Inspection on 01/12/05 for Dunton Road, 71-73

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunton Road, 71-73 27/06/06

Dunton Road, 71-73 03/08/05

Dunton Road, 71-73 02/03/05

Dunton Road, 71-73 27/07/04

Dunton Road, 71-73 30/03/04

Dunton Road, 71-73 27/01/04

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 Dunton Road, 71-73 71-73 Dunton Road Bermondsey London SE1 5TW Lead Inspector Lisa Wilde Unannounced Inspection 1st December 2005 11:00 Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dunton Road, 71-73 Address 71-73 Dunton Road Bermondsey London SE1 5TW 020 7232 0016 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) Three C`s Mr Michael Kimpton Butler Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 7 (seven) people male or female with mental disorder other than dementia, some of whom may be over 65 years old. residents with disabilities which restrict their mobility must be accommodated on the ground floor 3rd August 2005 Date of last inspection Brief Description of the Service: The home consists of two large, older properties that have been joined together. The home is indistinguishable as a care home from the outside. There are seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues but there is no lift in the home. The bedrooms meet the space requirements of the standards as does the communal space. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. The home is close to several bus routes into central London and the surrounding area. The Old Kent Road, which offers shopping facilities, pubs, restaurants and a large supermarket is close by. There are a number of smaller shops and a Post Office in Dunton Road. The home tells service users that its aim is to create a home in the community for people needing support and to provide a high standard of care which encourages independence and individual choice and respects your rights and dignity. The home provides care for up to seven people with mental health issues. On the day of the inspection there was one vacancy. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in December 2005. The inspector spoke with service users, staff and management. There had been a meeting with the Business Manager of the organisation prior to the inspection to gather further information. One of the Commission’s pharmacist inspectors is due to attend the service in the week beginning 03/01/06 to fully assess the medication standard. The service users who spoke with the inspector said that they enjoyed living at the home and they had no complaints. They liked the staff and liked their rooms. They did not talk to the inspector much about specific issues they had about the home but wanted to have more general conversations. The inspector found significant improvement in this service since the last inspection, which had previously suffered from the long-term lack of a permanent full-time manager. The current manager is part-time but it has been agreed with the Commission that this is acceptable as she is due to become permanent at the home by February 2006 at the latest. There is still work to be done at this home to ensure that more of the National Minimum Standards are met but there was evidence from this inspection and the meeting with the senior manager of the organisation that there is a commitment to that improvement and to working closely with the Commission to make things better for the service users. What the service does well: The standards assessed at this inspection the home showed that: • the potential service users’ assessment procedure is thorough and effective. • care plans are comprehensive and clear. • service users are supported to make decisions about their lives as far. • risks are fully assessed and action taken to manage or minimise them. • service users are supported to maintain their relationships with family and friends and to develop new relationships as they choose. • service users choose their food and are encouraged to develop healthier menus and more varied options. • service users health and personal care needs are fully met. • there are systems in place for enabling service users to complain • service users are protected from potential abuse. • the shared spaces of the home are large enough to meet the needs of the service users and the home is comfortable and clean. • service users rooms are all big enough to meet requirements. • the staff team is effectively trained and qualified. • generally the numbers of staff on duty are enough to safely and effectively meet the needs of service users (although there is still some question about the levels of permanent staffing at night). Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 6 • • • staff are effectively supported and supervised by management. the home is well run by a manager who is fit to be in charge and understand the needs of the service users. This manager is currently part-time but is due to become full-time by February 06 at the latest. health and safety systems are being operated at the home 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. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 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 Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 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): 1&2 Work has been done to update the Service User guide and Statement of Purpose but the full information necessary for current service users to understand what they are entitled to at the home is not as yet given out to them. The potential service users’ assessment procedure is thorough and means that service users know that the staff team has decided together that they can meet their needs before they are offered a place at the home. EVIDENCE: There was a previous requirement that the Registered Provider must ensure that copies of the Statement of Purpose and the Service User Guide are sent to the Commission by the target date. The general service user guide had been updated but they were still waiting for the housing association to send through printed versions of their new tenant’s guide and still waiting for the service specific part of the guide to be included. The requirement is partially met and reworded. (See Requirement 1) The home gets referrals from the High Support Rehabilitation Team in the borough and visits them to undertake their own initial pre-assessment with the care co-ordinator. The most recent referral understand but does not speak English to visits were done with their brother who does speak English. The preassessment form covers all the required areas and allows the staff team to make the decision whether they can meet their needs or not. The managers Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 9 discussed how they felt that currently the criteria are not entirely clear and the staff team are not entirely clear whether they are supposed to be accepting higher needs than previously they were required to do. Although the preassessment process is clear further clarification is needed for the staff team to be certain of the levels of risk and need they are expected to work with. (See Requirement 2) Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans are comprehensive and clear which means that staff work with service users to establish what they need and what they want to achieve and how staff will support service users to meet those needs and achieve goals. Service users are supported to make decisions about their lives as far as is possible. They are fully involved in their care and the day-to-day running of the home. Written risk assessments show that any identified risks are thought about with service users and plans put in place that highlight action to be taken to manage or minimise those risks which means that service users are supported to be as safe as possible while at the home. EVIDENCE: There was a previous requirement that the Registered Person must ensure that care plans are in place for all service users resident in the home, even if they are admitted for a short period. The care plans were seen and had been updated to ensure that all service users have them in place. A new service users is in the process of undergoing trial stays before they choose to move Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 11 permanently to the home. The initial assessment has been done and staff are in the process of drawing up the initial care plans. There was a previous requirement that the Registered Person must ensure that care plans are reviewed at a minimum of six-monthly intervals. These were seen and all are now reviewed at least six-monthly. The manager talked about how they are currently discussing as a team how to make care plans more useful documents that are reviewed as needed by staff and service users together. There was a previous requirement that the Registered Person must ensure that documented risk assessments are in place to support staff in dealing with difficult behaviours displayed by service users. These were seen on file for all service users. The manager discussed how staff support servoice users to make decisions. She felt that the staff work in an entirely enabling and empowering manner which allows service users to be given information and make informed choices while being fully aware of any consequences of their decisions. Conversations with staff showed this to be the case. Staff talked with the inspector about the curernt needs of service users and showed a full knowledge and understanding of their needs and how the staff team should work to meet them. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The home is not fully supporting service users to be involved in the local community and stimulating activities both in and outside of the home. Service users are supported to maintain their relationships with family and friends and to develop new relationships as they choose. The staff team support service users to choose their food and encourage them to develop healthier menus and more varied options. EVIDENCE: There is a weekly chart on the wall outlining the activities of the service users. The manager stated that they attempt to link service users into the local community but often this is difficult as service users choose not to do things. The manager stated that they have acknowledged as a team that they are not doing enough in-house to engage and stimulate service users and have planned a meeting to discuss the issues. (See Requirement 3) Most service users have some family and they are involved as much as they choose. They are invited to reviews if the service user wishes it. Development Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 13 of relationships is encouraged although staff said that service users currently have not expressed a desire to develop any further relationships other than those they currently have. Service users choose what they want to eat and staff cook lunch and dinner while service users get their own breakfast. Service users sometimes help out if they are able. They are aiming to encourage more of a communal atmosphere by everyone eating together in the dining area. They have recently decided that they are not eating healthy enough food as a home and are attempting to introduce healthier options and sample meals for service users to try, although service users are free to choose whatever they wish to eat. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Service users’ health and personal care needs are fully met by the staff team or by bringing in external professionals. EVIDENCE: The files showed that healthcare needs are fully assessed and service users are supported to attend regular check ups and specific appointments around any particular problems. Staff and the managers were able to fully describe the current health issues these service users are managing and how those needs were being met by staff or by bringing in external professionals. Service users at this home do not have high levels of personal care needs, just needing support and prompting to enable them to maintain their own care and care of their rooms and environment. There were several requirements in place from the last inspection around medication. The Commission’s pharmacist inspector will be attending. The service in the week beginning 03/01/06 to assess the medication standard. The previous requirements are therefore carried forward but were not assessed on this inspection. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 15 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 Although there are systems in place for enabling service users to complain there is not sufficient evidence to be sure that service users know that their views are listened to and acted on. The lack of advocacy and robust consultation systems at the home means that service users may not be certain that they have the right to complain, may not know how to complain or may not know that there are other people they can complain to other than staff at the home. Service users are protected because staff are trained to understand and react to any potential or alleged abuse of service users and the organisation has policies and procedures in place to tell them what to do in the event of any abuse. EVIDENCE: There was a previous requirement that the Registered Person must ensure that independent advocates are sought for all service users with a specific brief to ensure that they are aware of their right to complain, how to complain and supported to voice any current concerns they may have. The manager said that the organisation and the service users’ care-coordinator are looking into this. The previous issue had been that there is a Complaints Policy and a Complaints Record. Guidance on the book stated that the record was specifically to record informal complaints as well as more serious complaints. There were no complaints recorded in the book. Given the vulnerability of this service user group, the lack of service users guide and the lack of independent advocates at the home the inspector was not confident that the lack of complaints was because everyone was completely happy with this service. (See Requirement 9) Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 16 The organisation has a protection of vulnerable adults policy and procedure and staff have recently attended training in this area. Management and staff were able to describe what they would do if they suspected abuse of any service user. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 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, 28 & 30 The shared spaces of the home are large enough to meet the needs of the service users and the home is comfortable and clean. Service users rooms are all big enough to meet requirements. EVIDENCE: The home consists of two large, older properties that have been joined together. The home is indistinguishable as a care home from the outside. There are seven single bedrooms, one of which has en-suite facilities and is suitable for people who may have mobility issues. The bedrooms meet the space requirements of the standards as does the communal space. The premises are comfortable. There is a small garden to the rear of the house. There are two sitting rooms, a large kitchen with adjoining dining area and a separate laundry area. On the day of the inspection the home was clean. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Service users are being offered support from a skilled and knowledgeable group. Generally the numbers of staff on duty are enough to safely and effectively meet the needs of service users although there is still some question about the levels of permanent staffing at night. Staff are now effectively supervised by management which means that service users are offered a service from staff who have somewhere to go for advice, information and support. EVIDENCE: The manager has conducted a training audit and established what core training and more specialist input the staff team needs. She said that these would become more detailed when appraisals are conducted next year. All staff have completed NVQ Level 2 or 3 in Care. There is a Training and Development Manager within the organisation. Staff said that training they are offered is very good and there is nothing that they felt they needed further training in to enable them to do their jobs. There was a previous requirement that the Registered Person must ensure that a review of staffing is undertaken, specifically with regard to the lone waking night and the lone periods during the day including reference to all recent Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 19 incidents when staff or service users had been vulnerable. This review must be sent to the Commission. The Business Manager had informed the inspector prior to this inspection that this review had been undertaken but it had not been sent through to the Commission. The rota had been altered to get rid of the periods during the day when there was only one member of staff on duty but there is still one member of staff on duty at night. The manager stated that they are free to bring extra staff in should they feel that risk of current service users has increased and the double staff is needed for a period of time. The issue mentioned previously about the staff team not being clear about the levels of need they are expecetd to work with at this home links to this area as increased need would mean they would need to have two staff on duty at night. Following finalisation of the criteria at this home the staffing will need to be finally reviewed to ensure that night time cover is sufficient to meet that need. (See Requirement 10) There was a previous requirement that the Registered Person must ensure that POVAFirst checks are completed for all staff who have not received back enhanced CRB checks. This has been done. There was a previous requirement that the Registered Provider must ensure that staff receive regular recorded supervision at least six times a year covering all the issues detailed in standard 36.4 and ensures that the appraisal system is implemented. Supervisions were seen and the manager has now initiated supervisions for all staff approximately every six or seven weeks. Appraisals have not begun yet as the manager stated that she had not been in post often enough and did not know the staff well enough yet. She plans for the appraisals to start next year. Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 20 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 Generally the home is well run by a manager who is fit to be in charge and understand the needs of the service users. The management structure at the home is not clear to the managers or the staff team and the nursing manager role is causing confusion to the team about what type of referrals they may be expected to take at the home. There is no way for failings in the systems to be identified or for the home to develop and improve in a way that is based on the views of service users, families and other stakeholders. There is now a plan for this to be introduced. The people who are in day-to-day contact with the home and service users are not fully clear about how to manage all health and safety issues. EVIDENCE: There was a previous requirement that the Registered Person must submit an application for a manager to be registered under the Care Standards Act 2000. This has not happened and is repeated. (See Requirement 11) Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 21 There was a previous requirement that the Registered Provider must ensure that full-time manager is in post at this service who is able to fulfil the requirements of the post and of the Registered Manager role with the Commission. There is a manager in post who is currently part-time but due to become full-time by February 06 at the latest. This manager showed that she was competent and effective during this inspection with a full understanding of the needs of the service users and how the staff team should meet those needs. She is due to start the Registered Managers Award NVQ Level 4 in January 06. There is another manager who has been employed from an agency who has been employed as a nurse in the home. These managers discussed the management structure with the inspector and it became clear from this and previous discussions with staff that the structure causes confusion for the staff team. The manager is not certain that the nurse manager is her deputy and staff are not clear about who has seniority or more responsibility between the two managers. The managers have not seen their job descriptions. The nursing aspect of the one post implies to that the home can take nursing care service users, which it is not registered to do. Staff can be hired who have a nursing qualification but a nursing qualification cannot be a requirement of any post. (See Requirements 12 & 13) There was a previous requirement that the Registered Person must ensure that an effective quality assurance system, based on seeking the views of service users, their families and other stakeholders, is in operation at the home. The Business Manager had met with the inspector prior to the inspection and discussed how the organisation is bringing in external assessors to undertake an audit. The inspector discussed with staff how an internal system understood and operated by staff and service users would also be necessary. (See Requirement 14) There was a previous recommendation that the Registered Person should consider using an externally recognised professional quality assurance tool in the home. The planned external audit will be assessed at the next inspection. There was a previous requirement that the Registered Person must ensure that the COSHH cupboard is locked at all times and that hazardous substances are stored safely in this cupboard. On this inspection the cupboards were locked. There was a previous requirement that the Registered Person must ensure that the Fire Safety systems are operated consistently and as planned specifically with regard to fire drills and fire system testing. The housing officer stated that now when she is in leave another member of staff will operate the systems. The records were checked and the checks and drills are taking place as planned. There was a previous requirement that the Registered Person must ensure that all health and safety risk assessments are completed and on file and that regular health and safety checks occur as per policy and are recorded. There was some confusion between staff as to where the files were and which health Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 22 and safety syetms were in operation. The manager felt that this was because the health and safety systems are currently operated by the housing association or by senoir members of staff in the organisation. The staff undertake weekly health and safety checks of the building which were recorded and general maintenance issues are handled promptly by staff. Although some work had been done in this area, more work is necessary to ensure that all staff are clear about everyone’s responsibilities and the recording of any issues is understood and monitored by the staff team. (See Requirement 15) Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dunton Road, 71-73 Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 2 2 X X 2 X DS0000007100.V269699.R01.S.doc Version 5.0 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 YA1 Regulation 4&5 Requirement Timescale for action 31/03/06 2 YA2 3 YA12YA13 4 YA20 The Registered Manager must ensure that all service users are issued with the up-to-date service user guide and a copy of the housing association’s tenants’ handbook. 12(1)(a) The Registered Individuals 31/03/06 13(4)(c) must ensure that the staff team and potential referral sources are clear about the admission criteria and levels of need the home can work with. 16(2)(m)(n) The Registered Manager must 31/03/06 ensure that all service users have an individual programme of appropriate and stimulating activities within and outside of the home. 13 (2) The Registered Person must 31/03/06 ensure that the systems in place for recording and monitoring the administration of medication in the home are used effectively and consistently specifically that staff sign the medication adminstration records for all mediciation administered or notes are made when medistration is not DS0000007100.V269699.R01.S.doc Version 5.0 Dunton Road, 71-73 Page 25 5 YA20 13 (2) 6 YA20 13 (2) 7 YA20 13 (2) 8 YA20 13 (2) 9 YA20 22 (2) 10 YA33 13(4)(c) administered. Previous requirement not assessed at this inspection. The Registered Person must ensure that an effective system of stock tracking and checking all medication is in place. Previous requirement not assessed at this inspection. The Registered Person must ensure that medication is counted and checked when it is handed over the the chemist courier for collection. Previous requirement not assessed at this inspection. The Registered Person must ensure that the systems in place for recording and monitoring the use of PRN medication is used effectively and that management regularly check the use of these medications. Previous requirement not assessed at this inspection. The Registered Person must ensure that a comprehensive action plan (drawn up by senior management as requested) is in place that addresses all the issues highlighted in the last Community Pharmacist letter of January and February 2005. Previous requirement not assessed at this inspection. The Registered Person must ensure that independent advocates are sought for all service users with a specific brief to ensure that they are aware of their right to complain, how to complain and supported to voice any current concerns they may have. Previous requirement: Unmet timescale 31/12/05 The Registered Individuals DS0000007100.V269699.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Page 26 Dunton Road, 71-73 Version 5.0 18(1)(a) 11 YA37 11 (1) CSA 12 YA37YA38 18 (1) (a) 13 YA37YA38 18 (1) (a) 14 YA39 24 15 YA42 13(4)(a)(c) must ensure that following finalisation of the admission criteria, the night time staffing levels are reviewed to ensure that permanent staffing levels are sufficient. This review must be sent to the Commission. The Registered Person must submit an application for a manager to be registered under the Care Standards Act 2000. Previous requirement: Unmet timescale 01/07/05 & 07/10/05 The Registered Individuals must ensure that both management posts are clearly defined, that job descriptions are given to the managers and that the authority and responsibility levels are clearly explained to the staff team. The Registered Individuals must ensure that a nursing qualification is not made a requirement of any post at the home. The Registered Person must ensure that an effective quality assurance system, based on seeking the views of service users, their families and other stakeholders, is in operation at the home. Previous requirement: Unmet timescale 31/12/05 The Registered Manager must ensure that all management and staff are made aware of all the health and safety systems that are operated and recorded in the home and understand how they link to their own health and safety responsibilities. 31/12/05 31/03/06 31/03/06 31/03/06 31/03/06 Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dunton Road, 71-73 DS0000007100.V269699.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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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