CARE HOME ADULTS 18-65
Conan Doyle House 12 Tennison Road London SE25 5RT Lead Inspector
Claire Taylor Unannounced Inspection 16th September 2005 12:15 Conan Doyle House DS0000065291.V260406.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 Conan Doyle House DS0000065291.V260406.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. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Conan Doyle House Address 12 Tennison Road London SE25 5RT 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) 020 8768 1630 020 8768 1539 www.pathwayscare.net Care Support Services Ltd trading as Pathways’ Mrs Deana Pauline Hodge Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow one specified resident over the age of 65 to be admitted 25 April 2005 Date of last inspection Brief Description of the Service: Conan Doyle House is registered to provide care and accommodation for nine young adults who have learning disabilities and is operated by Kingscrest Residential Care Homes. The home is located in South Norwood and is well positioned to access a range of community amenities and transport links. The home provides a specialised service that currently caters for the needs of eight young adults who display behaviours that may challenge the care services that they require. The home supports people with autism. It is a large house on a three-floor storey with en suite single rooms provided for the service users. There are spacious communal areas that include a lounge, two dining rooms and a sensory room for relaxation. The rear garden is well maintained and has a patio, large lawn area and orchard/ vegetable patch at the end. Conan Doyle s mission statement says Our mission is to make a difference in peoples lives through learning, positive experiences and personal growth. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year and was unannounced. It lasted four hours and took place over a lunchtime and afternoon. The majority of the inspection focused on requirements and recommendations set at the home’s previous announced visit (25 April 2005). The home received a positive report for that inspection and has once again showed consistency in its application of the National Minimum Standards as well as showing a commitment to improve upon standards. Inspection time was spent examining records, talking to service users and staff, meeting with the home manager and touring the premises. Conan Doyle was undergoing some refurbishment at the time of this inspection due to necessary structural work needed for the building. The lifestyles of the service users did not appear unduly disrupted by the building works and staff were supporting them to carry out their usual activities. What the service does well:
Conan Doyle accommodates service users who may present behaviours that challenge the services they require and the home again, was able to demonstrate an ability to meet their specialist needs, which include autism. Due to these specialist needs, the majority of service users benefit from a stable routine in their lives and this home works hard to maintain familiarity and consistency for them wherever possible. The plans of care and intervention are well created, and reflect very closely the needs of the specific person. Service users are treated with respect as individuals and offered choices. Record keeping in the home is well organised and information is kept confidential where necessary. The home has good systems in place to make sure that staff have the necessary training and skills to support the service users. In addition, staff members confirmed that the team works well together to meet the service users needs and deal with sometimes challenging situations. Time was spent independently and informally with individual service users who gave favourable comments about the home and that they liked the staff team and activities. Staff put a lot of effort into arranging entertainment and organising activities that are centred upon service users choices, assessed needs and personal preferences. The manager and staff are commended on the service they continue to maintain. As mentioned in the previous report, key staff continue to support two service users to develop their independent living skills before a possible move to a more independent living arrangement. The home continues to be kept clean, safe and decorated to a good standard. Management take action to ensure that necessary repairs or maintenance are dealt with promptly. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Within the last twelve months, the home has worked hard to comply with National Minimum Standards and regulations resulting in a significant reduction in the number of requirements. Only four were identified of which three remain outstanding from the April 05 inspection. Staff carry a different key to each service user’s bedroom for emergency purposes. Given that some service users can be physically violent towards property or others, people could be put at risk. In order to gain quicker emergency access and to minimise a delay, staff should be provided with a master key that accesses all bedrooms. An up to date fire safety report for the premises was not available and the manager must arrange for one to be undertaken by the local fire service. Copies of staff contracts still need to be made available in the home although it is acknowledged that the owning organisation is taking steps to address the delay with staff returning their signed copies. The manager provides medication training for staff in the home. As a further safeguard to maximising safe practice, staff should be trained by an approved pharmacist or complete an accredited medication course. The wooden flooring in the main dining room could benefit from some refurbishment as it was quite scratched and scored in several places. As previously suggested, the home should consider the provision of homely remedies for service users to be used as and when required. I.e. domestic medication such as painkillers. Although the home does retain good communication links between service users and their family members, the manager is still looking at methods to further improve upon this. E.g. issuing a newsletter to keep relatives and other relevant parties better informed about Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 7 significant events and any other topics of interest about Conan Doyle. Agency staff should sign confirmation on completion of their orientation to the home. 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. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 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 Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Current service users’ needs have been assessed and the range of needs presented is being appropriately met. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission and that staff are aware of how to support them. EVIDENCE: There have been no new admissions to the home since the last inspection and the same group of service users continue to live at Conan Doyle, having done so for a number of years. Service users’ files were randomly sampled and record keeping continues to be well organised. As required at the previous inspection, full needs assessments have been obtained from the service users’ placing local authority care managers. Needs assessments had been reviewed within a six-month timescale in conjunction with the service users’ respective care plans. Content of the assessments was detailed and person centred to the service user’s individual needs. Files sampled also indicated that care managers assess their service users needs at appropriate intervals. Conan Doyle House DS0000065291.V260406.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 and 9 Service users’ plans of care clearly identify their needs and how they are supported to achieve their planned goals. Individual plans are frequently reviewed and reflect any changing needs. Choice and decision making for service users is promoted to a high standard enabling their involvement and opportunities to contribute to the operation of the home. EVIDENCE: All of the service users have a plan of care that reflects their identified needs. Records indicated service users are encouraged and supported to be involved with the development and continuation of their respective plans. Examples include a document known as “How has your day been” whereby service users are able to indicate how they have felt (i.e. happy, sad) and details of activities participated in are kept. Person centred plans sampled also refer to their individual likes/dislikes, strengths, and aspirations. Pictures and photos are included to make them more accessible to those service users who have limited verbal communication. Detailed behaviour management strategies and interventions are in place for service users who may behave in a way that puts themselves or others at risk of being physically harmed. The specialist communication and behaviour needs of each service user are clearly outlined
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 11 to enable staff to support them appropriately and minimise a potential incident. Guidelines are frequently reviewed or as changes occur together with associated risk assessments. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff are very good at making sure that all of the service users are allowed to make choices about how to live their life. There are formalised opportunities for service users to participate in group discussions/ meetings about the operation of the home. Minutes of service users meetings were sampled and discussions are geared towards their views. Service users are asked about the things that they like, what they want and how they want things to happen. Service users appeared comfortable with the staff, and staff members have clearly established positive and cooperative relationships with each individual. All the service users have a key nominated staff and are provided with one to one time to go on activities of their choice. In addition, service users benefit from weekly discussions with their keyworker; these are documented and reviewed. Conan Doyle House DS0000065291.V260406.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, 14, 15 and 16 The home provides opportunities for service users to build upon their personal development. Service users benefit from an excellent choice of recreational activities both within and outside of the home that are organised around their individual preferences. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. EVIDENCE: Records and observation showed that staff support the service users to develop their personal skills around the home. Each service user has at least one day during the week, known as a “home day”, when they are supported to be involved in personal domestic activities. Individual plans were in place for some service users that promote opportunities to learn and use practical life skills such as cooking. One service user attends a college where he is supported to develop independent living skills. Some service users access Psychology services to support them with their emotional needs. The home places a strong emphasis on community presence and involvement for the service users. Individuals spoken to confirmed that there are lots of things to do both within the home and the local community. Social needs are clearly described within the care plans that take account of service users preferences
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 13 and enable them to have the opportunity to take part in worthwhile and meaningful activities. During this inspection, service users were supported with their regular activities. I.e. two service users went out with their respective key worker staff, two attended their day centre and one went to his regular luncheon social club. Activities include regular visits to social clubs, pubs, restaurants, parks and other places of interest. Service users are regularly supported to use public transport services including bus, tram and train. Indoor entertainment includes television, videos, music system, karaoke machine, art and craft activities and a sensory room for relaxation sessions. Due to ongoing building work, this room was being temporarily used as an office during this inspection. The manager explained that the service users would be encouraged to use their bedrooms to relax if they felt upset or anxious while the sensory room was not available. The previous requirement concerning the service users bedroom door locks remains outstanding and has therefore been repeated. All bedroom doors have an individual mechanism that self-locks on closing and staff carry a different key to each bedroom for emergency purposes. Given that some service users can be physically violent towards property or others, people could be put at risk. In order to gain quicker emergency access and to minimise a delay, staff should be provided with a master key that accesses all bedrooms. Family and friends are welcomed when they visit and some of the service users go to visit their families, often staying for weekends or longer. “Family contact” sheets are kept which serve as a way to promote and maintain effective communication between service users, their families and staff. Previous recommendations highlighted the need to improve communication between the home and relatives/ friends or other representatives. The manager explained that the organisation was still exploring ways to improve this. Records showed however that the home maintains good communication links between service users and their families and the views of family members are taken seriously by the home and owning organisation, Pathways. Conan Doyle House DS0000065291.V260406.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, 19 and 20 Suitable arrangements are in place to ensure that service users’ physical and emotional health care needs are identified, planned for and met. Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Medication is well managed to maximise good health although staff need to attend proper accredited training in dealing with medicines. EVIDENCE: Service user plans are informative and clearly outline the ways in which the staff team will work with the individual to support them. Where support is required with personal physical care, this is identified and guidance is available on how specific tasks should be undertaken. Several service users have specific goal plans to help them develop their personal care skills. Daily routines and house rules promote independence and individual choice for service users. Staff were observed to interact and communicate with service users in a respectful and sensitive manner. The home encourages service users to be responsible for housekeeping tasks, which is specified in their care plans. Records examined confirmed that arrangements are in place for meeting healthcare needs. Information about health conditions such as epilepsy is available in the home. Staff have received training on epilepsy to enable them to fully support those service users with such specialist needs. Access to other NHS facilities is available and plans include detail of GP involvement as well as Consultant Psychiatrist, dentist, optician and physiotherapy services. These
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 15 systems are good examples of assurance that healthcare needs are being met and monitored appropriately. The manager plans to introduce health action plan books for each service user that will provide a more detailed profile of each person’s individual healthcare needs. A copy of this book was sampled and appeared very informative and person centered. None of the service users are able to self medicate and this has been documented in their plans. Medication was stored appropriately and as recently recommended by the home’s pharmacist, the medication cupboard has been moved to the kitchen for better accessibility. Records for the receipt and safe disposal of medication and administration records were up to date and accounted for. Stock medicines used for as required purposes are now accounted for as required at the last inspection. The manager carries out regular audits to monitor safe practice and check for errors. Guidelines for service users “as required” medication were detailed and provided clear instructions for their use. Staff have been trained to administer medication through in house training done by the manager. The registered manager must ensure that formal accredited medication training for staff is undertaken. As previously recommended, the home has yet to develop a homely remedies policy and this has been repeated. Conan Doyle House DS0000065291.V260406.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 and 23 The home operates a clear and effective complaints procedure that is available to all the homes service users in a suitable language/format. There are procedures and systems in place regarding adult protection and prevention of abuse. Since the last inspection, improvements have been made to maximise protection for the service users. EVIDENCE: The home has a complaints policy and record book, which is also provided in a user-friendly format. (E.g. pictures, photographs and symbols for those service users who have limited expressive speech). Records showed that one complaint had been made since the last inspection and that the complaint was dealt with appropriately and that the complainant was satisfied with the outcome. Service users who spoke with the inspector were clear about who they would speak to if they felt unhappy or worried about something. The home’s practices concerning adult protection have improved significantly since the April inspection. Notifiable incidents have been and continue to be reported appropriately to the adult protection team at Croydon as well as the Commission. Staff are now taking action more promptly to ensure that the service users welfare is safeguarded. For example, service users’ guidelines and risk plans are being reviewed as necessary and the manager now monitors adult protection incidents closely to check whether any trends are forming and identify action to be taken. The home’s Adult Protection Policy and Croydon Council’s Protection of Vulnerable Adults procedures has also been reintroduced to the staff through house meetings. The manager explained that the home’s induction pack for new staff was due to be amended to include training on adult protection. This will be checked at the next inspection.
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 17 Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 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 and 28 The home is kept in a good state of repair and the layout of furniture/ fittings has been well organised to ensure that service users safety is maximised and that they live in comfortable surroundings. Facilities are clean and safe although the premises is still due a fire safety inspection. EVIDENCE: A brief tour of the premises was undertaken and previous requirements related to this set of standards were checked. The home was undergoing some refurbishment at the time of this inspection due to necessary structural work needed for the building. I.e. the main office was not in use due to essential repairs being carried out to rectify a subsidence problem. Building contractors were therefore working in the home and the manager had completed a suitable risk assessment for safeguarding all those who live and work there. Communal areas are pleasantly decorated and furnished to suit the needs of the service users. There is a suitable sized lounge, two dining areas, sensory room and adequate kitchen and laundry facilities. There is a large spacious garden with covered fishpond and patio area. As previously required, more dining chairs have been purchased and the table has been revarnished. To further improve the dining area, the wooden flooring could be attended to as it was scratched and scored in places.
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 19 A report to show that the home complies with fire safety regulations was not available. The requirement is therefore repeated that the registered provider arranges for a visit from the LFEPA (London fire and emergency planning authority) to ensure that the premises comply with current fire regulations. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 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): 33 and 35 The home has a staff team who have had relevant training enabling them to meet the needs of the service users living at the home. There is a range of experiences, and an understanding of the needs of people with learning disabilities and of specialist needs such as autism. EVIDENCE: Since the last inspection, the staff team remains largely unchanged and a consistent core team of agency staff is covering the three staff vacancies. Rota allocation allows for three members of staff per shift with two at night including one sleep in staff. Extra staff are provided should the needs of a service user change or determine so and this was in place for one service user. Staff appeared clear about their roles and balance their work so that the individual and collective needs of the service users are met whilst ensuring that any necessary administrative tasks are undertaken. A senior agency staff was interviewed at the start of the inspection and advised that he had just started working in the home. He clearly described his induction and felt that he had been given good information about the service users needs and the way the home operates. As previously recommended it would be better if agency staff sign for confirmation when they have completed their induction. Staff have a handover between each shift to discuss any significant issues concerning the service users or general day to day operation of the home. Having joined in with the daily handover session, it was clear that good communication processes are upheld in this home. Conan Doyle has good
Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 21 recruitment procedures in place that are securely managed to maximise protection for the service users. I.e. staff are vetted correctly so that service users are safeguarded from people who should not be working there. A list of all the current employees CRB and POVA checks was verified at this inspection. The manager explained that three new care staff have been recruited and will start work once all appropriate checks have been completed, including a CRB and POVA check. Individual training needs for staff are addressed through supervision and appraisal with the manager. A training development plan for all staff is in place that covers health and safety training as well as courses geared towards the specialist needs of the service users. E.g. autism, epilepsy and the management of challenging behaviour. Completed staff contracts relating to their terms and conditions of employment were not available. The manager advised that the owning organisation, Pathways, were in the process of finalising the contracts as staff had not yet returned their signed copies. This is acknowlegded but the requirement is repeated. Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 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): 41 and 42 Record keeping is very well organised and the home’s policies and procedures and are well written and accessible to ensure that service users’ rights and best interests are safeguarded. The health, safety and welfare of service users is overall promoted and protected. EVIDENCE: Policies, procedures and expected codes of practice are in place that are appropriate to this home. They are clearly written and accessible and serve as a means of protecting the rights and best interests of the service users. To ensure clarity, the manager reviews home policies as changes occur. The home is good at making sure that the premises is kept in a good state of repair and health and safety guidelines are well observed. Fire drills are organised at regular intervals and fire alarms and equipment had been checked in August 05. Other maintenance records were not examined on this occasion as they were checked at the last inspection and all up to date. A regular check of the environment is carried out weekly to ensure that it remains safe for service users, the staff and any visitors. Accurate records are kept for accident and incident reporting. The home keeps the Commission appropriately informed of any incidents that affect the service users well being.
Conan Doyle House DS0000065291.V260406.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 X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Conan Doyle House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X 3 3 X DS0000065291.V260406.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes- 3 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 16 Regulation Requirement Timescale for action 31/12/05 2. 20 3. 24 4. 34 13(4)(a&c) In order to gain quicker 12(1)(a) emergency access and to minimise a delay, staff should be provided with a master key that accesses all bedrooms. (Timescale of 30.6.05 not met) 13(2)& All staff must receive accredited 18(1) medication training with records Sch.2(4) to evidence this kept in the home. 23(4) To ensure that the premises comply with the requirements of the local fire brigade (LFEPA), the Registered Provider must arrange for a safety inspection to be carried out with a report made available to inspection. (Timescale of 30.6.05 not met) 18(4)Sch.4 Copies of all staff’s terms and (6 e & f) conditions must be made available in the home. (Previous timescales of 30.11.04 and 31.8.05 not met. It is acknowlegded that the owning organisation is taking steps to address the delay with staff returning their signed copies )
DS0000065291.V260406.R01.S.doc 31/03/05 30/11/05 31/12/05 Conan Doyle House Version 5.0 Page 25 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 20 Good Practice Recommendations The registered manager, in consultation with the G.P., arranges for service users to be prescribed any necessary homely remedies and develops a policy to cover its use. (Outstanding from previous inspection, April 2005) The wooden floor in the dining area would benefit from refurbishment as it is scratched and scored in several places. The homes agency staff sign confirmation when they have completed their induction. (Outstanding from previous inspection, April 2005) The registered manager should implement measures to improve communication between the home and service users relatives/ friends or other representatives e.g. that they are kept updated on recruitment issues and informed about any new staff. (Outstanding from previous inspection, April 2005) 2. 3. 4. 28 33 39 Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Conan Doyle House DS0000065291.V260406.R01.S.doc Version 5.0 Page 27 - 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!
