Inspection on 24/11/05 for Coombe Road (82)

This inspection was carried out on 24th November 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coombe Road (82) 02/08/07

Coombe Road (82) 12/05/06

Coombe Road (82) 26/07/05

Coombe Road (82) 01/09/04

Coombe Road (82) 20/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Coombe Road (82) 82 Coombe Road Croydon Surrey CR0 5RA Lead Inspector Lee Willis Unannounced Inspection 24th November 2005 09:50 Coombe Road (82) DS0000028482.V265324.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 Coombe Road (82) DS0000028482.V265324.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. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coombe Road (82) Address 82 Coombe Road Croydon Surrey CR0 5RA 020 8681 8078 020 8681 8078 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) Milbury Care Services Limited Michael Luganda Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: 82 Coombe Road is a residential care home that is owned, managed and staffed by Milbury Care Services a public limited company that specialises in providing accommodation and personal care for younger adults with learning disabilities. The home is registered with the CSCI to take up to eight service users and currently has two vacancies. Michael Luganda continues to be the registered manager of the service, a post he has held since November 2003. This detached Victorian property is situated in a residential suburb in South East Croyodn and overlooks Lloyds Park. The home is well placed for accessing local public transport with excellent bus and tram links to central Croydon, London and the surrounding areas. There have been no significant changes made to the homes physical environment since its last inspection was carried out in July 2005. This three storey detached house still comprises of eight single occupancy bedrooms, located on both the ground and first floors, a main lounge, seperate dinning area, conservatory, kitchen, laundry room, office, staff sleep-in room and large entrance hall. There are sufficient numbers of toilet and bathing facilities located throughout the home near service users bedrooms and communal areas. The garden at the rear of the property is well maintained and contains a wide variety of different species of trees and shrubs. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 9.50 on the morning of 24 November 2005. It took three hours and forty minutes to complete. Since the homes last inspection the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the homes manager, a couple of the service users, and the three members of staff on duty at the time. The rest of this visit was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although a vulnerable adult protection meeting was convened by the Local Authority during this time. The subsequent case conference concluded that no abuse had occurred when trained staff had been called upon to physically restrain a service user, although the service providers acknowledge that some mistakes were made and valuable lessons learnt regarding future good practice. This matter is discussed in greater depth in the main body of this report and in the summary section, entitled - ‘what they could do better’. What the service does well: What has improved since the last inspection? Since the homes last inspection, carried out in July 2005, the majority of the requirements identified in the subsequent report, including most of the good practice recommendations, have either been met in full or significant progress made towards achieving them. Furthermore, the number of new requirements Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 6 identified in the main body of this report has fallen by almost 50 from 12 to 7. Areas of practice which have seen the most significant improvements since the last inspection includes the introduction of a far more person centred care plan format that contains far more detailed information about each service users personal, social and health care needs, as well as their personal preferences and aspirations. All the outstanding environment issues identified in the homes last report have also been met in full, including the replacing of the homes damaged oven and offensive smelling carpet in one of the service users bedrooms. With regard staff training, sufficient numbers have now attended working with adults with autism and non-verbal communication skills courses. Most of the current staff are now half way through their Makaton sign language training, which is the preferred method of communication of several of the service users who currently reside at 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 Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Coombe Road (82) DS0000028482.V265324.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 Coombe Road (82) DS0000028482.V265324.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): 1&2 The homes Statement of purpose contains all the relevant information service users and their representatives need to know about the home. This document is regularly reviewed. The service users guide will also need to be kept under review to ensure it accurately reflects any changes that occur at the home. EVIDENCE: The homes Statement of purpose was last reviewed in September 2005 and updated accordingly to accurately reflect the homes current conditions of registration. However, a service users guide located in a resident’s bedroom had not been reviewed for several years and consequently contained a copy of an inspection report undertaken by the Commission in 2002. As with the homes statement of purpose its service users guide needs to be kept under constant review. The home has not received any new referral since its last inspection and nor have any of the existing service user group moved out in this time. The home continues to have two vacancies. Coombe Road (82) DS0000028482.V265324.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 Significant progress has been made to improve the homes care plan format, which know contains far more detailed information about each service users individual personal, social and health care needs, ensuring staff have more information on which to plan for and meet any identified needs and/or wishes. EVIDENCE: It was positively noted from three care plans sampled at random that a far more person centred format had been introduced, which set out in greater detail each service users own personal, social and health care needs. Areas covered included each service users medical histories, living, social, and communication skills, as well as mobility and spiritual needs. Transferring all the information from the old care plan formats remains a work in progress. The new care plans will be assessed at the homes next inspection. All three of the care plans inspected had been reviewed in the past six months with the service user, their relatives and other professional representatives. It was positively noted that in attendance at one of the service users last care plan reviews had been their parents, care manager, behavioural specialist, the homes manager, as well as an independent advocate. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 11 The manager stated that no service users meetings had been held since May 2005 because the homes only other verbal service user had been admitted to a specialist unit to have their mental ill health assessed. Consequently, the manager argued that this type of large group forum was not the most effective way of ascertaining service users wishes and feelings about life at the home. It was evident from the way staff on duty interacted with the service users that they continue to actively support the service users to participate in all aspects of life in the home. This is often carried out on a more informal one to one basis. Each service user has a designated keyworker who is ultimately responsible for ascertaining the wishes and feelings of the individual they keywork. The Commission accepts the managers rational for not holding service user meetings, but this in turn does raise fundamental issues about the ability of the home to continue to meet the communication needs of its only verbal service user and ultimately the ‘suitability’ of their placement. As the vast majority of the service users are non-verbal this particular individual tends to communicate most effectively with members of staff are not their peer group. The manager said this matter will be discussed with the service user and all the relevant professionals involved with their care at her next care plan review meeting, which is due to take place in the next few months. Coombe Road (82) DS0000028482.V265324.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 The number and range of social, leisure and recreational opportunities the service users have to engage in, both at the home and in the wider community, are varied and clearly based on service users wishes. EVIDENCE: One service user met said they were about to go to college where they attended cooking classes. This particular individual said they liked to cook and that sometimes thy helped staff prepare meals at the home, although they went onto say that they would like to do more in the kitchen. This matter was raised with the manager who said a number of risks/hazards had been identified in respect of this particular individual helping staff to prepare hot meals in the kitchen and consequently the practice had been restricted to them preparing only cold snacks. The manager has been asked to discuss this matter with the service user and their representatives and look into the possibility of establishing an independent living skills programme for them, which identifies all the risks associated with this particular individuals cooking, as well as the management strategies that will need to be adopted to minimise them. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 13 On arrival one service user had already gone out to attend sessions at a local day centre, while as previously mentioned, another was preparing to go to college. This particular individual looked very smart in a matching woollen hat, scarf and jumper, which they said they had help choose. The rest of the service users were either relaxing in their bedrooms or in the main lounge at this time, although at least one other went out for a walk with staff during the course of this morning visit. Entries in three service users daily diary notes sampled at random revealed that in the two weeks previous to this unannounced inspection these particular individuals had participated in a number of stimulating activities both inside the home and in the wider community. Activities included aroma and music therapy sessions, walks, tram rides, swimming, shopping trips and home visits to see relatives. Each service user has a planned activities schedule and entries made in their individualised daily diary notes generally matched them. The manager said that in the absence of an activities coordinator he is ultimately responsible for ensuring service users engage in a variety of social, leisure and recreational activities of their choice. It was evident from the minutes taken at one service users last care plan review that all the relevant people involved with their care were satisfied with the number of opportunities this particular individual had to take part in activities. One service user spoken with at length said they liked living at Coombe Road and that there was always plenty of things for them to do. Coombe Road (82) DS0000028482.V265324.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 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. However, the current arrangements for the safe handling of medication received into the home are currently not sufficiently robust to ensure the service users are protected from avoidable harm and/or abuse. EVIDENCE: As previously mentioned one service user met said they could choose what they wore and where they went. Service users receive appropriate input from relevant healthcare professionals as and when required. One service user has been away since October 2005 having their mental ill health reassessed at a specialist unit. The manager said he continues to visit them on a weekly basis and offer comfort and support. The homes accident book revealed that two significant accidents involving service users had occurred since the homes last inspection. Staff on duty appropriately dealt with both the incidents at the time, although only one had been recorded in sufficient detail and reported to the Commission, in accordance with the Care Homes Regulations (2001). The manager must remind his staff team that the occurrence of any accident and/or incident that adversely affects the health and welfare of the service users must be reported to all the relevant agencies, including the CSCI and placing authorities. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 15 The home continues to use a recognised monitored dosage system and records kept for the previous four weeks of all medicines received and administered in the home had been appropriately maintained by staff. However, having checked the homes medication cabinet it was noted that unacceptable quantities of surplus stocks of ‘unwanted’ medication had been allowed to build up over a considerable period of time. In accordance with Milbury cares own medication returns policy and the Royal Pharmaceutical Societies code of good practice all ‘unwanted’ medication, including as required (PRN) medicines, should be returned to the dispensing pharmacist as soon as practicable. Furthermore, it was noted that a bottle of medication contained almost three times as many tablets as its label indicated. Although all these tables were eventually accounted for by cross referencing the number of tablets held by the home with its medicines received/administered records, the manager is nevertheless reminded that under no circumstances must staff be permitted to transfer medication from its original container to another. Labels must always accurately reflect the contents of bottles of medication held in the home. Finally, the home must ensure information about all the service users prescribed medication and current regimes, including ‘as required’ medication, is included on each service users medication administration records for staff to sign and date. Coombe Road (82) DS0000028482.V265324.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 Suitable arrangements are in place to ensure complaints are listened too, handled objectively and acted upon. The homes arrangements for dealing with incidents of aggression need to be improved including the recording, reporting and training of staff in the use of physical intervention techniques, to minimise the likelihood of service users being harmed or abused. EVIDENCE: The homes complaints procedure is conspicuously displayed in the home and is also available in a suitable format that some of the service users are capable of understanding. One service user spoken with said staff were good listeners. The home has not received any complaints about its operation since its last inspection. Since the homes last inspection staff have used Non-violent crisis intervention techniques (NVCI) to deal with an aggressive incident involving a service user. A written account of the incident was reported to the Commission without delay, although it was later conceded by senior representatives of the service providers that the record was not sufficiently detailed and lacked vital information about the nature of the physical intervention technique used. It transpired at the subsequent strategy meeting convened by Croydon Social Services vulnerable adult protection team that the manager had unwittingly used the wrong proforma to report the incident to the Commission. The manager has been reminded about Milbury cares own critical incident forms, which must be used to record and report any such incidents of physical restraint. The follow up case conference in respect of this incident concluded that all the staff involved in the incident, including the manager, had acted appropriately and only physically intervened as a ‘last resort’, in accordance with the British Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 17 Institute of Learning Disability (BILD) guidance. Furthermore, all the staff involved had received BILD approved training in the appropriate use of nonviolent crisis intervention (NVCI) techniques, although one member had not attended a suitable refresher course in the past twelve months. Staff training records revealed that three members of the homes current staff team must attend annual refresher courses in the appropriate use of NVCI techniques. This major shortfall was identified in the homes previous inspection report. The manager was able to confirm that dates for this training had been arranged to take place by the end of the year. Coombe Road (82) DS0000028482.V265324.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, 26, 27, 28 & 30 The size and layout of the home, which is furnished and decorated to a good standard, ensures the service users live in a clean, safe, and comfortable environment. EVIDENCE: There have been no significant changes made to the homes physical environment since its last inspection, although all the environmental issues highlighted in the previous report have been addressed, including the fitting of more suitable floor covering in one ground floor bedroom. The homes damaged oven has also been replaced with a new model. The manager also said that money has now been set aside for the rather worn-out leather sofas in the main lounge to be replaced by 1st April 2005. Furthermore, arrangements have been made for a new shower facility to be installed on the ground floor. Progress on these matters will be assessed at the homes next inspection. Having tested the temperature of hot water emanating from the two baths located on the first floor they were both found to be close to 43 degrees Celsius between 1pm and 1.05pm. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 19 The floor and walls of the ground floor laundry are readily cleanable and handwashing facilities prominently sited. The cupboard under the sink in this room, which is used to store COSHH products, was found to be unlocked during a tour of the premises. The manager stated that service users never enter the room, but it nevertheless a minimum consistent with health and safety that all COSHH products are kept secure at all times in lockable spaces. Coombe Road (82) DS0000028482.V265324.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): 32, 33, 34 & 35 In the main the home ensures that sufficient numbers of ‘suitably’ experienced and trained staff are on duty at all times to meet the health and welfare needs of the service users. EVIDENCE: The staff members on duty at the time of this visit were all observed interacting with the service users in a very caring and respectful manner. The manager stated that two out of seven members of his current staff team had achieved a National Vocational Qualification in care level 2 or above and that the rest of his team had enrolled on suitable courses, which he was confident all would have completed by the beginning of next year, in order to meet National Minimum training targets for care workers. There have been no changes to staffing levels since the homes last inspection, which appear adequate to meet the assessed needs of the service users. Four members of staff, which included the registered manager, were all on duty at the time of this unannounced inspection. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 21 One service user who is able to use of Makaton sign language was observed communicating their wishes to the manager, who was evidently able to understand the message being conveyed. The same service user demonstrated a number of the signs she used to communicate with other people. It was positively noted that as required in the homes previous report sufficient numbers of the staff team had now attended the first part of their Makaton training, as well as working with adults with autism. A second date has been arranged for staff to attend the second part of their Makaton training by the end of the year. Certificates of attendance and successful completion of this course will be viewed at the homes next inspection. The recommendation that sufficient numbers of staff should attend a person centred care planning course has yet to be arranged, although the manager is confident that a date will be set early in the new year. Progress on this matter will be assessed at the homes next inspection. No new members of staff have been employed since the homes previous inspection. This standard will be assessed in greater depth at the homes next visit. Coombe Road (82) DS0000028482.V265324.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): 37, 39 & 42 In the main the homes health and safety arrangements are sufficiently robust to ensure potential risks to service users, their guests and staff are, so far as reasonably practicably, minimised. Service users and their representative’s views about the homes operation must underpin all self-monitoring and consequently it is vital that the results of any surveys/questionnaires carried out by the home are published. EVIDENCE: The registered manager, Michael Luganda, is a qualified nurse and has achieved his registered managers award. Michael said he reports directly to his line manager, Julie Goodyear, who is always on hand to offer him advice and support as and when required. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 23 The home continues to use a professionally recognised quality assurance system, which uses surveys and questionnaires to ascertain the views of service users and their representatives. The homes latest annual review was carried out in October 2005, and as the process of collating all the information is still on going the results of this review has yet to be published. This shortfall was identified in the homes previous report when it was noted that the homes former operations manager had not published the results of the homes previous quality assurance review. Progress on this matter will be assessed at the homes next inspection. Up to date Certificates of worthiness were in place as evidence that ‘suitably’ qualified professionals had carried out periodic legionella checks in respect of the homes water outlets as required in the homes previous report. Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 3 X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coombe Road (82) Score 3 2 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X 3 X DS0000028482.V265324.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6(a) & (b) Requirement The service users guide must be kept under constant review and up dated accordingly to refect any changes. Previous timescale for action of 15th August 2005 not met. All the relevant agencies, including the Commission and placing authority, must be notified in writing and without delay about the occurrence of any ‘significant’ accident/incident that adversely affects the health and welfare of service users. The service providers arrangements for the recording, handling, safekeeping, and disposal of medicines received into the home must be adhered to at all times. Immediate requirement issued at the time of this inspection. Identified shortfalls were addressed at the time. On any occasion on which a service user is subject to physical restraint, the registered person must record the circumstances, including the nature of the restraint technique DS0000028482.V265324.R01.S.doc Timescale for action 01/01/06 2 YA19 37(1) 15/12/05 3 YA20 13(2) 24/11/05 4 YA23 13(8) 15/12/05 Coombe Road (82) Version 5.0 Page 26 used and all the staff involved. 5 YA23 13(6) & 18(1) All staff who have not yet attended an annual refresher course in the appropriate use of Non-violent crisis intervention techniques must do so as a matter of urgency. Documentary evidence of this training must be made avialable for inspection on request. Previous timescale for action of 15th Asugust 2005 not met. The cupboard under the sink in the laundry room where COSHH products are currently stored must remain locked when it is not in use. The results of any service user and/or their representative’s surveys/questionnaires, undertaken as part of an effective quality assurance system, must be published. Previous timescale for action of 1st November 2005 not met. 01/01/06 6 YA30 13(4) 15/12/05 7 YA39 24 01/03/06 Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 27 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 YA7 Good Practice Recommendations All the relevant representatives and professionals involved in one particular service users care should consider the suitability of the individuals placement at their next care plan review meeting, especially with regard to their communication/social needs being compatible with that of the other service users currently residing at the home. The manager should consider establishing an independent living skills programme, which identifies all the risks associated with a particular individual cooking in the home, as well as the management strategies that would need to be put in place to minimise these risks. All the rather worn out leather sofas in the main lounge should be replaced. 50 of the homes staff team to have achieved their NVQ level 2 or above in care by the end of 2005. Sufficient numbers of staff should attend a person centred care planning course. Recommended in the homes previous inspection report, but not actioned. 2 YA11 3 4 5 YA24 YA32 YA35 Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 28 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 Coombe Road (82) DS0000028482.V265324.R01.S.doc Version 5.0 Page 29 - 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!