Inspection on 17/02/06 for Flaxen Road

This inspection was carried out on 17th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Flaxen Road 12/11/07

Flaxen Road 18/01/07

Flaxen Road 13/06/05

Flaxen Road 02/02/05

Flaxen Road 12/07/04

Similar services:

Clovelly House Residential Home Ltd

Cherry Orchard Nursing Home

Coppermill Care Centre

Fountains Care Centre (The)

Eleanor Palmer Trust Home

Elmstead House

Bridgeside Lodge Care Centre

Dalemead

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

CARE HOMES FOR OLDER PEOPLE Flaxen Road 1 Flaxen Road Chingford London E4 9TF Lead Inspector Kristen Judd Unannounced Inspection 10:00 17 February 2006 th X10015.doc Version 1.40 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 Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 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 Older People. 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. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Flaxen Road Address 1 Flaxen Road Chingford London E4 9TF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 524 4422 0208 524 9656 London Borough of Waltham Forest Ms Mary Lee Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: 1 Flaxen Road is a purpose built, single storey bungalow style building with wheelchair access. It was built in 1989 and houses 24 elderly frail people, including dementia. Access to the grounds are through electric gates with intercom system.There are 24 single rooms each with its own sink unit, and one with en-suite facilities. The premises is divided into two units, each with 12 bedrooms, a lounge, dining area, kitchenette, bathroom,3 toilets and a shower room. There is a main kitchen where freshly cooked meals are provided daily, including special diets and cultural foods where requested.Service users are encouraged to join in activities, which also include those suitable for people with dementia. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was completed in one day between 10.00 and 5.30pm.This inspection followed up the requirements made at the unannounced inspection held on 13th June 2005. The inspector spoke with service users, relatives, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of records were examined. At the time of this inspection there were no vacancies. There have been eleven requirements and two recommendations made following this inspection. Verbal feedback was given at the end of the inspection and a comment card left for completion. It was noted that the manager received the verbal findings positively, and responded positively to resolve and further develop those areas where action is now required. The inspector wishes to thank the management team, staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? 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. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 6 The inspector believes that staff are clear about the service and what is expected to be provided to service users. Pre admission assessments are completed prior to people moving into the home to ensure that the service provision can meet all there assessed needs. EVIDENCE: The home has a Statement of Purpose, which was updated in December 2005.The Statement of Purpose is a comprehensive document, which includes all the information required by the National Minimum Standards. The registered providers information is lengthy and it is recommended that this information be summarised to make a more service user-friendly document. A pre – admissions assessment has been developed since the previous inspection, which covers areas of needs, assessment and outcomes, covering aspects of daily living care. The homes manager carries out assessments. Individual records are kept for each of the residents; records for the most recent admissions were inspected. Evidence seen showed that the registered Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 8 manager had assessed the service users prior to admission and had the opportunity to gain extensive information with regard to the service users needs. Assessments included information on such issues as personal care, mental state, mobility, medical, health and social and leisure needs. The registered manager also writes to the prospective service users separately with regards to the outcome of the assessment and if suitable offers a place. The inspector thought this was a lovely individual touch. The inspector was satisfied through observations made during the inspection and discussion with both staff and service users there was evidence that staff are able to meet the assessed needs of service users. The home does not provide intermediate care. If, at a future date, the registered provider should wish to provide such care, consideration would need to be given to staffing levels, appropriate staff training and the provision of dedicated space for this purpose. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Much work has clearly been achieved since the previous inspection in implementing new care plans and risk assessments. However attention needs to be taken in ensuring that all risks are assessed appropriately and actions taken to minimise risks both to service users and others. EVIDENCE: Staff were observed during the inspection treating service users with consideration and respect. Feedback from relatives present during the inspection was extremely positive. Through the tracking of information evidence was seen to show that information available prior to admission had been transferred to the individual care plans. The home has recently implemented new care plans, which cover issues such as mental health and cognition, continence, sleep patterns and day-to-day issues such as activities and leisure. The inspector noted a marked improvement and through the tracking of care it was noted that one member of staff had prepared very thorough and individual care plans that clearly reflected the individual service users needs. Through cross-referencing the Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 10 information obtained at the pre admission assessment it had clearly been used as a basis for the care plan. For example one plan was very clear about how to deal with a service who can be unpredictable providing clear guidance for staff another even included information about what service user likes to drink before going to bed. Others were deemed adequate covering basic needs however potentially standards could be higher. Through the case tracking undertaken it was noted that one care plan did require updating with regard to the service user smearing faeces at night times. Information about the concerns were available on the service users file. It is recommended that the registered manager implement a system for staff that will highlight such issues and ensure that the care plans are duly updated to make sure that accurate information is maintained and that high standards are maintained. In addition to updating care plans new risk assessments have also been implemented. Most service users files seen contained risk assessments which are made up of front sheet that identifies areas needed assessment followed by a break down of the individual activities, what is the risk to the service user by undertaking the activity, risk to others and what are the positive outcome for the service users if the activity is undertaken. Once completed action required is recorded and there is an opportunity for service users and relatives input. Once again some of the risk assessment were comprehensive and had been completed inline with the care plans. However through the tracking of care it was noted that in some cases key areas had not been appropriately assessed. For example on pre admission information for one service user it clearly stated that there had been episodes of being ‘verbally inappropriate toward female staff in hospital, has mood swings and can be aggressive’. Additionally daily records seen during the inspection evidence episodes of aggression, being uncooperative, shouting and one entry made reference to the service user hitting staff. However no risk assessment had been implemented and there were no clear strategies to manage and reduce the risk. Another file did not contain risk assessments for being at risk from choking. Although the service users was on a liquidised diet. Another file indicated that the risk assessment had not been reviewed in excess of a year. At the time of inspection none of the service users had pressure sores, although some service users had been deemed at risk and appropriate pressure relieving aids were in place referrals made directly to the district nurse are documented of service users files. Clear and comprehensive records are maintained of medical appointments. Staff record when visits are undertaken recording the outcome of the appointment and any further action required. These evidenced that service Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 11 users have access to a variety of health professionals such as G.P, chiropodist and stomer nurse. Files seen also indicted that service users had received flu jabs. The medication has been moved since the previous inspection to a cooler room. Records are maintained of the fridge temperatures. Records are kept of all medications entering the home. Medication Administration Record (MAR) charts are maintained. The home uses the Nomad system for storing and administering medications. A random check was conducted of the generic packaged medication. The practise is to date the bottle when opened however it was not clear as to which actual dose was the start of the medication and some of the dates were illegible and one bottle had no date on it as such discrepancies were found. Staff had to recover old records to check medication. On the day of inspection 17/2/06 a gap was noted on the MAR sheet, as staff had signed the sheet of the 18/2/06. Additionally on inspection of eye drops stored in the fridge it was noted by checking product container label and patient information leaflet that some were to be stored at room temperature after opening Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 The inspector continues to be satisfied that staff provide service users with the opportunity and support to take part in activities in the home which provides variation and interest for service users and is appropriate to their needs. EVIDENCE: Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 13 On arrival at the home the inspector noted that there was already much service user and staff interaction. Service users were observed to move about the home independently or with assistance and to choose where to spend their time. There was evidence of a structured activity programme, in addition to individual needs being addressed during the inspection. The registered manager and staff team continue to be very focused on ensuring the service users are continually stimulated throughout the day. On arrival to the home no televisions were on and music was calmly playing. Throughout the inspection there was no interest in television (which was not on) as service users were encourage to interact both with staff, visits and relatives visiting the home and join in activities which were varied. The inspector chatted with service users and relatives during the inspection. The three sets of relatives spoken to all of whom were very positive both about the care provided and the staff. Service users access the local community, including going to shops, and day trips, photographic evidence is on display around the home. The Christmas celebrations were on display including the trip to a local theater and a Christmas party where many relatives attended. Competitions such as darts and bowling are undertaken and results are on display. The most recent ten pin bowling competition was held on the 13/2/06. A group of three service users went out on the day of inspection into the local community. The inspector was informed that staff endeavour to take a small group of service users out every day. Contact with family is encouraged; the inspector spoke with relatives of service users who were visiting on the day of inspection. One gentleman had joined his wife for lunch and stated that he was always made to feel welcome and encouraged to stay for a meal. He was very complementary about the food and stated that staff had got his wife eating and she had put on weight. Another relatives husband was a recent admission and was clearly tearful and she stated that the staff were lovely and really helping her to come to terms from being separated from her spouse. Service users finances are managed through the local authority as a corporate appointee or via relatives. The administrator requests money when needed for service users. Records seen at the time of inspection were well maintained and deemed correct. The inspector questioned how service users would know how much they had in savings. The administrator stated that this information was easily accessible and would be requested from the head office. It is recommended that up to date information regarding service users accounts is available for service users in the care home. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 14 Menus seen reflected that the breakfast, lunch and evening meals provided were healthy and appetising. On the day of inspection fish was being served for the evening meal. The inspector was present in the home half an hour prior to the evening meal being served and noted that the fish was only just prepared. The cook commented the importance of freshly cooked food this is deemed good practise. The meals were all home made with fresh vegetables. The inspector saw the food storage facilities; fresh, frozen and dry stocks were appropriately stored. The cook informed the inspector that new suppliers were being used for dry stocks, which were not as good however this had been reported and was being addressed. Food provision continues to be of a high standard. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17& 18 The inspector believes that the home has appropriate systems in place for dealing with complaints. However clear accessible guidance must be available and training for staff must be undertaken to ensure that service users are not put at undue risk. EVIDENCE: The home maintains a complaints log, this evidenced that complaints have been appropriately recorded and investigated. There is a leaflet provided by the Local Authority available in the home stating the complaints procedure, which has three stages and a 28-day timescale for dealing with complaints. Request for copies of the complaints procedure is written in 6 languages. No complaints had been logged however during the inspection of the unannounced visits records the inspector noted a complaint was recorded. On discussion with the registered manager the inspector was informed that the complaint was with regards to an agency staff member who had left the agency. However the registered manager must ensure that all complaints are logged appropriately and outcomes recorded. The complaints procedure was displayed within the home, and this made appropriate reference to the CSCI. Relatives spoken to demonstrated a good understanding of whom they could complain to if they so wished. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 16 The home is run by the Local Authority, and has a copy of their adult protection procedure. Additionally there are the home guidelines for staff on adult abuse. The registered manager informed the inspector that most of the staff at the home have received training in adult protection issues. Through crossreferencing the training records and the staff rota the inspector noted that five of the current staff team (including apprentices) have not received training. Three of the team had training in 2003. It is required that all staff receive appropriate training in adult protection issues. There is an adult abuse incident reporting form to be used for incidents of abuse or suspecting abuse. The format is comprehensive requesting relevant information. The inspector was informed that there are have been no allegations made. The inspector was satisfied that the legal rights of service users are protected. For example all service users are on the electoral register. Service users finances were seen which were being recorded accurately and were deemed correct. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,21,22,23,24,25 & 26 The inspector was satisfied that the home provides adequate communal and private space for service users to meet assessed needs . However the home is still in need of some minor repairs and ongoing redecoration programme. EVIDENCE: Flaxen Road is a purpose built bungalow style premises, which is divided into two intercommunicating units each housing 12-service users. Paths, hedgerows and gardens surround the building. Areas of the home are looking ‘tired’ the registered manager is hoping to replace some of the soft furnishing over the next year. There have been some improvements internally for example the dinning areas have had new floors laid. The cleaning staff continue to keep the home clean and there were no odours noted during the inspection. The maintenance programme for the surrounding gardens and paths has now been completed which enable service users to use the grounds safely. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 18 A tour of the premises was conducted. There are sufficient toilet and bathing facilities to meet the needs of the service users. There are a number of minor repairs that require attention: Both shower rooms on each section had stained tiles, which require treating. The doorframe in the shower on the yellow side was rotten. Additionally the showerhead did not attached to the wall and required fixing. The toilet on the yellow side required cleaning on the back wall. On the red side there was a leaking tap in the toilet. Where the repairs have been made in the red side bathroom paintwork must be made good. All of the individual rooms seen had been personalised and were comfortable and service users were able to bring their personal belongings into the home. Rooms had adequate furniture including wardrobes and chest of draws. There is a small laundry facility, which was clean and tidy. However the linen cupboard was untidy and required sorting. There was evidence of appropriate aids and adaptations available for service users. The inspector was satisfied that the registered manager was fully aware of the care that could be provided and made appropriate referrals for service users if their needs indicated that they required nursing care. There is evidence of signs and pictures throughout the building to help service users’ with orientation. Signs on service users rooms are personalised with recognisable pictures, which are a lovely touch. Concern was raised during as during a tour of the premises it was noted that the cleaner’s room on the yellow side was open and contained a COSHH substance in an area that service users routinely access. During the rest of inspection on the red unit the cleaning cupboard was also open and contained COSHH substances and most concerning toilet cleaner. Given this is a home for service users with dementia this is a serious concern. The registered manager must ensure that all dangerous substances are stored securely. This issue will be a requirement under Heath and Safety standard. Further concern was raised when the inspector noted that latex gloves were in the normal rubbish bins in the bathrooms. Any such equipment used for personal care must be disposed of as clinical waste to prevent the spread of inspection. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30 It was the inspectors view that the home has an effective staff team who appeared to work well together to provide a good level of care to service users. However all mandatory training must be up to date to ensure that service users are not put at undue risk. EVIDENCE: Rotas indicated that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. There is always at least four staff and one senior on shift. Nights there are two staff on duty. Additionally there are administrative staff, a laundry assistant, domestics and a cook. The home produces a staffing rota, and on the day of inspection this accurately reflected the actual staffing situation. As previously stated staff were seen interacting well with service users, relatives spoken with during the inspection were very complementary about the staff and observations made confirmed good rapport between staff and service users. Throughout the inspection, the atmosphere was very calm and activities were observed to be going on. Service users appeared content and those spoken to state they were happy with the service they received from staff. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 20 Regular staff meetings are monthly, these are minuted, records indicated that relevant subjects are discussed such as policies and procedures and updating care plans. The registered manager keeps copies of staff files. A complete audit was undertaken. The following issues were raised: Five files did not contain CRB disclosure numbers No records regarding agency staff. Lack of references. Nine lacked evidence of photographic ID Application forms evidenced a lack of employment history. Lack of professional references or most recent employer. One file the leave to remain visa had expired. Two employees had no records at all. One started Sept 05 and one started December 05. One file had no application form. The inspector was informed that the main files were maintained at the head office. The registered manager must ensure that all files are accurately maintained or written confirmation on staff files to confirm that all relevant checks are completed and up to date. Training records are maintained. These evidenced that staff have undertaken received training in animate manual handling, food hygiene, and specialist courses such as diabetes. Records indicated that of the seventeen staff thirteen have at least NVQL 2 qualification. However, not all statutory health and safety training was up to date, for instance several staff have had no recent training in fire safety or first aid some noted as old as undertaken in 2000. It is required that staff receive all appropriate statutory health and safety training. Staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities, and were observed to interact with service users in a friendly and supportive manner. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33,35,36 & 38 The inspector was satisfied that is a well run and well managed home. The contents of this report reflect that the registered manager is sufficiently qualified and experienced to carry out their roles and responsibilities effectively. However, concerns have been raised with regard to staff supervision and this must be addressed as a matter of urgency. EVIDENCE: Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 22 The registered manager has attained her NVQ level 4 in Management and the City & Guilds Advance Management for Care. She has 25 years experience in the care industry in various capacities. The registered manager is aware of the National Minimum Standards and as reflected in this report endeavours to exceed them. The inspector continues to be satisfied that the home is managed in an open and positive way. The registered manager demonstrated a clear understanding of the management of services to this client group. The staff and service users were observed friendly, open and appeared comfortable within the care home throughout the inspection. There has been a marked improvement in the care planning and the home is commended for the standard of some of the plans in place. However although there has also been an improvement in risk assessments it was noted that some areas of risk had not been appropriately assessed and some were out of date and needed reviewing. The reports regarding the monthly-unannounced monitoring visit were seen however no visits were undertaken in August 2005,October 2005 or January 2006. This remains an outstanding requirement. The registered manager and members of the senior team are responsible for provision of supervision. A comprehensive check on records was conducted and it remains a concern that records seen indicated that this is not being completed to the minimum standard of six times a year. One staff member had no recorded supervision at all on file; one staff member last recorded supervision was December 2004.The registered manager stated that staff are continually supervised and she has an open door policy. However the registered manager must implement a structured supervision programme and keep records, which are to be available for inspection. This matter must be addressed as a matter of urgency. The service users’ finances and petty cash were seen which were being recorded accurately and were deemed correct. The following health and safety checks have been evidenced: The last recorded fire drill is recorded as 12/2/06 Alarm system/emergency light 13/1/06 Gas certificates were seen dated 03/05 valid for one year. Electric certificates were seen dated 04/04 valid for five year Portable Appliance Test were completed 06/05 Fire extinguishers were last checked September 05 Insurance certificate valid until 31/5/06 Insurance valid until 31/3/06 As stated earlier in this report concerns were raised, as COSHH substances were accessible during the tour of the environment. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 1 x 2 Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 13.4 (c) Requirement The registered manager must ensure that all unnecessary risks to the health and safety of service users are identified are so far as possible eliminated.(Timescale of 31/08/05 not met) The registered manager must ensure that medications are appropriately stored and records are accurately maintained. The registered manager must ensure that all complaints are logged appropriately and outcomes recorded The registered manager must ensure that all staff employed at the home receive appropriate training in adult protection issues. The registered manager must address the minor repairs as reported in this report. The registered manager must ensure that staff adhere to clinical waste policy to prevent the spread of inspection Timescale for action 31/03/06 2 OP9 13.2 31/03/06 3 OP16 22 31/03/06 4 OP18 13.6 30/06/06 5 6 OP21 OP26 23.2 13.4 31/03/06 31/03/06 Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 25 7 OP29 19.4 8 OP30 18.1 The registered manager must be 31/03/06 able to evidence that a robust recruitment process is in place and all relevant checks are undertaken prior to employment. 30/06/06 The registered manager must ensure that all staff receive all appropriate health and safety training. The responsible individual must 31/03/06 ensure that monthlyunannounced visits are completed and reports must be available for inspection. (Timescale of 30/06/05 not met) The registered manager must 31/03/06 ensure that all staff working in the home are suitable supervised and records are maintained. The registered manager must 15/03/06 ensure that all Control of Substances Hazardous to Health Regulations (COSHH) 1988 be appropriately stored. 9 OP33 26 10 OP36 18.2 11 OP38 13.4(a) 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 Refer to Standard OP1 OP14 Good Practice Recommendations It is recommended that the registered providers details be summarised within the Statement of Purpose. It is recommended that up to date information regarding service users accounts is available for service users in the care home. Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Flaxen Road DS0000058687.V259333.R01.S.doc Version 5.0 Page 27 - 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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