Inspection on 19/07/05 for Gate House

This inspection was carried out on 19th July 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 but made no statutory requirements on the home.

Other inspections for this house

Gate House 09/09/08

Gate House 27/09/07

Gate House 09/02/07

Gate House 15/06/06

Gate House 05/12/05

Gate House 04/11/04

Gate House 16/06/04

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

CARE HOME ADULTS 18-65 Gate House 238 New Cross Road London SE14 5PL Lead Inspector Kate Matson Unannounced 19 July 2005, 10:00am th 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. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gate House Address 238 New Cross Road, London. SE14 5PL 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) 0207 635 6883 Mr Lynval Palmer Ms Hazel May Parkinson CRH Care Home 10 Category(ies) of MD Mental Disorder, 10 registration, with number of places Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2004 Brief Description of the Service: Gate House is a care home providing support and accommodation for up to nine men and women who have support needs due to mental ill health and who are aged between 18 and 65 years of age. Accommodation is provided in 5 single and 2 double rooms. Service users admitted to the service have to be relatively physically able as access to the upper floor is via a staircase. The home is privately owned and located in a residential area of New Cross Road in South East London with good access to London Underground and mainline rail stations at New Cross Gate. There are also a number of bus routes stopping close to the home. Service users also have access to a wide range of local amenities and community resources. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was conducted over seven hours. The inspection included discussion with seven of the service users, staff members, the registered manager, a tour of the premises and examination of care plans, staff files and other records. Staff interviews were being conducted on the day of the inspection and the manager, staff and service users are thanked for their support during the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Although service users have a contract with the home there is some important information missing that must be included to ensure that service users rights are protected. Although most service users are able to access valued activities outside of the home there is very little activity offered by the home. This must be addressed to ensure that the stimulation needs of service users are met. It is also Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 6 recommended that service users be offered seven-day holidays outside the home that they help choose and plan. Most service users had not made complaints but one service user who had did not feel it was acted upon. This must be addressed to ensure that service users have confidence in the service. The home is homely and comfortable however although the provider has been in contact with CSCI regarding extensive refurbishment, plans have not yet been submitted to CSCI as required by regulation. Room sizes have not been supplied to CSCI to ensure that they suit service users needs and two service users sharing rooms stated that they would prefer not to. If a single room becomes available service users in shared rooms must be offered the chance of not sharing and the shared rooms becoming single rooms. Some broken items in one bedroom highlighted the need for a weekly audit of the premises. There is adequate communal space though the staff sleep in room is not fit for human habitation under the Housing Act 1985. This issue has been referred to the Local Authority Health and Safety Enforcement Team who may take independent action. Urgent action must be taken to address this issue and as there is a shared window between the rooms, a curtain must be provided in the staff room in order to reduce the disturbance to the service user in the adjoining room. The home was largely clean though some windows and toilet bowls were dirty and this must be addressed as it could lead service users to feel that they are not valued. Recruitment files revealed that one staff member had started work before appropriate checks were received. New checks must be done before staff start work in order to protect service users from abuse. Although some evidence of supervision was available staff need to be supervised at least six times per year to ensure that they are appropriately supported to meet the needs of service users. Quality assurance systems needs to be improved to evidence that the service is being monitored, reviewed and developed and to ensure that service users are confident that their views are taken into account. There are systems in place to ensure the health, safety and welfare of service users though a certificate of electrical safety was not available and the practice of door wedging places service users at risk in the event of fire. 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. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5 Service users needs are fully assessed before being offered a place at the home. Although service users have a contract this does not include the information required to fully protect their rights. EVIDENCE: Three of the service users personal files were examined and all included evidence of thorough assessment before admission to the home, to ensure that the home was able to meet their needs. It was noted at the previous inspection that although all of the service users had a contract, it had some of the required elements missing such as details about the personal support, facilities and services provided and the arrangements for reviewing needs and progress. At this inspection the manager stated that the contract had not yet been reviewed. This must be done in order to ensure that the rights of service users are protected. Continued non-compliance with this requirement may lead to enforcement action being taken. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7 Care plans reflect service users assessed and changing needs. Service users make their own decisions as far as possible. EVIDENCE: The three care plans examined showed that care plans covered the areas required to ensure that all service users needs are addressed. They were signed by service users to indicate their involvement in the process. The care plans evidenced that service users have regular contact with their mental health teams in the community and attend Care Programme Approach (CPA) review meetings as required. Discussions with service users and observations made on the day of the inspection indicated that service users are supported to make their own decisions as far as possible. All but one of the service users manage their own money and service users were seen to move come and go from the house freely. Service users confirmed that they are involved in the care planning process and that they are able to make their own choices about meals and how to spend their time. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 10 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, 14, 16 and 17 Service users take part in appropriate education and occupation activities outside the home. The home offers a low level of leisure activities that needs to be increased in order to meet the stimulation needs of service users. Routines at the home recognise and respect service users rights and responsibilities. Service users are able to choose meals that meet their needs and preferences. EVIDENCE: Some service users are supported by an employment scheme to find voluntary and paid work. Currently two service users have part time work and a third is looking for work. One service user is attending a literacy course at college. Some of the service users take part in social and educational activities at local day centres. Other service users spend their time visiting family and friends. All of the service users stated that there was little activity offered at the home. Some said that there was a barbeque around once a year. The manager stated that service users did not generally wish to take part in activities but that they are encouraged to do so. However the only activities on offer appeared to be board games. The level of activity offered within and outside the home needs to be increased in order to meet service users stimulation needs. In addition Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 11 service users should also be offered a minimum seven-day holiday outside the home that they help choose and plan. The daily routines in the home promote independence. Service users moved around freely on the day of the inspection. All of the service users have the key to their room and on the day of the inspection most service users had chosen to lock their rooms. Service users do not have the key to the front door but several service users explained that this was because they felt more secure having to be let in as it ensured that staff knew who was on the premises at all times. Staff use service users preferred form of address and one service user is addressed quite formally in accordance with his wishes. Most service users were happy with the meals provided. Service user meeting minutes showed that menus were chosen by service users and service users confirmed that staff would also cook something else if they didn’t want what was on the menu and cultural needs were provided for. The menu’s appeared varied, balanced and nutritious. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 12 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) None of these standards were inspected at this inspection, however all were inspected during the previous inspection year and were considered met. EVIDENCE: Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 13 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 Most service users had not made complaints but one service user who had made one did not feel that it had been acted on. EVIDENCE: It was recommended at the previous inspection that the complaints procedure include a statement that complainants will not be victimised. This has not been implemented but should be so that complainants feel confident to complain. The complaints record indicated that there had been one complaint that was appropriately dealt with. Most of the service users stated that they had never had to make a complaint apart from one who stated that he had made a complaint “years ago but nothing was done” (this relates to the staff sleep in room discussed under Standard 28). A requirement has been made regarding the issue but the registered provider must also ensure that all complaints are appropriately recorded and investigated, providing the complainant with a written response within appropriate timescales. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 14 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, 25, 26, 28 and 30 The home is homely and comfortable, however plans for extensive refurbishment have not yet been submitted to CSCI as required by regulation. Room sizes have not been supplied to CSCI to ensure that they suit service users needs and two service users sharing rooms stated that they would prefer not to. Some broken items in one bedroom highlighted the need for a weekly audit of the premises. There is adequate communal space though the staff sleep in room is not fit for human habitation under the Housing Act 1985 and also affects the service user in the adjoining room. The home was largely clean though some windows and toilet bowls were dirty. EVIDENCE: At the last inspection it was noted that the home required redecoration in many bedrooms and shared areas. Previous inspectors had been told that the registered provider was planning a total refurbishment of the premises. Plans included changes to the home layout, improvements to office and sleeping-in facilities, kitchen renewal and the opportunity for each service user to have a single bedroom The house would also be re-decorated and refurbished throughout. It was required that the registered person inform the CSCI in writing of proposals to alter the care home premises as significant changes would require an application for variation of registration, and that where Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 15 necessary redecoration is undertaken in communal areas and bedrooms. At this inspection the registered manager stated that redecoration had not been undertaken because the refurbishment would be soon underway. The registered manager stated that she understood an application for variation of registration had been completed and submitted to CSCI. However following the inspection it was found that an application had not been received by CSCI and the registered manager stated she would follow this up. Continued noncompliance with this requirement may lead to enforcement action being taken. Previous inspections had required that room sizes be supplied to CSCI and this is still outstanding. Continued non-compliance with this requirement may lead to enforcement action being taken. It was noted that two of the bedrooms were shared. National Minimum Standards state that service users must only share if they have made a positive choice to do so. Two of the service users sharing rooms stated that they would prefer not to share but there were not enough single rooms. It is acknowledged that refurbishment is planned allowing all service users single rooms however if a service user moves out from a shared room in the meantime it is expected that the room would be used for single occupancy. Previous inspections had recommended that bedroom redecoration and carpet replacement is considered within the planned refurbishment programme and as already stated this is yet to be implemented. Rooms seen by the inspectors included the required furniture and fittings including screens in shared rooms. It was noted in room 4 that one of the drawers was broken and that the shade on a table lamp was broken. This was potentially dangerous and was pointed out to the manager on the day of the inspection. The manager stated that she had not been informed previously of the breakages. Weekly audits of the premises must be completed in order to ensure that broken items are identified and repaired/replaced in order to protect service users and ensure that they feel valued. The home has adequate shared space for service users including a lounge, dining room and smoking room. There is a garden at the rear of the property. Previous inspections had noted that the staff sleeping in room has only borrowed light from the adjoining room and no opening window. This does not comply with the Housing Act 1985 (Section 604) and Standards of fitness for human inhabitation. Previous inspections had required that adequate and safe sleeping facilities must be provided for staff. The manager stated that this would be addressed in the forthcoming refurbishment, however this is a serious health and safety issue and must be addressed urgently independently of the refurbishment if necessary. Continued non-compliance with this requirement may lead to enforcement action being taken. This matter has also been referred to the Local Authority Health and Safety Enforcement Team who will conduct an inspection at the home shortly. It was also noted that the light from the sleep in room disturbs the service user who has the adjoining room, and in the short term a curtain needs to be provided to prevent this. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 16 The home was generally clean and washing facilities were appropriately sited. However several windows were dirty and a toilet in one of the en-suite bathrooms had bad lime scale. This detracts from the overall environment and could lead service users to feel they are not valued. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 17 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) 32, 34 and 36 Staff have the personal qualities required to meet the needs of service users. All staff have been registered to complete NVQ training to ensure that they are qualified to meet the needs of service users. An aspect of the homes recruitment practice potentially placed services at risk of abuse. Staff are not supervised regularly enough to ensure that they are appropriately supported to meet the needs of service users. EVIDENCE: Generally service users spoke positively about the staff at the home. Comments included; “Staff are very good at supporting you”, “I get on well with all the staff”, and “Staff are well mannered”. Staff were seen interacting with service users in a respectful way and it was pleasing to note that a high level of contact was being maintained with a service user who was in hospital. At the previous inspection it was recommended that at least 50 of care staff achieve NVQ level 2 by 2005. The manager stated that all staff are registered to commence NVQ training in September in accordance with this. Five staff files were examined at it was noted that all included evidence of appropriate checks, however one staff member who it was found had now left the home had started employment in the home with a Criminal Records Bureau (CRB) check from July 2003. This is not acceptable and it also means that a check would not have been made of the list of people considered unsuitable to work with vulnerable adults (POVA). This practice potentially places service users at risk of abuse. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 18 It was noted at the last inspection that although there was evidence available that staff are supervised and records indicated that discussions were appropriate, it was noted that staff were not supervised every two months as required to ensure that staff are properly supported to meet the needs of service users and supervision records were not stored securely. It was also recommended that staff be given a copy of the supervision record. At this inspection the manager stated that records were now stored securely and brought some records for examination. The records showed that since the last inspection eight months previously, staff had been supervised only once or twice and therefore would not meet the six times per year target. Continued non-compliance with this requirement may lead to enforcement action being taken Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 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) 39 and 42 Quality assurance systems needs to be improved to evidence that the service is being monitored, reviewed and developed and to ensure that service users are confident that their views are taken into account. There are systems in place to ensure the health, safety and welfare of service users though a certificate of electrical safety was not available and the practice of door wedging places service users at risk in the event of fire. EVIDENCE: The home had completed a satisfaction survey in December 2004, however the results of this had not been summarised and made available to service users and others taking part in the survey to evidence that their views are taken into account. An annual development plan was not available reflecting aims and outcomes for service users. Previous inspections had noted that the registered provider was not conducting monthly, unannounced quality assurance monitoring visits and required that he do so, supplying a copy of the reports to CSCI. This has not been done and four previous timescales have not been met. Enforcement action is being considered regarding this issue. It was also noted that although the registration certificate was displayed as required by Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 20 regulation, only one side of the certificate was on display. This must be rectified so that it is clear to any visitors what the home is registered to provide. Evidence was available of fire drills being carried out at appropriate intervals, testing and inspection of the fire alarm and equipment, gas safety and electrical appliances. Training on health and safety topics was also appropriately conducted. A certificate on the safety of the electrical installation of the building was not available. At the previous inspection it was noted that several doors marked fire door had been wedged open. The Manager was advised that this is not acceptable and that all wedges must be removed and advice must be sought from the local Fire Safety Officer in relation to approved alternatives. At this inspection two doors were wedged open and the manager removed them but stated that service users chose to do this. Continued noncompliance with this requirement may lead to enforcement action being taken. A fire risk assessment must be completed including this issue, in consultation with the fire brigade. Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 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 x 3 x x 1 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 x 1 x 1 Standard No 11 12 13 14 15 16 17 x 3 x 1 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 1 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gate House Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 1 x G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 5 Regulation 5 (1) (c) Requirement The Registered Manager must ensure the service user contract is updated to ensure it meets all areas outlined in Standard 5.2. A copy to be forwarded to CSCI (previous timescale of 28/02/05 not met) The registered provider must ensure that the level of activity offered inside and outside the home is increased in order to meet the stimulation needs of service users. The Registered Person must inform the CSCI in writing of proposals to significantly alter the care home premises(previous timescles of 29/02/04, 30/08/04 and 28/02/05 not met) The Registered Provider must ensure that where necessary redecoration and refurbishment is undertaken in communal areas and bedrooms (previous timescale of 28/06/05 not met) The Registered Person must supply the CSCI with the dimensions of individual rooms (previous timescales of 31/03/04, 30/08/04 and Timescale for action 31/10/05 2. 14 16 (m) and (n) 30/11/05 3. 24 39 (h) 30/09/05 4. 24 23 30/11/05 5. 25 23 (2) (f) 31/10/05 Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 23 28/02/05 not met) 6. 25 23 (2) (e) The registered provider must ensure that where rooms are shared they are shared by two service users who have made a positive choice to share with each other.Where single rooms become available those in shared rooms must be offered the chance to move and leave the remaining service user in single accommodation. The registered provider must ensure that broken furniture and equipment is repaired or replaced and that weekly audits of the premises are conducted to ensure awareness of any breakages. The registered person must provide adequate and safe sleeping facilities for staff (previous timescales of 03/11/03, 31/07/04 and 28/01/05 not met) The registered provider must ensure that a curtain is provided in the existing staff sleep room, that can be opened and closed to prevent light disturbance to the service user in the adjoining room. The registered provider must ensure that all areas of the home are kept clean, including windows, and that toilets are free of lime scale. The registered provider must not allow any staff to commmence employment in the home until new checks have been completed including a POVA check. The Registered Manager must ensure that staff supervision is undertaken at least six times a year and that supervision records are securely stored 31/10/05 7. 26 16 (2) (c) 31/10/05 8. 28 23 (3) (b) 31/12/05 9. 28 16 (2) (c) 31/08/05 10. 30 23 (2) (d) 31/10/05 11. 34 19 (1) (b) 31/08/05 12. 36 and 41 18 (2) and 17 (2) schedule 4 (6) (f) 31/10/05 Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 24 13. 39 26 14. 39 24 15. 39 24 (1) (b) 16. 39 17. 42 Sec 28 of Care Standards Act 23 (4) 18. 42 23 (4) 19. 42 23 (2) (b) (previous timescale of 28/02/05 not met) The Registered Provider must undertake monthly, unannounced quality assurance monitoring visits and produce a report that must be supplied to the CSCI (previous timescales of 03/10/03, 31/03/04, 30/08/04 and 28/02/05 not met) The registered provider must ensure that the results of quality assurance surveys are summarised and made available to service users and others taking part. The registered provider must produce an annual development plan, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. The registered provider must ensure that both sides of the certificate of registration are clearly displayed. The Registered Manager must ensure that the doors marked fire doors are not wedged open and that advice is sought from the local Fire Safety Officer in relation to suitable alternatives. A copy of the guidance to be sent to CSCI (previous timescale of 28/02/05 not met) The registered provider must ensure that in consultation with the fire brigade, a fire risk assessment is developed including the issue of door wedging. The registered provider must ensure that a certificate of safety of the electrical installation of the building is sent to CSCI and available at the home for future inspections. 31/10/05 31/01/06 31/01/06 31/10/05 31/10/05 31/10/05 30/09/05 Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 25 20. 22 22 (3) The registered provider must ensure that all complaints are recorded, fully investigated and the complainant provided with a written response within appropriate timescales. 30/09/05 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 14 Good Practice Recommendations It is recommended that service users have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. It is recommended that bedroom decoration and carpet replacement (where necessary) is considered within the planned refurbishment programme The Registered Manager should ensure that staff are given a copy of their supervision record The complaints procedure should include a statement that service users or their representatives who make a complaint will not be victimised for doing so 2. 3. 4. 26 36 22 Gate House G52-G02 S25620 Gate House V238301 190705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 46 Loman Street Southwark London SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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