Inspection on 25/05/06 for Evergreen

This inspection was carried out on 25th May 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 24/05/07

Evergreen 30/12/05

Evergreen 15/06/05

Evergreen 18/11/04

Evergreen 05/05/04

Evergreen 06/01/04

Evergreen 12/03/03

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 Evergreen 55 Barrow Road London SW16 5PE Lead Inspector Barbara Ryan Unannounced Inspection 25th May 2006 9:30 DS0000022799.V295675.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 DS0000022799.V295675.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. DS0000022799.V295675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 55 Barrow Road London SW16 5PE 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) 0208-677-4273 Jane’s House Limited Mr Atmah Victor Barsati Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places DS0000022799.V295675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: Evergreen residential care home provides accommodation and support for up to three adults who have support needs due to enduring mental health difficulties. At the time of this inspection there were no vacancies. The service is located in a former private house, which is sited in a quiet residential street and is indistinguishable from other houses in the street. The home is situated close to shops and amenities and has good access to public transport. The registered manager owns the property and also owns two other small homes nearby. During the inspection it was evident that the home has been well maintained and offers a homely physical environment for service users. It is laid out over three floors. The ground floor has a staff office, kitchen/diner, and a large communal lounge area. To the rear of the home there is a large garden. The first floor has the service user bedrooms, a toilet, and a bathroom with shower facility and toilet. The upper floor has sleeping accommodation for staff. The home provide information to potential service uses via their service uses guide, statement of purpose, their website and by phoning the home and arranging to view home. CSCI inspection reports are available in the communal areas. The weekly cost of the home is from £320.00p to £450.00. There are additional charges made for toiletries, hairdressing newspapers and holidays. DS0000022799.V295675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was completed between 9.30am and 5.00 pm. The method of inspection included a tour of the building, speaking to all three residents, speaking to one visiting relative, looking at all three residents care plans, discussion with the deputy manager and one member of staff, as well as observation of interactions between staff and residents and a sample medication count What the service does well: What has improved since the last inspection? What they could do better: The home should continue to work to ensure that their statement of purpose contains all the information required in it and provide information about independent advocacy in the complaints policy. Risk assessments should be regularly reviewed and there should be information about residents’ finances DS0000022799.V295675.R01.S.doc Version 5.2 Page 6 and financial assessments. Residents who self medicate should have risk assessments completed for them. Residents who benefit from having their weight monitored should have this done consistently. The home should ensure it has multi-agency procedure/guidelines on protecting vulnerable adults, and all staff have received training in it. The home should ensure the rotas accurately reflect who is on duty. The home should carry out an annual residents and stakeholder survey as part of their quality assurance. It should ensure that all hot taps have a thermostat fitted and refit the missing tile and replace the sealant around the bath. The home must carry out appropriate fire alarm test and fire drills and kept records of fridge and freezer temperatures. 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. DS0000022799.V295675.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 DS0000022799.V295675.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5. Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. The home have a statement of purpose and services user guide, these do not contain all the information required. The home has a policy of fully assessing all residents prior to admission. All the residents have contract of term and conditions. EVIDENCE: The statement of purpose for Evergreen House does not contain the information required under Schedule 1 of the regulations. The service user guide has a section on complaints; this should have information about how to contact an independent advocate for support if required. The home has had no new residents since the last inspection and all residents have lived at the home for several years. The home has a policy of obtaining a full assessment of the prospective resident’s needs and will also complete their own assessment. Prospective residents are encouraged to visit the home prior to admission. All the residents at the home had a contract of terms and conditions in their file. One resident did not have the fee on the contact, however this contract had been issued several years ago. DS0000022799.V295675.R01.S.doc Version 5.2 Page 9 DS0000022799.V295675.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. The home has introduced a new system of reviewing care plans and are establishing this. Care plans supported residents to make decisions about their lives. More information is needed with regard to residents’ needs around managing their money. Risk assessment should show evidence of an annual review. EVIDENCE: All three care plans were looked at. These had sections for any identified need, the objectives and actions required to meet it. The deputy manager said that they review care plans every three months, the key worker will go through the daily records and other information and this will be used to draw up a new care plan. Care plans for people over 60 years need to be reviewed monthly and there was not evidence of this. All files had risk assessments, these were quite comprehensive, with information around issues to do with triggers for behavioural issues or deteriorations in the person’s mental health and what actions to take. There DS0000022799.V295675.R01.S.doc Version 5.2 Page 11 remain some gaps in the record of them being regularly reviewed ever year and tippex had been used with regard to the date on one risk assessment which was confusing. Care plans need to be more specific with regard to residents’ needs around managing their money. One resident manages their own money without having any trustee or appointee; however, their care plan it states they are unable to manager their money without support. The deputy manager said that this referred to the support the resident needed with budgeting the personal allowance they get rather then a cognitive lack of ability. The care plan needs to explain in more details the residents’ needs with regard to managing his money. One resident has their money managed by a receiver appointed by the Court of Protection. It had been hoped that they would be supported to be more involved in managing their personal allowance and open a post office account. At present this has not happened. There was a requirement regarding the need for information about their entitlement, how the trust affected them and their finances as well as a running total to be kept of the amount the resident had and saving held for them. The deputy manager was aware of this resident’s anxiety about their saving and money held for them. The requirement still stands with regard to the information the home should have recorded; however, the home should work at the residents pace with regard to supporting them to be more independent in managing of their personal allowance. DS0000022799.V295675.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13,14,15,17. Quality in this outcome area is good. This judgment is made using available evidence including a visit to the service. Residents are able to benefit from opportunities for personal development, as well as access activities that they are interested in; they are able to maintain links with their family, access the local community and exercise choice over how they spend their day. Residents do not at present have keys to their rooms, whilst this has not been an issues in the past, the deputy manager will relook at this. Residents are able to access a healthy diet. EVIDENCE: All three residents were spoken to. They confirmed that they choose the activities that they undertake. All the residents had very different daily routines and interests that they follow. One resident spends their days mainly out of the home pursing his own interests quite independently, travelling on public transport using their bus pass, another spend more of their time in door, but going out on their own for walks in the local area. One resident is exploring options with regard to further volunteer work and their interests around music as well as beginning to think more about whether they might look further at DS0000022799.V295675.R01.S.doc Version 5.2 Page 13 issues around moving on in the future to more independent accommodation. All the residents either do their own shopping or are supported to shop with a carer accompanying them. Residents can cook for themselves and if needed will be supported in the kitchen. The home has a visit from the activities organisers two day a week. The home does not have a weekly programme; all activities are very much centred on individual resident’s wishes and choices. The deputy manager said that there was however a routine around some aspects of the home, i.e. residents had particular days when they might do their washing with the support of staff if needed. The home will organise group trips out at times and invite residents to barbecues etc. at a nearby home run by the organisation. All the residents said that they are free to have friends and family visit them at the home. There is a pay phone in the hall and this was being used by a resident on the day of the inspection. Residents are given their own post. The deputy manager said they would wait until residents came to them if they had any issues around post or letters they needed support with. None of the residents have keys to their rooms; the deputy manager said that this has not been an issue but is happy to relook at whether residents would like keys to their room, and if so would complete a risk assessment around this and give residents keys if they wish. Interaction between staff and residents was informal and relaxed, with staff supporting a resident around a particular issue on the morning of the inspection. The home has offered residents holidays, but report that residents have not been interested with this offer. Residents may have their own ideas around what sort of holiday destination they may like and this could be explored with residents and the multi- disciplinary team that know them. DS0000022799.V295675.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20.21. Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. Residents are supported in ways they prefer and their health and emotional needs are meet. The home should be consistent in monitoring the weight of residents who need this. The home has improved their management of medication. They need to continue work began around recording residents’ wishes with regard to illness and death. EVIDENCE: Residents are supported to maintain their physical and emotional health according to their needs. Residents’ files and care plans give information about residents’ health needs. Residents are fairly independent with regard to personal care; one resident has been assessed by the occupational therapist and has been provided with bathing equipment. Staff will support residents with personal hygiene mainly by encouragement rather than providing direct physical care. A record is kept of one resident’s weight, although there were some gaps in the monitoring of their weight. Other residents weight is not regularly monitored as this is not an issue. The home should weigh regularly residents that need and benefit from regular support to maintain or reduce their weight. DS0000022799.V295675.R01.S.doc Version 5.2 Page 15 The home has worked with one resident to support them around a recently diagnosed condition. The home have tried to support one resident with blood sugar level testing, but this did not work satisfactorily, so the home liaised with health professionals around other methods and means of doing this. Residents are in contact with various health professionals including care coordinators, psychologists and social workers. The deputy manager said they felt that they were well supported by other professionals and could discuss problems or issues with them if they needed. The home has begun gathering information around residents’ wishes and views regarding aging and death. There is little information on the information sheet they have produced. The deputy manager said that they are looking at how best to discuss this issue further with residents. The home has one resident who self medicates and travels independently to a clinic once a fortnight to receive injections. The home has a list of the person’s medication but have not completed a risk assessment. The resident was managing their own medication prior to coming to the home. The home must complete a risk assessment and ensure that all medication is returned to the pharmacy. Other residents are supported with their medication. The home have introduced a running total for the amount of medication they have left for each resident to ensure that they have the correct amount and this corresponds to the medication signed for from the pharmacy. The deputy manager said that they have found this method has improved their management of the mediation. Two staff from the home are on a six-month course around mediation and this has been very helpful. At the last inspection there was a requirement with regard to staff not signing for the meditation as given if the resident was going out. This situation has resolved itself as the resident doesn’t need medication in the middle of the day now. A sample pill count was done and the amount tallied with the records. There had been a recommendation with regard to contacting mental health organisation that might offer information and support to service users, and could act as a resource to staff. The deputy manager said that this had now been resolved. He said that they were aware of a number of organisations they could contact and also accessed the Internet for other recourses when needed. DS0000022799.V295675.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. The home have an appropriate complaints procedure, they need to obtain a copy of adult protection guidelines and all staff that have not received training in this area should complete some. EVIDENCE: The home has a complaints procedure. They have had no complains for some time before the last inspection. The home has a complaints book on a chest of drawers in the hall for residents or visitors to look at or write in. The home has information on the protection of vulnerable adults; the deputy manager said that they did have a copy of the multi-agency procedure, but could not find it. The home needs to obtain a copy of this. The member of staff spoken to was aware of issues around the protection of vulnerable adults. Two of the three care staff have had certificates in their files with regard training in on adult protection, all care workers must have training in this. DS0000022799.V295675.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. The home offers residents a pleasant and well-maintained environment, which is homely and uninstitutional. There are some minor repairs needed in the bath surround and tiles. Issues around residents having keys to their rooms needs to be relooked at. Not all the taps had thermostats and these should be fitted to ensure residents safety. EVIDENCE: The home is situated in a Victorian house in a residential street. There is a communal sitting room with french doors leading to a pleasant and wellmaintained garden. There is a kitchen with dining area to the rear of the ground floor. The front room on the ground floor is used as an office. There are three residents’ bedrooms on the first floor, a bathroom and WC and a separate WC on the same floor. The home is furnished in a homely and attractive manner, with an upright piano and a TV in the sitting room. The home has pictures, ornamentation, and plants in all the communal areas. The effect is very homely, with an atmosphere as a family home rather than a residential care home. DS0000022799.V295675.R01.S.doc Version 5.2 Page 18 Residents bedrooms have been personalised by them, two are quite large with room for a settee in one. The third bedroom is small, but the resident spoken to said they were quite happy with their room and in fact spent a fair amount of time in it. The bathroom had a tile missing from around the bath and the sealant around the bath is in need of replacing. However, with this exception, the home was well maintained and was clean and hygienic. The house has a cellar where food and other items are stored. This was generally well set out with items stored on shelving. There had been a requirement around the storing of dry items on the floor of the cellar; the only item stored on the floor was a sack of potatoes which did not give rise to a repeat requirement. The fridge in the kitchen has been replaced as required. The home has fitted a thermostat to the hot water tap in the bath, but not to the hot taps in the hand basin in the bathroom and the small WC. The water ran quite hot from these taps. The home should ensure that all hot water taps have a thermostat to ensure that all hot water is not above 43 c or a risk assessments confirming that these are unnecessary. DS0000022799.V295675.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,36 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. The home’s staffing rota must accurately reflect all the staff on duty at all times. Residents benefit from well-trained and regularly supervised staff and are safeguarded by the home’s recruitment policy. EVIDENCE: The staff rota was inspected, the home have one member of staff on duty in the home during the day and one sleeping member of staff at night. The deputy manager who lives upstairs said that he works as the sleeping night worker. On inspection of the rota for the previous two weeks, the rota for some nights had not been filled in. The deputy manager said that this was a mistake and that he had most definitely been on sleeping night duty upstairs on the nights queried. The registered manager must ensure that rotas are filled in and reflect accurately who is on duty at all times. The deputy manager said that if the home needs more staff either to take a resident out or for some other reason they will arrange for another member of staff or the activities organiser to act as an escort. The rota did not reflect the home arranging for extra staff to act as escort to residents outside the home. The home must ensure that the rota states who is on duty both in the home and who is on duty but working outside the home. There had been a DS0000022799.V295675.R01.S.doc Version 5.2 Page 20 requirement that the rota reflects the time the manager spends in the home and when they were on duty. The manager was included on the rotas inspected. The staff have over 50 of their care worker qualified to level 2 NVQ or above. No new member of staff has been recruited since the last inspection and the last member of staff employed has been at the home for almost 2 years One staff file was looked at and this gave evidence of an adequate recruitment policy and information, training and induction. There is a checklist for subjects for staff induction, items were not dated as ticked off and no other information was given. The file contained evidence of regular supervision and supervision notes. DS0000022799.V295675.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit to the service. Residents benefit from a well run home. The home needs to obtain the views of residents or other people that come to the home with regard to quality assurance. They need to explore how best to do this and provide some evidence of people’s views. The home need to ensure that aspects of health and safety, including fire alarm tests, fire drills and monitoring of fridge and freezer temperatures are undertaken and recorded. EVIDENCE: The manager and deputy manager are both in the process of completing an NVQ level 4. The deputy manager was able to demonstrate an in depth knowledge of the needs of the residents and the routines in the home. The home has not completed any resident surveys; they do complete selfmonitoring reports and send a copy to the CSCI office. The deputy manager said that they do not have residents meeting, in a formal sense; he speaks to DS0000022799.V295675.R01.S.doc Version 5.2 Page 22 people individually and feels that this works quite well. The home does not carry out surveys of relatives or other professional that visit the home. The home have an up to date certificate of liability, and this requirement is met. There were no thermometers to monitor the temperatures of the fridge and freezer. The home had been requested by the environmental health department to buy new digital ones and at present have not got theses. The record book of fire alarm tests and fire drill had no entrees since 20/02/06. The deputy manager said that they have done fires drills since then, however these were not recorded. The home must ensure that fires alarms are tested weekly and there are regular fires drills in line with the fire safely assessments. These events must be recorded. See standards 24 –30 regarding the environment and the need for thermostats on the hot water taps. Water temperatures must be tested regularly. A new fire alarm system was installed in May 05, the type of system was in line with the recommendation of the Fire department. DS0000022799.V295675.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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X X 1 X DS0000022799.V295675.R01.S.doc Version 5.2 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(1)(c) 4(2) 17(3) a Requirement The registered manager must ensure that all details required under Schedule 1 are included in the Statement of Purpose. The Registered Manager must ensure that risk assessments are reviewed annually and dated; if there are no changed this should be recorded. The Registered Manager must ensure that case files contain financial assessments of individual service users, and that detailed records are kept of any money held on behalf of any service user, any expenditure and/or balance held. This is a repeat requirements timescale of 01/02/06 not meet The registered manager must ensure that the home has a copy of the protection of vulnerable adults multi-agency procedure is in the home, and all staff receive training in this area. The registered manager must ensure that all the hot water taps in the home have DS0000022799.V295675.R01.S.doc Timescale for action 01/09/06 2. YA6 01/09/06 3. YA6 4(9) 01/09/06 4. YA23 13(6) 01/09/06 5. YA42 13 (4)(c) 01/09/06 Version 5.2 Page 25 6. YA33 17(2) Sch 4(7) thermostats fitted to ensure the safety of all residents or a completed risk assessment indicating that these are not necessary. The Registered Manager must ensure that a clear, accurate and up-to-date rota of staff is held at the home at all times. This is a repeat requirement timescale of 01/02/06 unmet The registered manager must ensure that they produce some form of written information around what they have done to monitor residents, relatives and other stakeholder views with regard to the quality of the service they provide. The residence manager must ensure that all fridge and freezer temperate are monitored regularly and the temperature recorded. The registered manager must ensure that i. that at lest one fire alarms point is tested every week ii. That regular fire drills take place in line with the recommendations in the fire safety report. and that these events are recorded. 01/09/06 7. YA39 24 (2) (3) 01/09/06 8. YA42 16(2) (j) 01/09/06 9. YA42 23(4) (c) (v) and 23(4) (e) 01/07/06 DS0000022799.V295675.R01.S.doc Version 5.2 Page 26 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. 3. 4. Refer to Standard YA19 YA21 YA16 YA16 Good Practice Recommendations The home should where it is identified that residents need their weight regularly monitored and they benefit from this, do this with consistency. The home should continue the work began around exploring residents wishes with regard to the end of their life, death and illness The home should relook at whether any of the residents would like keys to their room and if they would complete a risk assessment around this. The home should explore with residents and other professionals involved with them, their choices with regard to possible holiday destinations and who possible that would be for them. DS0000022799.V295675.R01.S.doc Version 5.2 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 DS0000022799.V295675.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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