Inspection on 25/05/06 for Horse Leaze (7)

This inspection was carried out on 25th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Horse Leaze (7) 30/11/07

Horse Leaze (7) 19/01/06

Horse Leaze (7) 29/07/05

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

CARE HOME ADULTS 18-65 Horse Leaze (7) 7 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Key Unannounced Inspection 25th May 2006 11:30 Horse Leaze (7) DS0000063910.V296344.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 Horse Leaze (7) DS0000063910.V296344.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. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horse Leaze (7) Address 7 Horse Leaze Beckton London E6 6WJ 020 7473 1945 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) www.heritagecare.co.uk Heritage Care Warren Spencer Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: 7 Horse Leaze is a care home for adults with mental health support needs. The home is operated by the Heritage Care organisation, which provides residential care services to a variety of service user groups across the region. The home is a single storey building located within a residential area of Beckton. There are bus routes and the Docklands Light Railway is accessible nearby. The home aims to provide a supportive environment within which service users can develop confidence, dignity and personal responsibility. Each service user has their own bedroom and access to communal lounge, dining, kitchen and bathroom facilities. The home has four male and two female service users in residence. The home is culturally reflective of the local community with service users from African Caribbean, Asian, Irish and White British backgrounds. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors fourth inspection of this home. The Inspection was carried out over the course of a day and its main focus was to inspect key national minimum standards. The Inspector met with a Senior Support Worker on the day of the inspection. Three service users and a support worker also met privately with the Inspector. Service users personal files and other documentation relating to the running of the home were also inspected. The Inspector toured the homes premises and four service users showed the Inspector their bedrooms. What the service does well: The home has been assessed as exceeding National Minimum Standards in the activities it supports service users to engage in both inside and outside of the home. During the inspection service users told the Inspector that they “like living here” and “get on well” with staff. The home obtains relevant assessment material for prospective service users and develops comprehensive individual plans. Service users are supported to make decisions about their everyday lives and to make decisions regarding their lifestyle. Staff support service users to manage their own finances and identified areas of potential risk are subject to assessment. Service users participate in regular meetings and choose the dishes that appear on the homes menu. Contact with family and friends is supported and identified in individual plans and service users receive assistance with personal care in the way they prefer. The home operates a range of comprehensive, corporate Heritage Care policies and procedures including medication, missing persons, adult protection and complaints. The home maintains records of all medication received and any un-administered medication that is disposed of. The staff member interviewed on the day of the inspection had received training on the administration of medication and adult protection and demonstrated a good understanding of these areas and their responsibilities. Over 50 of the staff group have obtained or are currently studying for NVQ level 3, and the ethnic and gender composition of the staff group reflects that of service users. A range of comfortable and homely shared and private space is available within the home for service users. Some refurbishments works have been undertaken in communal areas, and the current registration and insurance certificates are on display. Regular fire drills and fire point testing is carried out and recorded, as our water temperatures. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 6 Service users benefit from an experienced registered manager who is studying for NVQ level 4. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected 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 the service. Service users needs are assessed as part of the referral process to the home. EVIDENCE: There has been no new service users admitted to the home since the last inspection. The Inspector sampled the personal files of two service users currently living at the home. This evidenced that the service had obtained relevant background information from other professionals as part of the assessment process. It was further evidenced that the home has carried out its own assessment and developed an individual plan for each of the service users sampled. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 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, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has developed individual plans and assessed risks for each service user. However, individual plans do not evidence that they are reviewed at least six monthly, or how service users are involved in their development. EVIDENCE: The Inspector sampled the personal files of two service users. This evidenced that each service user has an individual service user plan that addresses health, personal and social care. The planning documentation for service users included information on their daily routine, and service users interests, such as music, reading, contact with friends or family and community based activities. One service user was evidenced as having a “Care and Support Plan” dated July 2005 and “Assessment and Daily Support Plans” dated August 2004 and February 2006. A previous inspection had identified that this service user was at risk of making false allegations against staff. The Inspector noted that their individual service user plan had not been reviewed to address this area. Entries in the service users personal file evidenced that some key working Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 10 sessions had been undertaken with this service user, but not in the current year. A second service user had a “Care and Support Plan” dated November 2005 and an “Assessment and Daily Care Plan” dated December 2003. Based on the two service users personal files sampled, the Inspector was unable to evidence that individual plans are reviewed at least six monthly or as service users needs change. Individual service users plans were not signed by the service user or their representative and key working or review type meetings have not recently occurred, and the Inspector was therefore unable to evidence service users participation in the planning process. The service users sampled by the Inspector manage their finances independently with support from care staff that is outlined in their individual plans. Discussion with service users and further sampling of individual plans evidenced that service users are supported to make their own decisions, for example activities they would like to be involved with and their daily routines, such as bedtimes. Each of the service user personal files sampled contained risk assessments addressing a variety of daily living occurrences such as managing finances, preparing meals and the storage of cleaning materials. One service user was assessed as being vulnerable when answering the door to strangers and guidelines for them to follow had therefore been developed. The home holds monthly service users meetings to involve service users in the day-to-day running of the home. The Inspector viewed the minutes of these meetings. Recent discussions have included service users preferences for takeaway food, the allocation of chores in the communal areas of the home, service users holiday choices and how service users get along with each other and promote a harmonious atmosphere in the home. The Heritage Care organisation has developed corporate policies and procedures that are available and implemented within the home. These include an “unexplained absences” policy that outlines the steps to take should a service user go missing from the home. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home supports service users to engage in meaningful occupational, community and leisure activities both inside and outside of the home. EVIDENCE: Discussion with the Senior Support Worker, sampling of service users individual plans and discussion with service users evidenced that service users are supported to participate in a range of occupational, leisure and community activities, according to their abilities and interests. Three service users are currently attending Parkside Community Project. One service user attends weekly flower arranging classes, another attends a computer skills class and a third service user is being supported to find a photography course. Another service user is supported to attend a local church of their choice and to attend an Afro Caribbean women’s group. Within Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 12 the home service users are encouraged and supported to undertake gardening and an arts and crafts session. All service users are invited to a weekly meal out to local pubs and restaurants. Within the home service users are supported and encouraged to maintain their own bedrooms and participate in daily chores in the communal areas. Service users are also supported and encouraged to undertake their own shopping for personal items. The home has also arranged for an aroma therapist to visit the home on a weekly basis and service users fedback that they enjoy this activity. Service users are also supported to maintain their relationships with family and friends by visiting them and also receiving them in the home. Previous inspections have evidenced that service users have participated in the development of a visitor’s policy for the home and that individual arrangements for maintaining contact with family and friends have been included in the individual service user plan. Throughout the inspection it was observed that staff talk to and interact with service users, and that service users can choose when to be alone or in company. The Inspector sampled the homes menu log. Service users have identified meals that they would like on the menu, and the three service users spoken to by the Inspector commented that that the food was “nice” and that they were happy with mealtime arrangements. Service users prepare their own light lunch with support as identified in their individual plan. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive care in the way that they prefer and are supported to comply with their medication. However, the home must ensure that service users are supported to attend all healthcare appointments and that all lists of medication correspond. EVIDENCE: By sampling individual service user plans and discussion with service users the Inspector evidenced that service users receive care in the way they prefer, and that information relating care preferences is included in the individual plan. This was evidenced particularly in the plan for one service user that contacted details on how best offer prompts and supports when assisting with personal care. Times for getting up, bed, showers and other activities are flexible according to the service users preferences and their individual daily routines. Service users choose their own clothes and their appearance reflects their personality. The personal file of service user sampled by the Inspector contained a record of all recent appointments attended for blood tests, attendance at the diabetes clinic, chiropodist and GP appointments. Entries included a brief summary of Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 14 the outcome of these appointments. A second service user personal file sampled by the Inspector included a record of all hospital appointments and their outcome. The Inspector noted that this personal file contained a letter stating that the service user was due for a smear test in December 2005, however the Inspector was unable to locate a record of this test being conducted. The Inspector sampled the Medication Administration Record (MAR) for three service users. This evidenced that a service user who had previously been missing medication by absenting himself from the home had been fully compliant with medication since the last inspection. The personal file of another service user contained a personal information sheet that includes a list of medication that does not correspond with that recorded on the MAR. The majority of service users medications are loaded into a dossett box prior to administration. The Inspector checked the actual medication available for two service users against that listed on the MAR sheet. These were found to correspond. The home maintains records of all medication received into the home and the disposal of any medicines not administered. The home operates Heritage Cares corporate medication policy that includes guidance on self-medication and the administration of controlled drugs. Neither of the service users sampled was self-medicating at the time of this inspection. The member of staff interviewed by the Inspector had received medication administration training and been assessed for their competence to administer medication. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home must improve its practice to ensure that its complaints and adult protection policies and procedures are properly implemented. EVIDENCE: The home operates the Heritage Care corporate complaints procedure within the home. The outlines the different ways in which service users can make a complaint and the timescales in which their complaint will be dealt with. The home also maintains a log of all complaints made, and the Inspector viewed this. No new complaints had been logged as occurring since the last inspection. However, the minutes of a service user meeting that occurred in February 2006 recorded that a service user complained of being harassed by another service user for cigarettes. The Inspector located no record of this complaint or the action taken. The home operates Heritage Cares corporate Adult protection policy. This includes definitions of the types of abuse vulnerable adults may experience and the procedure for staff to report any concerns. There is also a separate whistle blowing policy. The previous inspection in January 2006 had identified shortfalls in the homes recording and reporting of allegations made by a service user against a staff member. An investigation by the homes Responsible Individual concluded that the allegations were unfounded and that the service user has a history of making malicious allegations against staff. In the intervening period the Commission has received a retrospective notification of the incident, as have other relevant bodies. The London Borough of Newham Adult Protection Unit has advised the Commission that Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 16 they will be running a refresher training session for staff in the home in the near future. The Inspector sampled the individual plan for the service user identified as being at risk of making malicious allegations and noted that this need was not addressed or subject to a risk assessment and management strategy. The staff member interviewed by the Inspector had recently completed Heritage Care training addressing adult protection. They were able to identify a range of abuses vulnerable adults may experience and describe the procedure they should follow should a service user make a disclosure of abuse. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from a comfortable, homely environment with a range of private and shared space. However, the provision of appropriate bathing and shower facilities is a pressing issue. EVIDENCE: The Inspector toured the homes premises. These comprise of a communal lounge diner with doors to a large garden with patioed area. This space was homely and comfortable with a formal dining table and chairs and a range of sofas and comfortable chairs in the lounge area. The lounge has a satellite TV, video player, a choice of videos and a stereo. A kitchen is located off of the dining area, and this was fully refurbished in 2005. The home has a separate laundry room that houses an industrial type washing machine and tumble dryer. The staff office is located to the front of the property, adjacent to the front door. Each service user has their own bedroom and several service users showed the Inspector their bedrooms. These contained a sink, wardrobe, bed, chair and Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 18 chest of draws. Service users have been able to personalise their rooms by bringing in extra furniture where space permits, hanging pictures and photographs on the walls, and choosing how they would like their rooms decorated. The Inspector noted that a number of repairs and maintenance issues were required in service users bedrooms. The headboard in one service users room was badly stained, and their curtains not properly hung. In the lounge area seating used by an incontinent service user had been covered in a black plastic bag, the home should replace these with specialist incontinent covers. The Inspector noted that some service users bedrooms would benefit from redecoration as the walls were marked and stained. The Inspector noted that the bedroom of a service user with continence issues was well maintained with no evidence of odour. The home has one bathroom with a tub and no toilet, a shower room with WC and hand basin, and a toilet with hand basin. Previous inspections have identified that service users either prefer to use the shower, or are unable to use the bath. As a result of this the large bathroom is unused and is instead utilised as a storage area. Previous inspections have required the home to facilitate occupational therapy bathing assessments for each service user to identify their needs and then refurbish the current bathroom to address these. The Inspector had been advised at an inspection in January 2006 that a verbal request for these assessments had been, but no assessments had taken place. During this inspection the Inspector was unable to evidence that these assessments have taken place. In addition, the shower room facilities including the shower, screens and tiling would benefit from refurbishment. Since the last inspection communal corridors have been redecorated and new flooring fitted in the shower room, WC, laundry room and staff office. Redecoration of service users bedrooms remains an outstanding requirement from the last inspection. The premises were found to be comfortable, bright, and generally clean and free from odour. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from helpful staff that are studying at NVQ level. However, personnel records required by regulation were not available for inspection and staffs do not receive regular supervision. EVIDENCE: During the course of the inspection staff were observed to be accessible to, approachable by and comfortable with service users. One service user spoken to by the Inspector commented that they “couldn’t wish for better staff”. Of the homes eight support staff 2 have obtained and a further three are studying for NVQ level 3 qualification. The staff group has a mix of genders and ethnic and cultural backgrounds that is reflective of the composition of the service user group. The home implements Heritage Cares corporate recruitment policy and procedure. A centralised personnel office undertakes recruitment and pre employment checks. Heritage Care has a separate Equal Opportunities policy that also addresses recruitment. The home retains a summary sheet of pre employment checks carried out, and the Inspector sampled two of these. Each sheet contained the name, address and date of birth, position and contracted hours for each support worker. Photocopies of support workers passports were Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 20 also available to confirm identity and entitlement to work. However, no information relating to the references or medical clearance could be located. One support staff record included the date and reference number of the most recent Criminal Records Bureau check, but this information was not recorded for the other staff member. Neither of the staff records sampled by the Inspector included a copy of their induction record. Training and personal development plans for both support workers had not been updated since 1999. Photocopies of certificates awarded for successfully completed training courses were found on each of the sampled personnel files. The Inspector viewed the supervision records for two staff members. There were no supervision notes available for one staff member after July 2005. The other staff member had supervision records evidencing that supervision had occurred on two occasions in the last twelve months, on the 23rd September 2005 and 18th January 2006. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 21 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, 40 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from a generally well run home. However, restated requirements and identified shortfalls in some health and safety areas should be addressed as a priority. EVIDENCE: Previous inspections have evidenced that the Registered Manager has appropriate management experience and is currently studying for their NVQ level 4 award. The homes current registration and insurance certificates were in order and prominently displayed. The Inspector noted that a number of requirements had been restated over several inspections, these include the review of all individual service users plans every six months or as their needs change, and obtaining occupational therapy assessments for each service user and then developing and implementing a programme to refurbish the current bathroom provision. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 22 The Inspector sampled the homes incident log and accident log and found these to be in order. The homes fire record indicates that fire point testing and water temperature testing is carried out and recorded on a weekly basis. Evacuation drills have also been held and the outcome, along with evacuation times, recorded. The record of fridge and freezer temperatures had not been completed on the 13th and 14th May 2006. On several occasions since January 2006 the fridge temperature was recorded as 9 degrees or above with no indication of action taken to restore the fridge to an acceptable temperature. During the site inspection it was noted that potentially hazardous cleaning materials had not been secured in a locked cupboard. The officer in charge at the time of this inspection was not able to advise the Inspector of the homes quality assurance process. The Heritage Care organisation has developed appropriate policies and procedures that contain sufficient policy information and guidance on implementation. These policies and procedures are appropriate for use within the home. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 1 28 X 29 1 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 1 3 X 2 X Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Individual service user plans must be reviewed at least every six months or more frequently if service user needs change. This is a restated requirement. Previous targets of the 01/11/04, 01/03/05, 29/10/05 and 31/03/06 were not met. Service users must be supported to attend healthcare appointments. The list of medications taken by service users must match the medications recorded on the MAR, or be annotated to indicate a medical review resulting in stoppage. This is a restated requirement. The previous target of the 29/10/05 was not met. All complaints must be logged along with details of the complaint investigation, any action taken and the outcome. This is a restated requirement; the previous target of the 29/10/05 was not met. Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 25 Timescale for action 31/08/06 2. 3. YA19 YA20 13 13 31/08/06 31/08/06 4. YA22 22 31/08/06 5. YA23 13 & 21 3. YA24 23 Service users at risk of making malicious adult protection allegations against staff should have this area addressed in their individual plan and be subject to a risk assessment and management strategy. The following maintenance issues must be addressed: The soiled headboard in one service users room should be cleaned. The curtains in this service users bedroom should also be properly hung. A programme of redecoration for service users bedrooms should be developed and implemented. These are restated requirements. The previous target of the 31/03/06 was not met. Specialist incontinent covers should be fitted as needed to seating in the communal lounge area. The home should refurbish the under utilised bathroom in line with occupational therapy assessments required under Standard 29. A programme of refurbishment and redecoration should be developed and implemented for the shower room. This is a restated requirement. Previous targets of the 29/10/05 and 30/06/06 were not met. Occupational therapy assessments must be completed for each service users bathing needs, and identified aids obtained. DS0000063910.V296344.R01.S.doc 31/08/06 31/08/06 5. YA27 23 31/08/06 4. YA29 23 31/07/06 Horse Leaze (7) Version 5.2 Page 26 5. YA34 7, 9, 19 & Sch 2 This is a restated requirement. Previous targets of the 29/10/05 and 31/03/06 were not met. A summary of information of the personnel information required by regulation must be completed and be available in the home for inspection. This is a restated requirement. The previous target of the 31/03/06 was not met. The home must evidence that all staff complete a structured induction. Staff training and development plans must be updated regularly to reflect current needs. Staff must receive regular, recorded supervision at least six times per year. The registered manager must ensure that requirements are progressed within the specified timescales and any difficulties with compliance fully recorded. This is a restated requirement. The previous target of the 31/03/06 was not met. The home must develop its quality assurance process including obtaining feedback from service users, their representatives and other stakeholders. The results of this feedback should be published and made available to service users and other interested parties. A record of fridge temperatures must be maintained on a daily basis along with action taken when temperatures fall outside of acceptable parameters. 31/08/06 6. YA35 18 30/09/06 7. 8. YA36 YA39 18 24 30/09/06 31/08/06 9. YA42 16 31/08/06 Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 27 Potentially hazardous cleaning materials must be stored in a locked cupboard. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Horse Leaze (7) DS0000063910.V296344.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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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