Inspection on 09/05/06 for Croydon Road,78

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croydon Road,78 12/06/07

Croydon Road,78 08/11/05

Croydon Road,78 04/05/05

Croydon Road,78 01/11/04

Croydon Road,78 25/05/04

Croydon Road,78 02/10/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Herbert Street

Stacey Street Nursing Home

Haven (The)

Delrose House Ltd

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

CARE HOME ADULTS 18-65 Croydon Road,78 78 Croydon Road Penge London SE20 7AB Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 9th May 2006 10:00 Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Croydon Road,78 Address 78 Croydon Road Penge London SE20 7AB 020 8676 9965 020 8676 9965 claire.fakhet@community-options.org.uk 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) Community Options Limited Care Home 7 Category(ies) of Past or present alcohol dependence (7), Past or registration, with number present drug dependence (7), Mental disorder, of places excluding learning disability or dementia (7) Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/11/05 Brief Description of the Service: This home is part of the Community Options group. Community Options has a number of facilities in the Bromley area. The home has its own dedicated manager and staff team, whilst senior management and personal support are provided centrally. The home is a detached house in a residential area of Penge. It is located close to the High Street and is well served by public transport. The building itself is located over three floors accessed by stairs. There are no adaptations in this home as all residents are primarily younger, physically able adults. The purpose of the home is rehabilitation to enable residents to live independently. Residents in this home have mental health disorder and are subject to the Care Programme Approach. This is a system of multi-disciplinary monitoring and review to keep abreast of the individuals mental health. Staff are provided throughout the 24-hour period, including waking staff. All other health care support is provided through the community. The weekly fee is £326.01. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one and a half days. It was conducted unannounced. The inspector met with residents and as part of the process, case tracked two of them. On the first day the inspector was able to meet with the Responsible Psychiatrist, and the sister of one of the residents who was case tracked. The inspector met with the key workers to the residents who provided a good insight into care provided and demonstrated a good knowledge of the residents. Feedback forms for residents were left at the site visit. At the point of writing the report no feedback forms had been received. What the service does well: What has improved since the last inspection? What they could do better: The environment, in particular residents’ bedrooms, needs to have more staff input. Whilst the inspector appreciates that this is an area which residents may be resistant to address, it is important that all areas are maintained to a safe hygienic state for the individual residents themselves, and all other residents and staff who live and work in the home. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 6 Risk assessments are insufficiently robust to safeguard residents. Risk assessments need to be in place for every element of identified risk with interventions and contingency plans to address the risk. These must be kept under review by the multi-disciplinary team. 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. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information is gathered prior to admission and the senior staff in the home do assess prospective residents. However, the documentation relating to this needs to be available and consolidated. Comprehensive assessment information must be made available including information from the Care Programme Approach co-ordinator for the resident. EVIDENCE: Two residents were case tracked as part of the site visit and the assessment information was inspected as part of this. Terms and conditions or residency were located in individual files itemising the weekly charge of £326.01 and the room to be occupied was specified. Individual service agreements were in place. One resident’s terms and conditions referred to the placement as Hamilton Road. This needs to be amended. The inspector was unable to locate the Care Programme Approach (CPA) information received from the resident’s care co-ordinator prior to admission. Within the file there was a referral form and an assessment form dated 2003 for one resident. Staff from the home had conducted this assessment. This was limited in detailed information in respect of her needs. Within the file for the other resident, this information was not available. Neither of the files contained a letter confirming the home’s ability to meet needs. Other information such as information from the multi-disciplinary team was also available. There was a 21-page document outlining one resident’s psychiatric needs and hospital Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 9 admissions, little of which was on the home’s assessment, including reference to past threatening and abusive behaviour towards staff. All assessment information must be available prior to admission; this must comprehensively detail physical, mental and social issues. Staff must have this information available to them, to give an indication of the resident prior to admission, and from which staff can form an initial care plan. The self-assessment was completed for one resident. Please see requirement 1. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care plans and supporting risk assessments are not insufficiently robust to accurately reflect the resident’s needs nor do they detail sufficient interventions in identified areas of risk and need to address the issues. EVIDENCE: Two care plans were viewed as part of the case tracking. The files were cumbersome and it was difficult to find some of the necessary information. The care plan documentation contains many forms giving residents an opportunity to input into the procedure. This is good practice, however with ongoing mental health issues, limited insight and difficulties with concentration, many areas remained incomplete. The care plans were limited in content in respect of the stated objective and the interventions required to meet needs. The reviews were overdue having last been reviewed 26 March 2005. There was little information in the care plans in respect of mental health particularly those residents with fluctuating mental health issues and who are prone to relapse. In each file a monthly summary gives an overview of activities of daily living by residents. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 11 Risk assessments were similarly completed and limited in content. Current CPA reviews and care plans were unavailable. although one was provided at a later stage. It is essential that these documents are readily available as these form the basis of the care, and from which the home should form a comprehensive care plan on which to address care consistently. The Manager herself had undertaken a review and was fully aware of the outstanding issues within the care plan and risk assessment documentation. She had been away for a number of weeks having just returned a week prior to the inspection. The inspector met with the Responsible Psychiatrist for one of the residents. He felt that the home managed situations well and the residents were assisted with activities of daily living, which promoted greater independence. He felt that all staff had a good knowledge of residents and presenting issues. He felt that the multi-disciplinary team were used appropriately and communicated with regularly. The inspector met with the sister of a resident. She was happy with the level of support and felt staff engaged with her sister on an appropriate level. Staff were able to manage her behaviour and maintain safety whilst living in the community .She felt that she was involved with her support and communicated with appropriately regarding all developments in her sisters care The key workers for the two residents both had a good knowledge of the resident’s background, current needs and support required. Please see requirements 2 and 3. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have choices in their day, are encouraged to become part of the local community and access all facilities as par of on going rehabilitation. EVIDENCE: Residents’ care and support are based on promoting independent living within the community hence activities are rehabilitation based. Support is based on those areas, which need more input to facilitate a more independent life. The goals are often longer term. It was evident that residents had choice in their day; some were out, some were in bed and another had just returned from an overnight leave with her family. The residents themselves related various activities that they were involved with. Residents are encouraged to engage with the local community, accessing leisure and health facilities within it. The use of public transport is encouraged. Visiting is open; one visitor was in the day of the inspection, she visits quite often. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 13 The residents in this home are all under enhanced levels of CPA. That in itself indicates a mental health issue, which requires on going monitoring and input from professionals. Mental health issues can sometimes make residents resistive to rehabilitation programmes, however staff in the home must endeavour to promote rehabilitation offering structure and support in those areas identified. Meal preparation, budgeting and cooking are all part of residents’ rehabilitation. Residents choose what they want to cook, staff assist/support them with this task. Healthy eating is promoted although some residents are resistive to this input. The kitchen has areas for each resident to store food including chilled and frozen. Again there was limited crockery and cutlery although there was evidence that this had been replaced on several occasions. The Manager is investigating alternatives to ensure that sufficient kitchen utensils and crockery are available. The inspector observed the following interaction, which in her opinion was not well managed. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care is accessed through the local community, which for these residents is appropriate. Medications in this home are managed to a satisfactory standard. EVIDENCE: All six residents in this home are under the enhanced level of the Care Programme Approach. This is a system of aftercare in the community where residents are kept under review and have input from a multi-disciplinary team. Residents are either seen at the hospital outpatients’ clinics or within the home. Reviews are conducted and residents with there representatives invited to attend. All other health care is accessed through the community with or without staff support. Sometimes it can be difficult to extract accurate information when residents are unescorted, hence these records were limited. The mediations were inspected. One resident is self medicating and was said to be very capable. Generally the medication records were satisfactory. Records relating to the receipt and return of medication were in place .One resident’s photograph was not in place on the medication administration chart. The allergies were also not recorded. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 15 There has been one incident regarding a medication issue which has been investigated and staff have been reinstructed in medication procedures with amendments made to policies and procedures. The CSCI was notified of this incident and awaits the conclusion of the investigation. First aid boxes were available and appropriately stocked. It was noted the CSCI had not received faxed copies of recent Regulation 37 reports, one of which had had serious implications for the resident and members of the public. It was confirmed that these had been faxed to the correct number although not received. It was agreed that any incident of a serious nature would be verbally notified to the lead inspector and thereafter a Regulation 37 posted to this office. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information and avenues through which to address complaints is available. Staff have a working knowledge on dealing with abuse and how to action this. EVIDENCE: The complaints information was on display in the hall. Community Options have standard forms to be completed for all concerns/complaints raised. The complaints’ file was empty as there have been no complaints, nor have there been any received by the CSCI. It is recommended that the home develops a complaints log, which is a quick reference in respect of all complaints made. This would give a brief outline of the complaint, date received, investigation route and detail the date of closure and outcomes. All supporting investigation records would be safely stored although accessible if needed. Residents themselves said that they felt they could approach staff about concerns and residents meetings offered another avenue for discussion. Other multi-disciplinary team members were also stated as appropriate persons with whom to raise complaints. Some residents in this home are vulnerable from various forms of abuse from members of the public, which were noted in care plans. Staff were aware of these areas, however it is difficult to fully protect the residents who live, in the main, without restrictions. Staff were aware of what constitutes adult protection having addressed this through the company induction. On the training schedule provided, two staff had done updates on adult protection, all staff must have regular updates to keep abreast of developments. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 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): 24,25,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Parts of the home were unsatisfactory both in terms of hygiene and potential hazards EVIDENCE: Some of the communal areas were generally satisfactory. The dining room had benefited from a new table and chairs. The carpet was poor and on the windowsill cigarette ends and ash were evident. The curtains were in a poor condition. The area adjacent to the dining area was dirty. This is the smoking area for the home and must be maintained to a satisfactory standard. The kitchen was reasonable although cupboards and worktops had evidence of wear and tear. The pipe leading to the boiler was very hot and this must be made safe with suitable risk assessments in place for protection of residents. Several bedrooms were locked; only three were inspected. One was tidy and well maintained, two others were poor. One bedroom was malodorous and remains of takeaway dishes on the bedside table. The ashtray had cigarettes in it and the windowsill, cigarette butts and ash. This is particularly concerning as this is a top floor bedroom with limited access. The inspector is aware of the difficulties that some residents pose, when individual bedrooms reach an unacceptable level. However the home has a responsibility to ensure Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 18 residents’ welfare is addressed. Some areas within the home are not conducive to well being although it is the residents themselves who allow such a deterioration to occur. Staff must intervene when areas have got to a point where health and hazards are becoming an issue. Smoking in bedrooms must be discouraged and staff display extra vigilance around this. Appropriate risk assessments must address this issue. There is a fine balance to be struck between choice, individuality and human rights against safety of the residents and staff in the home, as well as the community at large. Please see requirements 4 and 5. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 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): 32,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training is provided ongoing and in relation to identified needs. More specific training in relation to residents identified needs and risks should be provided to equip staff fully for the role that they undertake. EVIDENCE: The staff personal files are retained at Community Options Head office. These will be inspected later in the year to confirm that robust recruitment procedures are in place. The home has an annual training plan in place. Training is identified through supervision conducted by the senior staff in the home. The training plan indicated that there is core training planned including first aid; food hygiene, moving and handling training. The training topics, which had already been addressed, included those relating to mental health and associated issues, whilst others related to team building and personal safety. The inspector met with two staff on the first day of the inspection. One staff member was an agency having started January 2006, the other a permanent member of staff who had been in post since 2003. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 20 The agency staff had received some training through the company including fire and other training through the supplying agency. He confirmed induction to the home and he confirmed that he always worked with senior staff. The second staff confirmed induction and ongoing training including the mandatory topics. Medication training had been provided with the subsequent proficiency test, and other topics relatings to mental health issues. Regular supervision was undertaken and an annual appraisal conducted. A third staff member was interviewed who was due to attend a number of training sessions this year. Many staff have undertaken training in personal safety. However for new starters, core training including challenging behaviour, COSHH and fire training must be undertaken in a more timely manner so that they are sufficiently skilled to undertake the work that they perform. It was noted form regulation 37 reports that one resident had required the use of restraint, due to his challenging behaviour. Staff had not been provided with SCIIP training, hence staff would not be able to apply the appropriate interventions and thereafter ensure accurate recordings of the interventions used were detailed. This leaves residents staff vulnerable. Please see requirement 6. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and inclusive manner. The management team are experienced with the residents group. Health and safety issues in the home are addressed although more attention to servicing of equipment is required. EVIDENCE: A number of service certificates were inspected including the gas landlords certificate was dated 4/05/06.The fire extinguishers were last serviced 2/04/05. These are due annually and the home is required to send the service certificate to the CSCI within the next week. In addition the fire alarm was last serviced 09/05. This should be addressed as a six monthly service. This was also overdue. The five year electrical was current, next due 06/08. The water chlorination was conducted 04/06. The fire alarm was checked weekly with different call points each week. However there were no signatures in place to confirm who is undertaking the checks. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 22 Three of the six staff have yet to receive fire instruction and this is planned for the near future. One member of staff on probation could not give correct instructions as to what to do in the event of a fire and had not yet been involved in a fire drill. Fire drills have been undertaken regularly but not all staff have been involved in one over the last year. On the day of the inspection hot water temperatures on those tested were satisfactory, however, records stated that these were running between 31and 75.1 degrees. The kitchen taps were stated to be running below the required temperature. Risk assessments must be in place for all those water outlets, which are running at variable temperatures. There were no accident records, although records made regarding Regulation 37 form notifications were in place. Staff need to ensure accidents, which require some form of first aid treatment, are recorded in accident book. One example of this was of an aggressive incident dated 20/01/06,during which a resident sustained a cut to his had, which required hospital treatment. There is an organisational business plan and individual project plan. The member of staff could not locate the projects individual plan. This was requested this be sent to the Commission. The business plan show eight key outcomes with numbers 1, 2 & 5 relating specifically for service users whilst others relate to the organisation and staff. Each outcome is audited through key performance indicators with the home auditing themselves on the key outcomes as detailed in the business plan. This includes obtaining service user feedback though surveys every six months. The home could offer no evidence that this had been undertaken and was requested to send the Commission a copy of the report undertaken on analysis of the survey. Other key indicators had not been met such as monthly residents meetings although the last one on file was dated 01/02/06. This was also true of staff meetings. There was no record of the audits, which have taken place to date. Regulation 26 visits - those noted in the home’s file were dated 28/04/06 and previous to that 19/09/05. There was no evidence of those in between. However, home is still required to keep copies of the reports to ensure they take action in those areas of non-compliance noted. Please see requirements 7,8,9 and 10. Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 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 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 3 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 3 12 X 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 2 X Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 24 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 YA3 Regulation 14 Requirement The Manager must ensure that all prospective residents are fully assessed and all information available prior to admission. The home must confirm in writing to the residents its ability to meet the identified needs. The Manager must ensure residents’ care plans are comprehensive in content and reflective of identified needs. Supporting risk assessments must be in place with appropriate interventions detailed. Previous timeframe 31/12/2004. This is now outstanding. The Manager must ensure that risk assessments are comprehensive in content to reduce the assessed risk. Previous timeframe 31/12/2004. This is now outstanding. Timescale for action 30/07/06 2. YA6 15 30/07/06 3. YA9 13 30/07/06 Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 25 4 YA24 23 5 YA25 23 6 YA32 18 7 YA39 26 8 YA42 23 9 YA42 23 10 YA42 37 The Manager must ensure that all areas of the home are maintained in a safe manner including the pipe work to the kitchen boiler. The Manager must ensure that all areas in the home are maintained clean and hazard free The Manager must ensure that all training is current, particularly the mandatory updates. Previous timeframe for action 30/11/05. This is now outstanding The Registered Provider must ensure that Regulation 26 visits are undertaken, unannounced, monthly and a report available. The Manager must ensure that all staff receive fire instruction in a timely manner and at regular intervals The Manager must ensure that risk assessments are in place for any environmental issues including fluctuating hot water temperatures The Manager must ensure that accident reports are made when necessary. 30/06/06 30/06/06 30/07/06 30/06/06 30/06/06 30/06/06 30/06/06 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 Croydon Road,78 DS0000006909.V290401.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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