Inspection on 21/08/08 for Elwis House, 1

This inspection was carried out on 21st August 2008.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elwis House, 1 08/06/07

Elwis House, 1 18/12/06

Elwis House, 1 18/01/06

Elwis House, 1 22/09/05

Elwis House, 1 01/11/04

Elwis House, 1 23/04/04

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 13/11/2008.

CARE HOME ADULTS 18-65 Elwis House, 1 2-8 Bell Green Lane Sydenham London SE26 5TB Lead Inspector Lorraine Pumford Unannounced Inspection 21st August 2008 11.00 Elwis House, 1 DS0000025617.V365745.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 Elwis House, 1 DS0000025617.V365745.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. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elwis House, 1 Address 2-8 Bell Green Lane Sydenham London SE26 5TB 0208 778 9485 0208 297 1207 ask@providenceproject.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) PLUS (Providence & Linc United Services) Paul Thomas Revely Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 8th June 2007 Date of last inspection Brief Description of the Service: Elwis House provides a residential service to a maximum of four people with learning disabilities and high support needs, including older people suffering from dementia. The home is run by a registered charity PLUS in (Providence & Linc United Services). Accommodation is provided in a purpose built ground floor home, designed to meet the needs of people using wheelchairs. All residents have their own bedroom. The area is served by public transport and has a selection of shops and local amenities. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star this means that people using the service receive an adequate service. The inspection was a key unannounced inspection. We looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. We were able to observe the support given to the current residents and to talk to residents individually. The inspector was also able to spend time talking to the registered manager as well as the care staff on duty. The homes Area manager was in attendance for part of the inspection and also provided some information. We undertook a tour of the premises and also looked at a range of records including resident records, staff files and health and safety documentation. The home had completed self-assessment questionnaire (AQAA) prior to the inspection. Current fees range from approximately £936.26 to £1045.67. What the service does well: What has improved since the last inspection? Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 6 A requirement was made at the last inspection with regards to care plans, residents now benefit from having care plans completed in sufficient detail to enable staff to meet their assessed need. The home has made some progress in supporting the residents to enjoy a range of activities during the daytime based on their individual interests. Requirements made at the time of the last inspection in reguards to medication have been addressed. 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. Elwis House, 1 DS0000025617.V365745.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 Elwis House, 1 DS0000025617.V365745.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that a comprehensive assessment of their needs will be undertaken to enable staff to provide the care they are assessed as needing. EVIDENCE: The resident group has remained the same since the last inspection and no new residents have been admitted to the home. The manager stated that the organisation has procedures in place to ensure that a comprehensive assessment of need will be undertaken prior to any person being admitted to the home. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having care plans completed in sufficient detail to enable staff to meet their assessed need. Current risk assessments are generic and must be designed specifically to promote individual residents health, safety and well being. EVIDENCE: A requirement was made following the last three inspections regarding the need for care plans to be reviewed and updated to meet the changing needs of the people accommodated. Following the organisations ongoing failure to meet this requirement a Statutory Requirement Notice was issued. There was evidence that action has been taken to address this requirement. On this occasion two care plans were examined in detail and two more were examined in relation to activities. There was evidence that reviews have taken place. Information was recorded in sufficient detail to provide staff with guidance on how to meet individual peoples assessed needs however Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 10 information continues to be held in four different files and logs making it difficult to find information promptly. Discussion took place with the manager and area manager regarding a simpler format. Each resident had a named key worker who has an additional responsibility for supporting the resident they work with by helping with personal shopping, attending healthcare appointments, ensuring all the residents personal care needs are met. Risk assessments seen are currently generic, for example guidance for staff on how to use a hoist. The area manager stated that all staff have received comprehensive risk assessment training and stated that risk assessments for each individual person living in the home will be in place by the end of September 2008. The four people living in the home have disabilities which affect their lives in very individual ways and therefore residents are consulted and supported on a one-to-one basis to make decisions about their lives. Three of the people living in the home have very limited verbal communication skills and there is guidance in their care plans for staff regarding how residents express themselves for example by using signs or facial expressions etc. A resident spoken with said staff supported her both in and outside the home. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to develop their daily living skills and are also enabled to follow their own routine. The home has made progress in supporting the residents to enjoy a range of activities during the daytime based on their individual interests. Residents are offered a healthy and varied diet. EVIDENCE: A requirement was made at the time of the last inspection regarding the need for residents to be provided with more opportunities to participate in suitable activities. None of the people living in the home are able to participate in employment or full-time education however the manager stated that a member of staff will be supporting a resident who is able to attend adult education classes in cooking and pottery the residents spoken with stated that Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 12 she was looking forward to this. Staff also support this person to attend a weekly club in the community. Three people living in the home have physical disabilities and in the past this has limited their access to participating in a varied range of social activities. Since the last inspection staff have worked hard to find more varied activities for residents and each person has a weekly activity plan. In May the provider hired a minibus and staff supported residents on a day trip to the coast. Staff also supported residents on individual shopping trips and outings to the local park. Staff also support residents to have individual holidays. Staff are currently arranging for one resident to stay in Blackpool so that he can specifically see the light displays later in the year. PLUS also run their own social club and some of the resident attend this group and join in art and craft, bingo and keep fit sessions. Unfortunately two of the residents living in the home do not have any regular contact with relatives. The manager stated that one resident has relatives who visit every day and they keep in telephone contact with another residents relatives who are unable to travel the distance on a regular basis. One resident is able to participate in some household tasks and also enjoys cooking and discussion took place regarding the need to include this area in the persons care plan with appropriate risk assessments. The home does not have a written menu, three of the people living in the home are unable to verbally express their likes and dislikes. Records seen indicate staff have recorded this information based on peoples reactions to food served to them over the time they have been living in the home. Staff maintain detailed records of all food and drink provided to residents during the course of the day. Records seen indicate people are provided with a varied nutritious diet. The majority of residents require assistance with eating and staff were seen to assist people in a calm and relaxed manner. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported in a manner that protects their privacy and dignity. Each person is supported to access professional healthcare based on their individual needs. Medication practises must be reviewed and updated to safeguard residents and staff. EVIDENCE: We observed during the inspection that staff were supporting the people living in the home to receive personal care in a manner that respected their privacy and dignity. It was observed that all the residents were wearing clothing that was in good condition and was appropriate for their age and the time of year. We looked at the healthcare records for two people living in the home. They had been supported to access a range of healthcare professionals including the GP, dentist and chiropodist. There was evidence that GPs had undertaken medical reviews. One resident had a pressure area at the time of our last visit and the district nurse has Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 14 provided written guidance for staff to help prevent the pressure area from returning. We looked at procedures in relation to the storage, recording and administration of medication. Medicines are provided by a local pharmacist who also undertakes regular audits of the system in place and provide some staff training. Discussion took place with the manager and area manager regarding the need for staff to have formal training in relation to medicines and their administration. We found that medication was safely stored and a record is kept of medication received and returned to the pharmacy for safe disposal. Two requirements were made at the time of the last inspection in relation to medication procedures and action had been taken to address these, however action is required to address the following issues. There should be a record of staff names and the signature they use on the MAR sheet (Medication Administration Record) for purposes of auditing the system. Hand written entries on the MAR sheet should be signed by two people to minimise the risk of an error. Staff had opened a second box of medicine when there were still tablets in the first box this makes auditing of medication more difficult. It was good to see there was a protocol in place for the administration of paracetamol PRN for one person, staff were advised that guidelines in relation to medication administered in care homes have been updated and include the need to develop a protocol for the administration of medication to residents who are unable to verbally express themselves to provided guidance for staff when to administer PRN medication. Additionally staff need to maintain an ongoing record of all medicine prescribed to people living in the home and staff need to be assessed as competent to administer medication on an annual basis. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures and training on safeguarding vulnerable adults are in place to protect the residents. Procedures in place ensure residents personal monies are being managed appropriately. EVIDENCE: The AQAA stated that there have been no written complaints made to the manager since the last inspection. One complaint was made to the commission and a random Inspection was undertaken and our findings are detailed in a separate report. There have been no adult protection issues since the last inspection. Copies of the organisations procedures and social service procedures are available in the home. All staff working in the home had received training in relation to safeguarding adults as part of the staff induction and there are regular training updates in relation to this area. We checked the personal finances for two residents who are supported by the home to manage their monies, including their cash record, cash and receipts. There is an individual finance record for each person and cash is held in a lockable cabinet. All expenditure is recorded and receipts are available. The record of expenditure was inspected, money had been spent appropriately and Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 16 receipts were available. Money being held on residents behalf tallied with records seen. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a clean, well-maintained home like environment. EVIDENCE: Residents live in a purpose-built home and all resident accommodation is on one level. There are private flats situated on upper floors, however residents of Elwis house have sole use of the small garden. We undertook a tour of the premises. Each resident has their own bedroom and share the toilets, shower and bathroom. There is a kitchen diner and a large lounge. There is an office which is also used as the staff sleeping in room. There is a small but well equipped laundry and staff stated that the equipment meets the needs of the people accommodated. On the day we visited a considerable amount of dust has built up around equipment and discussion Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 18 took place regarding the need for the area to receive a thorough clean to maintain a good standard of hygiene and safety in the laundry. The other rooms in the home seen were clean and tidy. One resident showed us her bedroom and said she was very “pleased with her room” and liked to keep it clean and tidy. All of the residents bedrooms were individually personalised and where necessary appropriate equipment has been installed to assist staff with moving and handling of residents. Residents have their own bedding and towels which are stored in their bedroom when not in use. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive a range of training, however evidence of staff training must be available for inspection and both residents and staff would benefit from more staff undertaking the NVQ 2 in care. Recruitment procedures help protect people living in the home. Staff benefit from regular supervision. EVIDENCE: We looked at the staff roster and this was an accurate reflection of people working in the home that day. The rota indicated that three people including the manager work an AM or PM shift, this staffing level needs to be maintained as a minimum as the majority of people living in the home require the assistance of two members of staff to help with personal care. At night there is one member of staff awake and one person sleeping in on-call. The Manager stated that the home has operated with out its full quota of permanent staff for some months and shifts have been covered by bank or agency staff, the manager stated that they always try to use the same carers to provide continuity of care for residents. Residents also benefit from the fact Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 20 the majority of permanent staff have worked in the home for a number of years. The area manager stated that the organisation has recently undertaken a recruitment drive and interviews had been arranged for the week following our visit. The manager stated that he would be part of the interview process and residents who are able will also be involved in the recruitment process. As part of this inspection two inspectors visited the organisations head office to view staff files in relation to the organisations recruitment procedures. The staff files for three people working in Elwis House were examined these indicated that prospective staff had been asked to provide appropriate ID, two of the files examined contained two references however one person had been employed (over two years ago) with only one reference. All of the staff had POVA/CRB checks. At present the home does not meet the National Minimum Standards as less than 70 of care staff working in the home hold a NVQ 2 qualification in care. Since our last visit one member of staff has attained an NVQ 3 qualification in care. The manager stated that the organisation provides comprehensive training however from staff records kept in the home it was not possible for the manager to provide us with evidence of this training. Evidence must be provided that staff undertake training appropriate to the work they carry out. The manager agreed to submit a training matrix for staff working in the home. At the time of writing this report this information had not been forwarded to us. We looked at the supervision records. All the staff receive regular individual supervision. The format used for supervision is appropriate and includes a record of any action agreed. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from the home being run on a day-to-day basis by a permanent manager. The provider must provide evidence that there is a monthly quality monitoring system in place. Residents and staff will benefit from the implementation of up-to-date health and safety policies and procedures. EVIDENCE: The manager has a number years experience of working with people who have learning and physical disabilities. The manager is registered with the CSCI and hopes to complete the registered manager award in the near future. The manager stated that PLUS arrange six monthly consultation groups which people living in the home are assisted to attend and they also seek the views of people using the service through the distribution of questionnaires. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 22 The area manager stated senior managers undertake a regular monthly audit of the care and service provided in the home. The last copy of a monthly audit (regulation 26 monitoring visit) that could be located in the home was for April 2008. Action is required to ensure that these reports are kept in the home and made available for inspection. The manager stated he is also required to complete audits to provide ongoing feedback to PLUS. Records seen indicate that there are regular checks to the fire detection system and to firefighting equipment in the home. There was evidence that staff participating in fire drills and the manager was advised to record the time of day that the fire drill was held and to ensure that night staff also included in training. Information provided at the time of inspection indicated that all staff have received food handling training. Information recorded in the AQQA indicates that some policies and procedures had not been reviewed since 2005; these include the fire safety policy, the health and safety policy, and the food safety and nutrition policy/procedure. The manager stated that these were due to be reviewed later this year. It is recommended that policies and procedures are reviewed on an annual basis. One of the residents uses an electric wheelchair on a daily basis and at present this is recharged in the persons bedroom overnight. The manager was asked to discuss this practice with the fire brigade community safety officer to ascertain if any additional safety measures are required. The AQAA showed that all the health and safety maintenance checks had taken place. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 X 2 2 X 2 X Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13 Requirement The registered person must ensure that there are risk assessments in place for each person living in the home that promote residents independence whist minimising the risk of harm to residents. The registered person must ensure that there are safe practises and procedure in place in relation to the administration of medication. In this instance There should be a record of staff names and the signature they use on the MAR sheet. Hand written entries on the MAR sheet should be signed by two people to minimise the risk of an error. Medication procedures should require Staff to open and use one box of medication at a time. The responsible person must ensure that staff responsible for the administration of medication receive appropriate training from a suitable qualified source in relation to safe medication procedures. DS0000025617.V365745.R01.S.doc Timescale for action 30/10/08 2 YA20 12 30/10/08 3 YA35 18 30/12/08 Elwis House, 1 Version 5.2 Page 25 4 YA35 18 5 YA39 26 6 YA42 13 The responsible person must be able to evidence that staff 30/11/08 working in the home are suitably compedent, qulaified and trained to undertake their work. The responsible person must ensure that monthly audits of 30/10/08 the service take place and a copy of their report is kept in the home and available for inspection. The responsible person needs to 30/11/08 ensure action is taken to reduce the risk of fire in the home. In this instance check with the fire authority regarding the charging of electric wheelchairs in the home. 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 YA9 YA16 Refer to Standard Good Practice Recommendations It is recommended that the care plan is simplified and made more user friendly. Residents responsibility regarding participation in household tasks should included in the homes Statement of Purpose and the residents care plan. Staff should ensure there is a protocol for the administration of medication to residents who are unable to verbally express themselves to provided guidance for staff when to administer PRN medication. Additionally staff need to maintain an ongoing record of all medicine prescribed to people living in the home and staff need to be assessed as competent to administer medication on an annual basis. Action needs to be taken to clean the Laundry. The organisation needs to continue to work towards a minimum of 70 of people working in the home attaining an NVQ 2 in care. DS0000025617.V365745.R01.S.doc Version 5.2 Page 26 3 YA20 4 5 YA30 YA32 Elwis House, 1 6 7 YA37 YA40 The manager should complete a suitable qualification care and management. The organisations policies and procedures should be reviewed on an annual basis. Elwis House, 1 DS0000025617.V365745.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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