Inspection on 20/11/06 for Greig House

This inspection was carried out on 20th 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

Greig House 07/11/05

Greig House 18/04/05

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Greig House Greig House 20 Garford Street London E14 8JG Lead Inspector Anne Chamberlain Unannounced Inspection 20th November 2006 10:40 Greig House DS0000061559.V319909.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 Greig House DS0000061559.V319909.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. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greig House Address Greig House 20 Garford Street London E14 8JG 020 7987 5658 020 7987 8942 greighouse@salvationarmy.org.uk 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) Salvation Army Rita Ann Carol Wooldridge Care Home 20 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present drug dependence (0) of places Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Greig House is an 20 bed residential detoxification project. It operates a two or three week voluntary admission for detoxification from drugs and alcohol, for men and women aged 18 - 65. In addition to the registered care manager, project manager, and deputy project manager, the home employs a mixture of nursing and care staff as well as administrative and maintenance staff. They retain the services of a masseuse and an art therapist. A psychiatrist visits daily and a psychotherapist twice a week. A keyworking system is in place. The treatment programme is holistic and in addition to medicated withdrawal complementary therapies are available, including acupuncture, massage, aromatherapy, and art therapy. Greig House comprises an older property and a new build. In addition to the bedroom accommodation and bathroom facilities there are spacious communal areas, and a number of office and meeting rooms. Greig house has one disability adapted bedroom and disabled access to all ground floor areas. It is situated just off East India Dock Road close to transport links and with a number of community resources close by. The home is run by the Salvation Army and has been open for five years. The fees at Greig House are £880 per week for detoxification from alcohol and £1210 per week for detoxification from drugs. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out in two sessions on different days and took approximately five and a half hours. The aim of the inspection was to inspect all the key standards and to revisit the requirements of the last inspection. There are two managers in Greig House. The care manager and the project manager. However the care manager is the registered manager of the service and any requirements are therefore addressed to her. The inspector was assisted by both managers. She spoke with two service users and viewed key documentation, two service user, and two staff files, and medication arrangements. She also toured the premises including two vacant bedrooms and ate her lunch in the dining room. The inspector would like to thank all who assisted her with the inspection of Greig House. What the service does well: The project is very successful in assisting and supporting service users to detoxify from alcohol and drugs. The process is well understood and the service is structured to cope with all eventualities. The service offers medical and psychological support, health education, group work and individual counselling, all to a high professional standard. At the time of the inspection the project was full. Aftercare needs are identified and appropriate referrals are made to help the service user avoid relapse. The service is also conscientious about those who do not complete the programme, giving them sound information and advice when they leave. The project is comfortable and welcoming with good facilities for community life. Service users told the inspector that they were comfortable in their rooms, the food was good and the staff very helpful. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Greig House DS0000061559.V319909.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 Greig House DS0000061559.V319909.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 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service offers comprehensive information to prospective service users and a thorough assessment. EVIDENCE: The previous inspection required the care manager to ensure that the statement of purpose carries the correct contact details for the Commission for Social Care Inspection. This is now the case. At the previous inspection the care manager was required to amend the service user guide. This has been done and the guide is now satisfactory apart from the omission of the qualifications of the staff. The index lists Staff Team page 19A, but the copy the inspector was given did not have a page numbered 19A, and the qualifications of the staff team were not given (see requirements). Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 9 The care manager stated that 98 of service users have a dual diagnosis, generally having some mental health needs. Service users before they come to the unit will have had an assessment by either a social worker or a nurse and this will have included physical health problems. On admission they have a medical and psychiatric assessment. Service users are also seen daily by nurses, registered mental health nurses and registered general nurses, who will if necessary update their assessment information. Greig House DS0000061559.V319909.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 user care plans are dynamic being reviewed on a daily basis. Service users are encouraged to take control of their lives within safe boundaries. There is active risk assessment. EVIDENCE: The care manager explained that the care plan at the unit just covers the duration of stay and is part of the overall care plan for the service user which will have been drawn up by their community worker. Care plans are individual but geared to the detoxification programme which is common to all. The inspector viewed two examples of care plans. These have been modified to involve service users more but are still evolving. The care manager stated Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 11 that service users share the file copy because the experience has been that if they are given their own copy they tend to leave them around the unit, giving others access to confidential information. The care manager further stated that service users sign a contract which gives all the conditions of the programme. Care plans are reviewed on a daily basis. At the staff handover an update is given on each service user. The care manager attends two of these each day and gives clinical guidance. Service users have one to one session with their keyworker every three or four days Given the nature of the project service users are not able to influence the running of the service in many ways. Their views regarding the comfort of the building and provision of meals are considered. Service users are however encouraged to take control of their lives and make decisions about their future after leaving the project. Service users hand over their monies and sign for cash on a daily basis. If a service user has the need debt counselling will be offered. Service users are asked to hand over their mobile telephones and use the house telephone. This helps them to disengage from their lives outside of the project and concentrate on their own recovery. Service users all have a generic risk assessment completed on admission to the unit. The inspector viewed a copy of the form. Examples of risks are risk of suicide or serious physical issues. If a risk is identified the care plan incorporates measures to reduce it. The home has a policy regarding early discharge and service users leave with appropriate advice to safeguard them. The inspector viewed the policy and the handout which is given. If the service considers an absentee service user to be vulnerable they would contact the referrers and take a decision with them as to whether to inform the police. Early discharge is also dealt with in the service user guide. Greig House DS0000061559.V319909.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 good. This judgement has been made using available evidence including a visit to this service. Appropriate activities are provided and where possible service users can access the community. Appropriate relationships are supported and rights and responsibilities upheld. Nutritious enjoyable food is provided. EVIDENCE: There are group sessions in the mornings and afternoons. Twice a week a psychotherapist is available for consultation. The service offers health education, and relapse prevention advice. The project has a snooker and table tennis table, television and music equipment. The garden has space and equipment for outdoor games. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 13 Service users are part of the local community, as their stay at the service is of short duration. They are allowed to go out after seven days. There is a link with the community through their referrer who is the instigator of the main care plan and responsible for aftercare arrangements. After discharge the service users general practitioner will be sent a discharge summary. Exclusive relationships between service users are not allowed and they may not go into each others bedrooms. Family and friends may visit after the first three days using visitor rooms or the lounges. Visitors are not allowed in bedrooms. Their bags are searched and they are asked to turn out their pockets and take off their shoes before they leave the reception area. The rights and responsibilities of service users are laid out in a charter in the service user guide The right to equal treatment irrespective of race, creed, colour etc. is stated. The service user guide states that any form of racial abuse of residents, staff or visitors will result in dismissal from Greig House. Clients rights are also listed in the statement of purpose under the headings, privacy, dignity and independence. The rules of the service do allow for room searches but the care manager stated that these are only undertaken if there are grounds for suspicion. Service users do not have room keys. They can lock their rooms from the inside but staff can open the doors. The provision of nutritious food is listed in the service user guide as a clients right. A catering contractor is used and meals from a set three week menu are provided three times a day in a pleasant dining room. A cooked breakfast is available on alternate mornings and a hot lunch and dinner are provided every day. The care manager stated that there are occasional complaints about food and the inspector noted from reading some client surveys that food had been criticised. The inspector did not sample the food at this inspection but she ate in the dining room. She was told by two service users that the food was fine. The inspector had the impression the appeal of the meals varies a bit but she was satisfied that healthy food is served in pleasant surroundings. Greig House DS0000061559.V319909.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. Emotional and psychological support is competently provided. Physical needs are also met and the arrangements for administering medication are sound. EVIDENCE: Users of the service need to be independent in personal care needs. Disabled people use the service but physical care cannot be provided. The care manager stated that there have been several service users with sensory impairments but this has never posed any real difficulties. A major element of the programme is the provision of emotional and psychological support and as previously mentioned there is groupwork and one to one counselling with keyworkers, and sometimes with the care manager. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 15 The project has a permanent psychiatrist who would make appropriate referrals for medical needs, probably after the detoxification. Service users retain their own general practitioners and are supported with their health needs whilst in the project. Diabetics are encouraged to manage their own regime although tablets will be kept locked away with other medications. Epileptic service users will continue with their usual medication. The inspector viewed the arrangements for the administration of medication. Medication at the project is complex. Many service users are supported to withdraw with a programme of medication which tapers off each day. The medication folder has a sheet of specimen signatures. Each service user is identified with a photograph. The medications cupboard has drawers identified for each service user with their prescribed medications and a separate section for stock medications. The project has a separate locked cupboard for liquid medications which come in large bottles. The inspector noted that the practice of listing prescribed prn medications on sheets with other prescribed medicines continues. The care manager stated that paracetamol should be on a nursing chart along with homely remedies. In some cases it had been included on the prescribed medications sheet. The previous inspection required the care manager to ensure that the paperwork relating to the administration of medication be designed to eliminate errors. The care manager stated that she had redesigned the prn form which had unnecessary numbers on it. The inspector viewed this. The care manager stated that the medications service users bring into the project with them are returned to them at the end of their stay, except drugs which they should not have. These are returned to the pharmacist. Lists of drugs being returned to the pharmacy are made and the inspector viewed a sample. The care manager stated that the pharmacist signs for controlled drugs returned to him. Greig House DS0000061559.V319909.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 good. This judgement has been made using available evidence including a visit to this service. There are good systems in place for handling complaints and service users are safeguarded from abuse. EVIDENCE: The inspector viewed the complaints folder. She noted that there was a complaint in July 2006 about food. The centre manager raised this with the catering contractor and the complaint was resolved. There was a complaint in August 2006 with which the inspector was already familiar, having been involved at the time. This complaint had been judged unfounded and the manager stated that following a letter to the complainant nothing further had been heard. The inspector was satisfied that complaints are handled well and recorded clearly. The manager stated that an ethics policy is signed by all staff. It is understood that they must have no contact with service users outside of the service and there is a whistleblowing policy. The project has a policy for the protection of Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 17 vulnerable adults. The project has a guideline which precludes inappropriate behaviour including self-mutilation. Clients would receive a warning for this and persistence would result in early discharge. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is safe, comfortable and homely. It is clean and health and health and hygiene practices are observed. EVIDENCE: The statement of purpose states that the community living guidelines it gives are designed to protect service users and keep them safe. The environment is safe, homely and comfortable. Bedrooms are well decorated and furnished. The project has a rolling decorating programme for painting walls. When the inspector toured the building, she noted that many walls have a lot of dirty marks and need to be repainted (see requirements). The cleaning of the home is contracted out. On the days of the inspection the home appeared clean and hygienic including the treatment area. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 19 Needles stick injuries although rare are monitored. The laundry arrangements are satisfactory. There is no foul laundry or need for sluicing. Staff do not wear uniforms. Spill packs are available and universal precautions like wearing gloves are observed. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 20 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): 32,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Requirements have been made around recruitment, training, supervision and appraisal. EVIDENCE: Staff at the project are a culturally diverse group representing the multicultural nature of the area. The project employs three registered mental health nurses (RMNs) and four registered general nurses (RGNs) The care manager stated that all the project staff either have NVQ 3 or are working on it. One care worker is undertaking a Drug and Alcohol certificate. Three project work staff are undertaking NVQ 3 through the Salvation Army, and the centre manager is an assessor. The care manager stated that workers undertake the general NVQ with some added studies specific to the nature of their work. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 21 The manager stated that since the last inspection the project has recruited a nurse and a night project worker. The inspector viewed the files for these two workers. The first worker started in December 2005. The file contained a completed application form and two references. The manager stated that everyone has a face to face interview but the notes of this are not kept. There was a copy of a Criminal Records Bureau disclosure dated May 2005 and confirmation from headquarters that a disclosure in the name of the Salvation Army had been received in February 2006. The manager stated that workers do not work alone with service users until their Salvation Army disclosure comes through. The second file contained similar documentation to the first except that there was one reference and this was from a friend. Two professional references should be taken up (see requirements). The inspector did not see evidence of induction for the two new staff whose files she inspected. The care manager stated that the workers would keep their own copy of the induction training check off as they go along. The inspector saw the Induction programme checklist which was comprehensive The project manager holds a training matrix which the inspector viewed. It was not up to date as staff had had training which was not recorded (see requirements). The managers both stated that all nurses and some project workers had renewed their annual mandatory training i.e. manual handling, fire etc. in November 2005 so the mandatory training is now due again (see requirements). The care manager stated that there are always nurses on duty. The inspector felt that given the nature of the service and the fact that most of the service users are fit able-bodied people it was not necessary for all the project workers to renew their training annually in the same way that the nurses do. The care manager stated that this year staff have had training on acupuncture and sexual behaviour and some individuals have attended conferences on Alcohol the Forgotten Substance and Journey to Recovery. There was a requirement at the previous inspection with regard to supervision. The care manager stated that supervision is still a problem as she has not been able to supervise staff six times per year. However a new system has been put into place for supervision. The manager has delegated responsibility for supervision of staff to the team manager and principle project worker. The Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 22 care manager is responsible for supervising those two workers. She also has responsibility for supervising the team leader of the sister service which has opened next door. The care manager is confident that the new system will make supervision at the required frequency manageable (see requirements). The inspector viewed an example of supervision which had been carried out by the team manager. The recording lacked actions and the care manager stated that she has already raised this with him. The care manager stated that new staff are seen every week for the first four weeks as part of their induction. They then have a review at three months and go on to two monthly supervision. The National Minimum Standards under the Care Standards Act states that staff should have annual appraisal with their line manager to review performance against job description and agree career development plans. The care manager stated that there is no appraisal system in place (see requirements). Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The project works with service users who have challenging issues. However it is structured to cope with all eventualities and runs smoothly. The views of service users are sought and their health and welfare are protected. EVIDENCE: The care manager stated that she believes the staff do a good job but dont keep full records. They see this as less important than the direct work with service users. On viewing a service users file the inspector found a good example of this. Service users should have a one to one session with their keyworker not less Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 24 than every three to four days. The recording in the file did not evidence one to one sessions at the proper frequency. However from reading the notes it was clear that the keyworker had worked one to one with the service user, but not recorded the meetings as such. The care manager stated that the recording of group meetings does not reflect the quality of the content. Despite possible shortfalls in recording, the inspector is of the view that the project is well run. The registered (care) manager is well qualified and has a wealth of experience of the medical and psychological needs associated with addiction and substance abuse. The care manager stated that she receives regular supervision as a manager and as a counsellor. The care manager stated that there is a quality assurance team in the unit. The work is linked to the Quality Alcohol and Drug Service (QUADS) standards. There is a manual for this and the project monitors a few standards each week, taking any necessary action to rectify shortfalls. Every service user is given a yellow feedback form to complete before they leave the project. The inspector viewed four of these. Generally service users seemed very happy with the quality of the therapeutic service they had received. There were a couple of negative comments about the food and one service user said she would have liked more organised games and competitions. House meetings are held and run by a staff members. The inspector viewed some minutes. The subject of noise and disturbance had come up and the care manager advised that some sound insulation is going to be installed. The care manager stated that the organisation undertakes a financial audit. She also completes a clinical audit every month covering any significant event. The inspector viewed the sheet for 2006 and noted that there had been very few adverse incidents. The care manager was reminded by the inspector of regulation 37 under the Care Standards Act 2000, Notification of death, illness and other events (which would include drug errors). The previous inspection required the manager to ensure that temperature recordings be made for all refrigerators on the premises. This has now been done and the inspector viewed the records which covered three refrigerators (not the main kitchen refrigerator). The temperature record for one refrigerator was satisfactory but the other two had been consistently out of range. The person who keeps the record said that she had tried adjusting the temperature controls but without any success. She Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 25 also said she had advised the project manager. The inspector looked at the thermometer in the fridge in the recreation room, and found the temperature was too high. The refrigerators must be seen by a maintenance person and if they cannot be repaired they must be replaced (see requirements). The refrigerator temperatures had been recorded under the appropriate date with just a plus or minus to show if they were above or below the acceptable range. The record must be kept with an actual figure for the temperature recorded on that day (see requirements). The project manager is mainly responsible for safe working practices within the unit. She stated that hygiene and infection control training is done on induction and would be repeated every year. The project manager stated that a health and safety risk assessment of the unit is undertaken every two weeks with visual inspection of extinguishers and doors. She stated that the fire alarm is tested on alternate weeks. The outside contractor responsible for the fire safety equipment visited in October 2006 for a maintenance visit and in February 2006 for an inspection, including extinguishers. The project manager stated that fire drills are undertaken three times a year. The inspector saw evidence of a drill in May and September this year. The gas safety inspection was undertaken in January 2006. The water supply was checked in October 2006 for Legionella. The project manager stated that there are valves fitted to the taps to ensure that the water is maintained at the right temperature. She agreed to institute a weekly water temperature test with a few different taps being tested each time. The results will be recorded on a sheet which the project manager will prepare and this will be available for inspection next time (see requirements). The project manager stated that a contractor is responsible for the control of substances hazardous to health COSHH. The inspector spoke with the supervisor representing the contractor and was shown their health and safety policy manual which was comprehensive. The inspector was satisfied that proper information is held about products used. She inspected the storage arrangements and was satisfied that hazardous substances are securely locked away. Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 26 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 x 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 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 2 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 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 27 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 care manager must ensure that the qualifications of the staff are included in the service user guide. The care manager must ensure that the rolling decorating programme allows for repainting of walls which are heavily marked. The care manager must ensure that all staff recruited have two professional references taken up. The manager must ensure that the staff training matrix is up to date. The manager must ensure that the mandatory refresher training which is now due is delivered to the staff. The care manager must ensure that staff have regular recorded supervision not less than six times per year (previous timescales of 01/06/05 and 01/03/06 not met). The care manager must consult with her senior manager regarding introducing an appraisal system into the project. DS0000061559.V319909.R01.S.doc Timescale for action 01/01/07 2. YA24 23(d) 01/04/07 3. 4. 5. YA34 YA35 YA35 19 18 18 01/01/07 01/01/07 01/01/07 6. YA36 18 01/01/07 7. YA36 18 01/03/07 Greig House Version 5.2 Page 28 8. YA42 13 9.. YA42 13 10. YA42 13 The manager must ensure that refrigerators in the project are kept within the proper temperature range, to ensure food is stored safely, otherwise taken out of use. The manager must ensure that the recording of temperatures of refrigerators shows the actual temperature recorded. The manager must institute a weekly water temperature test with a few different taps being tested each time. The results must be recorded on a sheet which will be available for inspection. 11/12/06 11/12/06 01/01/07 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 Greig House DS0000061559.V319909.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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