Inspection on 04/07/06 for Evergreen Lodge

This inspection was carried out on 4th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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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 South Park Hill Road, 21 21 South Park Hill Road South Croydon Surrey CR2 7DY Lead Inspector Michael Williams Key Unannounced Inspection 4th July 2006 10.00a South Park Hill Road, 21 DS0000066263.V298568.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 South Park Hill Road, 21 DS0000066263.V298568.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. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Park Hill Road, 21 Address 21 South Park Hill Road South Croydon Surrey CR2 7DY TBC TBC 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) Care UK Mrs Avril Ingrid Koroma Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection after registration Brief Description of the Service: Although currently registered with the Commission as ‘21 South Park Hill Road’ this care home is known as ‘Evergreen Lodge’. The home is owned and managed by Care-UK, a national organisation with services throughout the country. This home is based in South Croydon; it is situated in a quiet suburban road but is near to transport and shops. Evergreen Lodge is Registered to provide care for up to 12 adults, 18 to 65 years of age, and who have mental health problems – many also have secondary issues related to offending behaviour and the misuse of recreational drugs and alcohol. In view of the complex nature of residents’ needs the registration of this home will be kept under review. Evergreen Lodge has 12 single ensuite bedrooms and lounge and dining areas on each of its two floors. In addition to a fully equipped kitchen on the ground floor it also has a domestic scale kitchen suitable for rehabilitation support work with service users. The home has a reception area, an office, laundry, staff and meetings rooms. This project was set up by Care-UK in partnership with a local NHS Trust who therefore have all places in the care home reserved for placement through their forensic mental health team. Fees are set at £1900 per resident/week. Residents will pay for their personal requisites and any additional funding required for additional care will be negotiated with the funding authority. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection since initial registration at the beginning of 2006 and was a key, unannounced inspection. A site visit was conducted on 4th July and involved consultations with service users, staff and visiting professionals. The compilation of this report also included information held by the Commission. In respect of issues of diversity, this home, in common with many others, employs staff from a variety of national backgrounds and this reflects the diverse background of the current group of residents. There are male and female residents and likewise there are male and female staff. Amongst the choices that service users can make known to the care home is their cultural and religious wishes, and any lifestyles issues such as sexual orientation that the home should take account of. The home seeks to ensure residents can follow their lifestyles so far as is reasonable and in their interests. The home is adapted for residents who may have disabilities such as mobility problems. At present all residents use English as their first language. What the service does well: What has improved since the last inspection? What they could do better: Very few requirements and recommendation arise on this occasion. Firstly, a recommendation to include key information from the assessments in the care plans - such as known risks and relapse issues and secondly to include Mental Health Act orders that apply to residents so that all staff know the conditions and timescales for such orders. In respect of the environment, several points were raised by the residents, such as the showers and ventilation fan. The passenger lift is also not working and the manager is working to resolve their concerns. None of the residents has an independent advocate - though many will have family or friends to support them so a recommendation is made to establish links with mental health advocacy groups, such as MIND or a local legal team offering such advocacy, to ensure this form of independent support is available to residents. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 6 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. South Park Hill Road, 21 DS0000066263.V298568.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 South Park Hill Road, 21 DS0000066263.V298568.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New service users are being admitted only on the basis of a full assessment undertaken by people trained to do so and this involves the service user or, in some cases, their representative so residents know that their needs have been fully assessed and can be met in this home. EVIDENCE: During this site visit service users were consulted about all aspects of their care including the arrangements for their admission and they confirmed to the inspector that they met with staff from the home before being admitted and that they had every opportunity to share their ideas about how the home might support them. The case files indicate that full psychiatric assessment take place before admission. The home has a Statement of Purpose available for prospective serve users and their representatives and each is given a copy of the Service User Guide. Admissions are always through a single forensic metal health team and therefore the procedures for admitting residents are known to both parties, the care home and mental health team. Areas of strength are assessments that appear very detailed and comprehensive so as to assess the risks and the likelihood of Evergreen Lodge being able to provide the support needed for each service user; and no matters requiring improvement arise so this section, about initial assessment and placement, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning, the provision for service users to be involved in decision making and the procedures for dealing with risks are all satisfactory so as to ensure individual choice and needs of service users are identified and they are supported appropriately. EVIDENCE: To assess this section the inspector met with several of the service users, met with staff and the managers and checked a sample of case files. The inspector also met with visiting professionals including a psychiatrist and a trainer. The home also provided information in advance of the inspection including a list of policies and procedures held in the home. Residents are well aware that personal information about their care needs, their mental health issues and other related matters are held in confidential case files and that these files include care plans. The residents also know that they are supported by ‘key-workers’ who get to know them individually and learn how best to support them. The manager feels this has been a particular strength of the project in these early weeks. Two recommendations are made in respect of the care plans and they are firstly, to include more items as listed South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 10 in the assessment - particularly those have risked associated with them such as relapse, unauthorised absences and failure to comply with Mental Health Act conditions. The second suggestion is to include those Mental Health Act conditions (such as those attached to Section 25A) in a specific care plan so the conditions are clear to all and the timescales associated with such conditions are known to staff and residents and the visiting mental health team. Areas of strength are amount of time staff give to get to know and support residents and to encourage them to manage their mental health problems more effectively than in the past and to help residents plan for their future. Matters requiring improvement are the need to ensure information supplied by referring agencies is translated into the home’s own care plan format including risk assessments and action plans arising from this and to detail Mental Health Act conditions in the home’s own care plan format so that they are known to all staff, regularly reviewed and monitored to ensure they are complied with and action taken if not. This section, about needs and choice, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.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 at least once during a 12 month period. 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. The daily routines in this home are reasonably flexible, within the constraints of a specialist service. Service users are being supported and encouraged to maintain links with family, friends and to exercise choice and control over their lives in so far as they wish and are able to do so and is commensurate with their best interests. Service users are receiving a wholesome, appealing and well balanced diet in a congenial setting in accordance with their recorded requirements and preferences. EVIDENCE: A central tenet of this care home is that service users are fully involved in their personal development; the home is equipped to provide rehabilitations such as help with daily living skills – indeed the residents refer to their second kitchen as the ‘ADL kitchen’ knowing that it is there for them to use and developed catering skills. Whilst the home needs to monitor risks associated with residents mental health and drug/alcohol problems the home nevertheless South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 12 encourages all residents to make best use of local community resources including recreational and educational facilities as well as lot of shopping in Croydon’s well known shopping centres. The residents advised the inspector that in most instances they keep in touch with family and friends by going out to visit them rather than receive visitors in the home. Residents in this home acknowledge that immediately prior to their admission they will have experienced serious crises in their lives and need considerable support to reestablish themselves and their independence. For this they need support to develop personal relationships that are not harmful to them – or to other people – this is the role of support workers in the home. All residents will have been resident in a psychiatric hospital prior to admission and some will be subject to conditions attached to their discharge; their rights in this respect are those established under the Mental Health Act – it is noted that none of the residents has an advocate though many will have family or friends to support them so a recommendation is made to establish links with mental health advocacy groups such as MIND to ensure this form of independent support is available to residents. The home is commended for employing professional cooks whilst still offering the opportunity for residents to cook for themselves as their self-help skills grow. The residents say the meals in Evergreen are very nice. Several residents concede that they need help to lose weight and have joined weightwatchers – and doing very well they say. Based upon observation on the day and the feedback from service users this section about lifestyle is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.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 at least once during a 12 month period. 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 arrangements for care planning, the provision of health care and the procedures for dealing with medication are all satisfactory so as to ensure the social and health care of service users can be met not only in accordance with their wishes but also taking account of the advice provided by their mental health team. EVIDENCE: The home is promoting and maintaining service users’ health by ensuring they have access to health care services to meet their assessed needs and in doing so the home is supporting service users to make decisions about how their health will be managed. The home has in place procedures for ensuring the safe management of medicines. This includes, where appropriate, support and risk management for service users who aim to be responsible for their own medication so that they may do so safely if not within the home then to prepare them for when they move on to more independent accommodation. The residents in this home will have varying experiences about medication whether or not they feel they need medication, how it affects them and so South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 14 forth – it is the home’s role to help residents manager their medication (as advised by their mental health team). This home cares for residents who have complex needs; all residents will have a combination of mental illness and secondary problems relating to offending behaviour or drug and alcohol misuse, and as the visiting psychiatrist pointed out staff need to have more than the average care worker skills and training to support this group of residents. The manager is well aware of this and intends to appoint staff who already have relevant experience in the field of mental health. Visiting psychiatrist and Community Psychiatric Nurse confirmed that in these early weeks the home is doing a good job in supporting residents, who in many instances are making good progress – where they are not the mental health team is working in collaboration with the home to provide back up and alternative care if and when the placement breaks down. In view of the complex nature of the client group, and therefore the staffing levels and skills required to provide adequate care, the registration of this home will be kept under review by the Commission; whilst it is unlikely this home could be regarded as ‘Private or Voluntary Hospital’ it may well require to revise its registration to that of Nursing Home (Mental Health). Areas of strength are the close support provided by staff, the support in managing medication, the home’s collaboration with the mental health team and so forth; and no matters requiring improvement are identified so this section, about personal support and health care, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.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 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 good. This judgement has been made using available evidence including a visit to this service. The home has a clear and simple procedure for dealing with complaints so service users’ are confident their concerns will be dealt with promptly and effectively. To ensure vulnerable service users are safeguarded from abuse the home has written policies and procedures about the protection of service users and their property; this includes procedures for passing on concerns to the relevant authorities including the CSCI. EVIDENCE: Service users are provided with information about making complaints when they are admitted – this information is included in their Service User Guide. The home hold regular resident meetings at which time residents are enabled to voice their opinions – most recently they have complained about the ineffectual showers fitted in their ensuite shower rooms and the manager is working hard to resolve the matter. No complaints, other than this point have been noted by the home but it has the systems in place to do so. Staff confirmed that they have received training in the protection of vulnerable adults and this includes information about the local ‘Vulnerable Adult Procedures’ – which require prompt referral to the local Social Service Department Care Management team under these procedures if abuse is suspected – no such allegations arose during the course of the inspection. Under the section dealing with lifestyle above it was noted that current residents who not have independent advocates and this may well be something that could be established in respect of residents having complaints and their right to be supported by such advocates. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 16 Areas of strength are the clear and simple procedures for making complaints and the home’s preparedness for dealing with allegations of abuse; and matters requiring improvement are the suggestion to arrange for advocacy, recommended under standard 16 above, so this section, about complaints and protection, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.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 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the home and the manner in which it is being maintained means that this is a safe, comfortable and suitable environment for the service users. There were however a small number of matters requiring attention and they are outlined below. The premises are being kept clean, hygienic and free from offensive odours and systems are in pace to control the spread of infection. EVIDENCE: This home is newly registered, in 2006 and premises were considerably refurbished before opening so the home is very well appointed with large single rooms with ensuite showers and toilets. There are communal areas, dining and suiting rooms on each of the two floors and the home is in good decorative order although some ‘snagging’ is still needed such as the showers, a ventilation fan and minor damage to décor such as door frames. The home was assessed as fit for purpose at the time of registration and since admitting residents this has proved to be the case. The home was clean and tidy when visited and was free of offensive odours. Staff were undertaking training in infection control at the time of inspection. There are adequate bathing and laundry facilities in the home. The home employs a domestic to ensure good hygiene standards are maintained and this is commended. Overall standards in this area about the premises are assessed good. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. The required procedures are in place to ensure recruitment of staff protects service users. The home has a staff induction, training, support and supervision regime in place so service users can be assured that staff are competent in their jobs. EVIDENCE: The home is still in the process of recruiting a full staff team and is making good progress towards this. Recruitment procedures were checked in some detail and were found satisfactory but the home will need to confirm that CareUK and Evergreen Lodge in particular has a formal agreement with the Commission for police check [RCB] documents to held at their headquarters and not in the home itself. Such arrangements must include arrangements to make the documents available in the home at the request of the Commission. The company provided extensive induction training for the staff team involved in the opening of the home and the manager has since put in place a training programme for all staff that includes general issues such as health and safety, fire safety, protection from abuse and infection control and so forth and more South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 19 specific matters relating to the client group including mental health and supporting residents with complex needs (dual diagnosis). In view of the complex needs of the service users this home will require, and has, a higher than average ratio staff to residents. The manager also wants to ensure that staff employed have suitable background experience before joining the staff team and so many will be of a senior grade. Staff were interviewed during the course of the site visit and were found to be enthusiastic, committed and well informed. Staff confirmed that they receive formal supervision from a manger at regular intervals; that they have contracts and are satisfied with employment practices in the home. Residents said they found the staff team kind and helpful. Areas of strength are well organised staff team that is suitably recruited, trained and supervised and matters requiring improvement are limited to the need to confirm that Care-UK and Commission have a formalised, written agreement to hold CRB checks at their headquarters; so this section, about staffing, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is registered with the CSCI as a person fit and competent to run this home in accordance with its stated aims and objectives and so in the best interests of the service users. The home is well managed and is safe for service users. EVIDENCE: It was clear from an early stage of this site visit that this is a very professionally run service. The company has clearly put a lot of thought into developing a building that will meet the needs of service users who will in some cases pose quite high risks and will need close supervision. The premises are well appointed, to national minimum standards, and the residents appreciate this. The staff team appears substantial enough to provide adequate individual support to service users and they appear to be well managed by the senior staff. Service users confirmed that they meet regularly with staff - both individually and as group - so that their views, opinions and South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 21 concerns about the running of the home will be heard. An atmosphere of respect for service users was evident and it is clear the ethos of this home is, as the Statement of Purpose indicates, that in Evergreen Lodge service users can “expect a high quality of service, that is non-discriminatory and suited to their needs”. A Regional manager visits at least monthly, as required by Regulation and reports back to the home itself, to the Commission and to the owners as to the running of the service and this person is of course providing support and supervision to the manager of the service. The premises have been developed specifically for service users who may poses a risk to their own or other people’s safety and so the environment is modified to take account of this. No hazards were identified during the site visit. One suggestion is made, to apply to the Commission for a variation to change the name from ‘21 South Park Hill Road’ to ‘Evergreen Lodge’ if that is the wish of the company and service users. Areas of strength are preparation that went into establishing this service; the development of a good team of staff; a well organised care home led by a competent person and matters requiring improvement are limited to just one suggestion about the registered name of the home; so this section, about management, is assessed as good. South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 22 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 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard 1 YA34 Regulation 19 and 17 Timescale for action Safe Staff recruitment: The home 30/08/06 is to confirm that it has a formal, written agreement with the Commission to hold police and other recruitment checks at its head office and not within the home as required by Regulation 17. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Care Planning: It is recommended that any key issues highlighted in the referral information is translated into the home’s own care plan format, so as to be readily accessible to all staff. Care Plan: it is recommended that any Mental Health Act conditions, including the duration of the order, that apply to a resident be translated into a care plan/risk assessment so that they can be readily monitored and acted upon. Advocacy: contact with advocates groups is recommended so service users’ rights under Mental Health legislation can be supported where appropriate. Maintenance: It is recommended that the ineffectual showers and ventilation fan be made functional without further delay. It is acknowledged that the company is dealing with both matters - but rather slowly. DS0000066263.V298568.R01.S.doc Version 5.2 Page 24 2 YA6 3 4 YA16 YA24 South Park Hill Road, 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 South Park Hill Road, 21 DS0000066263.V298568.R01.S.doc Version 5.2 Page 25 - 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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