Inspection on 05/12/05 for Gate House

This inspection was carried out on 5th December 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 19/07/05

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 Inspection 5th December 2005 10:00 Gate House DS0000025620.V269269.R01.S.doc Version 5.0 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 Gate House DS0000025620.V269269.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gate House Address 238 New Cross Road London SE14 5PL 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) 0207 6356883 Mr Lynval Palmer Mrs Marjorie Palmer Ms Hazel May Parkinson Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 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 DS0000025620.V269269.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was completed over six hours. The inspection included discussion with six service users, two staff members, the registered manager, a tour of the premises, examination of four service users’ files, six staff files and other records. The manager had to leave before the inspection was finished and as a result Standard 34 and 37 could not be assessed. The manager was able to fax some information regarding Standard 34 to the inspector the following day and Standard 37 will need to be examined at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: The service user contract still lacks some information required to protect the rights of service users. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 6 Although general risk assessments are completed for each service user, plans to manage risk associated with mental health need to be in place. Although the manager states that service users are reluctant to engage in activities at the home, more proactive and innovative approaches are needed to ensure that the stimulation needs of service users are met. In addition, service users must be offered the opportunity of a holiday and more regular service user meetings would ensure that further opportunities for discussion around these issues could be offered. Although medication systems were largely robust, the homely remedies list required updating to ensure the safety of service users. The homes recruitment procedures had again placed service users at risk of abuse and a letter of serious concern was sent to the provider, requiring new Criminal Records Bureau check applications to be made for two members of staff. The provider has now decided not to proceed with the planned major refurbishment to create better office facilities, more suitable staff sleep in accommodation and all service users the opportunity of a single room. However, redecoration and carpet replacement is overdue in several areas and the provider has informed the inspector that this will take place in January 2006. In addition the provider needs to ensure that radiators give out sufficient heat, as although the heating was on some radiators were ineffective. Also radiators must be covered unless a risk assessment indicates this is unnecessary. Some service users share rooms and would prefer not to. When rooms become available those in shared rooms must be offered the chance to move rooms and double rooms revert to single occupancy. The local authority health and safety enforcement team have agreed that more effective ventilation in the staff sleep in room would be acceptable and the extended timescale in which to ensure that staff have adequate sleep in accommodation had not expired at this inspection. However, a temporary measure of the provision of a curtain at the window adjoining a service user’s bedroom was inadequate as it did not cover the window and cut out the light. Although a limescale problem had improved, windows were still dirty potentially leading service users to feel they are not valued. Although staff were undergoing some appropriate training, a plan must be in place, based on the needs of staff and service users and induction and foundation training must be to sector skills specifications to ensure staff are able to meet service users needs. Although the practice of door wedging had ceased, a fire risk assessment is still required. Only some staff had food hygiene certificates and these must be updated to ensure the protection of service users. 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 DS0000025620.V269269.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Although service users have a contract this does not include all of the information required to fully protect their rights. EVIDENCE: Previous inspections had noted that although all of the service users had a contract, some of the required elements were 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 provider was reviewing the contract but as yet this had not been done. This must be done in order to ensure that the rights of service users are protected. Continued non-compliance with this requirement will lead to enforcement action being considered. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Although risk assessments had been completed for general risks, there was insufficient evidence available of how risks associated with mental health problems were being managed. EVIDENCE: Risk assessments for four service users were examined. These indicated that risks in the environment and the wider community had been identified and addressed and there were also risk assessments in place for service users who were responsible for their own medication. However although service users had risk assessments completed as part of the Care Programme Approach (CPA) process, and these had highlighted risks such as self harm and violence, a risk management plan for dealing with these risks had not been completed by the home in the care plan or as a separate document. The must be addressed to evidence that risk is being managed appropriately in the home. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 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 the following standard(s): 13, 14 and 15 Service users are part of the local community and have appropriate relationships. A more proactive approach to activities is needed to meet the stimulation needs of service users. EVIDENCE: Service users are largely independent and use the local community as they wish. Information about resources in the community was available around the home. One service user is employed, a small number attend day centres, and one service user goes to church. They all use local shops and café’s. At the last inspection it was required that the level of activity offered within and outside the home be increased in order to meet service users stimulation needs. In addition it was recommended that service users be offered a minimum seven-day holiday outside the home that they help choose and plan. At this inspection service users again stated that there was little activity offered at the home and all said that they had not been offered a holiday. Some said that a day trip had been arranged but this was cancelled due to the weather but then was not rearranged. The manager stated that service users were encouraged to take part in activities but generally they did not wish to. She stated that some had been interested in getting a pool table but there was Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 11 no room for one. The home needs to be more proactive and innovative in providing activities, for example, organising a tournament at a local pool club if service users like to play pool. It was also noted that a service user meeting had not been held for five months and this must be addressed to ensure that issues such as activities and holidays can be regularly discussed as a group. The manager confirmed that service users are supported to maintain and develop relationships with family and friends. The home operates an open visiting policy and service users often invite their friends into the home. Most service users have frequent contact with their family either by telephone or in person. One service user has a long-term relationship and spends weekends away from home with her partner. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 Service users are supported in a flexible way. The physical and mental health needs of service users are addressed and monitored although a monthly weight check would assist in monitoring health. Medication systems are safe although the homely remedies list requires up dating. EVIDENCE: Service users are largely independent with their personal care and choose their own clothes. Care plans indicated that some required support in the way of prompting. The home has a key working system in operation to ensure consistency. Each service user’s file had a health monitoring form to ensure that all service users receive the appropriate checks from GP, dentist, optician etc. The home is covered by 2 GP practices and the manager reported no concerns about the service received. It was noted however that the weight of service users was not routinely checked in order to monitor their health. It is recommended that the weight of service users be checked on a monthly basis. Three service users manage their own medication and three are working towards it. Risk assessments are in place to support this. Medication records and supply were in order however it was noted that the homely remedies list had not been updated since 2002 and administrations were recorded on the service users records instead of a specific homely remedies record as required. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 13 The manager must ensure that an up to date homely remedies list including the names of service users and dosages, is approved by the GP. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users spoken to had not made complaints. Recruitment practices placed service users at risk from abuse and staff had not had training in this essential area. EVIDENCE: At the last inspection all 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 was made that all complaints are appropriately recorded and investigated, providing the complainant with a written response within appropriate timescales. At this inspection no complaints had been made and none of the service users spoken to said they had any complaints. The manager stated that she would ensure that any complaints would be dealt with appropriately. It was also previously recommended that the complaints procedure include a statement that complainants will not be victimised. The manager stated that the provider was dealing with this but it had not yet been done. The home has an appropriate adult abuse policy in place as well as a whistle blowing policy. The manager stated that she was clear about her responsibilities regarding the list of people considered unsuitable to work with vulnerable adults (POVA list). However two new staff members had started without a check being made against the POVA list. It was also noted that staff had not undergone training in adult abuse. The provider must ensure that all staff undergo appropriate training in adult abuse. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 and 30 The home is comfortable and homely although redecoration and refurbishment is overdue in many areas and the heating was inadequate. Service users continue to share some rooms but some would prefer not to. The staff sleep in accommodation continues to be inadequate but the extended timescale in which to take action has not yet expired. Although a curtain has been provided to reduce the disturbance to a service user in an adjoining room this is inadequate. The home was largely clean and hygienic but windows were still dirty. EVIDENCE: At a previous 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. 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 necessary, redecoration be undertaken in communal areas and bedrooms. At this inspection the registered manager stated that the provider had now decided not to go ahead with the major refurbishment but redecoration would Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 16 take place early in the New Year. A variation will no longer be required but the provider must ensure that requirements regarding room sharing are met and that redecoration and refurbishment takes place as required as many areas of the home are now in need of redecoration and new carpets. Continued noncompliance with this requirement will lead to enforcement action being considered. It was also noted that although the heating was on, radiators were not guarded and did not give out much heat in many rooms. The provider must ensure that radiators are guarded unless a risk assessment indicates this is unnecessary and that radiators give out sufficient heat. Previous inspections had required that room sizes be supplied to CSCI and in October 2005 rooms sizes in feet were sent to the inspector who advised that these must be in metres and included in the statement of purpose and service user guide. It was noted at the last inspection 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. The provider was required to ensure that 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. At this inspection it was found that although a single room had become available this had been offered to the service user whose room was next to the staff sleeping in room because of being disturbed by the light from the neighbouring room. Rooms seen by the inspector included the required furniture and fittings including screens in shared rooms. At the last inspection it was required that weekly audits of the premises 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. At this inspection it was found that these were now being completed and a broken headboard was noted in the book and awaiting repair or replacement. Redecoration and new carpets were overdue in some rooms and expected to be addressed in the New Year. 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. This matter was referred to the Local Authority Health and Safety Enforcement Team who conducted an inspection at the home and agreed that a more effective ventilation system would be acceptable. The extended timescale in which to meet this requirement had not expired at the time of the inspection. It was also noted at the last inspection that the light from the sleep in room disturbs the service user who has the adjoining room, and a curtain needed to be provided to prevent this. It was found at this inspection that although curtains had been provided, they did not entirely cover the window and they were thin allowing light through. The service user stated that he would be moving rooms anyway but this needs to be addressed if another service user uses this room. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 17 The home was generally clean and washing facilities were appropriately sited. However at the last inspection it was noted that 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. At this inspection it was noted that some windows were still dirty though lime scale had improved. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Although most staff are completing relevant NVQ qualifications, the home does not have a training plan and induction training does not meet national minimum standards. Recruitment practices potentially place service users at risk of abuse. Staff are not supervised regularly enough and records of supervision are not held securely. EVIDENCE: Three staff are doing NVQ level three and one is doing NVQ level two. This should ensure that the home will have more than 50 of staff with an NVQ qualification as required by National Minimum Standards. At the last inspection it was found that one staff member who had since left the home had started employment in the home with a Criminal Records Bureau (CRB) check from July 2003. This also meant that a check had not been made of the list of people considered unsuitable to work with vulnerable adults (POVA). This is not acceptable as it potentially places service users at risk of abuse. At this inspection the manager left before recruitment files could be examined, however at the inspector’s request, references and CRB checks were faxed to the inspector the following day. Although two references were in place for the two newest members of staff, the CRB disclosures were ones previously held and one was only at the standard instead of enhanced level. A letter of serious concern was sent to the provider requiring immediate action to be taken to ensure CRB and POVA checks are applied for and risk assessments completed on the members of staff. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 19 Folders containing training information and training records were examined in staff files. It was found that the home received notification of training from various sources including Southwark Social Services, however the inspector was unable to locate a training plan or a training record of training that had taken place. Also, although staff files included evidence of induction training, this was not to sector skills council specifications. The manager must produce a training plan to ensure that a proactive approach is adopted towards training and that it is based on the needs of staff and service users. Induction and foundation training must be to sector skills council specifications and it is recommended that the manager register with the London Skills for Care office to receive guidance and newsletters about training available locally. It is also recommended that the manager contact Lewisham to see if any training can be accessed through them. It was noted at a previous inspection that although staff were supervised and discussions were appropriate, staff were not supervised every two months as required and supervision records were not stored securely. It was also recommended that staff be given a copy of the supervision record. At this inspection, staff confirmed that they were now given a copy of their supervision, however records were kept in a filing cabinet, where staff could access the supervision notes of others. All of the staff files examined contained supervision notes however in one case records were not signed by the staff member to indicate their involvement in the session. During the last 12 months, staff had been supervised only three times and therefore would not meet the six times per year target. Continued non-compliance with this requirement will lead to enforcement action being considered. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Although some progress had been made in quality assurance further action is required to ensure that developments are based on service users views. The home is not registered for one service user who is over the age of 65. A fire risk assessment, food hygiene training are needed to fully ensure that service users health, safety and welfare are protected. EVIDENCE: At the last inspection it was found that the home had completed a satisfaction survey in December 2004, though 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. The provider has sent one report through (October 2005) though the inspector advised the provider that further detail was needed in the report. The requirement is considered partially met as reports must be sent through consistently on a monthly basis and Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 21 include the detail as required. It was also noted at the last inspection that although the registration certificate was displayed as required by regulation, only one side of the certificate was on display. This had been addressed at this inspection. An annual development plan was not available and results of surveys had not been summarised and made available to those taking part however the timescales in which to meet these requirements had not yet expired. It was noted that one service user is 67 years old but the homes registration is only for service user up to the age of 65. The manager stated that she had not applied for a variation of registration as she was still waiting for a social worker to reassess the service users needs. However the inspector stated that a variation must be applied for urgently, as currently the service is not registered to care for the service user. At the last inspection it was found that testing and inspection of the fire alarm and equipment, gas safety and electrical appliances were carried out appropriately. A certificate on the safety of the electrical installation of the building was not available. The practice of wedging fire doors open had continued, and a new requirement that a fire risk assessment must be completed in consultation with the fire brigade was made. At this inspection it was found that doors were no longer wedged open and staff and service users had been informed that this practice must not continue. However a fire risk assessment was not available. A certificate of electrical safety of the building had been sent to the inspector. Fire alarms were tested regularly. It was also found that only two staff had food hygiene certificates and these had been done in July and Oct 2002. The provider must ensure that all staff involved in food preparation have food hygiene training and it is recommended that staff with a certificate have refresher training every 3 years. Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 1 Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 X 1 X 1 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 1 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gate House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 1 X X 1 X DS0000025620.V269269.R01.S.doc Version 5.0 Page 23 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 timescales of 28/02/05 and 31/10/05 not met) The registered manager must ensure that where risks have been identified a plan to manage the risk is in place. 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. (Previous timescale of 30/11/05 not met) The registered provider must ensure 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. The registered manager must ensure that service user meetings are held at least every DS0000025620.V269269.R01.S.doc Timescale for action 31/03/06 2 9 4(c) 31/03/06 3 14 16(m)(n) 31/03/06 4 14 12(1)(a) 31/05/06 5 14 12(2) 31/03/06 Gate House Version 5.0 Page 24 6 20 13(2) 7 23 13(6) 8 24 23 9 24 23(2)(p) 10 25 4 Schedule 1 23(2)(e) 11 25 12 28 23(3)(b) 2 months and that meeting minutes are recorded more formally showing that previous meeting minutes were discussed. The registered manager must ensure that an up to date homely remedies list including the names of service users and dosages, is approved by the GP The registered provider must ensure that all staff undergo appropriate training in adult abuse. The Registered Provider must ensure that where necessary redecoration and refurbishment is undertaken in communal areas and bedrooms. (Previous timescales of 28/06/05 and 30/11/05 not met) The provider must ensure that radiators give out sufficient heat and are guarded or of a low surface temperature unless risk assessments indicate this is unnecessary. The registered provider must ensure that room sizes (in metres) are included in the statement of purpose and service user guide. 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. (Previous timescale of 31/10/05 not met) The registered person must provide adequate and safe sleeping facilities for staff. DS0000025620.V269269.R01.S.doc 31/03/06 31/05/06 30/04/06 31/03/06 31/03/06 31/05/06 31/12/05 Gate House Version 5.0 Page 25 13 28 14 30 15 34 16 34 17 35 (Previous timescales of 03/11/03, 31/07/04 and 28/01/05 not met timescale of 31/12/05 not expired at this inspection) 16(2)(c) 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.(A curtain has been provided but this does not cover the window and is too thin to block out the light. Previous timescale of 31/08/05 not met) 23(2)(d) The registered provider must ensure that all areas of the home are kept clean, including windows, and that toilets are free of lime scale.(Previous timescale of 31/10/05 not met though limescale had improved) 19(1)(b) The registered provider must not allow any staff to commmence employment in the home until new checks have been completed including a POVA check.(Previous timescale of 31/08/05 not met) 19(1)(b) The registered provider must ensure that appropriate application is made immediately for the two identified staff for a new CRB and POVA check and they must not work in the care home until a POVA check is received unless a risk assessment indicates how this will be managed safely. 18(1)(c)(i) The registered provider must ensure that the home has a training plan to ensure that a proactive approach is adopted towards training and that it is based on the assessed needs of DS0000025620.V269269.R01.S.doc 31/03/06 31/03/06 06/12/05 06/12/05 30/04/06 Gate House Version 5.0 Page 26 staff and service users. 18 35 18(1)(a) The registered provider must ensure that induction and foundation training is to sector skills council specifications. The Registered Manager must ensure that staff supervision is undertaken at least six times a year and that supervision records are securely stored. (Previous timescales of 28/02/05 and 31/10/05 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, 28/02/05 and 31/10/05 not met though one report received Oct 05) The registered provider must ensure that the results of quality assurance surveys are summarised and made available to service users and others taking part. (Previous timescale of 31/01/06 not yet expired) 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.(Previous timescale of 31/01/06 not yet expired) The registered provider must submit an application for variation of registration for the service user who is over 65 years old. The registered provider must ensure that in consultation with the fire brigade, a fire risk assessment is developed DS0000025620.V269269.R01.S.doc 30/04/06 19 36 18(2) 17(2) sch4(6)(f) 31/03/06 20 39 26 31/03/06 21 39 24 31/01/06 22 39 24(1)(b) 31/01/06 23 39 14 31/12/05 24 42 23(4) 31/03/06 Gate House Version 5.0 Page 27 25 42 16(2)(i) including the issue of door wedging.(previous timescale of 31/10/05 not met though door wedging has been stopped.) The registered provider must ensure that all staff involved in food preparation have food hygiene training. 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard 19 22 35 35 42 Good Practice Recommendations It is recommended that the weights of service users be monitored on a monthly basis. The complaints procedure should include a statement that service users or their representatives who make a complaint will not be victimised for doing so It is recommended that the manager register with the Skills for Care London office to receive guidance and newsletters about training available locally. It is recommended that the manager also contact Lewisham to see if any training can be accessed through them. It is recommended that staff with a food hygiene certificate have refresher training every 3 years Gate House DS0000025620.V269269.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark 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. Extracts may not be used or reproduced without the express permission of CSCI Gate House DS0000025620.V269269.R01.S.doc Version 5.0 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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