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Inspection on 06/09/05 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 6th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

While the home is maintained to an adequate standard of cleanliness, there are a number of areas which required attention in relation to general upkeep and maintenance. Records viewed were maintained in an organised manner and promptly accessed by the Acting Manager upon request from the inspectors.

What has improved since the last inspection?

The registered person has made an application to the CSCI for a variation of conditions of registration as required at the last inspection. However, supporting evidence for the application is yet to be forwarded to the CSCI. All staff employed at the home have undergone CRB checks.

What the care home could do better:

The home has experienced a number of changes in relation to the management arrangements in place. In addition, discussions with staff identified that staff morale is low resulting in some staff turnover that does not offer consistency of care to people using this service. While agency staff are currently having to be used to cover staffing shortfalls, it was positive to note that the recent recruitment drive has been successful and that the service hopes to have more permanent members of staff employed in the near future. There was a strong odour of stale urine in parts of the building indicating poor care and practice. While care plans are in place, these lacked detail as to how staff planned to achieve goals set and who was responsible for havingcompleted the review of care. A number of environmental issues require urgent attention. This includes fitting window restrictors on those bedroom windows where they are absent, ensuring that no means other than an automatic door closer control is used to render the self-closing device on fire resisting doors inoperative and taking appropriate action to reduce the offensive odour present in the home. In addition, some matters raised in the Environmental Health Officer`s Report of 15/3/05 remain outstanding and need acting upon. This includes obtaining data hazard analysis sheets for the cleaning substances used and conducting a risk assessment for the garden and external areas. The registered person must consult service users their preferences of meals and provide them with their choice rather than having the staff to choose for them. They practice of administration and recording of medication needs to be reviewed to ensure proper handling and administration of medication. It is required that service users` finances kept at the home including the records must be made available. The registered person must ensure that staff are supervised and have access to inspection reports of the home. The inspection reports must be made available to service users and to visitors who wish to have a look at them. It is recommended that by 2005 at least half of the existing care staff should achieve a care qualification equivalent to NVQ level 2.

CARE HOME ADULTS 18-65 HCS (Enfield) Ltd 20 - 24 Southbury Road Enfield Middlesex EN1 1SA Lead Inspector Teferi Degeneh and Angela Hunt (Regulation Manager) Unnannounced 6 September 2005 @ 12.35 pm 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 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 Stationary 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. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service HCS (Enfield) Ltd Address 20 - 24 Southbury Road, Enfield, Middlesex, EN1 1SA Telephone number Fax number Email 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 8364 6923 Mr Michael HJ Crausaz for HCS (Enfield) Ltd Vacant Post PC - Care home only 12 beds Category(ies) of LD(E) - Learning Disability - over 65 registration, with number LD(E) - Learning Disability of places HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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. Date of last inspection 24 May 2005 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. All service users have 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. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a period of 6 hours, commencing at 12.30pm and concluding at approximately 6.30pm. Angela Hunt, Regulation Manager accompanied the lead Inspector during the inspection. Gillian Malcolm, an agency member of staff currently covering the post of Manager and Christina Physentzou were present throughout the inspection. The inspection activity undertaken included a tour of the building, the examination of service users files including care records, the examination of health and safety records, the viewing of staff rotas and discussions with both care staff and the home’s management. While access to service users financial records were requested by Inspectors, these were not available. What the service does well: What has improved since the last inspection? What they could do better: The home has experienced a number of changes in relation to the management arrangements in place. In addition, discussions with staff identified that staff morale is low resulting in some staff turnover that does not offer consistency of care to people using this service. While agency staff are currently having to be used to cover staffing shortfalls, it was positive to note that the recent recruitment drive has been successful and that the service hopes to have more permanent members of staff employed in the near future. There was a strong odour of stale urine in parts of the building indicating poor care and practice. While care plans are in place, these lacked detail as to how staff planned to achieve goals set and who was responsible for having HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 6 completed the review of care. A number of environmental issues require urgent attention. This includes fitting window restrictors on those bedroom windows where they are absent, ensuring that no means other than an automatic door closer control is used to render the self-closing device on fire resisting doors inoperative and taking appropriate action to reduce the offensive odour present in the home. In addition, some matters raised in the Environmental Health Officer’s Report of 15/3/05 remain outstanding and need acting upon. This includes obtaining data hazard analysis sheets for the cleaning substances used and conducting a risk assessment for the garden and external areas. The registered person must consult service users their preferences of meals and provide them with their choice rather than having the staff to choose for them. They practice of administration and recording of medication needs to be reviewed to ensure proper handling and administration of medication. It is required that service users’ finances kept at the home including the records must be made available. The registered person must ensure that staff are supervised and have access to inspection reports of the home. The inspection reports must be made available to service users and to visitors who wish to have a look at them. It is recommended that by 2005 at least half of the existing care staff should achieve a care qualification equivalent to NVQ level 2. 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. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 5 The registered person has not made a significant progress since the last inspection in providing all service users with a signed contract. Service users are not clear about the terms and conditions of service. EVIDENCE: Four service users’ files were assessed. The files showed that the home has two types of terms and conditions. The first type is a contract between the service users and the home which contains terms and conditions of the service. This format has pictorial illustrations to help service users understand the contents. Three of the four assessed files contained contracts, which were signed and dated by the home and a service user or their representatives. The copy of the contract seen in one of the service users’ files was not signed or dated. The other version of the home’s contract has been designed to be signed by the provider and the placing authorities. This format is detailed and contains terms and conditions of service including the costs. However, none of the copies seen in service users’ files were signed or dated. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 6 While a system is in place to review service user plans, improvements must be made to ensure that any action identified is acted upon so as to improve the quality of life for service users. The lack of detail in care plans as to how goals set are to be met, potentially places service users at risk of their needs not being satisfactorily met. EVIDENCE: Of the four service users files examined, one indicated that a service user whose last review was held in March 2005 had identified a continence problem. Upon examining in detail the records pertaining to this particular service user, there was no evidence of appropriate support being given to improve the quality of life for this individual. While records indicated that other residents had complained about the service users’ bedroom smelling strongly of urine and that staff had discussed the issue with the community nurse and continence adviser, there was no indication as to the outcome of this or of any active programme to promote continence being in place. While care plans indicate the care and support needed, those examined lacked detail as to how care staff planned to achieve goals set. This inevitably makes HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 10 it difficult to monitor the progress and incentives given to both service users and staff. Inspectors also noted that care plans had not been signed by the person responsible for having completed them. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 12, 14, and 17 The meals provided and the areas where service users sit to eat their meals are below service users’ expectation. The arrangements for managing service users’ finances are not satisfactory with the absence of evidence to show that the records and money kept for each service user are in order. EVIDENCE: There is a cook. The menu was seen and provided for two alternative meals. Discussions with the staff and service users indicated that the meals provided were not in line with the day’s menu. It was mentioned during discussions with staff that frozen food items were not taken out of the freezer in time to defrost and cook. This was the explanation given as to why the meals provided were different from those indicated on the menu. One of the inspectors recalled that service users were not provided with the meals identified on the menu on the day of the previous inspection. An examination of care plans showed that dietary needs of service users have been identified and recorded. There were no fresh fruits available in the home. Two small dining halls were available. The dining rooms and the sittings looked unattractive and when the inspectors arrived one of the tables in the dining rooms was being used for writing with a number of writing materials piled up on it. Some service users were having their lunch at the same time. Discussions with the acting manager showed that HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 12 some service users occasionally went out to cinemas, cafés and the park. The acting manager said finances of some service users have their families to look after their finances while the home manages the monies of a number of service users. At the last inspection issues related to the policies, procedures and management of service users were discussed and a requirement was made. From discussions it was evident that the amount of money kept in cash and the arrangements for managing service users’ finances have been reviewed. It was not possible to inspect the service users’ finances and records as keys to the safe where these have been locked were not available. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 19, and 20 The systems for administering medication in this home are poor and service users’ health is put at risk. EVIDENCE: All service users have their own general practitioners. On the day of the inspection a general practitioner was at the home visiting a service user. In a discussion, the general practitioner confirmed that they have known the home for a number of years and that they have no concerns about the care provided at the home. The records and the home’s diary and a discussion with the acting manager confirmed that service users have regular dental and eye care. Medication is stored in a locked cabinet in the office. An examination of the home’s medication administration record sheets (MARS) and the blister packs showed discrepancies in the administration of medication. For example, on one occasion (3rd week, day 1) staff signed on MARS even though medicines were not administered to a service user. On another occasion (3 September 2005) medication was not administered or recorded for one service user. It was evident from staff files that the acting manager had a meeting with a member of staff to discuss an incident, where the staff failed to administer medication and report this incident to the relevant authorities. The acting manager said the systems of receiving, storing and administering medication are being reviewed and the plan is for all staff to undergo retraining. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 14 MAR sheets were noted to contain tippex in instances where it was reported that errors had been made. Inspectors relayed that such practice is poor and that staff should be reminded not to use correction fluid on such records. The acting manager was accepting of this comment. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 22, and 23 Service users are protected by the staff members understanding of the action they should take in the event of an allegation or suspicion of abuse. Service users are confident that the home is able to deal with any complaints they may have. EVIDENCE: The home has a policy on the protection of vulnerable adults from abuse. It was evident from the documents of the home and discussions with the acting manager that the home has followed the placing authorities policy and procedures of the protection of vulnerable adults to address allegations of abuse. At the time of the visit a member of staff has been suspended pending the outcome of an investigation. The home is revising its procedure of managing service users’ finances. Currently, a senior member from the head office of the company is responsible for dealing with service users’ money. Meanwhile, a petty cash system is used for the day-to-day personal expenses of service users. Receipt and records are kept for all expenses. Four members of the care staff team gave a satisfactory description of their knowledge of abuse and how to deal with an alleged or real abuse of a service user. They confirmed that they are aware of the home’s whistle blowing policy. Service users and visitors who completed feedback cards at the last announced inspection confirmed that they are aware of the homes complaints procedure. The complaints procedure includes a format with pictorial illustrations and bigger fonts suitable for people with sight or reading difficulties. There have been no recorded complaints since the last inspection. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 standard(s) 24, and 30 The odour of incontinence that is evident in parts of the home undoubtedly impacts on the quality of the environment for service users, staff and visitors to the home. Service users’ health and safety is at risk due to the home’s poor practices of leaving bedroom doors open without any self-closing mechanism in case of a fire; and because of the provision of windows without restrictors. EVIDENCE: The home is located on a main road with close proximity to the Enfield Town shopping and leisure facilities. Each service user has a single bedroom. On the day of the inspection, there was evidence of an offensive smell of stale urine being present in the corridors and in some bedrooms on the first floor. The acting manager confirmed that the home is aware of this problem and is looking into ways of providing appropriate care to people who are incontinent. She said that some service users have expressed in meetings of their concerns about the bad smells in the home. It was evident that this was also causing distress to one particular service user concerned. Improvements must be made to eliminate such odours and to reduce the impact on service users. It was observed during a guided tour of the premises that a number of bedrooms were wedged open and that some windows have no restrictors. The chairs and tables in the dining rooms were not attractive and observations HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 17 showed that the dining tables were used by the staff for writing, even when some service users were having their meals. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 36 Even though the staff ratio is satisfactory, consistency of care has not been achieved due to regular staff changes. Despite the previous requirement the home is yet to issue terms and conditions of employment to the staff. There is a noticeable lack of supervision for the staff. EVIDENCE: Discussions with the acting manager and care staff and an assessment of the rotas indicated that there are five staff members working during the early and late shifts and two waking night staff at nights. Three of the care staff have completed care training equivalent to NVQ Level 2. From discussions it was evident that the staff have previous experience of working in care homes and have attended a number of core training programmes relevant to their job. However, evidence was not available to confirm that the staff are regularly supervised. Indeed, as stated below, the home has not had a registered manager for a long time. The staff believe that the home relies to a great extent on agency staff which makes it all the more difficult to ensure consistency in the provision of care. From the rotas and discussions with the staff it was obvious that half the staff on shift on some occasions are either from agency or are care staff who are doing overtime. It is obvious that agency staff who are new to the service and permanent staff who constantly work long hours are not expected to provide a high quality of care. It was HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 19 understood from the acting manager that the provider has recognised the staffing issues of the home and has advertised to employ permanent care staff. At the previous inspection the registered person was required to ensure that each member of staff has terms and conditions of employment and that this is available for inspection. There was no evidence to show that this requirement has been complied with. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, and 42 A lack of permanent and registered manager in this home has negatively impacted on the quality of services and facilities provided to service users. The care staff have not been informed in writing of their role as shift leaders and have not had the opportunity to read or discuss the inspection report of the home. Service users have not benefited from the home’s system of quality assurance. Even though parts of the home were clean and tidy, there were areas in the home that were below the standard of cleanliness expected by service users. EVIDENCE: It was mentioned above that the home does not have a registered manager. The current acting manager has been temporarily employed through an employment agency and has been in post for approximately one month. When the acting manager is not on shift, one of the care staff on shift is assigned to be a shift leader with a responsibility of running the home and administering HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 21 medication. Written job description of a shift leader was not available for inspection even though the staff spoken to were able to describe their duties as shift leaders. They said they know how to contact emergency services and the senior managers if there is a need and when they are in doubt of what course of action to take to address certain issues. During discussions it was clear that the staff have not seen the last inspection report of the home. It was mentioned earlier that a number of windows have no restrictors and some bedroom doors were wedged open. There was evidence to show that the registered person has developed an action plan to address the recommendations made by the Environmental Health Officer on 15/3/05. There was no evidence presented, however, to support that all the matters identified by the Environmental Health Officer had been satisfactorily met. No new progress has been made on the home’s quality assurance since the last inspection. The registered person is yet to develop tools for consulting visitors regarding their views of the home. It was highlighted in the last inspection report that the registered person has used questionnaires to gather the views of service users about the services and facilities of the home. The registered person is yet to produce the outcome of the quality assurance system. HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 x 3 x x 2 Standard No 31 32 33 34 35 36 Score x 3 3 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 HCS (Enfield) Ltd Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 3 x G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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 5 Regulation 5(1)(b) Requirement The registered person must ensure that the service users terms and conditions are signed on their behalf by a representative. (The previous timescale of 31/7/05 not met). The registered person must ensure that all care plans are reviewed, to ensure that where possible they contain clear and attainable goals and how these are to be met. A continence promotion programme must be put in place for the individual identified at the inspection, based on advice and information from a local continence nurse or advisor and for the home as a whole. The registered person must ensure that the money kept at the home for service users, including the records, is available for inspection. An accurate record must be kept of the food provided for service users. Menus displayed must provide an accurate record of the food provided. Appropriate facilities must be provided for service users to sit and end eat Timescale for action 30/10/05 2. 6 17(1)(a) 30/11/05 3. 6 13(1)(b) 31/10/05 4. 12 17(2);Sc. 4(9) 15/10/05 5. 17 17(2) 30/09/05 HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 24 6. 20 13(2) 7. 8. 24 24 23 23(4)(a) 9. 24 13(4)(c) 10. 36 18; 19 11. 36 18(2) their meals. The registered person must ensure that dining tables are not used for writing while service users have their meals. The registered person must ensure that medication is appropriately administered to service users by trained and competent staff. The registered person must investigate the recording and medication administration discrepancies observed in the home and put in place a satisfactory action plan, which prevents a similar incident from happening. Copies of the investigation report and and an action plan must be forwarded to the CSCI Inspector. The matters raised in the EHO report on 15/3/05 which remain outstanding must be completed. All doors which are designated as fire doors must be kept shut. Alternatively appropraite mechanisms must be fitted to doors which do not compromise fire safety and which the LFEPA are satisfied with. All windows which service users have access to must be fitted with appropriate window restrictors. The Registered Person must conduct a risk assessment in order to prioritise having restrictors fitted throughout the home. The registered person must ensure that each member of staff has terms and conditions of employment issued and available in their files. (The previous timescale of 31/7/05 not met). The registered person must ensure that persons working at the care home are appropriately supervised. 15/10/05 30/11/05 immediate Req issued 06/09/05 immediate req issued 6/09/05 30/11/05 30/11/05 HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 25 12. 37 9(1)(2) 13. 37 17; 24 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). The registered person must make available to the staff and service users copies of the inspection reports. 30/11/05 15/10/05 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 20 Good Practice Recommendations It is strongly recommended that staff are reminded of the appropriate method to amend medication records where an error has been made and to discontinue the use of correction fluid (Tippex) on the MAR sheets. The registered person should ensure that at least 50 of care staff achieve a care qualification equivalent to NVQ Level 2 by 2005. It is recommended that the registered employs staff who is sufficient number in order to ensure consistency of care provided to staff. It is recommended each member of staff asked to lead a shift is provided with an appropriate job description. 2. 3. 4. 32 33 34 HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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 HCS (Enfield) Ltd G59 S10582 HCS Southbury Road V246276 06.09.05 Stage 4.doc Version 1.40 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. 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