Inspection on 20/12/05 for Jennifer`s Lodge

This inspection was carried out on 20th December 2005.

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

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

Other inspections for this house

Jennifer`s Lodge 03/10/08

Jennifer`s Lodge 05/10/07

Jennifer`s Lodge 24/04/06

Jennifer`s Lodge 15/09/05

Jennifer`s Lodge 29/03/05

Jennifer`s Lodge 06/09/04

Jennifer`s Lodge 10/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Jennifer`s Lodge 105 Wellmeadow Road Catford London SE61HN Lead Inspector Ms Lynn Hampton Unannounced Inspection 20th December 2005 08.45 X10015.doc Version 1.40 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 DS0000025597.V274017.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. DS0000025597.V274017.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Jennifer`s Lodge Address 105 Wellmeadow Road Catford London SE61HN 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) 0208 4612516 Mr Eric Blackwood Mrs Jennifer Blackwood Mrs Jennifer Blackwood Care Home 4 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places DS0000025597.V274017.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. up to 3 persons aged 65 years and above, one of whom may be suffering from dementia to include one person aged 55 years or above 15th September 2005 Date of last inspection Brief Description of the Service: Jennifer’s Lodge is a small, privately owned care home providing support and accommodation for four older people. Mr and Mrs Blackwood are the proprietors, and Mrs Jennifer Blackwood is the registered care manager. The home is located on a residential road with direct access to public transport and a short distance from the main shopping area of Catford. There is on street parking available but no off road parking. The home is laid out on the ground floor and first floor of a detached house, and provides a service to four older people. Each resident has their own bedroom, which has been adapted to have en-suite facilities. Improvements are underway to enlarge the communal dining area, and it is planned to move a bedroom, which will promote privacy and quality of accommodation for one resident. On the day of inspection there were no vacancies. Changes are required to ensure that the current Certificate of Registration accurately reflects the categories of service users that the home can admit. DS0000025597.V274017.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the morning of a weekday, on 20th December 2005, and lasted nearly five hours. During the visit the inspector met the Registered Manager and two care staff. A range of documents was examined and a tour of the building took place. The inspector met all four current residents, and spent time with three residents who were articulate and able to express their views on the service provided at the home. What the service does well: What has improved since the last inspection? Building work is underway to provide a new, spacious dining area for residents. It is also proposed to move one resident to another bedroom that would better suit his needs. Staff have individual training plans, and are undertaking relevant training and qualifications. Action is being taken to ensure that all relevant checks are in place for newly recruited staff. DS0000025597.V274017.R01.S.doc Version 5.1 Page 6 Action has been taken to meet Requirements made by the LFEPA and Water Board, and confirmation of this is to be sent to the Commission. 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. DS0000025597.V274017.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025597.V274017.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Action is needed to ensure that the Certificate of Registration accurately reflects the categories of service user that can be admitted to the home, which should inform the assessment and admission process in future. EVIDENCE: The home is registered to provide care to four older people, who may have dementia. The manager discussed this with the inspector, and explained that she had made efforts to have this changed, as it was never intended that the home would provide care to people with dementia. It should instead have been people with mental health problems, which is relevant to one of the current residents. The registered manager must continue to liaise with the Commission to ensure that the Certificate of Registration is amended to show the correct categories. However, one of the current residents has significant learning disabilities, and registration issues around this must be also clarified with the Commission. The manager was aware of the need to ensure that the home accepts only those people referred who meet the categories of registration. See Requirements. DS0000025597.V274017.R01.S.doc Version 5.1 Page 9 A Requirement was made in the report of the last inspection (September 2005) that the registered manager must ensure that all service users are assessed regarding their abilities and wishes regarding self-medication and that their decision is reflected in their needs assessments. Issues around care assessment are discussed in the section below, ‘Health and Social Care’. This Requirement is withdrawn and new Requirements around care planning are made. Standard 6 is not applicable, as the home does not provide intermediate care. DS0000025597.V274017.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Care planning documentation in the home is in need of urgent and comprehensive review. Consideration should be given to developing key working roles and building upon recent staff training to promote clarity in the assessment of service users, care planning and documentation. Continued non-compliance with Requirements made concerning these issues will lead to Enforcement action being taken. Residents’ changing physical health and mobility must be assessed to determine if aids or adaptations are needed. EVIDENCE: A Requirement was made in the report of a previous inspection that the registered provider and the manager must ensure that all essential information pertaining to the health and social care of service users is included in care plans, including risk assessments. This remained unmet for two inspections, and was judged to be partly met at the time of the last inspection (September 2005). The registered manager has been informed that continued noncompliance could lead to consideration of enforcement action, although work is progressing in this area. Timescales set of 30/10/04, 31/07/05, and 30/11/05 have not been fully met. This is an area for serious concern, and the issue was discussed with the manager at the time of the inspection. DS0000025597.V274017.R01.S.doc Version 5.1 Page 11 The manager spoke with feeling about how she enjoyed working on a 1:1 level with residents, but was able to acknowledge that this meant that she found it difficult to prioritise management tasks that includes record-keeping and care planning documentation. Care records seen by the inspector needed significant improvement, and this had been noted at previous inspections. There is still a need for more detail, more information on social and emotional needs, life histories and especially risk assessments. Care records should reflect individually considered and tailored responses to care needs, whereas the ones seen tended to be repetitive and did not reflect the practice that was reported to be carried out on a day-to-day basis. The discussion with the registered manager revealed some lack of clarity in the manager’s role, which needs to be less “hands on”, to enable her to address the overall direction of care and record-keeping in the home. As staff at the home are undertaking relevant training and qualification (see ‘Staffing’ section below), the manager could benefit from using their skills and knowledge in undertaking more care planning. A new Requirement is made that the manager introduce a Key Working or other care planning system in the home, to enable care staff to be clearer about their role in working with residents and to undertake some of the day-to-day tasks that would free the manager up to concentrate on management responsibilities. A further Requirement is made that each resident is turn is made the focus of a comprehensive care planning review, with Key Worker staff being involved in a complete review of the assessment, care planning, documentation and review of one named resident, over the period of a month. When this is complete, the process is to be applied to a second resident, and continue until the care process for each of the four residents is reviewed and brought up to the standards specified in the National Minimum Standards and best practice in this area. Care planning and recording will be the focus of the next inspection. It is hoped that this strategy will enable the registered person to systematically address the identified problems with the care process in the home, and permit a reasonable timescale to enable changes to be made. However, the original Requirement that essential information be included in plans remains in force, and if lack of progress in this area is identified at the next inspection, the Commission will have no recourse except to proceed with Enforcement Action. Requirements were made in the report of the previous inspection that care plans include service user signed consent regarding administration of medication, and that service users have been assessed regarding their ability and wishes to self medicate. These matters must be addressed in the new care planning review that is the subject of a new Requirement, and these Requirements are discontinued for that reason. DS0000025597.V274017.R01.S.doc Version 5.1 Page 12 One resident has been experiencing medical problems that have effected her mobility both within the home and her ability to go outside the home. The manager outlined action that had been taken to ensure that the resident had appropriate health care and assessment. However, this was not documented in her care records, and also the inspector was concerned about the suitability of the home’s physical environment to meet the resident’s changing needs in the longer term. The resident described problems with using the en-suite washing facilities, and the shared bath. The manager must ensure that an assessment of the resident’s needs, and the suitability of the environment, is undertaken by an Occupational Therapist. DS0000025597.V274017.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 & 14 Service users are supported to attend some activities, if they so wish, which includes regular attendance at Church. One resident’s choice not to go out is respected. Some problems were identified in meeting the full range of other residents’ wishes in respect of activities. EVIDENCE: The identified difficulties in the care documentation (as described above) inhibited the inspector’s ability to judge how the home assessed and responded to resident’s individual preferences in daily life and social activities. One resident clearly and decidedly told the inspector that she did not wish to go on trips out of the home. However, another resident clearly stated to the inspector that she wished to be able to go out more often. The home consistently provided this person with escorts to and from Church, but she wanted to be able to go out on other occasions, and reported that there were insufficient staff to allow this to happen. The rota indicated that often there was only one member of staff on duty in the home, so the resident’s perception is likely to be accurate. The manager reported that they tried to get volunteers to assist in taking people out, but this is not meeting the person’s needs. This must be central to the resident’s care plan review, and action is to be taken to meet identified needs, or give consideration to finding a placement that can. DS0000025597.V274017.R01.S.doc Version 5.1 Page 14 Another resident’s case file was viewed, which had a timetable of activities in place. However, there was evidence (from observation, entries in the diary and discussion with the manager) that these activities often did not take place. As part of the care planning review that must take place (see below) specific attention must be paid to assessing and recording resident’s individual wishes regarding activities and outings, and action is to be taken to ensure that these needs are met, including by ensuring that sufficient staff are available, and comprehensive records kept of when activities are carried out or if not, why not. Consideration is to be given to finding more suitable placements for residents if their social needs cannot be met by the staffing arrangements in the home. DS0000025597.V274017.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17, 18 None of the residents manage their own money, and documentation should be improved to clarify what arrangements are in place, and maintain an up to date record of expenditure. Further action must be taken to arrange for service users to access independent advocacy, which will also help to address any queries that residents may have about financial matters. EVIDENCE: A Requirement was made in a previous inspection that the registered person must ensure that access to advocacy services is facilitated. At the inspection that took place in September 2005, the manager told the inspector that she was working to find advocates for two of the service users. Previous timescales of 31/7/05, and 30/11/05, are not met. In discussion with the inspector at this inspection visit, the manager reported that advocates did visit some residents. Further discussion revealed that these were volunteers from the Church, who were undertaking a Befriending role rather than an independent advocacy role. The manager had information and contact details on independent advocacy services in Lewisham, and this must be followed up without further delay. DS0000025597.V274017.R01.S.doc Version 5.1 Page 16 None of the residents retain control over their own finances. The inspector was informed that one resident is subject to a Court of Protection order, although it was reported that she is not happy about this. The manager also informed that inspector that relatives who were Appointees administered the other residents’ finances. This has the potential to cause conflict of interest if relatives are paying the fees. The manager gave an example of an instance when a resident had made enquiries about finances, and the manager was uncertain about her role in responding to this appropriately. Independent advocates would have a clearer role in this, which would benefit residents, and concerns could be addressed (even if such concerns are unfounded). Records held indicated that the manager holds ‘pocket money’ given to some residents by their Appointees, which is used to purchase personal items such as toiletries. However, these records did not form a complete record of expenditure and receipts, and is in need of improvement. One resident’s case file indicated that the manager was acting as Appointee, which was reported to be a mistake. This must be rectified. DS0000025597.V274017.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 26 The home is laid out in a domestic style and residents have use of the ground floor as well as access to a large and attractive garden. Bedrooms have been converted to be en-suite. Building work is underway to provide a new, spacious dining area for residents. It is also proposed to move one resident to another bedroom that would better suit his needs. DS0000025597.V274017.R01.S.doc Version 5.1 Page 18 EVIDENCE: The home is laid out over three floors. The basement is accessed by a steep staircase, which is protected by a gate at the top (to prevent accidental falls). The basement is converted to accommodate a laundry area, and staff office space. There are three bedrooms on the ground floor. All have been converted to be en-suite by providing a toilet and sink area, which, in some rooms, is separated from the bedroom by a curtain. There is a separate toilet/bathroom, and a lounge for the use of the four residents. There is also a small kitchen open to service users at all times, and a very small dining area. A Requirement was made in reports of previous inspections that the dining area be enlarged. At the time of this inspection visit, building work was underway to address this, and the manager reported that the work would be completed by the New Year. This Requirement was within the new timescale given at the last inspection visit. There is access to a large well-maintained garden to the rear of the building. The first floor is mainly given over to the areas used by the registered persons and their family. At the time of this inspection, one of the residents has to go through this area to access his bedroom and small communal room. A Recommendation was made in the report of the last inspection that the owner needs to consider ways in which service users areas in the home are not infringed upon by the owner’s family living there. The manager informed this inspector that another room was to be converted for the use of this resident, which will benefit him not only by improving access and privacy, but also in that it is larger than his current bedroom. The Recommendation remains in force until the manager can consult with the Commission regarding any information that may need to be submitted in respect of this change, and until the move actually takes place. Areas seen by the inspector were clean. None of the bathing/toileting facilities are wheelchair accessible – see comments in ‘Health and Personal Care’ regarding resident’s changing needs. DS0000025597.V274017.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff have individual training plans, and are undertaking relevant training and qualifications. Action is being taken to ensure that all relevant checks are in place for newly recruited staff. EVIDENCE: See comments in the section ‘Daily Life and Social Activities’, regarding having staff available to escort service users if they wish to go on activities outside the home. A Requirement was made in the report of the last inspection, that the registered manager must ensure that 50 of support staff achieve NVQ level 2/3 within required timescales. The manager reported that staff had all been on the relevant course, although she was awaiting the certification for this. This Requirement was within the new timescale of 31/12/05. A Requirement was made in reports of previous inspections, that the registered person must ensure that all documentation required by regulation is received before staff start working in the home. Previous timescales of 31/7/05, and 30/11/05 have not been met. The manager reported that she had now requested a second reference for the member of staff who did not have one at these previous inspections. She reported that she expected this very soon, and is to copy this to the Commission immediately on receipt. This Requirement remains in force until this confirmation is received. DS0000025597.V274017.R01.S.doc Version 5.1 Page 20 A further Requirement was made in previous inspections that the registered provider must ensure that there is a staff training and development programme, which meets the National Training Organisation workforce training targets. As the home had demonstrated that it has a system for staff to access training, which includes local authority training and NVQ qualification, this Requirement is judged to have been met. The inspector viewed sample Individual Staff Training Plans, which included details and dates of Induction, NVQ, and Health & Safety training. DS0000025597.V274017.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 35, 37, 38 The manager has clear plans and priorities for the future development of the home. Action has been taken to meet Requirements made by the LFEPA, and confirmation of this is to be sent to the Commission. Records held in the home indicate that action is taken to comply with the full range of Health & Safety legislation, although records would benefit from being put into good order. EVIDENCE: See also comments under the section ‘Health & Personal Care’, regarding clarification of the care staff and management role, and ‘Complaints and Protection’ regarding service users financial arrangements. A Requirement was made in reports of previous inspections that the registered provider must ensure that there is an Annual Development Plan for the home. This was discussed with the manager during the inspection, who spoke openly and with honesty about the situation. As noted in other sections in this report, DS0000025597.V274017.R01.S.doc Version 5.1 Page 22 the manager is acutely aware of the priorities for the future development and management of the home, and intends to focus on ensuring that relevant documentation is in place regarding aims and outcomes for service users. This Requirement is discontinued, and is superseded by new Requirements that more effectively reflect these priorities. A further Requirement was made that the registered provider and manager must ensure that the requirements of the LFEPA fire officers report as described in YA Standard 38 are addressed by the due date of 14/02/06. This included: 1. Undertake a risk assessment and formulate an emergency plan. 2. 2. Develop an ongoing training programme for staff and record attendance. 3. Get certificates of maintenance for the fire alarm system annually and keep inspection results on the premises. 4. Ensure that all exit routes are free from obstruction and that all exit doors are easily open-able without using a key. 5. Ensure that all fire doors have self-closing mechanisms 6. Emergency signage to conform to Health and Safety regulations. This Requirement was within timescale at the time of this inspection visit, and will be checked at the next inspection. The inspector reviewed Health & Safety information that was available in the home. A Health & Safety Book contained records of some checks and certification, but it appeared that there were gaps and omissions. This was discussed with the manager, who was able to produce a range of documentation covering Health & Safety training; fire equipment checks and required certification. It would benefit the management of the home for this documentation to be reviewed and put into good order, which will support management planning and also facilitate the inspection process at future visits. Records seen indicated that five staff had training in First Aid; that routine inspections of Fire Equipment were undertaken and regular quarterly fire drills took place. Fire Alarms had been serviced in October 2005, and smoke/heat detectors in December 2005. A current Certificate of Employers’ Liability Insurance was on display. The manager also reported that she was contracting an agency that would assist her in undertaking a full Risk Assessment of the home. DS0000025597.V274017.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 2 18 3 3 2 3 3 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 3 X 2 X 2 3 DS0000025597.V274017.R01.S.doc Version 5.1 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 OP3OP4 Regulation 6 Requirement The Registered Manager must liaise with the CSCI to ensure that the Certificate of Registration accurately reflects the categories of service user that the home provides care for, by 1/4/06. The manager must ensure that this is used to inform the assessment and admission of residents in the future. (Registration Regulations) 2. OP7 15 The registered provider and the manager must ensure that all essential information pertaining to the health and social care of service users is included in care plans, including risk assessments. Previous timescales of 30/10/04, 31/07/05 and 30/11/05 partly met. Continued non-compliance will lead to consideration of enforcement action. 31/03/06 Timescale for action 01/04/06 DS0000025597.V274017.R01.S.doc Version 5.1 Page 25 3 OP7OP32 10, 12(1), 18(1) The Registered manager must implement a Key Working system in the home, (or other care planning system), that will (a) enable care staff to be clearer about their role in working with residents and to undertake more of the day-today tasks (b) clarify the role of the manager and enable her to give due attention to management tasks and responsibilities. The Registered Manager must ensure that each service user is turn is made the focus of a care planning review, until each service user’s care plan is reviewed and brought up to the standards specified in the National Minimum Standards and best practice in this area. This to include Risk Assessments, assessments of activities and medication, and Reviews. Systems for on-going care recording, linked to these plans, are to be put in place. The first review is to be completed by 31/3/06, and the process to be completed by 30/6/06. 01/04/06 4 OP7 10, 12(1), 15 30/06/05 5 OP8 13(1)b The Registered Manager must ensure that an assessment of the needs of the resident experiencing mobility problems, and of the suitability of the environment, is undertaken by an Occupational Therapist or other suitably qualified care professional. 31/03/06 DS0000025597.V274017.R01.S.doc Version 5.1 Page 26 6 OP12 16(2)m, n 18(1)a The Registered manager must ensure that service users’ wishes and preferences are assessed and recorded, in respect of their social interests, and that action is taken to meet these needs through developing programmes of activities and ensuring that sufficient staff are available to implement the programme. Records are to be maintained that indicated whether activities took place, and the reasons why they did not (if appropriate). The registered person must ensure that access to advocacy services is facilitated Previous timescales of 31/07/05 and 30/11/05 are partially met. Continued non-compliance will lead to consideration of enforcement action. 30/06/06 7. OP17 12.1 30/06/06 8 OP17OP35 12(1) 13(6) 17(2) The Registered Manager must ensure that: (a) Detailed records are kept of the financial arrangements in respect of each service user, (b) Service users have access to independent advocacy to ensure that arrangements are appropriate, and to assist them if they have any concerns, (c) An accurate and up to date record of money held on behalf of service users is kept, in accordance with Schedule 4(9) of the Regulations. 30/06/06 DS0000025597.V274017.R01.S.doc Version 5.1 Page 27 9. OP20 23.2 g The registered person must ensure that there is a dining area large enough for all service users to eat together This is the subject of a previous requirement, within timescale at the time of this inspection visit. The Registered Manager must liaise with the Commission regarding plans to move one resident to a different room, to confirm that this complies with relevant standards and Regulations. The registered manager must ensure that 50 of support staff achieve NVQ level 2/3 within required timescales. This is the subject of a previous requirement, within timescale at the time of this inspection visit. 31/12/05 10 OP20 23(2)e, f 01/03/06 11. OP28 18.1 a&c 31/12/05 12 OP29 19.1 a&b The registered person must ensure that all documentation required by regulation is received before staff start working in the home. Previous Timescales of 31/07 & 30/11/05 partly met. Remains in force until a copy of the reference is received by the Commission. 31/01/06 13. OP38 23 The registered provider and manager must ensure that the requirements of the LFEPA fire officers report as described in YA Standard 38 are addressed by the due date of 14/02/06 Within timescale. 14/02/06 DS0000025597.V274017.R01.S.doc Version 5.1 Page 28 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 OP20 Good Practice Recommendations The registered provider and manager should consider ways in which service users areas in the home are not infringed upon by the owners family living there, and include plans for improvement in the homes Development Plan. DS0000025597.V274017.R01.S.doc Version 5.1 Page 29 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 DS0000025597.V274017.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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