This inspection was carried out on 4th December 2008.
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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Evering Road (41) 41 Evering Road Stoke Newington London N16 7PU Lead Inspector
Anne Chamberlain Unannounced Inspection 4th December 2008 10:30 Evering Road (41) DS0000010268.V373412.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 Evering Road (41) DS0000010268.V373412.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. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Evering Road (41) Address 41 Evering Road Stoke Newington London N16 7PU 020 7241 2145 020 7241 2145 evering@hilt.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) Hackney Independent Living Team Syed Salique Ahmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th August 2008 Brief Description of the Service: 41 Evering Road is a residential home which is registered to accommodate six younger adults with a learning disability. Hackney Independent Living Team (HILT), a voluntary sector organisation, is the registered provider for the home. The home is a converted terraced house with a self-contained flat for one person and accommodation for five more people on the ground and first floors. The ground floor is wheelchair accessible. The home is situated in a residential area of Stoke Newington in the London Borough of Hackney. It is within easy access to local shopping and transport facilities. The stated aim of the home is to support people with a learning disability to live happy and fulfilling lives in the community. The current weekly cost of a placement is between £1040 and £1680, depending on the person’s needs. The home currently has a service user in the independent flat, four service users in the house and one vacancy. Evering Road (41) DS0000010268.V373412.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 1 star. This means that people who use this service experience adequate quality outcomes.
This inspection was undertaken on behalf of the Commission for Social Care Inspection and the terms we and us will be used throughout. It was a key inspection and was announced to ensure that the manager was at the service. The site visit took place on one day over six hours. We spoke to two service users and met four staff members. We were assisted in the inspection by the manager of the home and a manager from the organisation. We toured the home, excluding the bedrooms of service users and we inspected the arrangements for the administration of medication. We viewed two service user files and checked the records for two staff members, along with policies procedures and key documentation. What the service does well: What has improved since the last inspection?
A reassessment of need has been undertaken for a service user. Care plans have been reviewed. Key information is now signed and dated. Risk assessments have been reviewed. Arrangements for physiotherapy are clearer. Keys to the medication cupboard are kept on the senior staff member on duty. Adult protection policies for the home and the local authority were to hand. Missing persons information is now readily accessible including a
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 6 photograph. The health and safety policy has been reviewed. Fire exit signs have been put up. The home has a fire assessment. The downstairs shower area has been refurbished. They have purchased new dining room chairs and a new tumble drier. Buckled heater covers have been straightened out. The home has taken on a monthly cleaner who washes the paintwork. 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. Evering Road (41) DS0000010268.V373412.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 Evering Road (41) DS0000010268.V373412.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): People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager would make a comprehensive assessment of the needs of any prospective service user before offering a place at the home. EVIDENCE: The service has not admitted any new users since the last inspection. However the manager stated that they do have a vacancy and have looked at one prospective user. He said that the assessment would involve meeting with the person and their family and ascertaining the level of support they would need. He stated that he would also have to consider mobility and compatibility issues and whether or not waking night would be needed. The manager said that introductory visits would be offered to any prospective user. As required at the previous inspection the manager has undertaken a reassessment of the needs of service user A whose assessment information was three years old. We viewed this assessment which relies on ticking boxes. He stated that it had not given rise to any change in the care plan. Evering Road (41) DS0000010268.V373412.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): People experience adequate quality in this outcome are. This judgement has been made using available evidence including a visit to this service. Care planning is adequate and service users are supported to make decisions. Risk assessment is not comprehensive. EVIDENCE: We viewed care plans for two service users. These had recently been reviewed. The care system at the home relies on the following: individual shift support plans (these contain lists of tasks to support the individual) generic shift plan (these show what must be done on each day of the week and include tasks with individuals and general tasks) care plans in personal files a laminated planned activities sheet which works with the generic shift plans
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 10 induction folder There is a certain amount of cross referencing of the above, and care plans need to be read in conjunction with supplementary documentation from these other sources. The information was generally available in one place or another, but we felt that if the care plan is not going to give all the information then it needs to contain signposts to where the information is available, or to have the relevant sheets attached to it. The home supports decision making for non verbal service users with pictoral information, some of which is photographs of the service users and therefore relevant for them. We saw evidence in the weekly residents meetings where service users decide what they would like to eat. Once a week they have a takeaway and the manager stated that they take it in turns to decide what kind to have. They also decide whether they want to go out and where, shopping decisions, etc. We viewed risk assessments on files. The manager stated that they are also kept in the induction folder. We noted that a clinical psychologist had been appropriately involved in one risk assessment. One risk assessment contained information which would sit better in the care plan and we pointed this out to the manager. We noted that the risk assessments had been signed by service users and the assessor, and dated. The manager stated that he diaried the review of risk assessments so that they did not become overdue. We noted he had done this in the 2008 diary. Two of the service users at the home use wheelchairs and need considerable support with their mobility. One has a hoist provided upon which he is semidependent. Neither service user has a manual handling risk assessment. As already stated the service has put effort into producing information in a way which supports service users. This demonstrates respect for service users and commitment to upholding their dignity. Evering Road (41) DS0000010268.V373412.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): Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service supports a range of opportunities for service users and encourages family and community links. Meals are nutritious and appetizing. EVIDENCE: Two service users at the home attend day centres four times a week and one attends twice a week. One has no structured activity programme but is encouraged to access the community, including joining the home group on their weekly night out. We were told that service users go out with volunteers and they all go out for their personal shopping. The manager stated that all the service users will be supported to go out and do their Christmas shopping. One has already done some with his sister. One service user goes out with his brother and a friend and one goes home sometimes. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 12 The service has TV and DVD and craft items available. Whilst we were inspecting a service user was playing a keyboard while staff sat with him and another service user. Both service users seemed to be enjoying themselves. Most of the service users have quite good family links with brothers and sisters and friends. The service supports these relationships. The manager stated that they had a well attended Bar B Q last summer and they expect families to call in around Christmas time. As previously mentioned service users choose what they would like to eat. We noted a request for Shepherds Pie in the minutes of the weekly residents meeting. One service users likes Nigerian food and the manager stated that he cooks this with support from staff once a week. Evering Road (41) DS0000010268.V373412.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): People experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Service users receive individual support and their physical and emotional needs are met. However the home needs to ensure that their practice with the physically disabled service users is grounded in professional advice and supported by risk assessment. Medication practice is sound. EVIDENCE: Between the care plans and the other documentation we viewed there was evidence of service users being supported in an individual way. Three service users need to be supported with regular physiotherapy exercises. The manager stated that this is a mandatory part of their care plan which staff must deliver. Two service users use wheelchairs. One resident had a DVD which carers watch to see how to do the physiotherapy exercises. The other had a two photo guides with pictures of himself doing the exercises. Service users do their exercises at day centres and the manager said this had been confirmed in reviews. We viewed the evidence of these two service users doing their exercises at home.
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 14 On Tuesdays a masseuse calls at the service for a Body Awareness session. The two service users have a massage each and do their exercises. There was evidence that this is done regularly. The care plan of one service user says he should have physiotherapy exercises on Fridays. This appears on the laminated planned activities sheet and also was evidenced on Friday shift plans which had been completed. The care plan of the other service user states that he should have physiotherapy exercises on Fridays and Sundays. This was again indicated on the laminated sheet of daily planned activities and also on the daily shift plan. One shift plan for a Sunday however had been written on a Saturday sheet which did not contain any instruction to do physiotherapy exercises. There was no evidence for physiotherapy on three Sundays in November written on a Saturday sheet which did not contain any instruction to do physiotherapy . The manager stated that the Sunday physiotherapy has only recently been arranged. There was evidence on shift plans that physiotherapy exercises were done on three Fridays in November. A physiotherapy assistant calls to see one of the service users who has physiotherapy needs but there is no other physiotherapeutic oversight. We have required that the manager seek reviews by a physiotherapist for the three service users. Neither of the two service user who have limited mobility and use wheelchairs have handling plans or manual handing risk assessments. One has a care plan which says he uses a hoist. The manager stated that he is only semidependent on this as he has some upper body strength. We asked the manager how people know how to position or handle the service users. He stated that one has a personal profile which gives some indication. We viewed this but could find little to guide carers with positioning or handling. We have required that the manager obtain specialist handling plans for the two service users and obtain or undertake manual handling risk assessments. One service user came to the home with a very serious health need. The staff have worked consistently with this and reduced the risk of further deterioration significantly. We viewed the arrangements for the administration of medication. The home uses a blister pack system. The medication folder included photographs of service users. We checked the medication for one service user who takes a high number of drugs every day. There were no discrepancies. We noted that the home has a good stock of one preparation which is taken by two service users. We recommend that they do not re-order until some of the stock has
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 15 been used. We noted that the medication folder does not bear a list of the initials (signature) of the staff who administer medication and we recommend that this is added to the folder. The home keeps a returns book for medication disposed of and we noted that the pharmacist has signed for medication returned to him which is good. Evering Road (41) DS0000010268.V373412.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. JUDGEMENT – we looked at outcomes for the following standard(s): People experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service listens to the views of service users and protects them from abuse and neglect. EVIDENCE: The manager stated that no complaints had been received since the last inspection. We viewed the complaints information. This was quite satisfactory except that in one part the details of the CSCI were incorrect. We viewed the policy and procedure for adult protection. The home has a satisfactory adult protection policy which refers to the local authority policy and has a good procedure. They keep a copy of the local authority procedure. At the previous inspection we required a staff member to renew their adult protection training. The manager stated that this worker is a bank worker and has not worked at the service since. He stated that she will not work at the service until she has renewed the training. Evering Road (41) DS0000010268.V373412.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): People experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The environment at the home has improved and is now adequate. The home is clean and hygienic. EVIDENCE: We viewed the environment at the home. We were pleased to see that the ground floor shower room has been refurbished and is in a satisfactory condition. However there were footrests from a wheelchair on the floor which we considered hazardous for service users and staff using the facility. We require that these be got off the floor and it was suggested that a cupboard or some hooks be provided for storing these pieces of equipment when they are not in use. The light over the basin in this area is not working and must have a replacement bulb or be repaired. The torn dining room chairs have been replaced. The buckled heater covers have been straightened out (as far as possible)
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 18 The light over the basin in the first floor toilet is not working and must have a replacement bulb or be repaired. There are outstanding refurbishment issues, cracks to repair and repainting of walls needed. We were given a copy of a planned programme of maintenance and major repairs/improvements which is a long list of repairs and improvements which the home has worked up a budget for. The service was required by us at the last inspection to refurbish the first floor bathroom. This has not yet been done and we saw a request from the landlord Family Mosaic, asking to see the wording in our previous report requiring the first floor bathroom to be refurbished. It would seem that the service has to exert continuous pressure on the landlord to achieve maintenance of the property. We viewed a report which was produced for the board of Hilt. It states that if the landlord Family Mosaic fails to support the meeting of requirements relating to the environment Hilt will commission the works themselves to avoid enforcement action by CSCI. This was noted. The home now employs a cleaner to clean the paintwork once a month and we noted that the skirting boards were clean and the doors and switch plates were free from finger marks. The inspection before last recommended that the kitchen be replaced and this was revisited in the last inspection report which stated The kitchen appears to be a cheap one which has not withstood the rigours of residential provision. It was in a poor state of repair, not clean, and really needs replacing. We are now requiring that the kitchen be replaced. The home has adequate laundry facilities. The manager stated that there is some incontinence laundry and this is taken to the laundry room in a covered bowl and not taken through the kitchen. The home has a washing machine which has a very hot programme. The floor of the laundry room is impermeable. Evering Road (41) DS0000010268.V373412.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): People experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home employs competent and experienced workers. However it does not ensure that they update their training and it does not formally supervise them to the required level. EVIDENCE: The manager stated that the home is staffed with a combination of permanent and bank staff. On the day of the inspection we met with a bank staff who had been working on the day of the previous inspection. At the last inspection on 19 August 2008 we gathered the following information: A staff member spoken to said he needed to update his health and safety and food hygiene training. He said that all staff have had medication training, although his was two years ago and his first aid training was in 2006. He said that he was currently undertaking an NVQ 3 qualification. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 20 Following the site visit the manager was asked to supply by e-mail, evidence regarding recruitment and that staff are adequately trained and supervised. He supplied information regarding training which indicated that there is a serious and significant shortfall in staff training including the following examples: Staff not had first aid training since 2002 Staff not had manual handling training since 2001 Fire training not done since 2001 Medication training not done since 2004 We looked at the recent records for the training of two staff, including the worker mentioned above. He had still not renewed his food hygiene training or undertaken manual handling training. Another worker had not done food hygiene or adult protection training. Neither of the two workers had renewed their first aid. However the manager stated that all staff had fire training on 2/10/08. He further stated that all staff had health and safety training on 18/7/08. The evidence of training rested on names on lists and we suggested to the manager that he keep a photocopy of staff training certificates to provide more detailed evidence The requirement of the previous inspection regarding staff training has been restated. At the last inspection we required a volunteer to have or revisit training in the protection of vulnerable adults. We asked the managers about the training of volunteers in this topic. We were told that volunteers do not undertake formal adult protection training. However adult protection is highlighted to them and the induction pack they are given provides a basic outline upon which they build. They are told that they must report any allegation or suspicion of abuse to the manager. We were also told that volunteers do not undertaken personal care with service users or any finance or money handling. They are not alone with service users unless they take them out in the community. They have a Criminal Records Bureau disclosure (CRB) check before starting work. Based on the above and the fact that the home has a good adult protection procedure we have dropped the requirement. We viewed the records of staff supervision for two staff members. One worker had had supervision in November (appraisal), September, July and April. 2008. The other worker had had no formal supervision since April 2008 although the manager stated that he had given him informal supervision. The level of staff supervision is inconsistent and in the case of the second worker not sufficiently frequent. Staff supervision is ultimately the responsibility of the manager and
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 21 if a senior worker is not conducting regular and frequent supervision with a supervisee the manager must intervene. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 22 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): People experience adequate quality in this outcome are. This judgement has been made using available evidence including a visit to this service. There are sound management structures in place. Quality assurance needs to be further developed and health and safety practice improved. EVIDENCE: There was evidence at this inspection of adequate management. The home is organised and runs quite smoothly. The CSCI were appropriately informed of a recent medication incident. The manager offered as evidence of quality assurance the shift support plans. He said that these can be monitored and he plans to develop these to produce graphs of what care is provided. He further stated that the organisation has a five year plan and a service users forum is held at the central office although
Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 23 to date no service users from the home have attended. There are person in control visits monthly and we noted evidence of the last one on 18/11/08. We recommend that the manager undertakes some quality assurance work by surveying the people who are involved in the home, for their views on it. This could include service users, their relatives and friends, professionals and visitors like the masseuse. We viewed the health and safety arrangements for the home. The home has a health and safety policy updated in 2008. Control of Substances Hazardous to Health (COSHH) products are locked away and we saw this. We checked the data sheets kept and noted that for two products there were no matching data sheets. A requirement has been made. A certificate for the fixed wiring, fuse boards, lighting and consumer unit of the home has been obtained from a contractor who undertook an inspection on 14/10/08. However this inspection related to no 41B which is the main house. It did not cover 41A which is the self-contained flat within the house. The manager must obtain an inspection certificate for fixed wiring for the selfcontained flat no 41A. The home does not have an up to date PAT testing certificate. The manager stated that the tester has cancelled two appointments. A requirement has been made and the manager is reminded that this must include portable electrical items in the self-contained flat. The manager stated that an outside contractor manages the fire equipment checks in the home. To date they have not tested the smoke alarms but the manager will ensure that they do this next time. The smoke alarms are on an electrical circuit rather than batteries and are quite high up on the wall. The manager stated that he has tested the smoke alarms himself, getting up on a ladder. He produced a health and safety checklist dated 25/11/08 which had a tick against smoke alarms and emergency lights. We noted that the home has a new tumble drier and Fire Exit signs are now in place. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 24 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 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 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 2 3 x 3 x 3 x x 2 x
Version 5.2 Page 25 Evering Road (41) DS0000010268.V373412.R01.S.doc Are there any outstanding requirements from the last inspection? YES 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(4) Requirement Risk assessments must identify a full range of possible risks to individuals (previous timescale of 15/10/07 and 01/10/08 not met). Timescale for action 01/01/09 2. YA19 13 3. YA19 13 4. YA22 22 5. YA24 23 The manager must obtain specialist handling plans for the two service users who use wheelchairs and must obtain or undertake manual handling risk assessments for them. The manager must seek physiotherapy review for the three service users who need physiotherapy exercises. The contact details for CSCI must be updated in the complaints information. The kitchen must be replaced with a new and adequately robust kitchen. 01/02/09 01/01/09 01/01/09 01/06/09 Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 26 6. YA27 13 7. YA27 13 8. 9. YA27 13 13(4)23(2)(d) YA27 The wheelchair footrests must be stored away when not in use, not left on the floor of the ground floor bathroom. The light over the basin in the ground floor shower area must be made to work. The light over the basin in the first floor bathroom must be made to work. The registered person must ensure that the first floor bathroom is redecorated or refurbished for the health, safety and comfort of people using it (previous timescale of 15/10/07 and 01/10/08 not met). 01/01/09 01/01/09 01/01/09 01/03/09 10. YA35 13(4)(c) 18(1)(c)(1) The manager must ensure 01/03/09 that staff receive adequate training. This must include up to date first aid training and refreshment of basic core topics including: Health and safety Food Hygiene People moving people Adult protection (previous timescale of 01/12/08 not met) 11. YA36 18(2) Staff must have regular recorded supervision meetings with their manager at least six times per year (previous timescale of 01/11/08 not
DS0000010268.V373412.R01.S.doc 01/01/09 Evering Road (41) Version 5.2 Page 27 met). 12. YA42 12 The manager must obtain an inspection certificate for fixed wiring for the self contained flat no 41A. 01/02/09 13. 14. YA42 YA42 12 23 (2)(c) 23(4) The manager must obtain 01/01/09 a PAT for the home. The registered person 01/01/09 must ensure that the electrical installation in the home is tested and that documentary evidence of this is kept for inspection. This is to ensure that people living and working in the home are properly protected in this area (previous timescale of 15/10/08 not met). Partially met 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. 5. Refer to Standard YA6 YA20 YA20 YA35 YA37 Good Practice Recommendations Care planning information should be accessible. If it is not contained in the care plan then it should be attached or the plan should state where it can be found. The home should stop re-ordering a prescription which of which they have a good stock. The home should have a list of the initials (signatures) of staff who administer medication. The manager should photo-copy staff training certificate to provide better evidence of training. We recommend that the manager undertakes some quality assurance work by surveying the people who are involved
DS0000010268.V373412.R01.S.doc Version 5.2 Page 28 Evering Road (41) in the home, for their views on it. Evering Road (41) DS0000010268.V373412.R01.S.doc Version 5.2 Page 29 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
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