Inspection on 09/11/06 for George Lane, 103

This inspection was carried out on 9th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

George Lane, 103 27/08/08

George Lane, 103 29/08/07

George Lane, 103 26/01/06

George Lane, 103 17/10/05

George Lane, 103 22/06/04

George Lane, 103 24/02/04

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

CARE HOME ADULTS 18-65 George Lane, 103 Catford London SE13 6HN Lead Inspector Sean Healy Unannounced Inspection 9th November 2006 10:00 George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service George Lane, 103 Address Catford London SE13 6HN 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) 020 8265 8671 0208 778 6145 Providence Project Care Home 4 Category(ies) of Learning disability (0) registration, with number of places George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: 103 George Lane is a converted Victorian house situated on a quiet road between Lewisham and Catford. It is one of a group of homes for adults with learning disabilities, all of which are in the London Borough of Lewisham. It is close to shopping centres, local transport and a range of public amenities. The Registered provider, Providence Project, has merged with another other care organisation in April 2006, to form PLUS (Providence, Linc, United Services). The organisation is in the process of negotiating the appropriate change in registration/certification with the Commission. The building is owned and maintained by London & Quadrant Housing Association. The home accommodates four adults with learning disabilities. It aims to provide a comfortable, homely atmosphere in a safe and clean environment. Each service user has their own bedroom, and shares communal facilities, which includes lounge, kitchen/diner and garden. At the time of this inspection, there were two men and two women service users living at the home. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. Each service user has been given a copy of these documents. The recent CSCI report is currently kept in a file in the hallway cupboard and is accessible to service users. At 9th November 2006, the homes fees are set at £245 per month support and accommodation and are paid directly to Lewisham council. This charge includes food provided. This is paid for by the local authority. Residents have to pay for other personal expenses such as hairdressing, transport and personal shopping. The home does not have an email address. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 9th November 2006. It was facilitated by the team manager, who proposes to become the Registered Care Manager. Three residents were present for part of the inspection and gave their views privately about how they felt living at the home. The method of inspection included discussion with the homes manager, and four of the support staff. The building was also inspected for health and safety, suitability for service users and cleanliness. Service users records and other documentation about how the home is run were examined. Care assessments and care plans were examined to ensure that care needs were being planned for and the owners and service users were questioned about these plans, to check that plans were being put into action. What the service does well: What has improved since the last inspection? The home’s policy for protecting service users from abuse has been improved and now is in line with the Lewisham Adult Protection policy. The registered provider visits the home every month and writes a short report showing what is going well in the home and what needs to be improved. There is now a copy of these reports kept at the home. The service users feel that they are being listened to and have got to know staff very well, but are not sure about future development plans for the home, George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 6 such as any plans for spending money on improvements (see “what they could do better”). Comments from service users included “I am glad they listened to us when they were talking about making lots of changes, and because of that the changes did not happen”. There was a suggestion that the home would benefit from having more staff, and the management looked this. All service users and the manager feel that current staff levels are enough to provide the support needed by service users. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users’ individual aspirations and needs are being assessed by the home. Service users are in possession of information to help them to make informed decisions about where they live, and have contracts of terms and conditions informing them of their rights and responsibilities. However, these documents need to be updated. EVIDENCE: There was a requirement at the last inspection that the service users must have up to date contracts and tenancy agreements in place, and that these should be reflected in the home’s Statement of Purpose and service user guide. This was because the organisation had changed its name and some key managers had also changed. The contracts or terms and conditions did not reflect the charges being made, or who paid the fees. This has not been done and continues to be a requirement. (Refer to repeated requirement YA1 not met.) The home has the capacity to meet the needs of the service users. The main support issue within the home concerns learning disabilities support needs. All of the staff and the manager are experienced in providing care in this area. The service user group’s cultural needs are reflected in the make up of the staff team. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 9 Each service user has a tenancy agreement, which now has the organisation’s name included, but which does not show the fees to be charged. This tenancy agreement has been signed by each of the service users and contains a section called “payment for the property” which includes sections for breaking down the fees. However, the amount to be paid for each is not completed at all. A separate accommodation charge of £245 per month is paid by each of the service users to Lewisham Partnership and includes food, but no mention of this is made in the terms and conditions statement between the home and the service user. The fees to be charged must specify the amount of fees to be paid, with a breakdown of what the fees are for, e.g. care and support, food, transport, or any other services. They should also be clear reference as to who pays the fees where the fees are being paid by anyone other than the service user. In this case the local authority pay fees for all service users and this should be referred to in the service users’ guide and in contracts/terms and conditions. (Refer to requirement YA1 and YA5.) George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be sure that all of their assessed needs and personal goals are reflected in their individual plan, and they do get help to make decisions about their lives. They are supported to take assessed risks, which enable them to be more independent. EVIDENCE: Each of the four residents has a personal profile and a personal care plan, which has been regularly updated. There is also a ‘life plan’, which is their person-centred plan. This allows the service users to have a better voice in their care planning. All have had an annual review in June 2006 with good involvement from key workers, GPs, the manager and other interested parties. The notes taken from these reviews are very detailed and show that previous aims of service users have been reviewed and new aims for achievement or activities have been set. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 11 The service users are able and independent, and some are involved actively in the organisation’s service users’ speaking up group. One service user is on the organisation’s Board of Management. Two service users describe their work on the speaking up group and said that they carry out monthly interviews with service users in other homes, asking for their views about how their home is run. Both of these service users said they are very happy in doing this work and are able to feed back the views of service users in many homes to the Board of Management. Excellent systems are in place to enable service users to fully make independent decisions about their lives. Three out of the four service users ask the home to safeguard their money; the other service user is totally independent in managing his money. Within the home, two of the service users ask for views about how the home is run, and feed these comments back to the home’s manager. Each service user has a full range of risk assessments, which have been reviewed between August and October 2006. There are many risk assessments and all are being regularly reviewed at least every six months by the home. This shows good attention to protecting and safe guarding service users and staff. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have appropriate activities and are part of the local community. They have good relationships with family and friends, and their rights are respected and responsibilities are recognised in their daily lives. A healthy diet is provided for and meals are provided at times which suit service users. EVIDENCE: All service users have assessments that clearly state their interests and preferred activities that were in place when they moved into the home. These include education, training and leisure activities. Care plans reflect these activities, and these have been improved and expanded to include service users’ views on desired new activities. Three service users have voluntarily jobs, for which they receive a small payment. These jobs include working at the Salvation Army shop, office cleaning and acting as service user representatives on the speaking up group. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 13 There are also good links with the local adult education system and a number of service users attend classes. All service users have full access to activities in the local community and further afield in London. Staff provide support when necessary but also enable service users to go out independently when they are able to. Activities include going to public houses, cafes, boating in Surrey Docks, gardening and attending service users’ groups and day centres. One service user had just returned from a hairdressing appointment and said she goes out often and really enjoys her job on the speaking up group. She said that she gets to meet lots of people in other homes and really likes trying to help them have a better service. She said the staff are very nice and helpful. All service users have regular family who come to see them. One service user visits her sister each Saturday and another visits his mother who lives very near by. Two service users said that they see their family as much as they like, and that the staff help them to do this. All residents have their own rooms for which they have their own key. Staff respect service users’ right to privacy and only enter the room with permission. One service user said “Staff only come in when I ask them, but they leave me to myself when I need it.” Three out of our service users have a key to the front door, and the fourth service user asks the staff to look after her key. Service users are involved fully in shopping, and cooking and are offered choices of food on a daily basis. Good records of menus are kept, and the manager reviews these to see that good food is being offered. This has resulted in an improved diet for two service users. Service users spoken to said they choose what they want to eat, and the food is good. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and their needs are being met in all other areas. Support with medication is appropriate for the service users’ assessed needs. EVIDENCE: All service users are independent in personal care and this is shown in their care plans. All are fully mobile and have minimal support in personal care. All service users’ files contained good health care support plans, which have been reviewed annually. The last review took place in June 2006. All service users are registered with a GP and have annual check ups. All are registered with a dentist and have at least annual visits to the dentist. Other regular health care appointments include visits to the optician and chiropodist. All service users are on medication, which is managed by the home with the service users’ permission, and this has been agreed in their care plans. Boots Chemist is used for all medication and most of the service users are being encouraged and supported to sign for the medication to help their George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 15 understanding of what the medication is for. The Community Pharmacist visits annually to check the record keeping and there is good, consistent recording of medication given. It is recommended that the home review whether selfmedicating is appropriate for any of the service users. (Refer to recommendation YA20.) George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel that their concerns are listened to and acted on and they are protected from harm by the home. EVIDENCE: The home has a good complaints policy in place that was last reviewed in 2006. Service users were able to describe to whom they would speak if they had any concerns about the service being provided. There is a good relationship between the staff and service users, and service users say they feel confident to speak with the manager whenever they have any concerns. There have been no complaints since the last inspection. There was a requirement at the last inspection that the home must review the adult protection policy to reflect the local authority’s policies and procedures for protecting vulnerable adults. This was done and the home now has a copy of the Lewisham Adult Protection Policy. Staff spoken to showed that they had a good understanding of how to report suspicions of abuse. There have been no reported adult protection issues since the last inspection. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ home is homely, comfortable, safe and clean. EVIDENCE: The premises are suitable and well maintained. Accommodation is provided for four service users, all of whom have individual rooms. These rooms, and the premises as a whole, are in a good state of repair and decoration. The home is not wheelchair accessible but none of the current service users need a wheelchair and there are no vacancies. All of the service users have lived at the home for a number of years and two of them said they are very happy there and they get out a lot in the local community. The home is well furnished and service users have been able to choose the decoration of their own rooms and other areas in the home. The premises are clean and well maintained. There is one bathroom with a WC and sink, and a separate ground floor WC. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 18 Cleaning is done by the service users with support from staff and there is a rota for doing this. There is no clinical waste. A maintenance book is being used and a repairman provided by the Registered Provider carries out any repairs needed. The kitchen surfaces have recently been replaced. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are competent and effective, but not yet qualified to the level needed for this home. The home’s recruitment practices do not yet adequately demonstrate that they protect service users, which creates potential risk to service users. Staff are appropriately trained with the exception of NVQ training. EVIDENCE: The Registered Manager at the home feels that the staff are motivated and know the service users very well. All of the staff are accessible to service users as the home is a normal-sized house. The manager said that there had been some issues with the introduction of new staff but that the staff team worked together well as a team now. Three staff who were interviewed said that they was a good working atmosphere in the home and two service users said that the staff are “Happy and do help me whenever I need it. They are always very nice.” Staff interviewed showed that they were very knowledgeable about service users’ support needs. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 20 There is one volunteer support worker in the home. There is guidance in place to ensure that he does not work alone and does not manage medication or money. A discussion with him showed that he was also knowledgeable about service users’ needs. There was a recommendation at the last inspection that the Registered Person should investigate suggestions that the home may need additional staffing. This has been done and the Manager said he felt now that there are enough staff to provide the care needed. The staff team consists of one Manager and five support workers. All of the support staff have received good foundation training and two are working towards NVQ level 2 and 3. Recruitment records are kept at the organisation’s head office. An inspection in June 2006 showed that appropriate CRB checks had not been consistently carried out for all staff employed by the registered provider, who were recruited prior to April 2006. As there are no staff employment records available at the home it was not possible to specifically check the recruitment records of the staff employed in this home. The Registered Provider must ensure that employment information about all of the staff who work at the home, is kept at the home for inspection. This information is contained in Schedule 2 of the Care Home Regulations. The provider’s failure to provide this information at the home for inspection presents a potential risk of possible oversights made during recruitment going unchecked. (Refer to requirement YA34.) There was a requirement at the last inspection that the Registered Person must set timescales to ensure that all staff are supported to achieve the appropriate NVQ qualifications; this has not been done yet. Staff who are qualified to the appropriate NVQ levels are now less than at the last inspection. This is due to staff moving. The Registered Provider must ensure that at least 50 of support staff are registered on a course as soon as possible. (Refer to repeated requirement YA35.) All of the staff employed at the home have received a full induction and undergone an assessment over a six-month probation period. Training is scheduled by the organisation’s training manager and there is appropriate training being scheduled. All of the staff have had an annual appraisal and have a personal training development plan. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home, but consistent management changes are a cause for concern. Service users may not be confident that their views underpin the home’s development processes, which may result in their exclusion from this process. Service users’ rights and best interests are safeguarded, and their safety and welfare are promoted. EVIDENCE: At the last inspection there was a requirement for the Registered Person to submit an application for the registration of the manager of the home with CSCI. This has not been done. The last Registered Manager appearing on the registration document moved from the home more than two years ago, to work in another home. The last team manager was moved to another home in June 2006, and the current manager took up his post at that time. The current manager intends to apply to register as a registered care manager. This is now George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 22 an urgent matter and has been the subject of requirements at two previous inspections. (Refer to repeated requirement YA37.) The new Manager has registered on an NVQ level 4 course in care management and hopes to complete the course by March 2007. (Refer to requirement YA37.) At the previous inspection the Registered Person was required to ensure that a formal quality assurance monitoring system and annual development plan was put in place. While there is lots of good information is being passed between service users, staff and the organisation this is not being pulled together formally to include in a development plan for the home. The home has six to eight weekly house meetings and the person in control of the home visits consistently every month. The service manager attends service users’ annual reviews and there is lots of work being done by two service users who ask the views of the people who live at the home about how it’s managed. However, these views are not being specifically taken on board in developing the home and the service provided. (Refer to repeated requirement YA39 partially met.) Service users’ records mainly consist of care assessments and care plans, together with a record of any complaints or allegations made. These records are well maintained and are available at the home for each service user to read whenever they need to. The Registered Individual now consistently carries out monthly visits to inspect the home and the care provided, and records of these visits are being kept at the home. The home keeps good records on all issues relating to health and safety. There are safe working practices regarding moving and handling, fire safety, food hygiene and infection control. There have been no reports of dangerous diseases or occurrences, and there are good records on the testing of fire equipment, electrical equipment, water and gas within the home. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 3 3 X George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 17(2) Schedule 4(8) Requirement Timescale for action 28/02/07 2. YA1 YA5 5. (1) 3. YA5 6 The Registered Person must ensure that all service users have accurate and up-to-date contracts and tenancy agreements in place, that reflect any change in the organisation’s name or registration, and that all relevant documentation is updated, including the Statement of Purpose and Service User’s Guide. This was a requirement of the previous two inspections, timescale 01/02/06 and 30/04/06, not met. Failure to meet this requirement may result in enforcement action being taken. 28/02/07 The Registered Provider must ensure that the details of the fees to be paid are included in the home’s Statement of Purpose and Terms and Conditions for each service user as required by NMS. As discussed in this report YA1&5 The Registered Person must take 28/02/07 action to ensure that Certificates of Registration are amended, or to address any registration DS0000025621.V318563.R01.S.doc Version 5.2 George Lane, 103 Page 25 4. YA34 7,9 & 19 Sch. 2 5. YA35 18(1)a 6. YA37 8, 9 7. 8. YA37 YA39 9.2 b (i) 24(1)a, b issues arising from the recent organisational merger. (Registration Regulations). This was a requirement of the last two inspections, timescale 01/12/06 and 30/04/06. Not met. Failure to meet this requirement may result in enforcement action being taken. The Registered Provider must ensure that employment information about all of the staff who work at the home is kept at the home for inspection. This information is contained in Schedule 2 of the Care Home Regulations. The Registered Person must set targets and timescales, to ensure that all staff are supported to achieve the appropriate NVQ qualifications, to meet the requirement for the home to have 50 of staff qualified to NVQ Level 2/3 certification. This was a requirement of the last inspection, timescale 31/03/06 not. Failure to meet this requirement may result in enforcement action being taken. The Registered Person must ensure that an application for registration of the manager is submitted to the Commission. This was a requirement of the previous two inspections, timescale 01/12/05 and 31/03/06, not met. Failure to meet this requirement may result in enforcement action being taken. The Registered Manager must enrol on an NVQ level 4 course in care management. The Registered Person must ensure that a formal quality DS0000025621.V318563.R01.S.doc 28/02/07 28/02/07 31/12/06 28/02/07 28/02/07 George Lane, 103 Version 5.2 Page 26 assurance monitoring system and annual development plan are put into place. A previous timescale of 30/09/05 and 31/03/06 and is partially met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The Registered Provider and Manager should review whether it is appropriate for any of the service users to self medicate. George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 George Lane, 103 DS0000025621.V318563.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!