CARE HOME ADULTS 18-65
Coxley House 28 Bow Road Bow London E3 4LN Lead Inspector
Lea Alexander Unannounced Inspection 22nd August 2006 10:30 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Coxley House Address 28 Bow Road Bow London E3 4LN 020 8980 1599 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) East Living Limited *** Post Vacant *** Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Can provide care for three (3) named service users over the age of 65 years. 15th November 2005 Date of last inspection Brief Description of the Service: Coxley House is a purpose built care home offering accommodation and support to thirteen service users with mental health difficulties. The home is built over two floors and comprises 13 flatlets. Each flat is open plan with a kitchenette, bedroom/sitting area and private bathroom comprising of wc and handbasin. There are an additional three shared bathrooms and a shared shower room that service users can access. There is a large ground floor, open plan, communal area that has a dining area and main kitchen at one end and a sitting area and service user kitchen at the other. On the upper balcony there is a second sitting area with mezzanine walkway to an art area. From the dining area there are french windows into a pleasant courtyard garden. The home is situated on the Bow Road with good public transport links. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by one inspector over the course of a day. The main focus of this inspection was to review progress made with requirements made at a previous inspection and to inspection key National Minimum Standards. During the course of the inspection the Inspector sampled service users files, toured the premises, met with the senior staff member on duty and spoke with five service users. The Inspector would like to thank service users and staff for their assistance with this Inspection. What the service does well:
The home has been assessed as exceeding National Minimum Standards in one area, as a high proportion of staff have already obtained NVQ level 3. Service users spoken to by the Inspector fedback that they liked living at the home and that staff were friendly and helpful. The obtains relevant information from other professionals as part of the referral process. It also carries out its own assessments on potential service users. When service users move in the home signs a contract with each service user. The home develops with services a plan that details their personal, social and healthcare needs. Service users are supported to be independent with their finances where appropriate. Some service users have been comprehensively assessed for risk. The home involved service users in the day-to-day running of the home by regularly holding house and menu planning meetings. Service users are also supported to attend college and day services. A range of entertainment and activities are provided within the home including art groups with an art therapist, a music group, a cookery group and social evenings. Service users are supported to maintain appropriate contact with their families. The home accommodates service users from diverse cultural backgrounds and has appointed diversity officers to address differing service users needs. A range of varied and nutritious meals is provided, and service users are generally satisfied with these. Individual service users have varied times for getting up, baths and meals according to their individual plan and activities. The home maintains a record of all healthcare appointments and their outcomes for each service user.
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 6 Service users benefit from a private room that includes a kitchenette and WC. The home also provides comfortable and generally well maintained communal spaces. The home implements corporate adult protection and complaints procedures. No adult protection issues or complaints have been received since the last inspection. The staff member spoken with during the inspection demonstrated an understanding of how to promote dignity and respect whilst providing personal care and allso demonstrated a good understanding of adult protection issues and their responsibilities. All new care staff complete an induction to the home, and East Thames provide regular training courses with training needs being identified during supervision. A Manager has been appointed who is in the process of registering with the Commission for Social Care Inspection. The Manager has obtained NVQ level 4 and has previous experience as a care home manager. The homes deputy manager is currently studying for their NVQ level 4. What has improved since the last inspection? What they could do better:
The home must ensure that all individual plans are reviewed at least six monthly or as service users needs change. Each plan should be risk assessed and for service users who require assistance with personal care this should be appropriately recorded in their plan
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 7 A programme of refurbishment for remaining service users rooms should be developed and minor maintenance issues should be addressed. Potentially hazardous cleaning materials should be stored in locked cupboards and fridge temperatures must be maintained within acceptable parameters. Staff must receive a minimum of six supervisions per year and the home should develop its quality assurance process to include the views of service users, their families and other stakeholders. Outcomes from this feedback should be collated and published. 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. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home gathers appropriate information and carries out its own assessments for prospective service users. EVIDENCE: The Inspector sampled the personal files for three service users currently living at Coxley House. Case tracking evidenced that the home obtains appropriate referral information including reports and assessments from other professionals. The home also carries out its own assessment as part of the admission process. The home operates corporate East Thames policies and procedures, including an admissions policy that details trial periods and the admission process. The three service users sampled all had a contract with the home that had been completed upon moving in. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 adequate. This judgement has been made using available evidence including a visit to the service. The home develops an individual plan for each service user. However, these must be reviewed at least six monthly and be subject to a risk assessment. EVIDENCE: Through the sampling of three service users personal files the Inspector evidenced that the home develops an individual plan for each service user, and that this addresses their health, social and personal support needs. The plans seen by the Inspector included information relating to service users personal care needs, maintaining service users environments, service users activities and maintenance of mental health. The support plans sampled by the Inspector had been signed by service users to evidence their participation in their development. By examining the dates of individual plans the Inspector noted that for one service user this had been reviewed six monthly. For a second service user their plan had been reviewed in August 05 and again in June 06. For a third
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 11 service user their most recent support plan was dated November 2005 with no evidence of subsequent review. One of the service users sampled by the Inspector is independent in managing their finances. The other two service users receive support to manage their finances. Each service user who is identified as requiring support to manage their finances has their own financial log where a record of all financial transactions is maintained. The home organises monthly meetings for service users to participate in the running of the home. The Inspector sampled recent minutes for these meetings and evidenced that matters such as maintenance, activities and the organisation of a shopping rota have been discussed. Two of the service users files sampled contained risk assessments for a variety of activities including managing money, mobility, non-compliance with medication and the risk of falls. All the risk assessments seen by the Inspector had been reviewed early on in 2006. One of the service users personal files sampled did not contain any risk assessments. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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): 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 engage in a range of educational and occupational activities and to maintain appropriate contact with their families. EVIDENCE: The home has developed links with a local adult education college and three service users will shortly be starting a social and life skills development course. Another service user has recently completed NVQ level 2 studies in catering. Six service users are currently attending local day services. Service users are also supported to engage in the local community and attend a local bingo hall. Service users are also supported to visit local shops to purchase their personal care items and to participate in weekly shopping for the home at a local supermarket. A range of entertainment is available within the home including social evenings where service users choose DVD’s, play table tennis or join sing-a-long groups.
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 13 The home also runs regular art sessions with an art therapist, a music group and a cookery group. Service users are supported to maintain family links and friendships outside of the home. Personal files evidence that some service users have overnight visits to family; whilst others have family members visit them at the home. Throughout the course of the inspection the Inspector observed that service users choose when to be alone or when to join in an activity and that staff talk to and interact with service users. Since the last inspection the home has developed its overnight visitors policy and this contains guidance on promoting individual service users rights whilst protecting others. The home accommodates service users from diverse cultural backgrounds. Two staff members have been identified as diversity officers with responsibilities for monitoring and identifying diversity issues within the home. On a day-to-day basis the home addresses cultural needs through means such as menu planning, where a range of foods that is reflective of service users cultural backgrounds and requirements are offered. The home recently organised a day where service users and staff each prepared foods from their cultural background and shared them with the larger group. The home employs a chef and prepares food in an industrial style kitchen. The Inspector viewed the homes log of meals offered and noted that a range of nutritious and varied meals is offered. A regular menu-planning meeting is held with service users to identify meals that they would like to appear on the menu. The home regularly surveys service users to obtain feedback on the meals offered. Feedback given to the Inspector on the day of the inspection indicated that service users are generally satisfied with the meals provided. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 good. This judgement has been made using available evidence including a visit to the service. The home promotes service users physical well being, and its medication practices protect them. However the home must detail the kind of support some service users need with their personal care in the individual plan. EVIDENCE: Two of the homes current service user group require assistance with personal care. The Inspector sampled the individual plan for one of these service users and found that this did not provide guidance to staff on the level and nature of support required by the service user and how they preferred to receive this. A member of staff on duty who was interviewed by the Inspector demonstrated a good understanding of how to promote service users dignity and respect whilst providing personal care and identified the need to explain what is to be done and ensuring that windows and doors are closed. The home aims to meet individual service users needs, and times for getting up, going to bed, baths, meals and other activities are therefore flexible and tailored to the service users individual plan.
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 15 The Inspector sampled three service users personal files. Each of these contained a health appointment matrix where details of the date, appointment and outcome were recorded. Recent healthcare appointments evidenced as occurring include GP, dentist and specialist out patient clinics. The home operates a corporate East Thames medication policy. This gives guidance to staff on the ordering, receiving, storage and disposal of medication, including controlled drugs. The home has developed a local policy for self-medication. This identifies the need for self-medication to be identified in the individual plan and subject to a risk assessment. The Inspector sampled the individual plan and risk assessments for one selfmedicating service user and found these to accurately reflect the service users current self-medication regime. The Inspector sampled the Medication Administration Record (MAR) and actual medication available for three service users. The Inspector evidenced that the medications available corresponded with those listed on the Medication Administration Record. In February 2006 the home reported an incident to the Commission for Social Care Inspection when a staff member incorrectly administered a dose of medication to a service user. As a result of this East Thames have introduced refresher training on medication for all staff that includes an assessment that must be passed before staff can administer medication. Since the last inspection the home has implemented the corporate East Thames protocol regarding ageing, death and dyeing. This states that these factors should be considered as part of the on the ongoing needs of the service user. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 good. This judgement has been made using available evidence including a visit to the service. Service users views are listened to, and they are protected from abuse. EVIDENCE: The home operates a corporate East Thames Complaints policy. This includes a four-stage complaints process with timescales. An easy access pictorial version of the complaints procedure with contact details for the Commission for Social Care Inspection has also been produced and is displayed within the complaints log. The Inspector viewed the homes complaints log and noted that there had been no complaints recorded. The home also operates East Thames corporate Adult protection policy. This includes definitions of the different types of abuse service users can experience and makes appropriate reference to local adult protection guidelines. The policy contains guidance for staff on the steps to follow should they have any adult protection concerns. There is a separate Whistle blowing policy. The Deputy Manager advised the Inspector that no adult protection concerns had been reported since the previous inspection. The member of care staff spoken to by the Inspector at the time of the inspection was able to identify several different types of abuse and potential abusers. They also demonstrated a good understanding of their responsibilities to report any adult protection concerns. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a generally well maintained and comfortable home. However, a programme of refurbishment for all service users rooms must be developed. EVIDENCE: The home is purpose built and provides private rooms for service users and spacious communal areas. The communal areas comprise of a large hall divided into a dining area, lounge area and service users kitchen area. There are doors from this area on to a good-sized paved garden that has been landscaped and equipped with a range of seating. On a mezzanine level there is a service users art area and a second lounge area. Since the last inspection the communal areas have been redecorated and new flooring installed. The communal areas have been personalised with soft lighting, new furniture and framed service users artworks. There is also a large entrance hallway, an industrial style kitchen and industrial style laundry facilities. Three staff offices are also housed within the building.
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 18 Service users bedrooms are arranged in small clusters around a communal bath or shower room. Each service user room contains its own kitchenette and a WC with hand basin. The Inspector visited two service users rooms. These were noted to be generally well maintained with personal furniture and service users mementos. The Deputy Manager advised that some service users bedrooms had been redecorated since the last inspection. However, one of the rooms visited by the Inspector would benefit from redecoration and new flooring. The Inspector viewed all of the shared bathrooms. Three of these contain a bathtub with mixer tap, and one has been converted to a walk in shower. All four also contain a WC and hand basin. The Inspector noted that the toilet seats in several of the bathrooms were broken, and that the drain on the walk in shower was blocked. The Inspector noted that the home was generally clean, hygienic and free from offensive odours. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected by the homes recruitment practices and benefit from appropriately trained staff. However, the home must ensure that all support staff receive at least six supervision sessions per year. EVIDENCE: In addition to a Manager, the home employs a deputy, five senior support workers and seven support workers. Additionally a cook, a housekeeper and two domestic staff are also employed within the home. East Thames operates a central human resources department that retains all personnel records. A local file is held at the home that includes a summary sheet detailing the pre employment checks completed prior to the care worker taking up their post. The Inspector sampled three local personnel files and evidenced that a summary sheet was present in each that stated that two satisfactory references, proofs of identification and an enhanced Criminal Records Bureau (CRB) check had been obtained for each. Two of the personnel files sampled were for care staff, and a completed induction record was located on their file. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 20 The Inspector sampled the supervision records of three staff members. It was evidenced for one staff member that six supervision sessions had occurred in the last twelve months. However, the other two staff members were evidenced as having received three and four sessions respectively. The Deputy Manager advised the Inspector that of the twelve care staff eight have obtained NVQ level 3 with a further two care staff currently studying for NVQ level 3. The Deputy Manager also told the Inspector that East Thames produces a yearly training brochure that is available to all staff and that training needs are discussed in supervision. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 & 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a generally well run home. However, appropriate steps must be taken to comply with all relevant health and safety requirements. EVIDENCE: The home has appointed a Manager who is in the process of registering with the Commission for Social Care Inspection. The Manager has obtained NVQ level 4 and has previous experience working as a care home manager. The homes Deputy Manager is currently studying for their NVQ level 4 award. Since the last inspection the Responsible Individual has supplied the Commission with copies of reports detailing their monthly visits to the home. The Inspectors discussion with the Deputy Manager evidenced that the home needs to further develop its quality assurance processes to include feedback
Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 22 from service users, their families and other stakeholders. The results of this feedback should be collated and made available to interested parties. The Inspector noted that several copies of the homes policies and procedures were distributed around the premises and are available to staff at all times and to service users upon request. The Inspector sampled a range of health and safety records that the home is required to maintain. Water temperatures are regularly recorded and these were found to be within acceptable parameters. The home also carries out weekly fire call point tests and records indicate that these are all in working order. The home also carried out a fire evacuation drill in June 2006 and recorded this along with the evacuation time. The Inspector viewed the homes accident and incident logs and found these to be in order. The home records temperatures for its refrigerators and freezers twice each day. However, temperatures in the staff room and training kitchen refrigerators were regularly recorded at 10 degrees, which is outside the acceptable limit with no record of action taken. Whilst touring the homes premises the Inspector noted that several bathrooms had potentially hazardous cleaning materials kept on open display. Since the last inspection the home has developed a business plan that includes the objectives for the service and identifies indicators that will evidence that these have been met. Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 3 3 X 2 3 X 2 3 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14(2) Requirement Service users plans must be reviewed at least every six months. This is a restated requirement. Previous targets of the 06/11/05 and 31/03/06 were not met. Each service users individual plan must be subject to a risk assessment. Where service users require assistance with personal care the nature of this support must be recorded in the individual plan along with the service users preferences for receiving this support. With service users agreement and involvement their flats must be redecorated. This is a restated requirement. Previous targets of the 06/11/05 and 31/03/06 were not met. Broken toilet seats in the communal bath and shower rooms must be repaired or replaced. Timescale for action 30/12/06 2. 3. YA9 YA18 14(2) 12(4) 30/12/06 30/12/06 4. YA24 23(2)(d) 30/03/07 5. YA27 23(2)(j) 30/09/06 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 25 6. YA36 18(2) The blockage in the shower room drain must be cleared. Staff must receive regular 30/12/06 supervision meetings, and a minimum of six of these sessions per year. This is a restated requirement. Previous targets of the 06/11/05 and 31/03/06 were not met. The home must develop its quality assurance process to include the views of service users, their families and other stakeholders. The outcomes of this process should be collated and made available to interested parties. Maintain fridge temperatures within acceptable limits. 7. YA39 24 30/12/06 8. YA42 16 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 Page 26 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 Coxley House DS0000063898.V309187.R01.S.doc Version 5.2 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!
