Inspection on 15/08/06 for Highfield Road (5)

This inspection was carried out on 15th August 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfield Road (5) 11/06/07

Highfield Road (5) 19/12/05

Highfield Road (5) 23/11/04

Highfield Road (5) 10/05/04

Similar services:

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Highfield Road (5) 5 Highfield Road Purley Surrey CR5 2JJ Lead Inspector James O`Hara Key Unannounced Inspection 15th August 2006 09:00 Highfield Road (5) DS0000028115.V308238.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 Highfield Road (5) DS0000028115.V308238.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. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Road (5) Address 5 Highfield Road Purley Surrey CR5 2JJ 020 8660 6676 020 8660 1547 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) Surrey Borders and Partnership NHS Trust Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: 5 Highfield Road is a residential home for adults with physical and learning disabilities, it is owned, managed, and staffed by the Surrey and Borders Partnership NHS Trust, a specialist health provider for people with learning disabilities. There are ten residential places at the home and one respite bed. Highfield Road is a large detached house located in a quite residential road in a quiet area of Purley and is well placed for access to Croydon and Purley town centres. The home has a large lounge, separate dining room, kitchen and laundry room. There is also a sensory room attached to the lounge. To the rear of the home is a large, well-maintained private garden, which is very popular with the service users in the summer months. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 9.30am and 3.30pm on a Tuesday morning/afternoon. The home manager, Ms Madhi, was not present in the morning; a senior member of staff ably supported the inspection process. Ms Madhi came to the home in the afternoon. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with the senior member of staff and Ms Madhi. Records examined included service users person centred plans, care plans, risk assessments, complaints, adult protection, staffing records, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed with Ms Madhi. What the service does well: What has improved since the last inspection? All staff has had their training needs assessed. Ms Madhi provided evidence that all staff has had training on adult protection. Some members of staff attended training in October 2004, October 2005. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 6 The acting home manager arranged for Criminal Records Bureau Checks to be examined on the 01/02/06 no new member of staff has started work at the home since then. The Commission has seen all current staffs Criminal Records Bureau Checks. What they could do better: There were three requirements and one recommendation set at the last inspection. Two requirements have been met. As a result of this inspection five new requirements and seven new recommendations have been set. There are now six requirements and eight recommendations. Management of the home has been erratic over the last year or so however Ms Madhi has recently returned from long-term leave and is keen to organise and improve systems in the home. Now that a permanent home manager is in place service users and staff can be sure that they will be supported in a consistent manner. The Surrey and Borders NHS Trust needs to ensure that Ms Madhi is registered with the Commission For Social Care Inspection. There were a number of weaknesses identified during the inspection the most significant being the homes continued failure to comply the requirement that service users care plans are reviewed by their care managers. The home could do more to ensure that all service users person centred plans and risk assessments are kept under review. The home could do more to identify the individual service users preferred activities and ensure that a programme of activities is developed for each service user. The home manager needs to ensure that the whole staff team receives regular supervision so that the service users benefit from having a consistent approach to their needs. Ms Madhi acknowledged that improving communication systems would benefit both the service users and staff. Ms Madhi said that she would contact the Surrey and Borders NHS Trust Speech and Language Therapist for advice on total communication. The Commission is confident Ms Madhi will meet all of the requirements and recommendations set in this report in a timely fashion. The inspector would like to thank the service users, members of staff on shift and Ms Madhi for their support during the course of the inspection. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. No new service users have moved to the home since the last inspection. The home provides prospective service users and their representatives with the information they need to make an informed decision about whether or not to use the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Service User Guide includes all the necessary information specified in regulation 5 of the National Minimum Standards. The home manager, Ms Madhi, could not locate the Statement of Purpose on the day of the inspection. It is recommended that the home manager keep a copy of the Statement of Purpose in the office. No new service users have moved to the home since the last inspection. Surrey and Borders NHS Trust has its own assessment for admission to residential care, which is completed by the home. The fee charged at the home is £67,192,11 per annum. The fee is currently under review. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 10 Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 11 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 poor. This judgement has been made using all the available evidence including a site visit to this service. The home is failing to ensure that service users care plans are kept under review. All service users have a person centred plan that includes detailed information on their needs and personal goals, however the home is failing to ensure that some of the service users person centred plans are kept under review. Service users have risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner, however the home is failing to ensure that these risk assessments are kept on the service users files so that the staff team and the service users are aware of the identified risks. EVIDENCE: Two service users personal files were sampled at random. Both service users files included a care plan completed by a care manager from their placing Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 12 authority. However both service users care plans were completed in September 2003. A requirement was set at the inspection on the 25 of April 2005 that the home manager ensures that all service users have their needs assessed by their care manager. On the 19th December 2005 the requirement was amended to the acting home manager must ensure that all service users have their care plans reviewed by their care manager and that the issue of the two service users sharing a bedroom is discussed as part of their review. Ms Madhi provided evidence that the deputy manager had written to one of the service users care managers on the 17th November 2005 requesting a copy of the most recent care plan. None was received. Service users files examined indicated that the service users care managers attended Person Centred Planning reviews in February and March 2005 however the service users care plans were not reviewed. The service users person centred plans have not been reviewed since these dates. Staff team meeting minutes indicated that two other service users had their person centred plans reviewed on the 18th of May 2006. The home manager must ensure that all service users Person Centred Plans are kept under review. Both service users files sections on risk assessments were examined, both had a number of risk assessments that had been reviewed in March 2005 but not reviewed since that date. Ms Madhi produced evidence on the homes computer that all of the service users risk assessments had been reviewed in March 2006 and sent to the service manager for agreement. Ms Madhi stated that these needed to be printed off and placed in the service users files. The home manager must ensure that all service users risk assessments are reviewed at appropriate timescales and copies of the risk assessments are kept on the service users files so that the staff team and the service users are aware of the identified risks. The home manager must contact all of the service users care managers and request a copy of the most up to date service users care plan. If the service users care plan has not been reviewed in the last 12 months then the home manager must request that the care manager arrange a date to review the care plan. The homes continuous failure to comply with this requirement represents a serious breach of the care homes regulations and urgent action must be taken by the home manager to address the requirement to avoid the Commission taking further action to enforce compliance. Ms Madhi is advised to monitor the anniversary of the annual review date in order to request that the placing authority fulfil their statutory duty. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 13 Ms Madhi explained that service users attend a part of the staff meeting to discuss issues important to them, however for most of the service users communication is difficult. It is recommended that the home manager contact the Speech and Language Therapy Department at Rees House, 2 Morland Road Croydon, CR0 6NA for advice on Total Communication. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using all the available evidence including a site visit to this service. The home could do more to identify the individual service users preferred activities, ensure that a programme of activities is developed for each service user and that a record of activities attended is kept. Contact between service users and their families and friends are encouraged to help them maintain relationships. EVIDENCE: Currently none of the service users attend employment or day services, the home offers a range of recreational activities both in and outside of the home. The senior member of staff on shift stated that service users stopped attending Geoffrey Harris House day services in November 2005. Since then the home has taken up the responsibility of arranging daytime activities for the service users. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 15 She explained that the home generally has four staff on each shift and that the home has two minibuses, so it is usual when there are two drivers on shift to take two groups of five service users out into the community. One service users activity records were examined with the member of staff, these records did not clearly indicate the actual activity attended by the service user. The home does not have a programme of activities for the service users. The member of staff stated that individual service users finance records would better indicate the activities attended by service users. It is recommended that the home develop an appropriate system for recording the actual daily activity attended by individual service users. The senior member of staff stated that service users go out for lunch, cinema, clubs, shopping, bus rides and in house activities such as aromatherapy, relaxation, sensory room and relaxation. Ms Madhi stated that the Service Manager was working to develop other day services in Epsom. The home manager must review individual service users assessed needs, care plans and person centred plans and ensure that an individual programme of activities is developed for each service user at the home. The home encourages service users to remain in contact with their relatives. There is an open visitors policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Family and friends are invited to any social events held at the home as well as reviews. Service user can be visited in any of the homes communal areas as well as the service users bedrooms. The homes menus were examined; menus are based on a four-week rota. The Surrey and Borders NHS Trust dietician checks menus for nutritional balance. Service users dietary and cultural requirements are reflected in the menus. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using all the available evidence including a site visit to this service. The arrangements for meeting the health care needs of the service users are good. The Surrey and Borders NHS Trusts policies and procedures for handling medicines ensure that the service users are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: A new medicine cupboard is located in the hallway. The home uses a blister pack system for medication. The home also has medical profiles of each of the homes service users. A photograph of the service users is on the record sheet. The home uses a local chemist and a returns book is in place. Administration records examined were up to date at the time of the inspection. There are no controlled drugs used at the home. One service user is diabetic. A number of senior members of staff have been trained by a Specialist Diabetic Nurse to administer insulin. The member of staff on shift produced records of when this training took place. It is recommended that staff have periodic refresher training on the administration of insulin. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 17 Some service users have epilepsy and number of senior members of staff has been trained by a Surrey and Borders NHS Trust to administer PRN. The senior member of staff on shift stated that the service users had not had a seizure for a few years. It is recommended that the home manager contact the service users General Practitioners for advice and guidance on how the service users epilepsy presents and under what circumstances staff should administer PRN to the service user. The home manager should then provide guidelines for staff to follow in the event of these service users having an epileptic seizure. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 18 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 all the available evidence including a site visit to this service. The home has an appropriate complaints procedure. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse. EVIDENCE: Ms Madhi stated that there had been no complaints raised with the home since the last inspection. A number of relative’s questionnaires were returned the Commission as feedback. The feedback indicated that two of the service users relatives were not aware of the homes complaints procedure. It is recommended that the home manager forward a copy of the homes complaints procedure to all the service users relatives. Ms Madhi provided evidence that all staff has had training on adult protection. Some members of staff attended training in October 2004, October 2005. It is recommended that all members of staff have periodic refresher training on adult protection. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting this home is that it is generally well decorated, homely, comfortable, clean and hygienic. EVIDENCE: Two of service users share a double room. Previous requirements that the service users have their care plans reviewed by their care managers and that the issue of sharing a bedroom is discussed as part of their review have yet to be met. See Standard 6 of this report. On the day of the inspection the premises was clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. The home has five toilets and two baths. One of the baths is suitable for people with mobility problems. The bathrooms are situated close to service user bedrooms and communal areas. The toilets and bathrooms were clean and in good working order. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 20 The home has a spacious lounge, which was large enough for all the service users to sit together if they wish. The dining room area was again domestic in nature and contained suitable tables and chairs. There is also a sensory room just off the lounge area that is fully equipped and used to run aromatherapy and sensory sessions for the service users. There are laundry facilities with a sluice and an industrial type machine, which is capable of washing at high temperatures. The Surrey and Borders NHS Trust provide maintenance for the home on an as required basis. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable service users are not placed at risk of harm or abuse. The home manager needs to ensure that the whole staff team receives regular supervision so that the service users benefit from having a consistent approach to their needs. EVIDENCE: A requirement was set at the last inspection that the acting home manager must send evidence to the Commission that all staff have had their training needs assessed and that all staff has receive training on Adult Protection. Ms Madhi provided evidence that all staff has had their training needs assessed. Ms Madhi provided evidence that all staff has had training on adult protection. Some members of staff attended training in October 2004, October 2005. A requirement was set at the last inspection that the acting home manager must make arrangements with the Commission for staff Criminal Records Bureau Checks to be examined. The acting home manager arranged for Criminal Records Bureau Checks to be examined on the 01/02/06 no new Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 22 member of staff has started work at the home since then. The Commission has seen all current staffs Criminal Records Bureau Checks. Ms Madhi and the deputy manager share the responsibility of supervising the staff team. Ms Madhi provided evidence that daytime staff are receiving regular supervision, however nighttime staff has received one supervision session in 2006. The registered manager must ensure that all members of staff receive supervision at least six times a year. Highfield Road (5) DS0000028115.V308238.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 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 adequate. This judgement has been made using all the available evidence including a site visit to this service. Management of the home has been erratic over the last year or so however the home manager has recently returned from long-term leave and is keen to organise and improve systems in the home. Now that the home has a permanent home manager service users and staff can be sure that they will be supported in a consistent manner. The Surrey and Borders NHS Trust has yet to ensure that the home manager is registered with the Commission For Social Care Inspection. Appropriate quality assurance and quality monitoring systems are in place so that the views of the service users and their representatives are considered about the running of the home. EVIDENCE: Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 24 A requirement was set at an inspection on the 10th of May 2004 that the organisation must appoint a registered manager to run the home and inform the Commission for Social Care Inspection of when this has been done. Ms Madhi was appointed in 2005 by Surrey and Borders NHS Trust to run the home. However she has not yet registered with the Commission For Social Care Inspection to be the registered manager for the home. The requirement from the inspection of the 10th of May 2004 is still outstanding. Ms Madhi had been off on long-term leave and had returned to work at the home in March 2006. She explained that she had completed her Criminal Records Bureau Check for the Commission and was planning to request an application form so that she could complete the process. Ms Madhi was given the telephone number of the Commissions Central Registration Team. Ms Madhi stated that she would contact the Central Registration Team following the inspection. The Surrey and Borders NHS Trust must ensure that the home manager is registered with the Commission For Social Care Inspection to run the home. Ms Madhi stated that she is currently completing the Registered Managers Award and NVQ Level 4 in Care. Regulations 26 visits are carried out by the organisation in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare a written report on the conduct of the care home. The home has regularly sent monthly copies of the Care Homes Regulations 26 visit reports to the Commission. A large number of service users relative’s questionnaires were returned the Commission as feedback. In general feedback was positive however some felt that although some of the homes agency staff was very helpful and caring there should be more permanent staff, and permanent staff that can drive. Ms Madhi stated that service user and service users relative’s questionnaire/ survey had been carried out in 2005. The questionnaire/survey is part of the homes quality monitoring system and ensures that the views of the service users and their representatives are considered about the running of the home. Ms Madhi stated that the home would shortly be sending the questionnaires to the service users and their relatives. Portable Appliance Testing was requested for the home on 31/01/06 (receipt) however the records indicated that the test was carried at the home in June 2006. It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 25 Ms Madhi could not locate the Landlords Gas Safety Certificate or Legionellas Testing Certificate; she contacted the works department and was informed that the tests had been carried out on the 06/0/06 and 23/06/06 respectively. The works department informed Ms Madhi that they would send copies to the home for their records. It is recommended that the home keep up to date copies of Portable Appliance Testing, Landlords Gas Safety and Legionellas Testing Certificates in the home for future inspections. The Commission is confident Ms Madhi will meet all of the requirements and recommendations set in this report in a timely fashion. Highfield Road (5) DS0000028115.V308238.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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 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 2 X 3 X X 3 X Highfield Road (5) DS0000028115.V308238.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 YA6 Regulation 14 (2) a. Requirement The acting home manager must ensure that all service users have their care plans reviewed by their care manager and that the issue of the two service users sharing a bedroom is discussed as part of their review. Amended requirement. First set 25 of April 2005. The home manager must contact all of the service users care managers and request a copy of the most up to date service users care plan. If the service users care plan has not been reviewed in the last 12 months then the home manager must request that the care manager arrange a date to review the care plan. The homes continuous failure to comply with this requirement represents a serious breach of the care homes regulations and urgent action must be taken by the home manager to address the requirement to avoid the Commission taking further action to enforce compliance. The home manager must ensure DS0000028115.V308238.R01.S.doc Timescale for action 17/11/06 2. YA6 15 (2) c. 17/11/06 Page 28 Highfield Road (5) Version 5.2 3. YA9 13 (4). 4. YA12 16 (2) m and n. 5. YA36 18 (2). 6. YA37 8 (1). that all service users Person Centred Plans (service users plans) are kept under review. The home manager must ensure that all service users risk assessments are reviewed in appropriate timescales and copies of the risk assessments are kept on the service users files so that the staff team and the service users are aware of the identified risks. The home manager must review individual service users assessed needs, care plans and person centred plans and ensure that an individual programme of activities is developed for each service user at the home. The registered manager must ensure that all members of staff receive supervision at least six times a year. The Surrey and Borders NHS Trust must ensure that the home manager is registered with the Commission For Social Care Inspection to run the home. 17/11/06 17/11/06 16/08/06 18/09/06 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. 2. Refer to Standard YA42 YA7 Good Practice Recommendations It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. It is recommended that the home manager contact the Speech and Language Therapy Department at Rees House, 2 Morland Road Croydon, CR0 6NA for advice on Total Communication. It is recommended that the home develop an appropriate system for recording the actual daily activity attended by DS0000028115.V308238.R01.S.doc Version 5.2 Page 29 3. YA12 Highfield Road (5) 4. 5. YA20 YA20 6. 7. 8. YA22 YA23 YA42 individual service users. It is recommended that staff have periodic refresher training on the administration of insulin. It is recommended that the home manager contact the service users General Practitioners for advice and guidance on how the service users epilepsy presents and under what circumstances staff should administer PRN to the service user. The home manager should then provide guidelines for staff to follow in the event of these service users having an epileptic seizure. It is recommended that the home manager forward a copy of the homes complaints procedure to all the service users relatives. It is recommended that all members of staff have periodic refresher training on adult protection. It is recommended that the home keep up to date copies of Portable Appliance Testing, Landlords Gas Safety and Legionellas Testing Certificates in the home for future inspections. Highfield Road (5) DS0000028115.V308238.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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