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Inspection on 25/04/06 for H.C.S. (Enfield) Ltd (Southbury Road)

Also see our care home review for H.C.S. (Enfield) Ltd (Southbury Road) for more information

This inspection was carried out on 25th April 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 9 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

New people`s needs are assessed before their admission. Care plans and risk assessments are regularly updated. People who live at the home can access all communal areas. Visitors are welcomed in the home. There are sufficient number of staff to provide appropriate care to service users. Service users` health needs are closely monitored and arrangements are made for them to see dentists, chiropodists, general practitioners and opticians. The complaints procedures and the policies in relation to the protection of vulnerable adults from abuse are satisfactory.

What has improved since the last inspection?

Significant improvements have been observed since the last inspection. The home is cleaner and window restrictors have been provided in bedrooms. Care plans have been reviewed for all service users. A continence promotion programme has been implemented for a service user. The registered person has developed a system for safe keeping and monitoring of service users` money. A system has been put in place to ensure that fire doors are kept closed at all times.

What the care home could do better:

Appropriate activities must be planned and provided at the home or in the community when people do not attend a day service. The registered person must improve the sitting and dining areas. For example, the sitting arrangement in both areas can be improved to provide more space and comfort for people who use the service. People must be consulted about the food they eat and records of this should be kept. The home must meet the needs of each individual in respect of the food they eat. New staff must not start work at the home until important documents such as satisfactory written references and CRB certificates are obtained. There is a need for the provider to employ a registered manager to run the home. All stakeholders must beconsulted about the quality of the services and facilities provided at the home. The registered person must ensure that the gas boiler is serviced and all portable electrical appliances are tested to ensure that they are safe to use.

CARE HOME ADULTS 18-65 H.C.S. (Enfield) Ltd (Southbury Road) 20-24 Southbury Road Enfield Middlesex EN1 1SA Lead Inspector Mr Teferi Degeneh Unannounced Inspection 25th April 2006 09:30 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service H.C.S. (Enfield) Ltd (Southbury Road) Address 20-24 Southbury Road Enfield Middlesex EN1 1SA 020 8364 6923 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) H.C.S.(Enfield) Ltd Care Home 12 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five specific service users who are currently resident in the home and are over 65 years of age may remain accommodated in the home. This condition must be reviewed at such times as any of the specified service users vacate the home. 6th September 2005 Date of last inspection Brief Description of the Service: Southbury Road is a care home managed by HCS (Enfield) Ltd and the registered provider is Mr Crausaz. The service is registered to provide 12 places to younger adults with a learning disability. The home was originally established to provide support to older people with a learning disability but over the years the service has been extended to younger adults with a learning disability and high physical care needs. The home currently has 5 service users who are over the age of 65. The home consists of a group of terraced houses, which were combined into one dwelling. Each service users has a large single bedroom. The home has a lift to the first floor. The service users with higher physical care needs have bedrooms on the ground floor. There is one assisted bathroom on the ground floor. There are two dining areas. Service users can either eat at a table in the large kitchen area or alternatively in a small separate dining area, where a few of the more independent service users choose to eat. There is one lounge where service users choose to sit in two groups. Most of the service users have a TV and a music system in their own rooms. There is a conservatory at the rear of the house, which acts as a sitting area and as a smoking area. There is a very pleasant garden with some sensory features. Staffing consists of 5 care staff working on a morning shift and 4 on a late shift. The night shift is covered by two waking night staff. The home also has a domestic who works five hours a day from Monday to Friday and a cook who works three hours a day from Monday to Friday. Information about the home including Service users’ guide and the CSCI Inspection reports are available from the home by contacting the providers. The weekly fees of the home range between £883.00 and £1380.00. The level of the fees depends on the support and services provided. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is based on information obtained mainly through discussions with five of the people who live at the home and three members of staff. Observations of the people, the staff and the premises are also used as evidence gathering tools for this inspection. A reviewing officer from the placing authority was also spoken to. The files of the people who live at the home and those of the staff were analysed. Other documents such as the rotas, policies, procedures, medication administration sheets and the menus were seen. The acting manager, Christina Physentzou, was present throughout the inspection. The staff were observed while supporting people with activities such as moving, assisting with meals and administering medication. What the service does well: What has improved since the last inspection? What they could do better: Appropriate activities must be planned and provided at the home or in the community when people do not attend a day service. The registered person must improve the sitting and dining areas. For example, the sitting arrangement in both areas can be improved to provide more space and comfort for people who use the service. People must be consulted about the food they eat and records of this should be kept. The home must meet the needs of each individual in respect of the food they eat. New staff must not start work at the home until important documents such as satisfactory written references and CRB certificates are obtained. There is a need for the provider to employ a registered manager to run the home. All stakeholders must be H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 6 consulted about the quality of the services and facilities provided at the home. The registered person must ensure that the gas boiler is serviced and all portable electrical appliances are tested to ensure that they are safe to use. 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. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New service users are confident that their needs are assessed by the home and by their social workers before their admission. EVIDENCE: One new person has been admitted since the last inspection. A discussion with the responsible person and an examination of the service user’s files showed that assessments have been completed prior to admission. The responsible person said the new service user has been known to the home for a long time. She said the new service user has been attending a day centre run by the Company that owns this home. It was evident from the files that new service users’ assessments have been completed by a social worker and a representative of the home. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home have benefited from the home’s processes of care plans and risk assessments. EVIDENCE: Six service users’ files were randomly selected and assessed. All the files contained up-to-date care plans. Annual reviews are undertaken regularly. Two people who live at the home were having their annual reviews on the day of the inspection. It was clear from discussions with the responsible person and an assessment of records such as the home’s visitors’ book, service users’ representatives are involved in the reviews. The service users spoken to confirmed that they attended their reviews. The home has a policy which states that all “service users should be involved in all aspects of their user plan at all times and should be consulted about any changes to their care plan, their treatment or their care programme”. It was also evident from the files that service users risk assessments have been completed. The care plans and risk assessments are kept in the office and it was not clear whether or not all the staff are familiar with all the changes that take place from time to time. The responsible person said staff are required to read and sign all files to ensure that they are aware of what is going on in the home. The responsible person H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 10 was aware that there was a need to find more suitable ways of ensuring that the staff know details of service users’ care plans and risk assessments. There are appropriate adaptations in the home for people with physical disabilities. Observation of service users and discussions with them indicated that they are able to access all communal areas in the home. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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, and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The activities and the food provided at the home can be improved. A number of service users’ needs in respect of day activities and dietary needs are not fully met. EVIDENCE: Discussions with the staff and the service users, and an examination of service users’ files showed seven people were at the home and four people were at a day centre on the day of the inspection. Also there were five care staff, a cook and a cleaner were working at the home during the early shift. The responsible person said the service users are provided with activities when they stay at the home. A programme of activities was displayed on a wall on the ground floor and copies were kept in service users’ files. The responsible person said staff provide a number of activities at the home. However, from observation and tour of the premises the facilities at the home were not adequate for service users and there was no evidence to suggest that people who live at the home were engaged in activities at the home. Observations showed that service users spend most of the days watching television programmes or listening to H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 12 music in the lounge. The lounge itself, as described below, is not suitable for people to enjoy television programmes or to listen to the music. The responsible person confirmed that service users go to shops with staff. A system has been put in place regarding service users’ money. All incoming and outgoings are properly recorded and receipts are kept. The money and records kept in six different money boxes were checked and were found to be correct on the day of the inspection. There is evidence in care plans showing that the home has discussed with service users about their spiritual, cultural and dietary needs. Discussions revealed that the home encourages and supports people who live at the home to exercise their rights to vote and to go to places of worship. All these are reflected in care plans. Three staff spoken to gave satisfactory description of how to ensure privacy, dignity and right of service users while supporting them with personal care. The registered person said that the cook prepares the menus. An assessment of the menu showed that the meals offered for lunch was different from what was stated in the menu. The responsible person explained that the lunch was prepared after consulting the service users. This was not evident from records or discussions with the people. It was also clear from previous inspections that people were offered food, which was different from the menus. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Even though there is improvement in handling and administration of medication, and in personal care support, there is work to be done by the registered person to ensure that the medicines received and disposed of or administered are accounted for. This will ensure that service users’ medicines are appropriately administered and the risk to them from possible over or under dose will be minimised. EVIDENCE: At the last inspection the registered person was required to ensure that medication is appropriately administered to service users and that an investigation is carried out regarding the discrepancies of records and medication kept at the home. From discussions with the staff and from an examination of staff files it was evident that the staff who administer medication have undergone relevant training. The medication administration record sheets (MARS) were all signed by the staff. However, the medication records books were not clear and it was not possible to know the balance of some tablets. The responsible person knew that this is an area, which needs to be improved. • All the people who live at the home are registered with their own general practitioners. Records were available to show that service users had access DS0000010582.V290248.R01.S.doc Version 5.1 Page 14 H.C.S. (Enfield) Ltd (Southbury Road) to primary health care. The diaries and service users files showed that dentists, chiropodists and opticians have seen service users. General practitioners visit the home. Health and personal care needs of service users are included in care plans. Following the findings of a previous inspection the home has now supported one specific service user with incontinence management. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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, and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures to ensure that service users’ concerns are listened to and dealt with. EVIDENCE: A strategy meeting has recently been convened to establish what course of action to take regarding a concern about the quality of care provided to a person who used to live at the home. This is still ongoing. The home has policies, procedures and systems in place to deal with complaints and real or alleged cases of abuse. Three staff spoken to gave satisfactory description of what constitutes abuse and what to do in order to protect vulnerable adults from abuse. It was evident in staff files that abuse is discussed in supervision and staff have attended training on abuse. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 16 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, 28, and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered person has made encouraging progress in terms of making the home clean and safe. There are, however, works to be done to make the rooms and facilities a more comfortable place for service to live in. For example, the lounge can be improved to enable service users to use it for social and recreational activities. EVIDENCE: The registered person has provided window restrictors as required at the last inspection. All fire doors are now kept closed and the registered person is looking into purchasing door guards as an alternative. The home was clean and it was evident that there were no offensive smells in the communal areas or in the bedrooms inspected. The registered person has employed a cleaner. Discussions with the responsible person and a service user’s file showed that the home has developed an incontinence management programme for a service user. The home is located close to shops and transport facilities. Two televisions sets are kept in opposite corners of the lounge. There is also a music player. The provision of the television sets and the music player have been intended to allow service users to make a choice of programmes to watch or to listen to. It appears from the observation of the services users and the lounge that the right to choose television programmes and music have not H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 17 been complemented with the right to enjoy them quietly. The level of the noise of the two television sets, when used at the same time, would be very high to enjoy the programmes. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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): 34, and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have benefited from trained and experienced staff provided by the home. There is a need for the registered person to obtain satisfactory written references and CRB in respect of all new staff before employing them to work at the home. EVIDENCE: The files of two staff who have been employed since the last inspection were assessed. One of the new staff was transferred from another owned by the same company. In both files the two written references were written in a general certification format and there was no evidence that they have been verified. One of the files contained a CRB certificate that had been issued as part of previous employment. The responsible person was aware that CRB checks are not transferable and that there is a need for the home to ensure that appropriate checks are undertaken in relation to the care worker without a current CRB check. The files of the staff contained details of training programmes they have attended. It was evident from the records that the home has developed a list of training areas which staff need to undertake. Three staff, who were spoken to, were confident in discussing their previous care related work experience and their knowledge and skills of supporting people with a disability in a care H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 19 home. They confirmed that they have attended training in fire safety, health and safety, first aid and medication. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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, and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Lack of a registered permanent manager has negatively impacted on the services provided at the home. Even though the appointment on a temporary basis of an acting manager has resulted in some improvements, service users are not sure whether or not the acting manager will stay there on a long-term basis. The quality assurance system is poor and service users do not know if their views are systematically sought and taken seriously. EVIDENCE: The home has been running without a registered manager for a number of years. An acting manager has recently resigned and has been replaced by a new acting manager. The new acting manager has been brought from another care home owned by the same company to run this home on a temporary basis. The acting manager has a long experience of managing a similar home. The staff and service users have positive attitude about her and there have been improvements in areas such as the cleanliness of the home and the reviewing of care plans. The improvements observed at the home are due to H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 21 the acting manager’s and the staff efforts. A previous acting manager has been on suspension for the last two years awaiting the outcome of court proceedings. The home has started a quality assurance exercise. Questionnaires have been prepared as a tool for gathering feedback from people who live at the home. The responsible person said that similar questionnaires would be prepared for visitors. It was stated that the questionnaires would be distributed to and collected from the respondents for analysis. At a previous inspection, the registered person was required to develop a strategy for addressing any shortfall that my come to light as a result of the home’s quality assurance process. As stated elsewhere in this report the registered person has complied with a number of health and safety issues. For example, window restrictors have been fitted and fire doors are always kept closed. A cleaner has been employed. The cleanliness of the home has improved with the smell of stale urine substantially reduced. Records showed that health and safety activities such as fire alarm testing, alarm calls, emergency lighting and fire extinguishers have been tested or serviced and are due for retesting in September or October 2006. There was written evidence to indicate that the bath and hoists were serviced on 5/12/05 and the passenger lift was serviced on 21/03/06. The portable electrical appliances and the gas boiler testing and servicing took place on 04/06/04 and 13/09/04. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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 2 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 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.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 YA12 Regulation 16(2)(m) Requirement The registered person must consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities. The registered person must provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users. Menus displayed must provide an accurate record of the food provided. The registered person must keep records of all medicines received, administered, disposed of, and returned to the pharmacist. The balance of medicines kept at the home must be updated regularly. The registered person must ensure that there is DS0000010582.V290248.R01.S.doc Timescale for action 30/06/06 2 YA17 16(2)(f); 17(2) 31/05/06 3 YA20 13(2) 31/05/06 4 YA28 23(2)(h) 31/07/06 H.C.S. (Enfield) Ltd (Southbury Road) Version 5.1 Page 24 5 YA34 6 YA34 7 YA37 8 YA39 9 YA42 adequate sitting, recreational and dining space for service users. The lounge and the dining room must be improved. 17 Sch 2 & Sch The registered person must 4 (6) ensure that two references (one of which is from the most recent employer) are obtained for each member of staff and are available for inspection. The registered person must satisfy himself that the references are verifiable. 19(1)(2) (3) The registered person must ensure that all staff employed by and working at the home have satisfactory current CRB checks undertaken for the purpose of working at the home. The registered person must conduct a POVAFirst check in respect of one staff without a current CRB certificate and ensure that the person applies for a CRB check. 9(1)(2) The registered person must ensure that a manager is appointed to run the home and that an application for registration is submitted to the CSCI by this individual. (The previous timescale of 31/8/05 not met). 24(1)(a)(b);(3) The registered person must put in place effective quality assurance and quality monitoring systems, which seek the views of service users, visitors and professionals. The outcome of the surveys must be published and made available to all parties including the CSCI. 23 (2); 17 The registered person must DS0000010582.V290248.R01.S.doc 21/06/06 21/06/06 31/07/06 31/07/06 21/06/06 Page 25 H.C.S. (Enfield) Ltd (Southbury Road) Version 5.1 ensure that all portable electrical appliances and the gas boiler are tested or serviced and are safe to use by service users and the staff. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The registered person should ensure that staff have an upto-date know service users’ care plans and risk assessments. H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 H.C.S. (Enfield) Ltd (Southbury Road) DS0000010582.V290248.R01.S.doc Version 5.1 Page 27 - 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!