Inspection on 04/04/06 for Elmstone, The

This inspection was carried out on 4th April 2006.

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

Other inspections for this house

Elmstone, The 10/09/07

Elmstone, The 16/11/05

Elmstone, The 01/03/05

Elmstone, The 21/06/04

Elmstone, The 27/03/04

Elmstone, The 13/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Elmstone, The 17 Norwood High Street West Norwood London SE27 9JU Lead Inspector Sonia McKay Unannounced Inspection 4 -5th April 2006 09:30 th DS0000022763.V289051.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 DS0000022763.V289051.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. DS0000022763.V289051.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmstone, The Address 17 Norwood High Street West Norwood London SE27 9JU 0208 655 9631 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) elmstone.lambeth@larche.org.uk L`Arche (Registered Office) Mr Flavio Carneiro De Moura Care Home 5 Category(ies) of Learning disability (0) registration, with number of places DS0000022763.V289051.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: The Elmstone is a home for five adults who have a learning disability. It is one of six residential care homes in the area that are part of the Lambeth LArche community. The home is a large Victorian house. Each service user has their own bedroom and access to a communal living room, dining room and kitchen. The Elmstone is in a one-way street, which is not residential, and there are therefore no immediate neighbours. The home is adjacent to the LArche Lambeth head office and workshops, with which it shares a large patio area. The LArche community aims to provide a strong sense of belonging and value for community members and their assistants. There is on street parking available nearby. West Norwood Station is near as is the High Street with bus links, shops, community and leisure facilities. DS0000022763.V289051.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two days and involved talking with two service users, one family member, two members of staff, the home manager, the home’s senior co-ordinator and the activities co-ordinator. Records relating to care, the environment and staff recruitment were examined and there was also a tour of the premises. What the service does well: What has improved since the last inspection? Steps have been taken to ensure that risks posed to a service user from a hot radiator and hot water have been addressed and hot water temperatures are now tested regularly. Lighting in one bathroom has been improved and the types of locks used on bathroom doors have been changed to ensure easier staff access in an emergency situation. Staff on duty were familiar with symptoms to look out for and what action to take if one particular service user showed signs of being unwell. DS0000022763.V289051.R01.S.doc Version 5.1 Page 6 The records of financial transactions and money held in safe keeping by staff on behalf of service users are better maintained and provide service users with an adequate safeguard against financial abuse. 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. DS0000022763.V289051.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 DS0000022763.V289051.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): 1, 2 & 4 Prospective service users have adequate information to make an informed decision to move into the Elmstone. Individual needs and aspirations are assessed and there are extensive opportunities to ‘test drive’ the home. EVIDENCE: There is an informative ‘Statement of Purpose’ and ‘Service Users Guide’ to the home. Emphasis is placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. L’Arche offers long-term placements and there is a lengthy placement process. This is tailored to meet the needs of the individual and involves at least two brief visits to the home and three longer visits, including overnight stays. This provides an opportunity to experience life in the home before making a positive choice to move in for a trial period. There are three service users currently living in the Elmstone and there is no resettlement work underway with any prospective service users. Emphasis is placed on providing staff with communication skills including Signalong training and training in communicating with adults with a learning disability. A database of photographs of all community members (service users and staff), significant locations and other useful objects is being developed to assist with this. DS0000022763.V289051.R01.S.doc Version 5.1 Page 9 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 Service users’ assessed and changing needs are reflected in their individual care plans and service users can make decisions about their daily lives. Risk taking procedures are in place although there is a need to ensure that formal risk assessments are reviewed and developed alongside increasing independence. EVIDENCE: Each service user has a file that contains detailed personal information, assessment information, written care plans and goals, and minutes of recent care review meetings. The placing authority has recently reviewed each persons placement. These files contain a considerable amount of historical information and in some cases conflicting and out of date support guidelines. This is potentially confusing for staff and therefore potentially dangerous for service users. (See recommendation 1) L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a key worker. Service users have a key member of staff to work with who has special responsibility for assisting with decision making, planning and day-to-day arrangements. DS0000022763.V289051.R01.S.doc Version 5.1 Page 10 L’Arche uses a semi-independent advocacy system with people who know the service user well. This ensures that someone from outside the home is involved. When major decisions need to be made L’Arche aims to provide the services of fully independent advocates. Involving people with learning disabilities in decision making is a LArche priority for 2006/07. Service users are encouraged to participate in the dayto-day running of the home and in community planning. They take part in weekly house meetings, ‘talking group’ meetings with the director nine times a year, community council elections and other community gatherings. Service users are involved in the assessment of new staff during their probationary period and increased involvement in staff appraisal is being developed. There has been service user involvement in setting the priorities for the Community as a whole and in the formal review of the day services. The service users make day-to-day decisions about what to wear, how to spend their leisure time, who to invite to dinner and what to cook. All need assistance from staff to manage their own finances. A service user agreed that she was able to make decisions but said, Sometimes I need help (from staff) to choose. She spoke confidently about making decisions. In regard to a previously planned activity she said, Sometimes I do not want to go, so I stay here (at home) instead. Staff are trained in capacity to consent issues and the home manager is aware of the need to involve the service user and multi disciplinary professionals involved in the care of each service user in any decisions made in an individuals best interests. The manager and staff are clear that service users are entitled to take risks as part of developing a more independent lifestyle. However, the written risk assessments held in each service users file do not reflect the current risks being taken. For example, one service user goes swimming without staff support and travels to other activities independently. Risks have been considered informally and the service user carries small cards for the lifeguard explaining that he is epileptic. Many written risk assessments are out of date and contain inaccurate information and misleading risk management strategies. For example, staff are advised to administer PRN medication to one service user during extended epileptic seizures. However, the PRN is not available and staff are not trained. This poses a significant danger to the service user and does not ensure that staff have clear and correct information available to enable them to take appropriate action. The current risks to each service user must be considered and adequate risk assessments developed and reviewed regularly or when needs change. (See requirement 1) DS0000022763.V289051.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Service users have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Appropriate relationships with family and friends are encouraged and supported. EVIDENCE: L’Arche is a faith-based community and offers active support to each service user to develop their faith and spiritual lives. Service users who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature. Each of the service users has a place in the L’Arche workshops (weaving, stone work, gardening and candle-making). Two service users also attend college. The close proximity of the other L’Arche homes provides a close community, and service users regularly visit each others homes for supper. L’Arche Lambeth has been operating for more than 25 years and has developed good relationships with local individuals and organisations. DS0000022763.V289051.R01.S.doc Version 5.1 Page 12 The service users are younger adults and the manager recognises that there is a need to explore appropriate sex/relationship education opportunities. (See recommendation 2) All service users are offered a minimum two weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. Service users regularly attend a wide variety of activities including a disco, swimming, sailing, church services and a mens group. Contact with family is maintained by visits and telephone calls. A family member visiting on the day of the inspection commented that he visited the home regularly and was made to feel welcome. A service user said, Its nice living in the community. Going out for lunch is my favourite. College is good, I like college, I go on holiday. I have been to Canterbury and France and I like going to the park and The food is nice, I like to cook Shepherds pie and mashed potatoes. Another service user said, Living here is fine, the foods good and I like going to the disco and to the pub to play darts and pool. Staff spoke about the ways in which they are supporting the cultural needs of the service users. This has involved researching meals, buying appropriate cookery books, visiting restaurants and other elements of cultural heritage. Staff liaise with family members who sometimes assist in this area. Records of the meals eaten show that a variety of meals are prepared. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Each service user chooses and prepares one evening meal each week to the best of their ability and as part of their skills development. The cooker rings are colour coded to assist service users to identify which knobs to use and there is good visual information about essential food groups and recipes. DS0000022763.V289051.R01.S.doc Version 5.1 Page 13 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 Service users receive personal support in the way they prefer and require. Physical and emotional health needs are addressed but more must be done to ensure that one service user with epilepsy is adequately and safely supported. Service users are encouraged to take responsibility for their own medication where possible although self-medication support guidelines and associated risks must be formalised to ensure safety. EVIDENCE: Times for getting up and going to bed are flexible and reflect planned activities. Service users are able to undertake personal care tasks without support from staff. Risks to a service user who has epileptic seizures are minimised by use of a shower rather than a bath and not having a plug (to prevent drowning). Service users are able to choose their own clothes and hairstyles, with minimal assistance from staff. Assistance provided is advice such as, the need to put on a clean shirt and wear appropriate clothing. Service users are well dressed in clothes that reflect their personal taste and their planned activity. For example, sensible work clothes for a gardening job. LArche is able to provide a degree of consistent staffing despite regular staff turnover. There are four full time staff (two men and two women) and staff DS0000022763.V289051.R01.S.doc Version 5.1 Page 14 shortfalls (as a result of leave or sickness) are covered by other members of community staff who are known to the service users. Staff support service users to make and attend healthcare appointments. Each persons care file has a detailed health information form to be given to medical staff in the event that a service user has to be taken to hospital in an emergency. This is good practice. Health action plans are in place for each person and service users receive regular health checks, for example, dental checks, audiology, chiropody, ophthalmology and well man/woman screening, in addition to individually required healthcare such as neurology. The Lambeth specialist team for adults with a learning disability provides input on referral from the home when necessary. Input includes psychology and speech and language therapy. One of the service users has epilepsy. Although individual epileptic seizures are recorded on the incident logs, the seizure record maintained in the service users file has not been completed for a year. The service user has recently experienced a number of seizures in succession. As the seizures occur at night, staff are not aware until the signs are noticed in the morning. The service user and was previously prescribed the PRN medication. This is no longer available and the current staff team are not trained in the administration of this emergency medication. There is no record of why this option for treatment has ceased. The service user had experienced a seizure on the night before the inspection. He had sustained facial injuries that may have been caused by banging his head on furniture around his bed and friction burns from the carpet. All areas of this service users support needs in regard to epilepsy must be reviewed with input from appropriate professionals and ways in which staff can be alerted to a night time seizure and minimise possible injury should be explored. (See requirements 2 & 3 & recommendation 2) Staff were clear about signs to look out for that would indicate that one service user (who has a cranial shunt) was in need of emergency medical attention. The local pharmacy provides staff with training and supplies prescribed medication in pre-filled measured dose packs. Homely remedies (over the counter medication for minor ailments) are seldom used. There is no stock record book of what is being kept, running stock total or authorisation from each individual service users GP to say that the homely remedy is suitable for use (in case of interaction with prescribed medication). A record must also be kept of their administration. DS0000022763.V289051.R01.S.doc Version 5.1 Page 15 (See requirement 4). Two of the service users are able to take a degree of responsibility for selfmedication. Staff support these individuals to do this in different ways but there are no self-medication support plans or risk assessments in place. (See requirement 5) The medication administration record used to record staff administration of medicines for one service user also records the use of homeopathic medication. This is good practise. Receipts and returns of medication are recorded in a separate log. Staff undergo a two-day training course by a pharmacist. There is an authorised signature list of staff that are trained to administer medication. This list includes the names of staff from other L’Arche homes that occasionally work at the home. DS0000022763.V289051.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 Service users’ views are listened to and acted upon. Service users are protected from abuse by well-trained staff and adult protection policy and procedures. EVIDENCE: There is a complaints policy with a text version and a more accessible version for service users who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area and has colour photographs of people who can assist with a complaint, including the CSCI. Regular house meetings provide service users with an opportunity to raise concerns. The record of complaints shows that there have been no complaints made in the last twelve months. A service user said that she would talk to staff if she had a complaint to make. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. A staff member on duty had a thorough knowledge of signs of abuse, forms of abuse and action to take if he witnessed or suspected abuse. All service users require assistance with financial issues. Receipts are retained for all transactions and stored with the individual accounts that were in good order. A record of visitors is available and is being used appropriately. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. DS0000022763.V289051.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, 26, 27, 28, 29 & 30. Service users live in a clean, comfortable and homely environment. Shared spaces complement and supplement individual living space. However, ventilation in the womens bathroom may be inadequate. EVIDENCE: The premises are safe, comfortable, bright, airy, clean and free from offensive odours with sufficient lighting and heating. The home is in keeping with other homes in the area and is indistinguishable as a care home. The home offers good access to local amenities, transport routes and relevant support services. Furnishings and fittings are of good quality and there is a homely atmosphere with many photographs of service users and their friends displayed on the walls. All bedrooms are single occupancy, well furnished and personalised. The home has a men’s bathroom and a woman’s bathroom situated close to the bedrooms. Both rooms have a WC and a shower facility in the bath. A radiator cover had been fitted to the radiator on the mens side of the house as one of the service users has occasional seizures. Bathroom door locks are of a type that can be opened from the outside in an emergency. DS0000022763.V289051.R01.S.doc Version 5.1 Page 18 A separate toilet is available on the ground floor close to the dining area. There is a ground floor laundry room. A procedure is in place to ensure that soiled laundry is not carried through the kitchen during food preparation to prevent the spread of infection. The home has a communal lounge adjoining the kitchen. There is a separate dining room and large rear courtyard area with a fountain and seating areas. Smoking is permitted in the rear courtyard. Staff who sleep-in at the home have an adequate bedroom and places to keep personal belongings. The ceiling in the womens bathroom has patches of black mould on it, possibly caused by poor ventilation. (See requirement 6) DS0000022763.V289051.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): 31, 32, 33, 34, 35 & 36. Staff have clearly defined roles. Steps are being taken to ensure that staff are equipped with the specialist training required to meet the needs of the service users although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures are adequate and staff are supervised and supported. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Each has a clear job description and contract of employment. Staff do not live on premises but take turns to sleep at the home to provide night cover in case of an emergency. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. A new duty pattern has been introduced to ensure that staff have adequate time off. Records are kept of all staff duty rosters. Between one and two members of staff are on duty in the home depending on the activities and needs of the service users. A framework of policies and procedures provides staff with guidance. There is also ongoing staff support from the homes co-ordinator and other longstanding community staff. DS0000022763.V289051.R01.S.doc Version 5.1 Page 20 As assistants usually only stay for between one and three years they do not normally have an NVQ qualification. The director of L’Arche has conceded that it will be hard for the organisation to meet this standard by 2005. (See requirement 7) Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and has revised the LArche recruitment procedures. Recruitment records examined were in accordance with regulation. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’ and training provided by the local specialist learning disability team. A training co-ordinator has developed a training needs assessment for staff working at the Elmstone and records of training undertaken by individual staff are available. An appropriate range of training, specific to the needs of the service users, is available. The training planned for 2006 and 2007 includes self- injurious behaviour, capacity to consent, risk assessment, using objects, photos and symbols as aids to communication and independence, challenging needs, autism and training around the mental health needs of service users with a learning disability. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along and medication administration. Records of supervision meetings between the assistants and the home managers are maintained and provide evidence that meetings are held regularly. Staff said that they felt adequately supported and that there were always senior staff available by telephone if they needed advice. DS0000022763.V289051.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, 40, 41, 42 & 43. The home manager has recently registered with the CSCI and is completing the necessary vocational qualifications. The views of service users underpin the development of the LArche community, although monthly monitoring on behalf of the provider has not been carried out with the required frequency. Steps are taken to ensure health and safety but some areas must still be improved. EVIDENCE: The recently registered home manager has commenced the required NVQ 4 in Care and the Registered Managers Award. Staff commented that the manager is approachable and has an open and inclusive management style. Staff are comfortable to contribute their ideas and raise concerns if they have them. Records are well maintained although there is a need to archive some material to ensure that current information is easily accessible. DS0000022763.V289051.R01.S.doc Version 5.1 Page 22 The L’Arche community has an annual development plan for quality assurance in place although monthly monitoring visits on behalf of the registered provider have not been conducted with the required frequency. (See requirement 8) Regular house and community meetings are held to ensure that the views of the service users impact on the running of the community and planning home life. Policies and procedures are reviewed regularly and a number have been reviewed or developed in 2004/5, including physical restraint, challengingbehaviour, risk assessment, internal incident reporting, internal financial controls, confidentiality, medication, visitors, transport and recruitment. L’Arche has demonstrated that policy and procedure are reviewed in light of changing circumstances. Staff conduct regular health and safety checks of the premises and record the outcomes. Mains electricity circuitry had been safety checked in October 2004. Small electrical appliances had been subject to an annual electrical safety test in January 2005. (See requirement 9) Hot water temperatures are restricted to within safe limits to prevent scalding. Temperatures are tested and recorded regularly. Temperature checks are conducted on refrigerated items on a regular basis and the results are recorded. Window opening restrictors are fitted. Fire authorities inspected the premises in January 2006 and raised one area of concern; fire doors had been wedged open. The service was required to discontinue the use of wedges. Food hygiene arrangements were inspected in January 2005 and the report confirms that no major issues were identified. Regular checks are conducted on fire detection and emergency equipment both in-house and by professional service. Fire evacuation drills are held with the required frequency and the results recorded. Environmental risk assessments were last reviewed in October 2004. These risk assessments should be reviewed annually. (See requirement 10) Accidents, incidents, injuries and illnesses have been dealt with and recorded and reported appropriately. DS0000022763.V289051.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X 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 2 2 X 3 3 2 3 3 2 3 DS0000022763.V289051.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 YA9 Regulation 14(2)(a) 13(4)(b) Requirement The registered persons must ensure that risks posed to individual service users are reviewed regularly and when needs change. Previous timescales of 30/09/05 and 31/12/05 not met. The registered persons must ensure that the healthcare support needs of a service user with epilepsy are reviewed with appropriate professional input (devices to alert staff of seizures). The registered persons must ensure that advice is taken on whether PRN medication previously prescribed for one service user with epilepsy is still advised. If deemed as necessary staff must be appropriately trained in the safe administration of this PRN medicine and a record kept of individual staff competence. DS0000022763.V289051.R01.S.doc Timescale for action 19/05/06 2 YA19 12(1)(a)(b) 30/06/06 3 YA20 12(1)(a)(b) 30/06/06 Version 5.1 Page 25 4 YA20 13(2) 5 YA20 13(2)(4)(b) 12(1) 6 YA27 23(2)(b)(p) 7 YA32 18(1)(a) 8 YA39 26 The registered person must ensure that if needed, Homely Remedies are stored at the home, with a stock record book of what is being kept, a running total, authorisation from each individual residents GP to say that these Homely Remedies are suitable for use (have no interaction with prescribed medication) and a record of when they are administered. Previous timescales of 31/08/05 and 31/01/06 not met. The registered persons must encourage and support service users to retain, administer and control their own medication, within a risk management framework. The registered persons must take action to prevent mould in the womens bathroom and redecorate ceiling areas affected by patches of mould. The registered person must ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. Previous timescale of 31/12/05 not met. The registered person must ensure that monthly monitoring visits are conducted and the reports DS0000022763.V289051.R01.S.doc 30/06/06 30/06/06 31/08/06 31/08/06 30/06/06 Version 5.1 Page 26 9 YA42 23(2)(c) 10 YA42 23 12(1) 13(4)(a) of the outcomes of these visits be maintained in the home and supplied to the CSCI Southwark office. The registered person must 30/06/06 ensure that all small electrical appliances are safety tested annually. The registered person must 30/06/06 ensure that environmental risk assessments are reviewed annually. 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. 2 Refer to Standard YA6 YA9 Good Practice Recommendations The registered persons should ensure that out of date information held in service users individual care files is archived. The registered persons should consider ways in which the bedroom environment of one service user, who experiences epileptic seizures at night, can be made safer. For example, bedside floor covering that reduces the risk of friction burns and bedside furniture that reduces the risk of injury. DS0000022763.V289051.R01.S.doc Version 5.1 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000022763.V289051.R01.S.doc Version 5.1 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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