Inspection on 03/04/07 for Dagenham Road

This inspection was carried out on 3rd April 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dagenham Road 25/03/09

Dagenham Road 10/01/06

Dagenham Road 28/06/05

Dagenham Road 10/03/05

Dagenham Road 07/09/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Dagenham Road 357A-359 Dagenham Road Romford Essex RM7 0XX Lead Inspector Ms Gwen Lording Key Unannounced Inspection 3rd April 2007 08:45 Dagenham Road DS0000027897.V334879.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 Dagenham Road DS0000027897.V334879.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. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dagenham Road Address 357A-359 Dagenham Road Romford Essex RM7 0XX 0208 595 5336 020 8984 8989 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) Outlook Care Pauline Dora Dean Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: The home is situated in Dagenham Road, with easy access, by bus to Romford town centre or Dagenham Heathway. The home has two units of four beds each. There are places for 8 adults with mental health support needs. The service user group at the time of inspection were semi-independent, needing prompting, reassurance and support from staff. The staff team work hard to ensure the service users independence is maintained, and liaise with other professionals to regulate service users health and wellbeing. The home is staffed 24 hrs a day with a waking member of staff at night. Outlook Care provides the support whilst East Thames Housing Group is the landlord. On the day of the inspection the fees for the home were £929.00 per week. A copy of the Statement of Purpose and Service User Guide are available in the home, together with a copy of the most recent inspection report. Dagenham Road DS0000027897.V334879.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, which started at 08.45am and took place over six hours. The registered manager was available during the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/ 2007. Discussion took place with the manager and two members of care staff, who were asked about the care that residents receive and were observed carrying out their duties. The Inspector was able to talk to five residents and asked their views of the service and their experience of living in the home. Three other residents living in the home were on a week’s holiday in Austria accompanied by two members of care staff. A tour of the home was made and all areas were clean and tidy with no offensive odours. Residents files were viewed, together with examination of staff and other home records, including medication administration, staff rotas, staff training records and accident/ incident reports. Information was also taken from a pre-inspection questionnaire completed by the manager. Staff meetings are held monthly and in order to gain additional information about the service the inspector attended one of the staff meetings held earlier in the year. More detailed information about this meeting can be found in the main report. The inspector had a discussion with staff and people living in the home about how they wished to be referred to in the report. They expressed a wish to be referred to as resident. This is reflected accordingly in the report. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: There is a strong focus on maintaining and promoting the independence of people living in the home. Staff understand the importance of supporting residents to take greater control of their lives and make their own decisions. The attitude and practice of the service and that of the staff team promote opportunities for residents to exercise choice and express their wishes and needs. The home has an experienced manager who sets high standards for the home. She works with a strong staff team that are committed to further improve the quality of care for people living in the home and this is reflected in the provision of care to residents. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 6 100 of care staff are qualified to NVQ level 3 and this demonstrates a very positive commitment to training from both the organisation and the care staff. What has improved since the last inspection? 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 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 Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 & 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Assessments undertaken by the home and the information and reports received from health and social care professionals means that staff have detailed information to enable them to determine whether or not the home can meet a prospective resident’s needs. EVIDENCE: There are currently no vacancies at the home. Five of the residents have lived in the home since it opened in 1992. The most recent resident was admitted to the home in 2004. However, through discussion with the manager and viewing pre-admission assessments/ documentation held on file, it was evident that no admissions would be made to the home unless a full needs assessment had been undertaken. Each resident has a Service Agreement/ Contract, which details the responsibilities of the provider and the rights and obligations of the individual. It is easy to understand and residents are clear of what they can expect. All contracts seen had been signed by the individual resident. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 9 The Care Homes Regulations 2001 have been amended with effect from the 1st September 2006 for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the service users guide. Details of information to be included are contained within the amended regulations. Therefore, the service user guide must be reviewed and amended by the stated timescales. The manager was also provided with a copy of the Commission’s ‘Policy and Guidance on Provision of Fees Information by Care Homes’. Dagenham Road DS0000027897.V334879.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents’ general health, social support and personal care needs are set out in individual care plans. However, not all care plans clearly detail individuals care related specifically to their mental health needs to ensure that these care needs are being understood and met on a daily basis. The home maximises independence wherever possible and staff provide residents with information, assistance and support to make decisions about their own lives. Residents know that the staff handle information about them appropriately and their confidences are kept. EVIDENCE: Individual files were available for each resident and the care plans and related documentation of three residents were case tracked. Care plans are developed Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 11 for each resident following the principles of “person centred “ planning. Care plans examined generally covered in sufficient detail personal, social support and general health care needs, but could have included more information around individuals mental health needs and how these were to be met. For example, there was no care plan in place for one resident with an enduring mental health problem where the risk of relapse was considered to be quite high. There is a key worker system in operation and care plans were being evaluated and regularly reviewed. Residents are actively involved in this process and in most cases involved external professionals. The manager expressed concern that she has encountered difficulty in getting the participation of some professionals. However, she is actively addressing these issues through the local Community Mental Health Team (CMHT) with the support of her line manager. There is a strong focus on maintaining and promoting independence. Staff understand the importance of supporting residents to take greater control of their lives and make their own decisions. Individual staff were observed providing residents with information, assistance and support, and were respectful of their right to make decisions. All the residents have access to independent advocacy services through HUBB – Barking, Havering and Brentwood Mental Health User Group. There is a wellresourced notice board in the kitchen of both units, containing information about local activities and events in the borough, both mainstream and those specific to people with mental health needs. Risk assessments were in place for each resident and were being reviewed and updated. Residents are supported to take risks as part of promoting their independence within a risk management framework. Where there are limitations in place, such decisions had been made with the individual and were recorded. Dagenham Road DS0000027897.V334879.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12, 13, 14, 15, 16 & 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff for all residents to enable them to participate in the community in which they live. They are supported to exercise their rights, which are respected and promoted by staff. Residents are provided with meals that are varied reflective of residents’ choice, cultural and dietary needs. EVIDENCE: People living in the home are individually and collectively involved in determining the type of activities they wish to participate in, when and with whom they choose. Resident meetings are held every month and from viewing the records, it was apparent that activities and other house matters are discussed in this forum. At the time of the inspection three of the male residents were on a weeks holiday in Austria accompanied by staff. There is a Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 13 wide range of leisure activities for residents to engage in both in the home and the community. This included attendance at day centres; college for literacy skills; yoga and relaxation; computer skills; arts/ crafts and flower arranging. Day trips are also arranged and there is an annual summer barbeque to which friends and families are invited. On the day of the visit staff were observed to be supporting individuals to pursue their individual interests and hobbies. A supportive ‘women’s’ group is held in the home once a month by a member of the support time and recovery team from the Shaw Trust. Those residents spoken to enjoyed these regular meetings and viewed them as a very social event. Where there are family links/ friendships, residents are encouraged and supported by staff to maintain these links with their family members and friends. One resident visits her family at weekends and said “she enjoyed this time with her family”. During the inspection, the residents were observed accessing all areas of the home independently. The home has limited facilities for private meetings but residents said they are able to see people in their bedrooms. All residents are involved in taking responsibility for their own rooms and some communal household chores with the support of staff. Staff shop, prepare and cook meals with involvement from the residents. The menu for the week is discussed and planned one week in advance. Menus are in place and records maintained. Residents spoken to confirmed that they are involved in choosing them. In line with promoting equality and diversity menus were reflective of the cultural and diverse needs and preferences of the residents. One of the residents is of the Muslim religion and staff ensure that Halal meat and other culturally appropriate foods are purchased for her. On many occasions she prefers to cook her own meals. Residents confirmed that they choose to have their main meal of the day in the evening, as this suits individual residents activities and daily schedules. Throughout the inspection residents were observed helping themselves to drinks and snacks and have full access to kitchen facilities. The lunchtime meal was observed to be very relaxed with residents choosing what they wanted to eat on the day, which they prepared themselves. Food was being adequately stored, with a good variety of food available, which included meat, fish, dairy produce; and a fresh supply of fresh fruit and vegetables. Dagenham Road DS0000027897.V334879.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 & 21. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents physical and emotional health care needs are monitored and this ensures that their needs are recognised, understood and met. Personal support is provided in a manner, which suits their individual needs and preferences. Medication policies and procedures are clear and regular management checks are undertaken and recorded to monitor compliance and ensure the safety of residents. EVIDENCE: All five of the residents spoken to confirmed that they were happy with the support they receive around their personal care needs. Residents have a choice in relation to same gender care preferences when receiving personal care, and their care plans set out how their personal support is to be provided. Some residents require a higher level of staff involvement however; this was seen to be well balanced by helping those individuals to be as independent as possible and supported to take responsibility for their personal care needs. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 15 All of the care and health plans examined, clearly recorded referrals to specialist health care professionals and that appointments were being kept. Records indicated that residents attend routine health appointments including GP, dentist, chiropodist and routine cervical and breast screening. As far as possible residents are given the opportunity and support to independently attend their appointments, and are seen as individuals taking responsibility for their own healthcare. Residents have regular reviews of their medication undertaken by their GP. There are policies and procedures in place for the handling and recording of medication. An audit was undertaken of the management of medicines in the home, and Medication Administration Record (MAR) charts were examined. Medication storage was satisfactory and medication records were being fully completed. Regular checks are undertaken and recorded by the manager to monitor compliance. One resident is able to keep and administer their own medication with the support of staff. However, there was no current completed risk assessment in place. Risk assessments must be undertaken for all residents who are self medicating, with regular reviews to ensure that individuals are administering and managing their medication safely. One resident who has reduced mobility problems has the appropriate aid to enable them to mobilise independently in the home and staff have recently sought advice to identify and purchase a suitable wheelchair for use outside. However, staff reported issues in relation to the use of the wheelchair and their difficulties operating the wheelchair on pavements and kerbsides. The manager is aware of the issues and is actively addressing this in terms of health and safety concerns for staff. The wishes of some residents around dying and the arrangements they want after death had been sensitively discussed during the development of care plans. These wishes are clearly recorded in the individuals care plan so as to be respected and known to staff in the home. One resident had expressed a wish for “friends to gather and celebrate her life”. Dagenham Road DS0000027897.V334879.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The manager and staff make every effort to sort out problems and concerns. However, all complaints, concerns or issues of dissatisfaction must be routinely recorded so it is clear that any concerns have been acted upon and resolved. All staff working in the home have received training in adult protection/ abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There are policies and procedures for dealing with complaints and all residents spoken to were aware of this. From discussions held with residents, they felt able and confident to raise issues of concern, should they feel the need to. One resident said she would “speak to her keyworker or the manager” another said they would “bring it up at the residents meeting”. The complaint log was examined and no complaints had been recorded since the last inspection. The inspector had a discussion with the manager as to what constituted a complaint to be logged. This should include verbal issues of dissatisfaction or concern, as well as formal written complaints or those considered to be of a serious nature. The manager must ensure that staff routinely record all verbal issues of dissatisfaction or concern, so it is clear that such concerns have been acted upon and resolved. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 17 There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff have received training in adult protection/ abuse awareness, and this is would be included in the induction training for any new staff. Those staff spoken to during the inspection were aware of the action to be taken if there were concerns about the welfare and safety of residents. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The premises are homely and the atmosphere in the home is very welcoming. The living environment is appropriate for the particular lifestyle and needs of the residents and is clean, safe and comfortable. EVIDENCE: The home was toured at the start of the inspection, accompanied by one of the care staff, and all areas were visited later during the visit. The home has two adjoining units with four beds in each. Each unit has its own kitchen/ dining area, lounge, bathroom/ toilets, and utility room. There is one staff office, which divides the two units. All the bedrooms are single and there is one with en suite facilities. The inspector visited the bedroom of one resident by invitation. This was furnished and decorated to suit the individual’s preferences and particular needs; and was reflective of her interests and lifestyle. All areas of the home were clean, tidy and free from odour throughout, with the exception of one bathroom, which will be detailed later in this report. A part Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 19 time housekeeper is employed two days a week. There is a small utility room in each unit which residents use, some with the support of staff as part of maintaining their independent living skills. The home is close to community facilities and local services, with good transport links. Since the last inspection new dining room furniture has been purchased for both units; the office has been re-decorated and there is a planned programme of decoration and replacement of carpets for all bedrooms. The residents are fully involved in all decisions about the décor and any changes to the accommodation. The building is owned by East Thames Housing Group (ETHG). The registered organisation is Outlook Care who ultimately have responsibility to ensure that the building and the service complies with the Care Home Regulations 2001. There has been an ongoing problem with damp in a downstairs bathroom, on a part of the adjoining wall to the next-door property. This has been a problem since October 2006 and still has not been successfully resolved in spite of the fitting of a new extractor fan. The bathroom has a very strong and unpleasant odour caused by the damp. The registered persons must resolve the ongoing issue of the damp/ odour problem in the downstairs bathroom, to a satisfactory resolve for the benefit of people living in the home. An action plan will be required for a date for this work to be completed within a timescale of three months. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed staff team who have the skills and training to meet their needs. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Dagenham Road has a small but very stable workforce and a number of staff have worked in the home since it opened in 1992. Staff interacted well, both with each other and the residents, and effective team working was observed and evidenced throughout the inspection. It is evident that the residents have confidence in the staff that care for them, and that staff have a good understanding and knowledge of the individual needs of the residents. In Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 21 discussion with staff it was evident that they understand and fully support the main aims and values of the home. The home uses a small number of bank staff to make up any shortfalls for annual leave, sickness or training. A record is maintained of staff training and records showed that staff have undertaken training in essential areas such as fire safety, food hygiene, protection of vulnerable adults, medication administration and manual handling. Some staff have undertaken training around mental health awareness, working with depression and working with schizophrenia. The preinspection questionnaire completed by the manager states that 100 of care staff are qualified to National Vocational Level 3. This demonstrates a very positive commitment to training both from care staff and the registered providers. There is a training and development plan in place for all staff. The manager completes a training needs plan at the beginning of the year for submission to the organisation’s training department. Training needs are identified as either being essential or desirable. The manager had identified mental health training for all staff as desirable. In view of the specialist mental health needs of the residents in the home it is strongly recommended that this training be considered an essential element of training for all staff working in the home, so as to equip them with the relevant skills. Staff meetings are held monthly and as part of the inspection process the inspector attended one of the staff meetings held earlier in the year. These meetings are held for consultation about proposed changes in the home and the organisation, training and the involvement of staff in the development of the service. All staff have the opportunity to attend these meetings and actively contribute. Individual supervision sessions take place regularly and are recorded in writing. No new staff have been recruited since the last inspection. However, evidence from the last inspection was that: The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, 41, 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The manager of the home is a well qualified and experienced person and residents benefit as the home is run in their best interests. Monitoring visits are undertaken regularly by the responsible individual to monitor and report on the quality of the service being provided in the home. EVIDENCE: The manager has the qualifications and experience to manage the home and is able to demonstrate a clear understanding of the needs of the residents. Ms Dean is very resident focused and works continuously to improve the service and provide an increased quality of life for the residents with the support of a strong team, and in partnership with the family of residents and professionals. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 23 The home benefits from the quality assurance procedures of the registered organisation, Outlook Care. A representative of the registered organisation undertakes monthly Regulation 26 monitoring visits to monitor and report on the quality of the service being provided in the home. A copy of the report is sent to the Commission. The home has responsibility for the personal allowances of some of the residents and secure facilities are provided for their safekeeping, with records being maintained. A wide range of records were looked at including, fire safety; emergency lighting; Portable Appliance Testing (PAT); recording of water temperatures and accident/ incident reports. These records were found to be in good order, up to date and accurate. The inspector had a discussion with the manager around the introduction of the Mental Capacity Act 2005, which becomes effective from April 2007. The manager was aware of this new legislation and had recently attended a workshop with other managers’ from the organisation. She will be discussing this with staff, relatives and people living in the home. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 X 3 3 X Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 25 NO 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 YA6 Regulation 15 Requirement Timescale for action 31/05/07 2. YA20 13 3. YA22 22 4. YA27 YA24 23 The registered persons must ensure that care plans contain more detailed information around individual’s mental health needs. This will ensure that the specialist needs of people living in the home are clearly understood and met. The registered persons must 03/04/07 ensure that risk assessments are completed for all residents who are self medicating and must be regularly reviewed. This will ensure that individuals are administering and managing their medication safely. The registered persons must 03/04/07 ensure that staff routinely record all issues of dissatisfaction or concern, so it is clear that such concerns have been acted upon and resolved. The registered persons must 31/07/07 resolve the ongoing issue of the damp/ odour problem in the downstairs bathroom, to a satisfactory resolve for the benefit of people living in the home. An action plan is required detailing the works to be DS0000027897.V334879.R01.S.doc Version 5.2 Dagenham Road Page 26 undertaken with timescales. 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 YA35 Good Practice Recommendations It is strongly recommended that all staff working in the home undertake ongoing mental health training, so as to equip them with the relevant skills. Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Dagenham Road DS0000027897.V334879.R01.S.doc Version 5.2 Page 28 - 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. 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