 30/09/06 2. YA9 14 30/09/06 3. YA14 16 30/09/06 4. YA18 14(1) 30/09/06 met. 5. YA20 13, 17 & Sch 3 The current medication policy must be revised to adequately cover self-medication. This is a restated requirement. The previous target of the 18/09/05 and 01/06/06 were not met. All lists of medication must correspond with the instructions on the medication. 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. Previous targets of the 18/05/05 and 01/06/60 have not been met. The home must review its adult protection policy to include guidance for support staff on action to be taken if they have adult protection concerns. 30/09/06 6. YA21 12(3) 30/09/06 7. YA23 13 & 21 30/09/06 8. YA24 All staff must receive adult protection training at the time of their induction, and refresher training at regular intervals. 13, 16, 23 The communal lounge would & 39 benefit from redecoration. This is a restated requirement. The previous target of the 01/06/06 was not met. The stairway carpets should be cleaned or replaced. The hallway walls should be redecorated. The communal kitchen diner should be redecorated. 30/09/06 Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 27 The loose floorboard on the upper landing must be repaired. This is a restated requirement. Previous targets of the 18/09/05 and 01/06/06 have not been 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. Previous targets of the 18/06/05 and 01/06/06 have not been met. The wall in the front garden must be repaired to an appropriate standard. Routine maintenance and repairs should be attended to promptly. Shared spaces should reflect the personality of service users. 9. YA28 13, 16 & 23 30/09/06 10. YA29 23 11. YA33 12 & 18 This is a restated requirement. The previous target of the 01/06/06 was not met. The registered person must 30/09/06 ensure the provision of environmental adaptations and disability equipment necessary to meet the individually assessed needs of service users. The Registered Person must 30/09/06 consider how to meet the cultural needs of service users whose culture and ethnicity are not reflected in the staff group. Staffing levels must be regularly reviewed to reflect service users changing needs. This is a restated requirement. Previous targets of the 18/07/05 and 01/06/06 have not been met. The homes recruitment policy requires minor revision to clearly state that it will obtain its own
DS0000043729.V294155.R01.S.doc 12. YA34 19 30/09/06 Companion In Care Version 5.1 Page 28 13. 14. 15. YA35 YA36 YA37 18 12 & 18 9(2)(b) enhanced level Criminal Records Bureau check for all new employees. The home must evidence that all new staff have completed an induction. Staff must receive supervision at least six times per year. The registered manager must commence an NVQ level 4 courses or equivalent in management. 30/09/06 30/12/06 30/09/06 16. YA39 12 & 24 This is a restated requirement. The previous target of the 01/06/06 was not met. The home should develop its 30/12/06 quality assurance process to obtain the views of professionals, service users families and other stakeholders. The outcome of the quality assurance process should be published and made available. Policies and procedures must comply with current legislation and recognized professional standards. This is a restated requirement. Previous targets of the 18/09/05 and 01/06/06 have not been met. Potentially hazardous cleaning materials must be appropriately stored. A record of water temperatures must be maintained. 17. YA40 12 30/09/06 18. YA42 13 & 23 30/09/06 Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 29 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 YA42 Good Practice Recommendations The Registered Person must ensure that an up to date Portable Appliance Testing certificate is obtained. Companion In Care DS0000043729.V294155.R01.S.doc Version 5.1 Page 30 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.V294155.R01.S.doc Version 5.1 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. 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!
