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Inspection on 02/05/06 for Great Western Road, Flat 3, 22-24

Also see our care home review for Great Western Road, Flat 3, 22-24 for more information

This inspection was carried out on 2nd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides service users with a clean, comfortable, safe and homely environment, which is well located to transport links and local amenities. Service users are supported to make their own choices and are supported to maintain a full programme of activities, which includes taking part in the local community. Service users who completed comment cards commented that they were satisfied with the overall care received at the home.

What has improved since the last inspection?

The home has met four of the nine requirements set at the last inspection. Improvements have been noted in the recording of medication and records now accurately reflect the medication given. Improvements have also been noted in the health and safety monitoring in the home. Steps have been taken as per the recommendation of the last report to review service users` health records and archive old records.

What the care home could do better:

A total of 13 requirements and two recommendations are made within this report. Six of these requirements are being repeated from previous inspections. There is a need for the home to ensure that service users` care plans and risk assessments are up-to-date so that they fully reflect the needs of service users.The reporting and the ways for dealing with allegations of abuse must be improved to ensure that service users are protected from abuse. Accident and incident records must also be improved. Staff training records must be improved and the home must provide the CSCI with a plan of how they propose to ensure that 50% of staff achieve the necessary qualification for caring for service users. Permanent management arrangements must be put in place and the permanently allocated person must register as the Registered Manager with the CSCI. The home`s Quality Assurance systems must include service users and quality of care must be regularly reviewed.

CARE HOME ADULTS 18-65 Great Western Road, Flat 3, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Ffion Simmons Unannounced Inspection 2nd May 2006 10:15 Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 3, 22-24 Address 22-24 Great Western Road London W9 3NN 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 7289 5041 020 8964 5507 The Westminster Society for People with Learning Disabilities Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Flat 3 is a purpose built, wheelchair accessible, first floor flat providing accommodation for six service users of either gender with a learning disability. The property is owned and maintained by Paddington Church Housing Association, and the care is provided by the Westminster Society for People with Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Grove, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has their own bedroom. Communal areas, bathrooms and toilets are shared. The current scale of charge for the service as obtained from the pre-inspection information is £1,104.46 per week with no additional charges. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day in May 2006 and lasted 6 ½ hours. The inspector spent time observing care practices and talking to service users and staff. The care of three service users were tracked during the course of the inspection and their records were checked. Service user, friends/relatives and health and social care professional were given the opportunity to comment about the service within a confidential questionnaire. What the service does well: What has improved since the last inspection? What they could do better: A total of 13 requirements and two recommendations are made within this report. Six of these requirements are being repeated from previous inspections. There is a need for the home to ensure that service users’ care plans and risk assessments are up-to-date so that they fully reflect the needs of service users. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 6 The reporting and the ways for dealing with allegations of abuse must be improved to ensure that service users are protected from abuse. Accident and incident records must also be improved. Staff training records must be improved and the home must provide the CSCI with a plan of how they propose to ensure that 50 of staff achieve the necessary qualification for caring for service users. Permanent management arrangements must be put in place and the permanently allocated person must register as the Registered Manager with the CSCI. The home’s Quality Assurance systems must include service users and quality of care must be regularly reviewed. 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. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Full information is available on the needs of service users prior to them moving in. Service users have the opportunity to visit the home prior to moving in to get to know staff, service users and to become familiar with the environment. EVIDENCE: There have been no further admissions to the home since the last inspection. Full needs assessments are in place for each service user prior to admission. The Society has an admissions procedure in place, which includes the opportunity for service users to visit the home prior to moving in. The service user who most recently moved in to Flat 3 was well known to the service users and staff at Flat 3 and a close friend of one of the service users in flat 3. They visited the home on a number of occasions prior to moving in. This gave them the opportunity to get to know the staff and feel familiar with the environment. The service user commented that they are settling in well. All service users who completed a comment card said that they were asked if they wanted to move into the home and that they received enough information about the home before they moved in. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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): 6, 7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are reflected in a person-centred plan but the plans are not in an accessible format and not regularly updated to reflect changing needs. Risk assessments are thorough, but should be kept up-to-date to fully promote service users’ safety. Service users are supported to make their own decisions about their lives. EVIDENCE: The care of three service users was tracked during the course of the inspection. This included checking their personal files. Each service user has a plan of care outlining their support needs. The care plans are thorough and person centred, and they provide a good level of information. The inspector noted however that two of the three care plans had not been reviewed since April 2005 and May 2004. The requirement set at the last inspection to ensure that care plans are reviewed at least every six months with the input of the service user remains ongoing. The care plans and daily notes demonstrated that service users are given opportunities to make decisions about their care. Resident meetings also take place where service users are given opportunities to comment about aspects of Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 10 the running of the home. Service users spoken with during the inspection felt that staff listened to what they had to say and enable them to make their own decisions. Two team members have completed multi-media training with the aim of supporting service user to make individual plans more accessible. Currently these skills are not being utilised in the current care plans as these were heavy in text. Consideration should be given to making the care plans more accessible to service users. Each service user whose care was tracked had a risk taking profile on file. Although the three risk assessments were thorough they are in need of being reviewed and updated to reflect the service users’ current needs. One of the service users has developed a pressure sore (see also section under healthcare) and must be reflected in the risk assessment. Risk management strategies must be drawn up to manage and minimise further tissue damage. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 11 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): 12, 13, 15, 16 & 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 opportunities for personal development, have a full programme of suitable activities and are supported to maintain relationships with friends and family. Service users are well supported to be part of the local community and re offered healthy meals of their choice. EVIDENCE: The service users have a full programme of activities. All service users have access to day services and take part in various classes and activities. This provides them with opportunities for personal development and social interaction with other service users and staff. The service users’ weekly programme is outlined in their plan of care. The staffing rotas were checked and it was noted that there were sufficient staff on duty to enable service users to be supported to follow their programme of activities, which occasionally require two to one support. The service users case tracked during the inspection expressed in their care plan that they enjoyed trips out to local cafes and enjoyed having lunch out. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 12 There were a number of references seen in their daily notes where these wishes had been met and where service users were supported to be part of the local community. In fact on the day of the inspection two of the service users case tracked enjoyed a meal out at a local bar. Service users are also encouraged to maintain relationships with relatives and friends and have opportunities to meet up socially with service users from another registered service, flat 4 (upstairs). The daily routines in the home are flexible and service users choose when they would like to get up and when they would like to go to bed. On the morning of the inspection, one of the service users was enjoying a lie-in, which was respected by the staff team. Service users’ individual abilities and housekeeping responsibilities are highlighted in individual plans. Service users are supported with tasks such as preparing meals and staff were offering service users with a choice of what they would like to eat. One service user has a pictorial menu to enable them to choose their meals. One of the service users commented “I always choose what to have for my breakfast and I choose that I have to eat and drink”. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 13 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 & 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ personal care needs are well documented, which promotes service users’ privacy and dignity. Steps must be taken to ensure that service users’ health care needs are fully met. Medication is securely stored and an improvement was noted in the completion of medication administration records thus promoting service users’ safety in this area. EVIDENCE: Service users’ personal care needs are outlined in their care plans. The plans outline their abilities, preferences and refer to maintaining service users’ privacy and dignity. Service users’ health care records reflected that service users have access to support from the multi-disciplinary team. The inspector noted that a service user had developed a pressure sore. It was unclear from the daily notes or the healthcare records what action was being taken by staff to manage and minimise the risk of further tissue breakdown. The Manager has been asked to ensure that the service user’s risk assessment is updated to outline this area of risk and to develop a risk management plan. The service user’s support plan must also be updated following the input of the relevant health care professionals to reflect their changing needs i.e. that she has a pressure sore, and to outline an agreed plan of care. The necessary Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 14 pressure relieving equipment must be made available to the service user to prevent further tissue damage. The medication in the home was securely stored at the time of the inspection and is mainly received into the home in blister packs. Since the last inspection, the home has produced a list of signatures and initials of all staff who are trained and responsible in the administration of medication. The inspector viewed the medication records of all six service users. There has been an improvement in the recording of the administration of medication since the last inspection. It remains a requirement that any known allergies are noted on the medication administration records. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 15 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 & 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users feel that they are able to voice their concerns and that their views are listened to. There were shortfalls noted in the home’s procedures for reporting and dealing with allegations of abuse, which need to be urgently addressed to ensure service users are protected from abuse. EVIDENCE: Service users have access to the home’s complaints policy a copy of which is available within their personal files and the service user’s guide. The policy makes good use of symbols and pictures of personnel to contact. The policy should be updated as some of the information within the policy is out of date and makes reference to individuals who no longer work within the Society. Service users spoken with were clear about what to do should they be unhappy with any aspect of the service. The complaints records were checked and it was clear from checking these records that service users’ concerns are logged. The inspector however noted within the complaints file, that a service user in December 2005 made an allegation that a temporary agency worker pushed her. The allegation was logged in the complaints file but it was unclear what actions had been taken by the home including if a referral was made to the relevant Adult Protection Team under the Multi-agency Adult Protection Policy. The local office of the CSCI had not been informed of the allegation as per the agreed policies. An immediate requirement notice was issued to ensure that all allegations of abuse are immediately reported to the relevant Adult Protection Team at Westminster Social Services and the CSCI must also be informed without delay. The Manager has also been asked to report to the inspection team, the details relating to the incident above including the outcome of any investigations undertaken. There is also a need to ensure that Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 16 staff receive refresher training on how to refer an allegation of abuse as per the local multi-agency adult protection policy. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users living at flat 3 benefit from a warm, homely, comfortable and safe environment. The home is clean and hygienic. Service users have access to the public transport and local amenities, which are located nearby. EVIDENCE: The inspector viewed all communal areas of the home. The home is purposebuilt, is wheelchair accessible and accommodates six people. The security in the home is good with entry to the main building via entry phone system. CCTV cameras have been fitted to monitor the main entrance. The home is located close to transport links and local shops, cafes and pubs. The home was clean, comfortable and homely. Since the last inspection it was noted that the main lounge has been decorated and re-arranged. One of the service users commented that they were involved in choosing the colour schemes of the room. New good quality leather sofa and chair has been purchased. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a team of staff who have been inducted into their role. Steps must be taken to bring the percentage of staff trained to NVQ level 2 up to at least 50 . This will ensure service users are supported by a well-qualified staff team. Service users are protected by the home’s recruitment practices. EVIDENCE: The staffing rotas demonstrated that there are sufficient staffing levels for meeting the needs of service users. Since the last inspection, four new staff have joined the team. Their training records were checked during the inspection. The training records of one of the staff team indicated that they had attended a week-long induction programme which included training on identifying abuse and health and safety. There was nothing recorded for the other three staff. The new staff however confirmed during the inspection that they all had attended induction training but the records did not reflect this. It is a requirement that training records are improved and kept up-to-date to reflect the training undertaken. It remains a recommendation that a system is set up to highlight when staff are in due training updates in safe working practices. The information within the pre-inspection information indicates that 37 of the current staff team are qualified to NVQ level 2 or above. This falls slightly short of the national minimum standard that 50 of care staff in the home Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 19 should be qualified to NVQ level 2 or above. The Society is asked to report to the CSCI on their proposal for meeting this standard. The personnel files of the staff team were unavailable at the time of the inspection as these were securely store and the key holders were off duty. The staff spoken with however confirmed that they attended an interview and that pre-employment checks had been completed prior to them commencing work. The checks included three reference checks and a CRB and POVA check. One of the service users spoken with confirmed that they are given the opportunity to be part of the recruitment Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from having a permanent manager recruited to manage the home. Service users would also benefit from better quality assurance procedures including seeking their views on aspects of running the home. An improvement in the health and safety monitoring has promoted the home’s ability to maintain health and safety of service users but there is a need to ensure that the home improves the accident and incident recording and reporting. EVIDENCE: The home is still without a registered manager and the staff on duty during the inspection were not aware of the permanent arrangements for filling this post. The post is still being covered temporarily by the registered manager of the flat above. This acting up post was initially for a three month period. It remains a requirement that steps are taken to formalise these arrangements and ensure that the allocated person is registered with the CSCI as the Registered Manager. Some of the staff members felt supported by the management team, but some comments such as lack of consultation regarding changes Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 21 were voiced. A Team Leader is in post to oversee the day-to-day running of the home. Both acting service manager and team leader were not available at the time of the inspection. A tool is available for assessing the quality of the care in the home. It is unclear from the records in the home when the last full audit of the service against the national minimum standards took place. There was no evidence that service user questionnaires have been completed and no evidence of a report available based on service users views and others such as families, advocates and healthcare professionals. It remains a requirement that the Society must ensure that its Quality Assurance system includes service users and their representatives and that the quality of care is regularly reviewed. The inspector noticed an improvement in the health and safety monitoring in the home since the last inspection. Fire alarms are now tested weekly as per the regulations and water temperatures are also tested and recorded weekly. Fire drills are performed and the fire equipment is tested. Portable electrical equipment tests have been completed and an electrical and gas certificates were on file. Recent building and fire risk assessments have also been completed. Incident and accident books were seen during the inspection. An entry was seen in the book indicating that a service user had a swollen hand but there was no record of how this happened and no indication that the GP had been contacted for advice. There is a need to improve the recording within these books to include more details relating to any incident leading to any injury to service users and any action taken. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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 YA6 Regulation 15 2 Requirement Timescale for action 10/06/06 2. YA9 13 4 3 YA9 12 & 13 [1] (b) [4] 4 YA6 12 & 13 [1] (b) [4] Staff must ensure that the individual plans are reviewed at least every six months with the input of the service user and representatives where appropriate. Previous timescale of 01/03/06 has not been met and this is now a repeat requirement. Risk assessments must be 10/06/06 regularly reviewed to reflect the changing needs of service users. Previous timescale of 01/02/06 has not been met and this is now a repeat requirement. The Manager must ensure that 15/05/06 the service user who has a pressure sore has an updated risk assessment outlining this area of risk and has a risk management plan. The service user’s support plan 15/05/06 (see above requirement) must also be updated following the input of the relevant health care professionals to reflect the changing needs. DS0000010877.V288363.R01.S.doc Version 5.1 Great Western Road, Flat 3, 22-24 Page 24 5 YA19 12 & 13 [1] (b) [4] 13 2 6 YA20 The necessary pressure 15/05/06 relieving equipment must be made available to the service user to prevent further tissue damage. Any known allergies must be 10/06/06 noted on the front of the medication administration records. Previous timescale of 03/04/06 has not been met and this is now a repeat requirement. All allegations of abuse must 02/05/06 immediately be reported to the relevant local Adult Protection Team and the CSCI must also be informed without delay. Immediate requirement The Manager must report to the 12/05/06 inspection team, the details relating to the noted incident including the outcome of any investigations undertaken. Please also confirm that the incident has been reported to the relevant Adult Protection team. Staff must receive refresher 01/07/06 training on how to refer an allegation of abuse as per the local multi-agency adult protection policy. Training records must be 10/06/06 improved and kept up-to-date to reflect the training undertaken. The Society is asked to report to 01/07/06 the CSCI on their proposal for meeting this standard of 50 of staff qualified to NVQ level 2 or above. 7 YA23 13 [6] 8 YA23 13 [6] 9 YA23 13 [6] 10 YA35 17 [2] [3] Schedule 4 18 [1] 11 YA32 Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 25 12 YA37 39 The Society must notify the 01/07/06 Commission of the permanent arrangements for replacing the Registered Manager of flat 3. Previous timescale of 01/02/06 has not been met and this is now a repeat requirement. The newly appointed manager 01/08/06 must complete a registered manager’s application with the CSCI’s Central Registrations Team. Previous timescale of 01/03/06 has not been met and this is now a repeat requirement. The Society must ensure that its 01/07/06 Quality Assurance system includes service users and their representatives and that the quality of care is regularly reviewed. Previous timescale of 01/04/06 has not been met and this is now a repeat requirement. The recording within the 10/06/06 accident and incident books must be improved to include more details relating to any incident/any injury to service users and any action taken. 13 YA37 CSA 2000 14 YA39 24 15 YA42 17 [2] [3] Schedule 4 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 26 No. 1 2. Refer to Standard YA6 YA35 Good Practice Recommendations Consideration should be given to making the care plans more accessible to service users. A system should be developed to highlight when staff are due training updates in safe working practices. Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Great Western Road, Flat 3, 22-24 DS0000010877.V288363.R01.S.doc Version 5.1 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!