Inspection on 14/06/05 for Faircross Avenue

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faircross Avenue 05/06/07

Faircross Avenue 13/06/06

Faircross Avenue 10/11/05

Faircross Avenue 20/01/05

Faircross Avenue 28/09/04

Faircross Avenue 27/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Faircross Avenue 100 Faircross Avenue Barking Essex IG11 8QZ Lead Inspector Roger Farrell Unannounced Inspection 14 June 2005 16:30 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 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 Stationary 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. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Faircross Avenue Address 100 Faircross Avenue, Barking, Essex IG11 8QZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8591 5655 020 8471 6959 Mr Nasser Kassouri Mrs Beverley Rose Kassouri Mr Nasser Kassouri CRH Care Home 3 Category(ies) of LD Learning disability (3) registration, with number of places Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 January 2005 Brief Description of the Service: 100 Faircross Avenue is a registered care home providing accommodation and support to three people who have learning disabilities. It is a compact midterrace property situated in Barking, a short walk from shops and transport links. All three residents have lived at this home for a number of years. The owners are Mr and Mrs Kassouri. It was understood that Mr Kassouri worked as the full-time manager, and Mrs Kassouri as the part-time deputy. The three men who live here are well settled, and have over the years had contact with specialist health workers. The owners have bought the next-door house and are planning to make the home larger, adding extra places and improving the existing areas such as larger bedrooms with their own showers and wc. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on Tuesday 14 June 2005, between 4.30 and 6.45pm. The inspector found a number of serious failings in how the home was being run. The staff member on duty was helpful, but was unable to find much of the paperwork asked for, or give answers to some important questions. The home’s phone was not working. Mr Kassouri, the manager/owner was listed on the rota, but the inspector was told that he was abroad, and had not been at the home for nearly two weeks. The staff member who arrived just after 5pm and was to be in charge through until the next morning had only worked at the home for a couple of weeks, and said part of her reason for taking this job was to help improve her English. The day-time worker stayed on to help the inspector with the checks. Most of the other workers listed on the rota were described as also having started within the last few weeks. The second owner/deputy was listed as being ‘off-duty’ over recent weeks, including during the period the manager had been abroad. The other senior person on the rota was the ‘team-leader’, but she does a full-time job elsewhere and only works one day a week at Faircross Ave. No information was available about staff other than their first name shown on the rota sheet. The inspector spoke to Mrs Kassouri on the phone. She said that Mr Kassouri was due back the following morning. She agreed to contact the phone company to get the phone fixed. The inspector said that he would return the following afternoon, and asked for Mr or Mrs Kassouri to be at the home and have available staff details. The following morning calls were received saying neither were available, and no other arrangements could be made to show the inspector the staff files he asked to see. When the inspector returned the next afternoon the person in charge was a part-time worker who had started at the home only three weeks earlier. He had begun his shift at 10am that day, and was due to work through to 2pm the following day, including doing the sleep-in duty. Mr Kassouri was listed as due to be on duty between 9am and 6pm, but this had not been the case. The owners were served with four ‘Immediate Requirement Notices’ for failing to maintain adequate standards in the following areas: • To have on display a rota that gives true details about staff cover, including the manager’s hours; • To have available details about staff, including the steps taken to check that they are suitable to work in a care home; • To have available records covering fire safety, including a log of drills and making sure staff know what action to take; • To maintain a record that shows residents are being provided with an adequate choice and variety of food. The owners were sent a letter setting out the Commission’s concerns, and a meeting was arranged to talk about their legal duties, and the consequences of not carrying out their responsibilities. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? Nothing positive can be included under this heading based on what has been found at visits this year. For instances, at the visit in January most of the fire alarms were not working. The owners were served with an ‘Immediate Requirement Notice’ for this worrying lapse in safety arrangements. They were asked to write to the Commission saying how they would make sure this would not be allowed to happen again. Yet, they had to be chased up on this matter, and a letter was not received until seven weeks after the visit. The report of the visit in January carried forward three items, and set two further areas needing action. The owners provided a plan saying these areas had been achieved, such as having a true record of staff cover – including the manager’s hours - and carrying out necessary fire safety checks. At these recent visits these areas were still found to be a problem. All items have to be carried forward again. The owners have been told that a failure to show that they are achieving the required improvements will lead to the next stage of legal action, and this can include prosecution. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 7 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. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 9 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 standard(s) 1 and 2. All three residents are well settled in this home, and there is good a good level harmony and tolerance within the group. Faircross Avenue is intended to be their ‘home for life’. The proposed increase of places will need to be sensitive in maintaining the existing compatibility. EVIDENCE: All residents were established in this setting prior to the current owners/manager taking over. Two residents moved to this house with the previous provider in 1998. The practice file system carries forward some original assessment material, such as psychiatrist and psychologists’ reports. Less relevant and out-dated material has been archived. The inspector has been shown the Mencap ‘Statement of Support and Action Plan’ which would be used as the main assessment schedule for future residents. Having an accurate ‘statement of purpose’ comes under this heading. The owners need to revise the section covering staff. This needs to set out the staff complement (saying how many posts there are, and the number of hours), including those of the manager and other staff who have supervising responsibility such as the team-leader. Where reference is made to qualified and trained staff, this needs to be accurate. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 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 standard(s) 6. Staff continue to be involved in helping residents with their day-to-day domestic routines. However - based on how residents had been spending their time recently, the absence of a management presence, and the number of new staff – it is not clear how broader ‘person centred planning’ approaches are being operated. EVIDENCE: Previous reports have talked about a gradual improvement in how care plan files are maintained. The main document is the ‘statement of support and action plan’ sheets, with bullet point entries under twenty-one or more headings. These provide good practical advice on assisting the residents with day-to-day living needs, and setting up additional ‘person centred planning’ files had started last year. The last inspection report said that some entries remain basic, but nevertheless it represents a significant step forward compared to the previous system. The overall weakness is that the manager acts as ‘key-worker’ to all three residents. He previously said that he was spending over forty hours a week at the home, including coming in at weekends to support some social activities. From visits this year it is clear that he is spending considerably less time at the home than previously claimed. Given the level of staff turn-over and the number of new staff, it is by no Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 11 means clear how service users are being helped beyond providing assistance with daily domestic routines. This group of important standards will be examined in more details at following inspections. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 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 standard(s) 12, 13, 16 and 17. This home has had a good track record of helping residents use community facilities, including college courses. However, the range of activities was found to be less well planned, such as attending a cultural centre and going horseriding – and this appears to be linked to the decreased time the manager is spending at the home. The arrangements covering basic services, like providing meals, was well below the expected standard. Menus were an example where the records are a false representation of what was found to be the reality. EVIDENCE: At previous visits good descriptions have been given of how residents have been helped use community facilities. This has included a planned programme of gradually increasing the time two residents spend out on their own. The rota had built in times with two staff on duty so that one person was free to go out with residents. Regular activities included horse-riding, car boot sales at weekends, and visiting a cultural social centre. At these recent visits such activities had not been occurring recently, mainly because the manager had not been around. A staff member said that the main activity that day had been Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 13 going to buy fish food which had run out, with all three residents going as there was only one person on duty. How meals are being arranged shows the lack of coordination and a slapdash approach. One longer serving care assistant had left. It was said that she often checked household arrangements. The menus on show were well out-of-date, no one having taken on this duty since she had left. On the first day of these visits the lunch on offer was take-away chicken and chips. The evening meal was chicken soup and bread. The next day take-away chicken and chips had again been the lunch choice – the person on duty not being aware that this was yesterday’s option as no records were being kept. One resident did not want chicken and chips, and he went out and bought himself sandwiches on both days, and it seemed he had paid for these from his own money. By the second day a menu had been put up, but what was being served, and the stocks available did not match this meal plan – the evening menu options on display were meat or vegetable pie with mashed potatoes – what was served was tinned chilli-con-carne. The person preparing this meal was not aware that there was a menu to be followed. Staff agreed that the small range of vegetables left in the fridge were now beyond use. There was no fresh fruit. The owners say that residents have a right to choose an item not on the menu. What was found at these visits was that menu planning was not taking place, there was no day-to-day coordination of meals, and staff were improvising with what food was in the cupboards or getting take-aways. This is an unacceptably poor standard in such a basic area of providing residential care. Requirements have been set about improving meal planning and the food served. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 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 standard(s) 0. These standards were not checked at this visit. EVIDENCE: Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 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 standard(s) 22 and 23. During the course of these two visits the inspector met with three staff. Two had started within the last month, and one had been at the home for eight months. In general, they were not familiar with the home’s records and were frustrated in their searches to find the requested documents. This included those covering complaints and protection procedures. Consequently these two standards are recorded as not met. EVIDENCE: Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 16 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 standard(s) 24. The owners are still failing to show that they are taking adequate action regarding the safety of residents. Shortfalls in fire safety arrangements were again found. It was again necessary to serve a notice in this area. Unless consistently improved standards are found, the next stage of legal action will be taken, and this can lead to prosecution. EVIDENCE: At the last inspection in January the owners were served with an ‘Immediate Requirement Notice’ because most of the battery operated fire alarms were not working. At this visit the inspector was shown a supply of batteries and a spare smoke detector. However, the fire log listed the last weekly test of the smoke alarms as four weeks earlier. By the next day back-dated entries had been added, it subsequently being claimed that tests were carried out but no entries had been made. These late entries say that all alarms were working. This was not the case – the alarms in one resident’s room had the batteries removed. The owners say the resident removes these. It is known that this person smokes in his room. It is essential that detailed risk assessments and monitoring take place to ensure this person’s safety, and that of the household overall. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 17 The record of drills presented listed the last planned drill as having taken place one year ago on 26 June 2004. When asked about responding to a fire alert at night an established staff member described evacuation as the priority. The essential step of calling the brigade was not mentioned, nor the need to make sure fire doors were closed. Given that improving fire safety is raised in previous reports, and an ‘Immediate Requirement Notice’ was served earlier this year, it is of grave concern that shortfalls in fire protection and response arrangements are still being found. The owners were served with a further ‘Immediate Requirement Notice’ regarding fire safety. The seriousness of this matter is such that further legal action will be taken if failings are found, and this may include the Commission seeking a prosecution. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 Based on the evidence available at this inspection, routine cover was often being provided by inexperienced new staff, including being on duty on their own. They are left with the responsibility of being in charge as the manager was not at the home despite being listed on the rota. One or two part-time staff have some relevant experience, but in general duty staff are mainly involved in household matters such as cleaning, shopping and arranging meals. The owners are failing to carry out the legally required vetting of new staff. EVIDENCE: It is of concern to the Commission that there was a failure to make available records covering the recruitment and vetting of staff, even when twenty four hours notice was given. In response to the ‘Immediate requirement Notice’ the owners provided some staffing details. This listed the referee details given by applicants, but not when references were received. Equally, this also showed that fresh CRB certificates had not been obtained before staff started, and in one instance of an established worker there was no details that a check had been undertaken. It was also said that Mr Kassouri interviews all staff, but one worker told the inspector that his interview and introduction had been carried out by the ‘team-leader’ who works at the home one day a week. The owners have been told that further legal action will be taken if they fail to carry out the required checks on staff before they start, or have records available that show they have done this. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, and 42. Based on the evidence found at these visits, this home is failing to meet a significant range of requirements because of a lack of management presence. Despite the warning given earlier in the year, the manager is continuing to list himself as being on duty when he is not. The main conclusion of this report is that the owners are not fulfilling their responsibilities to ensure the day-to-day safety and well being of service users. EVIDENCE: The last inspection report said that the manager must maintain a record of the time he spends running the home. This needed to include his duty hours on the rota. It is therefore of serious concern to the Commission that at these recent visits he was listed on the duty rota sheet over a couple of weeks but was abroad. An ‘Immediate Requirement Notice’ was served, and further legal action will be taken if it is found at subsequent visits that the rota is not a true record. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 20 At a subsequent meeting with the Commission Mr Kassouri said that he had reduced his hours to being part-time. The Commission had not been informed, as is required when such major changes covered by the ‘statement of purpose are made. The owners made the following proposals: • That Mr Kassouri was considering ceasing to be the manager, and appointing a replacement. A candidate was being considered. An application must be submitted regarding any new manager; • That Mrs Kassouri would no longer be designated as the deputy as she rarely provided cover at the home. She would continue to provide a back-up service, and visit the home to monitor conditions in line with her responsibilities as an owner. • It needs to be a major cause for concern to the owners that this inspection scores only two of the twenty-two standards rated as satisfactory. Eight are judged to be only ‘partially met’, with twelve recorded as ‘unmet’, notably under this management heading. The owners have been asked to provide a detailed ‘action plan’ in response to this report. This needs to include itemised statements setting out how they will achieve enduring compliance with the requirements listed in this report. They should include in the plan an estimated timescale regarding the planned upgrading of facilities, and this needs to be covered in the next service improvement plan. Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x x Standard No 11 12 13 14 15 16 17 x 2 3 x x 2 1 Standard No 31 32 33 34 35 36 Score 2 1 2 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Faircross Avenue Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 1 1 1 1 1 x G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 22 Are there any outstanding requirements from the last inspection? Yes: Items 1 to 3 have been notified for the third time; Items 4 and 5 are carried over from the last report. 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 YA 40 Regulation 12(1); 17 Requirement Timescale for action 24/10/05 2. YA43 23(4) 3. YA 23 13(6) 4. YA24 23(4) Review the policies and procedures, making sure these are relevant to the service provided in this setting. Increase the frequency of tests 9/9/05 of the fire alarms to each week, and keep a record of these checks. Entries in the fire log must be made following each test. Have in place documentation and 9/9/05 systems that give clear guidance on the procedures to be followed regarding alleged or suspected abuse, including the Barking and Dagenham local guidelines on abuse procedures, and guidelines to follow on responding to an allegation of abuse that are specific to this home. The registered persons must 9/9/05 take adequate precautions against the risk of fire, including arrangements for detecting and giving warnings of fire, ensuring the maintainance of all equipment, including smoke detectors, and taking action Version 1.30 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Page 23 5. YA33 17(2)/ Sched 2, para 7 6. YA1 4/Sched 1 7. YA6 15 8. YA12 16(m),(n) 9. YA16 12(2) where faults are found. This must involve staff on duty knowing how to replace batteries, and having a supply of back-up batteries on site. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Have available at all times a duty rota that is a true record of staff cover, including any variations to the planned cover. This must include the manager’s hours on duty, and details of duties being undertaken off-site. An ‘Immediate requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Have available an up-to-date statement of purpose. This needs to include an accurate description of the staff cover provided, including - the number, designation and contracted time of each post including the manager hours and other supervising positions such as deputy and team-leader. Have available an up-to-date service user plan. This needs to include who will take a lead on supporting the service user with identified needs, such as having an allocated key-worker. Consult with service users, and arrange a suitable programme of educational, leisure and social activities. Provide sufficient staff cover to enable these activities to take place. Maintain a record of such activities. Consult with service users regarding the daily routines and arrangements in the home, such as offering a reasonable choice and variety of meals. 9/9/05 26/9/05 24/10/05 24/10/05 26/9/05 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 24 10. YA17 16(2)(i) 11. YA17 17(2)/ Sched 4, para 13 12. YA17 24 13. YA22 22; 17(2)/ Sched 4, para 11 14. YA23 18(4) 15. 16. YA23 YA24; 42 18(4) 23(4)(d) 17. YA24; 42 23(4)(e); Provide suitably wholesome, nutritious and varied meals.An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Maintain a record of the food provided in sufficient detail to enable an inspector to determine whether the diet is satisfactory. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Operate a system for reviewing standards of service, including monitoring the quality of meals, and how planning menus involves consulting with service users. Maintain a record of these checks. Have available a record of complaints, and guidelines for staff to follow where a complaint or concern is made. Ensure that the responsible in charge is aware of these procedures, and can locate the complaints record. Ensure that all staff are aware of the action to take if they become aware of, or suspect abuse including their duties in line with the whistle blowing policy, and in line with the GSCCs code of practice. Ensure that all staff are issued with a copy of the GSCCs code of practice. Make adequate arrangement for all staff to receive training in fire safety and response, including making calling the fire brigade a priority task. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Carry out at suitable intervals 9/9/05 9/9/05 24/10/05 9/9/05 26/9/05 24/10/05 9/9/05 26/9/05 Page 25 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 17(2)/ Sched 4, para 14. 18. YA24; 42 23(4)(c) (i) 19. 20. YA31 YA32; 33 8(1)(b)(i) 18(1) 21. YA34 19 22. YA34 19/ Sched 2; 17(2)/ Sched 4, paras 1 to 6 23. YA35 18(1)(i) 24. YA35 18(1) fire drills, and have available a record of these drills, saying which staff were involved, and the action taken where problems were found evacuating the building. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Make adequate arrangements for containing fire, including making all staff aware of the need to close critical fire doors, such as those protecting the staircase. Ensure that there is a full-time manager in day-to-day charge of the home. Ensure that staff have the necessary skills and experience for the tasks they perform, including the needs of adults with a learning disability. Carry out the required assessment of competency and range of checks on staff prior to them commencing work at the home. Have available all the required information on staff that demonstrates a responsible management approach to the selection and vetting of staff, in accordance with Reg 19, and as set out in Schedules 2 and 4. An ‘Immediate Requirement Notice’ has been served on the owners for a failure to comply with this responsibility. Ensure that all staff receive induction and training in core areas, including the safe handling of medication, food hygiene; first aid; fire safety; and general health and safety issues. Ensure that the staff team has the required skill mix, including 9/9/05 9/9/05 26/9/05 9/9/05 9/9/05 24/10/05 31/3/06 Page 26 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 25. YA36 18(2) 26. YA37 10(3) 27. YA38 12(4)(a) 28. YA 39 24 29. YA39 24 30. YA41 17 31. YA42 23(2) achieving the advised qualification quota. Ensure that all staff are appropriately supervised, and maintain a record that demonstrates that individual supervision is occuring at least six times in a year. Have available documentation that demionstrates that the manager is undertaking appropriate training, including working towards achieving the required qualification. Operate the home in a manner that is open and accountable. This must involve staff being aware when the manager will be on duty in accordance with the details set out on the duty rota. At least once a year carry out a review of the service, including consulting with service users and their representatives. Provide the Commission with a copy of the service improvement plan. It is recommended that this includes the plans to expand and upgrade the home, and projected timescales when these improvements will be introduced. Reference should also be made to the arrangements for the service users during the period of any building activity affecting their living arrangements. Have available for inspection the required documentation. It is expected that the responsible person in charge of the home is aware of, and can locate essential documents such as the fire log, accident book, complaints details, health and safety certificates, and the full names of staff working at the home. Have in place a system for 24/10/05 24/10/05 9/9/05 24/10/05 24/10/05 9/9/05 9/9/05 Page 27 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 responding to defects, such as reporting when the phone has broken, and providing a tv that works. 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 Good Practice Recommendations Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Faircross Avenue G55_S0000027898_Faircross Avenue_V233891_140605_Stage 4.doc Version 1.30 Page 29 - 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. 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