Inspection on 01/06/06 for Jane`s House

This inspection was carried out on 1st June 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jane`s House 31/05/07

Jane`s House 30/12/05

Jane`s House 15/06/05

Jane`s House 07/10/04

Jane`s House 23/04/04

Jane`s House 20/01/04

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

CARE HOME ADULTS 18-65 Jane`s House 89 Barrow Road Streatham London SW16 5BP Lead Inspector Barbara Ryan Unannounced Inspection 1st June 2006 9.30am DS0000022736.V295817.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 DS0000022736.V295817.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. DS0000022736.V295817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jane`s House Address 89 Barrow Road Streatham London SW16 5BP 0208-677-6196 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) Jane`s House Limited Ms Chan Bisessar Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) DS0000022736.V295817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: Jane’s House provides long term care for people who have enduring mental health problems. There are currently five male residents, although the home has accommodated a mixed gender group since opening in 1990. The home is situated in a residential street off the main road leading to Streatham High Street, and is close to public transport routes, shopping and leisure facilities. It is a semi-detached house on four floors, and blends in well with other houses on the same street. The registered manager owns the property and also owns two other small homes nearby. The philosophy of care states: The home is flexible with care and support provided as required by anyone who has suffered mental ill health. The home charges a weekly rate of £337.29 to £679.67. There additional costs for toiletries, newspapers, hairdressing visits to the barbers. Some residents are charged for the cost of staff escorts to accompany residents on visits to hospital. DS0000022736.V295817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that begin at 9.30 am and ended at approximately 4.30. The inspection included a tour of the building, inspection of three residents files, discussion with the manager, informal discussion and/or observation of three residents , interaction between residents and staff, and inspection of the mediation recorded and a sample pill count. What the service does well: What has improved since the last inspection? What they could do better: The home needs to continue to work to ensure that all the information required in Schedule 1 are incorporated in the Statement of Purpose and that it contains up to date information about the home. The home needs to ensure that risk assessments are reviewed once a year and that this is recorded, signed and dated. The management of medication at the home has improved but further work needs to be done to ensure accurate recording of the medication and its management. The home needs to ensure that it has a copy of the multi-agency protection of vulnerable adults procedure and that all staff that have not attend training do so. At present the home’s recruitment procedures do not ensure the residents’ safety with regard to protection from abuse. All staff must have an up to date DS0000022736.V295817.R01.S.doc Version 5.2 Page 6 CRB and/or POVA check prior to being employed by the home; staff should not be able to work at the home without a POVA check and should not at any time work unsupervised without the home having received an up to date CRB. 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. DS0000022736.V295817.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 DS0000022736.V295817.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): 1, 2, 4, 5. Quality in this outcome area is adequate. This judgment is made using available evidence including a visit the service. The home has a Statement of Purpose, but this needs to be updated to include all the information in Schedule 1. Residents have a full assessment of their needs prior to admission and are also able to visit the home. Residents are issued with a contract or term and conditions EVIDENCE: The home have a Service User guide and a Statement of Purpose. The Statement of Purpose contains a considerable amount of information, but at times it is difficult to see what is current information about the home and what is out of date information. It says that basic nursing is provided, however the home is not registered as a nursing home. There are some conflicting pieces of information about the number of staff employed, their qualification, and the home’s policy around CRB checks. There was no information about how to contact an independent advocacy service, or the size of the bedrooms. The home has not had any new admissions since the last inspection but have a policy of making a full assessment of a resident’s needs prior to admission. They receive assessments from the multi-disciplinary team involved with the person and complete a form of their own. Residents are able to visit the home prior to any admission and are issued with a contract, evidence of which was seen on the residents files looked at, and in discussion with residents. DS0000022736.V295817.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): 6,7,9,10. Quality in this outcome area is good. This judgment is made using available evidence including a visit the service. The home has established a new method of reviewing their care plans and this will benefit residents when it has been established. Residents are supported to make decisions and choices. Risk assessments are completed and should be reviewed once a year. Residents are informed of referrals and reassured around issues of confidentiality. EVIDENCE: Three care plans were looked at; these had sections to identity needs, objectives and actions and were quite comprehensive. Not all were signed or dated. The home have since the last inspection introduced a new method of review and evaluation of care plans, which was started in January of this year, and is in the process of being established. When it is, it is anticipated it will give a good monthly review of residents’ changing needs, goals achieved and areas where more support or changes to the care plan are needed. Files contained risk assessment and these were comprehensive, with information about trigger and warning signs around deterioration in residents’ DS0000022736.V295817.R01.S.doc Version 5.2 Page 10 mental health, and information on actions to be taken. The manager said that they review these once a year; there were some gaps identified in the annual reviewing of these assessments. The home operates on a user lead basis and residents are supported to make their own decisions about their lives. The home manager is aware of residents’ needs regarding confidentially and is able to reassure residents that they will be informed of any actions taken with regard to the contact of other agencies and that their permission will be sought with regard to passing on information where this is appropriate. With regard to residents’ money, some residents manage their own money, but may need support or advice around budgeting; another resident has a family member as appointee. The manager said that she is appointee for one resident and will hold cash for another. One resident’s cash was checked and this tallied with the amount the manager had recorded. DS0000022736.V295817.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): 11,12,13,14,15,17, Quality in this outcome area is good . This judgment is made using available evidence including a visit the service. Residents are supported with regard to personal development and are able to access a variety of activities, maintain links with their family and the local community and to live as independent a life as possible. Residents are supported to access a healthy and enjoyable diet; the home are continuing to look at how best to provide choice around mealtimes for residents. EVIDENCE: The home has an activities organiser who visits the home twice a week. She will work with residents on an individual basis and in a group depending on the needs and preferences at the time. She will escort residents out to do shopping and to other activities e.g. trips to the park, museums, bus rides, etc. The home have a small vegetable plot and residents are supported to work in the garden if they wish. There are also activities such as board games, art and other activities residents identify they would like to do. The activities organiser said they she will have a programme of activities but needs to be very flexible with this and work with residents on the day depending on mood and energy DS0000022736.V295817.R01.S.doc Version 5.2 Page 12 levels. There is a folder where the activities undertaken are recorded for each residents. One resident is undertaking a computer course at the local library and residents have in the past been supported to explore courses at Further Education colleges. The manager said that residents are free to choose what activities in the local community they would like to visit and information is given to residents about local events, e.g. jumble sales, events in the local parks or other community organisations, local churches and temples. If residents need support to attend they will be supported to do this. Residents are supported to maintain links with their family; one resident spends weekends at his family home. Residents are able to have a key to their room and the front door if they are able to manage this. Resident are able to receive their post unopened, but the home encourage residents who they feel need support to deal with correspondence to open their mail with a worker to support them in responding as needed to the letter or communication. Residents are supported to maintain their room and manage their laundry themselves as well as do their own washing up. The activities organiser is at present working on a personal activities prompt sheet for residents who need this to support them with undertaking daily tasks as independently as possible. Staff will continue to verbal prompt and support residents who need this as well. At the last inspection there was a requirement that the home should review their meal planning and offer more choice. The manager said that the home is looking at this; they have looked at the idea of doing a 4-week programme of meals. The manager said that all staff at the home would be starting a 6 month food and nutrition course in September. In the meantime they are trying to increase the amount of ingredients they have in stock and offer choice. This is something that the home needs to continue to work on. The manager said that some residents have a need for special diet and that they are supporting residents in this area and will encourage them to eat food that is healthy for them. There was one complaint in the complaint book and this was around issues to do with choice at mealtimes. The home record what residents eat but this had gaps in the recording. Meals are served in the kitchen dining area in front of the patio doors with a view of the garden. The food was sampled and was well cooked and served in a pleasant manner DS0000022736.V295817.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): 18,19,20,21 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit the service. Residents benefit from receiving support with personal care in a way they require and prefer and their physical and emotional needs are met. The home needs to continue to improve the administration of their medication. The home needs to continue to gather information around residents wishes at times of ill health and death. EVIDENCE: Residents are encouraged to be as independent with personal care as possible, staff spoken to were knowledgeable of residents needs and how best to support them to build on their independence. The home keeps records of when resident have visits to or from other health or social work professionals and maintain on file letters and commutations from health professionals. The home said they have a good relationship with the two new teams that have been set up in Lambeth, the Placement, Assessment and Monitoring Team the Rehabilitation Team. They have found these teams very helpful and will liaise with them with regard to residents mental health needs. During the inspection a community psychiatric nurse from the Rehabilitation Team visited a residents, they reported that the DS0000022736.V295817.R01.S.doc Version 5.2 Page 14 home are seen as quick to identify issues, changes and possible deteriorations in residents mental health and contact the team time in good time, they are then able work together quickly to avoid situations deteriorating. The manager demonstrated a comprehensive knowledge of residents needs and of mental health issues. Residents are weighted, although there were some gaps in the recording of this. One resident has been admitted to hospital after a lengthy period of weight loss. The home had recorded visits to the GP and other health professional with regard to the resident. At the last inspection there were two requirement to ensure that all medication is fully and accurately recorded, and that they record all medication received and to keep a running total on the medication sheet. On this inspection the home were observed to be recording medications received, however in some instances amounts of the medication received from the chemist were not all added to the running total of medicating kept in the home. Amounts written as received on the mar chart, did not in all instances correspond with the amounts recorded as received from the pharmacist. Amounts were not always entered in the appropriate section of the mar chart, and in some instances written in pencil. On one residents medication sheet, the resident had refused the medication and this was recorded on the back of the sheet, but had also been initialled as having been given on the front of the sheet. The staff are working hard to improve their recording around the administration of medication . All workers at the home are on a 6 month medication course, which will be ending in the summer. The home need to ensure that their recording around medication is accurate, that the running total reflects the amount of medication they have in the home, that they record an R when a resident refuse medication not their initials. The home has one resident who goes home at weekends; the home give his mother a dossett box each week and record OL for on leave in the mar chart. The home have a from for recording residents wishes around times of ill health and death, these have not been filled in some instances or in any great detail. The manager said that for some residents this was an issue that they did not wish to discuss. The home should continue to work with residents around this, if residents do not wish to have these discussions the home should record that. DS0000022736.V295817.R01.S.doc Version 5.2 Page 15 DS0000022736.V295817.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit the service. The home has a complaints procedure, the home needs to ensure that all staff have training around the protection of vulnerable adults and have up to date information about the local authority procedures, however there are issues around recruitment and the protection of vulnerable adults. See Page . EVIDENCE: The home has a complaints procedure, they need to ensure that there is information contained in it about independent advocacy. The complaints book is kept on a sideboard in the kitchen for residents and others to access. and was inspected. There was one complaint from a residents recorded the day before the inspection. This was around choices of food, the residents was not available to speak to when the book was looked at, but the manager will discuss the issue with them. The book has a section for recording the actions taken and outcome of the complaint. As this was the only complaint and the residents was not available there was not way of judging how complaints are dealt with , but the manager said that generally complaints or concerns are made verbally and she will discuss the issues with the resident and try to resolve the problem. If this is not possible they will then follow the complaints procedure to the next step. The home have some information on adult protection they did not have a multi agency procedure available , The manager said that there is an adult protections coordinator from Lambeth Social Services visiting the home in June 06 and they hope they will get some up to date information at this meeting. There was evidence that staff that had been at the home for some DS0000022736.V295817.R01.S.doc Version 5.2 Page 17 time have had training around adult protection, but new staff have not had training. All staff working at the home should have training in this area. DS0000022736.V295817.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,28, 30 Quality in this outcome area is adequate. This judgment is made using available evidence including a visit the service. Resident’s benefit for living in a homely, safe and non-institutional environment. The home needs to continue with its programme of refurbishment. Residents bedrooms seen were personalised and meet their needs, the home is clean and hygienic. EVIDENCE: The building have had the stair carpet replaced and the stair case redecorated, the living room, small conservatory which is smoking room and one of the bedrooms has also been redecorated. The kitchen had been painted. The kitchen units and work surfaces are quite old and home the would benefit from having them replaced. The manager said that this was something they would not however be able to undertake this year. The bathroom and both WC ‘s are due to be redecorated. The tiles around the bathroom and the sealant need to be replaced . A new shower curtain and screen had been fitted however. There is a plan to put in a shower room by using part of one of the bedrooms. This has been discussed with the resident and his family. The resident will loose some of his bedroom space, but will have a door from their bed room into the showroom with a lock on both sides. DS0000022736.V295817.R01.S.doc Version 5.2 Page 19 There will also be a door from the hallway, so other residents will not have to access the shower room through this residents bedroom. Two residents rooms were seen, these had been personalised and were pleasant and homely. There is small conservatory style room at the back of the house that residents can use as a smoking room, this now has had seating and a small table, it also has a door leading on the garden. The Perspex corrugated roof still had some stains on it. The home is decorated in a very domestic style, the furniture and ornamentation in the home were in places rather old fashioned, it was however comfortable, very homely and non institutional. The home have a redecoration schedule and should continue to work to refurbish the home and to involve residents in choices around this. The home was observed to be clean and hygienic throughout DS0000022736.V295817.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 36. Quality in this outcome area is poor This judgments is made using available evidence including a visit the service. The residents of the home benefit from having a qualified and competent staff, however the homes recruitment procedures are not rigorous enough to ensure that residents are fully protected. The home must ensure is always undertakes an up to date POVA and CRB check for any employee it is offering a post to, and obtain a reference from their last employer. EVIDENCE: The staff rota was inspected , there was one staff member on duty and the manager on the day on inspections, at present there are only three residents in the home as two are in hospital. There was sufficient staffs on duty to meet residents needs. The home have over 50 of the staff trained to NVQ level 2 or above. Staff are starting a 6 month health and nutrition training course in September when they have finished their medication course. There was evidence of staff have been on various training courses including health and safety, moving and handling and fire safely. The manager said that she is arranging to have some lectures for staff on mental health issues to give staff a general update and refresher. She will also DS0000022736.V295817.R01.S.doc Version 5.2 Page 21 give information and updates with regard to mental health and best practice to staff around residents needs as situations arise. There was evidence of regular supervision taking place and notes placed staff files. on The home have employed one new member of staff in the last 12 months. This persons file was looked at. There was an application form and references from three past employers. The application form was completed in a somewhat confusing manner and the most recent employment on the application form did not seem to tally with the reference given. The manager said that the worker had worked for a temporary agency and had worked at number of short term posts. The CRB check was from another organisation the staff member worked for, and dated from May 2004. It was over one year old at the time the present post was taken up. An immediate requirement was made that the manager does an urgent POVA first check and a CRB check. DS0000022736.V295817.R01.S.doc Version 5.2 Page 22 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, 42 Quality in this outcome area is good . This judgment is made using available evidence including a visit the service. Resident’s benefit from a well run home, and a manager experienced in supporting people with mental health needs. The home needs to carry out regular quality assurance monitoring and gather the views of residents, relatives and professionals that visit the home. The home needs to ensure that they record the fridge temperate regularly. EVIDENCE: The manager of the home is a qualified nurse mental health nurse, who has many years of experienced working an a variety of hospital and community setting, she has completed her NVQ level 4. The manager has a comprehensive knowledge of mental heath issues and skills in working with people who need support with regard the their mental health. The home is well run and residents benefit from this. DS0000022736.V295817.R01.S.doc Version 5.2 Page 23 The manager completes and returned some section 26 forms to CSCI, although there are some gaps in the more recent returns. There was no up to date information available with regard to how the home completes is quality assurance monitored of residents views. The home have had residents meetings in the past and have a form to minute these meetings, however there was no evidence that this had been undertaken recently, the information shown dating from 2003. The home have fire drills approx every three to six months, the dates recorded 22/9/05 19/1/06 9/3/06 Fire alarm were recorded as tested 15/4/06, 11/4/06 5/4/06, 1/4/06. There was evidence that the freezer in the kitchen was regularly check with regard to it temperature which was recorded as -18 c. The fridge temperature was not being recorded. DS0000022736.V295817.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 X 2 X X 3 X DS0000022736.V295817.R01.S.doc Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(1)(c) 4 (2) Requirement The registered manager must ensure that the statement of purpose contains up to date information, and includes all specified in schedule 1. A copy must be forwarded to the CSCI. The registered manager must ensure that all risk assessments are reviewed once a year, and this reviews is signed and dated. The registered manager must review meal planning and preparation in the home, to promote choice and healthy meal options for service users. The registered person must ensure that staff complete all medication records fully and accurately putting an R for refused on the mar chart, where medication has been refused. The registered person must make sure all medication received is recorded accurately at the time of receipt and a running total is DS0000022736.V295817.R01.S.doc Timescale for action 15/08/06 2 YA9 17(3)a 15/08/06 3. YA17 16(2)i 15/08/06 4. YA20 13(2) 15/08/06 5. YA20 17(1)a 15/08/06 Version 5.2 Page 26 kept on the medication sheet. This is a repeat requirement, previous timescale of 12/10/05 and 01/02/06 not met. The registered manager must 15/08/06 ensure that they have an up to date copy of the multi agency protection of vulnerable adults procedure and that all staff who have not attended training on this subject completed this. The registered manager must 15/08/06 continue with the programme of work as laid out in the development plans sent to CSCI. The Commission must be informed in writing with regard to times scales for the planned work and with regard to how residents will be consulted and involved with the planning of the improvements. The registered manager must 15/08/06 carry out repairs and redecoration to the bathroom and toilet on the first floor of the home. The manager must inform the Commission in writing with regard to timescales for work to be undertaken. This is a repeat requirement Previous time scare of 01/04/06 not met The registered manager must ensure that they apply for and urgent POVA with regard to the last member of staff they employed and complete a new CRB check for them This is the subject of an DS0000022736.V295817.R01.S.doc Version 5.2 Page 27 6 YA23 13(6) 7. YA24 23(2)b&d 8. YA27 23(2)d&j 9 YA24 19 (1) (b) 02/06/06 immediate requirement 10. YA42 16(20)(J) The registered person must ensure that the fridge temperature in monitored and recorded dally and that there is a thermometer available to do that. 15/08/06 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. Refer to Standard YA6 Good Practice Recommendations The home should continue to work with residents around the discussion and recording of their wishes with regard to illness old age and death. DS0000022736.V295817.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022736.V295817.R01.S.doc Version 5.2 Page 29 - 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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