Inspection on 06/10/05 for Gibson House

This inspection was carried out on 6th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gibson House 18/01/07

Gibson House 20/04/06

Gibson House 20/05/05

Gibson House 07/09/04

Gibson House 27/05/04

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

CARE HOME ADULTS 18-65 Gibson House 12 The Grange Bermondsey London SE1 3AG Lead Inspector Lisa Wilde Unannounced Inspection 10:00 6 October 2005 th Gibson House DS0000060232.V253092.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 Gibson House DS0000060232.V253092.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. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gibson House Address 12 The Grange Bermondsey London SE1 3AG 020 7252 3762 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) Odyssey Care Solutions for Today Mrs Phyllis Mary Phillips Care Home 8 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th May 2005 Brief Description of the Service: Gibson House is a purpose-built detached home with its own very large gardens. It is close to a lot of bus routes and street parking is available but on meters. There are no train or tube stations very close to the home. The home is spacious, built for for eight service users with learning difficulties and sensory impairment accomodated in large single bedrooms with ample bathroom and communal facilities, including a sensory room. There is a lift for people who live on the first floor. There is a kitchen on each floor and generally the home is run as if the upstairs and downstairs are two units. The home was designed as a “home for life” where service users are supported to attain as much independence as possible. The vision statement of Odyssey is an aspiration to:“ A society where a learning disability is not a barrier to somebody’s perceived value or ability to make a meaningful contribution”. On the day of this inspection there was one service user vacancy. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in October 2005. The inspector spoke with staff and management and met four of the seven service users. The inspector spoke with one relative on the day of the inspection and then telephoned other relatives following the inspection. The inspector also spoke with social services monitoring officers regarding their views of the home. The Registered Manager reported that the organisation is planning to sell the building within the next two years and a major piece of work is about to be undertaken to begin the consultations and planning work to ensure the service users are supported and moved onto appropriate alternate accommodation safely. The inspector was highly concerned that the vast majority of the requirements made at the last inspection had not been actioned. The social services monitoring officer stated that their department shares the same concerns as are held by the CSCI and as are outlined in this and the previous inspection report. Relatives spoken to by the inspector stated that they have concerns about some aspects of this service but that they did not like to speak to the staff about them and did not want to be identified to the home. One relative has made a very recent complaint to the management committee of the organisation that is currently being investigated by the home’s area manager. The requirements that are repeated from previous inspections have been given short timescales for action in this report. The inspector will be attending this home for an additional inspection later this year to check on the progress towards meeting those requirements and the new requirements made at this inspection. If the inspector is not satisfied that the Registered Individuals are making significant progress towards meeting all requirements and achieving compliance with the National Minimum Standards, the CSCI will consider taking enforcement action to ensure compliance. What the service does well: None of the standards assessed at this inspection were met so it not possible to state at this inspection what the home does well. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The standards assessed at this inspection showed that the home must undertake development work to ensure that: • the Service User Guide is in a language or form that could be understood by the service user group for which this home is registered (learning disabilites and sensory impairment) and that it includes information about all the areas required by the standard. • the service user plans address fully how identified goals are to be worked towards and how the plans are to be changed if the plan does not work. • that all individual areas of need (particularly aggressive or potentially harming behaviour) are addressed in the service user plans in a way that describes programmes designed to eventually change the behaviour. • service users are provided with individual programmes of activities both inside and out of the home, that engage and stimulate them. • staffing levels allow service users to move around the home as they choose or to undertake individual activities. • staff attitudes and approaches to service user care and support respect service users’ individuality and dignity. • service users’ clothes and bed linen are not mixed up with others’ or mislaid. • the systems for administering, recording and monitoring of medication stocks at the home are effectively operated. • the Complaints Policy and Procedure gives service users and their families information they need to complain to people and bodies other than the home or the managing organisation • the building is homely, comfortable and clean throughout and does not smell offensive. • recruitment takes place to fill all staff vacancies at the home and that the staff team is fully qualified and trained to meet the specialist needs of this service user group. • all systems in place for fire detection and prevention are operated effectively. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 7 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. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Service Users’ Guide is not in a language or form that could be understood by the service user group at this home and it does not include some of the areas required by the standard. Service users and their families are not provided with all the information they need to make an informed choice about where to live or about what they can expect from the home once they are there. EVIDENCE: There were previous requirements that the Service User Guide must be drawn up in a format that can be understood by more people from the service user groups for which the home is registered. That is, learning disabilites and sensory impairment. The Service Users’ Guide must cover all areas required by Regulation 5 and Standard 1. The documents were seen and the Registered Manager confirmed that no work had been done on these documents since the last inspection. The requirements are therefore repeated. (See Requirements 1&2) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The service user plans do not address fully how identified goals are to be worked towards and how the plans are to be changed if the plan does not work. Not all individual areas of need (particularly aggressive or potentially harming behaviour) are addressed in the service user plans in a way that describes a programme designed to eventually change the behaviour. Plans focus on managing the behaviour on a day-to-day basis without emphasising positive behaviour and ability which means that service users are not being helped to move on or develop independence as much as is possible. EVIDENCE: There was a previous requirement that Service User plans must focus on forward planning and how staff will support service users to achieve identified goals, develop positive behaviour and minimise negative or challenging behaviour and maximise independence. These plans must be reviewed at regular intervals to allow for plans to be changed if they are not working to ensure (as far as possible) that goals are met by the time the next six monthly mutli disciplinary review takes place. The Registered Manager talked about how staff have undergone Person Centred Planning training and are beginning to consider how this impacts on their practice. Care files were looked at and Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 11 the service user plans were still focussed around support guidelines as opposed to any action plans that focussed on development. The requirement is therefore repeated. (See Requirement 3) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 & 14 Service users are not provided with individual programmes of activities, both inside and out of the home, that engage and stimulate them. Staffing levels do not allow service users to move around the home as they choose or to undertake individual activities. Certain staff attitudes and approaches to service user care and support do not respect service user’s individuality and dignity. EVIDENCE: There was a previous requirement that the manager of the home must ensure that the current systems for monitoring service user activities are reviewed so that it is possible to identify if planned activities are not happening as they should be. If it is discovered that some staff are misusing the systems to avoid taking service users out or engaging in other activities then appropriate management action must be taken. The Registered Manager stated that she now monitors the monthly reviews more closely and ensures that the reasons for why activites are not undertaken are explained. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 13 On the day of the inspection staff talked to the inspector about service users without using their names, just using ‘he’ and ‘she’. Staff were observed sitting at the back of the lounge while service users were sitting in front of the television, not talking or interacting with service users. One relative told the inspector that when the visit the home some staff just talk to each other and do their own things while service users just watch television. (See Requirements 4 & 5) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 The systems at the home for keeping track of service user’s clothes and bed linen are not effective which means that service users possessions are mixed up with others and on occasion mislaid. The systems for administering, recording and monitoring of medication stocks at the home are not being entirely effectively operated which means that the home is not keeping an accurate account of all medication that is brought into the home. EVIDENCE: There were previous requirements that the Registered Manager must ensure that the systems for checking that service users have both sufficient and appropriate clothing, including underwear are improved. The Registered Manager must ensure that the systems for routinely checking service user’s clothing and discarding any which is old and worn are improved. There has been a recent complaint made by a service user’s family that clothing has gone missing and the Registered Manager stated that service users’ bedlinen still gets mixed up. One relative told the inspector that some of the clothes worn by their relative is not always the right size. The Registered Manager said that keyworkers now assess each service users’ clothing each month and inform her of any purchases that are required. It appears that the current problems with Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 15 clothing and laundry are around clothes going missing and not being appropriate rather than being worn and old so one requirement has been met, the other has not and a further requirement is made. (See Requirements 6 & 7) The medication stocks and records were checked. There were some gaps in the recording of the administration and although most stock that was checked did tally with the records of medication held there were found to be ten coproxamol missing from one service users’ medication stock. There is a Returns Book in place but the medication is not recorded in this book until it is taken to the chemist which means that there is opportunity for the medication to go missing in the interim. (See Requirements 8, 9, 10 & 11) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The current Complaints Policy and Procedure is not up-to-date which means that service users and their families are not being given information they need to complain to people and bodies other than the home or the managing organisation. The current system for recording complaints does not effectively monitor the process of investigation or whether the complainant was happy with the outcome which means that the home cannot know whether its procedure for listening to service users and acting on those views is effective. EVIDENCE: The organisation has a complaints procedure in place that includes out of date names and contact details for the Commission. (See Requirement 12) The home has a file in which it keeps investigations into complaints but there is no book, which chronologically records all complaints, any investigation and action taken with timescales, and whether the complainant was satisfied with the outcome. (See Requirement 13) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 The building is not homely or comfortable and the standard of decoration is not acceptable. The bathrooms in the homes are institutional in decoration and in their fixtures and fittings. The staff shower is broken meaning that staff have to use the service user’s bathrooms which is not appropriate given that this is the service users’ home. The home could not evidence that service users have the specialist equipment that they need to meet their individual needs with regard to bathing and showering. The home is not entirely clean and hygienic or free from offensive odours. EVIDENCE: There was a previous requirement that the Registered Provider must supply a copy of the planned maintenance and renewal programme for the fabric and decoration of the premises to the CSCI. This has not been done and the requirement is repeated. (See Requirement 14) On the tour of the building the inspector found that generally the whole home was in a poor state of repair with wallpaper peeling off some walls, skirting boards and furniture being chipped and worn, radiators covers being dirty and rusty and soft furnishings being torn. (See Requirement 15) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 18 There was a previous requirement that work must be done in all bathrooms to ensure that all repairs are carried out and any worn areas/fittings are made good or replaced. Bathrooms must be decorated and/or additions made to provide a comfortable and pleasant, homely environment. None of this work has been done and the bathroom were still institutional and bare. The requirement is therefore repeated. (See Requirement 16) There was a previous requirement that the staff shower must be fixed. This has not been done and staff are still using the service users’ bathrooms. The requirement is therefore repeated. (See Requirement 17) There was a previous requirement that any broken furniture in service user rooms must be made good or replaced on a regular basis. On the day of the inspection none of the furniture seen in service users’ rooms was broken. The Registered Manager said that they have got better at fixing furniture themselves. There was a previous requirement that an Occupational Therapists assessment must be made of all service users who need assistance with bathing. showering, transferring or moving to ensure that the most appropriate aids and fittings are being used in the home. These assessments must be reviewed every time a service users needs change. The Registered Manager said that a referral has been made but has not yet been undertaken. The requirement is therefore repeated. (See Requirement 18) There was a previous requirement that the home must be cleaned regularly enough or carpets and soft furnishings replaced often enough to ensure that the home does not smell of stale urine. On the day of this inspection the building again had an offensive odour and one relative told the inspector that the building smells on a lot of occassions. One of the bathrooms had what appreared to be faeces on the radiator next to the toilet. The requirement is unmet but the wording changed slightly in this report. (See Requirement 19) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 Although staff talked of feeling comfortable in offering basic support around personal care and health and safety issues the staff team as a whole is not fully aware of the specific needs of the service user group with regard to disability issues and sensory impairment. There are not enough staff trained to NVQ 2 in Care meaning that service users are not supported by an appropriately qualified staff team. There are staff vacancies that have been vacant for a considerable time, which means that the service users are not being supported by a consistent staff team. The staff team is not fully effective because there are not enough staff on duty to enable service users to engage in meaningful individual activities and not to have to spend time in groups. EVIDENCE: There was a previous requirement that the staff must undertake training that enables them to identify, understand and meet the needs of the service user group with regard to learning disabilities and sensory impairment issues. The Registered Manager faxed the training records to the inspector the day after the inspection and these showed that one member of staff has attended autism training with most having attended Person Centred Planning and Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 20 communication training since the last inspection. One member of staff is booked on risk assessment in people with learning disabilities and one is booked on self-injurious behaviour and challenging needs. Given the range of specialist needs of this service user group and the levels of support and care that are required this training is not sufficient to meet the previous requirement. (See Requirement 20) There was a previous requirement that the home must ensure that it meets the target of 50 of its care staff holding or undertaking the NVQ Level 2 in Care (or equivalent). Three of the permanent staff have NVQ Level 3 in care an done is booked to start in the next year. The Registered Manager was not certain how many of the agency staff hold the NVQ Level 2 in Care or equivalent. The home has positions for fifteen project workers at this service with two deputies, meaning that the home is still not meeting the 50 target unless the manager can satisfy herself that enough agency staff hold the qualifcation to bring the percentage up. (See Requirement 21) There was a previous requirement that the organisation must finalise plans for the management structure of the home and then recruit to the vacant posts. The Registered Manager stated that this has not been done, the second deputy post, which she felt was necessary at the home, is vacant. (See Requirement 22) There are currently six project worker vacancies at the home out of a total of fifteen. The Registered Manger stated that the organisation required that four of these posts are kept vacant and filled with agency or bank to staff to allow flexibility around annual leave and sickness cover. The Registered Manager said that no recruitment has been attempted since the last inspection but there is an internal advertisement out at the moment with the deadline for applications being 10/10/05. Given the ongoing problems at this service with engaging a fully qualified, motivated and effective staff team this situation is not acceptable. (See Requirement 23) On the day of the inspection the inspector observed that one member of staff was required to work with two residents or three service users which meant that when one service user wanted to leave the lounge where they were watching television they had to be brought back by staff because of staff’s need to observe a number of service users at one time. On one occasion chairs were used to block one service user from leaving the lounge and the kitchen was locked because service users may choose to enter there and there weren’t enough staff to watch them individually. There were guidelines in the care notes such as the use of the sensory room, which outlined programmes for service users to be able to use the room in an unplanned way however given the limited staffing observed on this day there was no way a service user could use the room in that way as staff would be required to be with other service users at the same time. (See Requirement 24) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 21 The inspector will be inspecting the home’s recruitment and personnel records at the organisation’s head office at some point following this inspection. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 22 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): 37 & 42 The home is not well run. The number of unmet requirements from previous inspections shows that the management of this home is not taking effective action to ensure it meets the requirements of The Care Home Regulations 2001 and the National Minimum Standards. The home is not effectively operating all systems in place for fire detection and prevention and as such is putting service users at risk. EVIDENCE: Given the number of unmet requirement from the previous report it is not possible to say that this home is currently being well run. The Registered Manager stated that she felt she needed to go out onto the floor more to support and supervise staff but was finding this hard with one deputy post vacant. Given the concerns regarding the general management of the home and the number of unmet requirements and the fact that the organisation is planning to sell this building, it will be necessary for the organisation to report regularly to the CSCI regarding consultation and development plans for this process. (See Requirement 25) Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 23 There was a previous requirement that all procedures and systems for ensuring adequate fire prevention and management must be adhered to. This has not been met in that the fire directions that were upside down at the last inspection were still upside down and doors that were on automatic closure system were wedged open with chairs. (See Requirement 26) The Fire Brigade has not inspected the home since 2000 and as such a requirement is made (See Requirement 27) There was a previous recommendation that the manager should adopt a programme of team building and motivation within the planned Team Away Day, team meetings and supervision to ensure that management and staff are assisted to identify and manage issues that are contributing to the low motivation and morale of the current staff team. This had been done and ideas for improvements had been identified. Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 2 2 2 2 LIFESTYLES Standard No Score 11 2 12 2 13 X 14 2 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gibson House Score 2 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 X DS0000060232.V253092.R01.S.doc Version 5.0 Page 25 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 5 Requirement The Registered Individuals must ensure that the Service Users’ Guide is drawn up in a format that can be understood by more people from the service user groups for which the home is registered e.g. learning disabilites and sensory impairment. Unmet requirement: Previous timescale 30/09/05 The Registered Individuals must ensure that the Service Users’ Guide covers all areas required by Regulation 5 and Standard 1. Unmet requirement: Previous timescale 30/09/05 The Registered Manager must ensure that Service User plans focus on forward planning and how staff will support service users to achieve identified goals, develop positive behaviour and minimise negative or challenging behaviour and maximise independence. These plans must be reviewed at regular intervals to allow for plans to DS0000060232.V253092.R01.S.doc Timescale for action 21/11/05 2 YA1 5 21/11/05 3 YA6 15 21/11/05 Gibson House Version 5.0 Page 26 4 YA14 5 YA14 6 YA18 7 YA18 8 YA20 9 YA20 10 YA20 11 YA20 be changed if they are not working to ensure (as far as possible) that goals are met by the time the next six monthly mutli disciplinary review takes place. Unmet requirement: Previous timescale 31/08/05 16(2)(m) The Registered Manager must (n),18(1)(a) ensure that service users are engaged in fulfilling and appropriate activities while in the home. 12(1)(b) The Registered Manager must 12(4)(a)& ensure that staff talk to and (b) engage appropriately with service users while in their company. 12 (1) (a) The Registered Manager must ensure that the systems for checking that service users’ have both sufficient and appropriate clothing, including underwear are improved. Previous requirement: Unmet timescales 30/12/04 & 31/07/05 12 (1) (a) The Registered Manager must ensure that service users’ bedlinen and clothing does not get mixed up or mislaid. 13 (2) The Registered Manager must ensure that all medication is signed for at the point of administration. 13 (2) The Registered Manager must ensure that all stocks of medication are regularly and effectively checked. 13 (2) The Registered Manager must conduct an immediate investigation into the missing co-proxamol and send a report of this investigation to the CSCI. 13 (2) The Registered Manager must ensure that all medication to be returned to the chemist is recorded in the Returns Book DS0000060232.V253092.R01.S.doc 21/11/05 21/11/05 21/11/05 21/11/05 31/10/05 31/10/05 14/10/05 31/10/05 Gibson House Version 5.0 Page 27 12 YA22 22 (7) 13 YA22 22 14 YA24 23 (2) (b) 15 YA24 23 (2) (d) 16 YA27YA24 23 (2) (b) & (d) as soon as it is identified as returnable rather than when it is being taken to the chemist. The Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Complaints Policy and Procedure and Service Users’ Guide The Registered Manager must ensure that a Complaints Book is maintained that provides a chronological record of all complaints at the home, including details of investigations, timescales for action and whether the complainant was satisfied with the outcome. The Registered Provider must supply a copy of the planned maintenance and renewal programme for the fabric and decoration of the premises to the CSCI. Unmet requirement: Previous timescales 30/12/04 & 31/08/05 The Registered Individuals must ensure that the general decoration of the home is regularly renewed and the environment is homely and comfortable throughout. The Registered Individuals must ensure that work is done in all bathrooms to ensure that all repairs are carried out and any worn areas/fittings are made good or replaced. Bathrooms must be decorated and/or additions made to provide a comfortable and pleasant, homely environment. Unmet requirement: Previous timescale 30/09/05 DS0000060232.V253092.R01.S.doc 21/11/05 21/11/05 21/11/05 21/11/05 21/11/05 Gibson House Version 5.0 Page 28 17 YA27YA24 23 (2) (j) 18 YA29 23 (2) (n) 19 YA30 16 (2) (k) The Registered Individuals must ensure that the staff shower is fixed. Unmet requirement: Previous timescale 30/06/05 The Registered Individuals must ensure that an Occupational Therapists assessment is made of all service users who need assistance with bathing. showering, transferring or moving to ensure that the most appropriate aids and fittings are being used in the home. These assessments must be reviewed every time a service users needs change. Unmet requirement: Previous timescale 31/08/05 The Registered Manager must ensure that the home is cleaned regularly enough or carpets and soft furnishings replaced often enough to ensure that the home does not smell of stale urine. Unmet requirement: Previous timescale 30/07/05 The wording of this requirment is altered and extended to The Registered Manager must ensure that the home is clean and free from offensive odours at all times. The Registered Individuals must ensure that the staff undertake training that enables them to identify, understand and meet the needs of the service user group with regard to learning disabilities and sensory impairment issues. Unmet requirement: Previous timescale The Registered Individuals must ensure that the home DS0000060232.V253092.R01.S.doc 21/11/05 21/11/05 21/11/05 20 YA32 18 (1) (c) (i) 31/12/05 21 YA32 18 (1)(a) (c) (1) 31/12/05 Gibson House Version 5.0 Page 29 22 YA33 18 (1)(a) & (b) 23 YA33 18 (1)(a) & (b) 24 YA33 18 (1) (a) 25 YA37 24 (1)(2) & (3) 26 YA42 23 (4) 27 YA42 23 (4) meets the target of 50 of its care staff holding or undertaking the NVQ Level 2 in Care (or equivalent). Unmet requirement: Previous timescale 30/09/05 The Registered Individuals must ensure that plans are finalised for the management structure of the home and then recruit to the vacant posts. Unmet requirement: Previous timescale 30/08/05 The Registered Individuals must ensure that suitably qualified, experienced and skilled staff are recruited to the vacant posts at the home. The Registered Individuals must ensure that there are enough staff on shift at all times to enable service users to engage in meaningful activities and not to have to spend time in groups due to there not being enough staff to allow them to undertake individual programmes. The Registered Individuals must ensure that quarterly reports are made to the CSCI that describe the planned process for the closure of this home, consultations that are taking place and the risk assessed move-on of the service users. The Registered Manager must ensure that aall procedures and systems for ensuring adequate fire prevention and management are adhered to. Unmet requirement: Previous timescale 14/06/05 The Registered Manager must ensure that the London Fire and Emergency Planning Authority (LFEPA) are DS0000060232.V253092.R01.S.doc 21/11/05 21/11/05 21/11/05 21/11/05 30/11/05 21/11/05 Gibson House Version 5.0 Page 30 contacted to undertake a safety inspection of the building. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 31 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 Gibson House DS0000060232.V253092.R01.S.doc Version 5.0 Page 32 - 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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