Inspection on 01/09/06 for John Kirk House

This inspection was carried out on 1st September 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

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 John Kirk House 25 Pearl Close Beckton London E6 5QY Lead Inspector Sarah Greaves Unannounced Inspection 1 September 2006 13:00p st John Kirk House DS0000067464.V309574.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 John Kirk House DS0000067464.V309574.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. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Kirk House Address 25 Pearl Close Beckton London E6 5QY 020 7511 6636 020 7511 9013 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.sanctuary-care.co.uk Sanctuary Care Ltd Mrs Tina Friswell Care Home 14 Category(ies) of Learning disability (14) registration, with number of places John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user over the age of 65 years 23/12/05 Date of last inspection Brief Description of the Service: John Kirk House is a registered care home for fourteen people with learning disabilities. Sanctuary Care manages the home, which is a voluntary sector provider of care services. John Kirk House is situated in Beckton, within easy reach of local buses, an underground station, a large supermarket and other amenities. The care home is divided into four separate living units; two of these units are located on the ground floor and two units are on the first floor (accessible by stairs). The premises contain a flat occupied by one person; this part of the building is not required to be registered by the CSCI. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one day. The inspection was timed to enable the inspector to meet as many of the service users as possible and to observe evening routines within the home. The inspector spoke to service users and staff; the registered manager was not on duty. Due to other observations, the inspector did not have an opportunity to speak to a visiting district nurse. The inspector read four care plans, observed service users receiving support with their eating and drinking needs, and watched the administration of medication. Information was also gathered from a tour of the premises, reading policies, checking health and safety documents, and looking at equipment. What the service does well: What has improved since the last inspection? The inspector found that the home had developed an active working relationship with local health care professionals in regard to meeting the eating and drinking needs of some of the service users. The need to fully explore individual and collective cultural needs had been worked upon with service users. The home had improved upon the bathing and showering facilities for service users. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 6 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. John Kirk House DS0000067464.V309574.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 John Kirk House DS0000067464.V309574.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The holistic needs of individuals are appropriately identified before admission to the home; however, the home should provide service users with contracts in a more straightforward pictorial format. EVIDENCE: The inspector was informed that the home had not admitted any new service users since the last inspection visit in December 2005. The inspector looked at the admission processes for new service users during the last inspection and found that the home employed a thorough approach. Prospective service users were offered opportunities to visit the home prior to moving in for a trial period. Pre-admission assessments were conducted by the home, in addition to the assessments received from social services and medical/health care professionals. A recommendation was issued in the previous inspection report for the home to produce a pictorial style contract, in order to promote the service users understanding of their rights and entitlements as residents of the home. This recommendation for good practice had not been progressed and has been repeated in this report. John Kirk House DS0000067464.V309574.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The needs of service users are identified through individualised planning; however, the home needs to increase upon its use of person centred planning. Service users are supported to make decisions about their current and future needs. EVIDENCE: The inspector read four care plans during this inspection. There was some inconsistency in regards to the regular reviewing of care plan objectives by staff. The inspector was informed that the home was working towards the production of ‘person centred planning’ (PCP) care plans for each service user; however, progress in this task appeared limited. Two members of staff had been trained to undertake the role of ‘person centred planning facilitators’ and had been working in partnership with the local Newham PCP organisation. The inspector was informed that some service users had declined ‘person centred planning’; it is recommended that their decision be discussed at their annual review (in the presence of their social worker) and documented. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 10 The inspector looked at the minutes for the service users monthly meetings. It was noted that service users actively contributed their ideas regarding the daily management of the home (for example, outings and entertainments, menus and environmental facilities). An external advocate chaired these meetings for a while; however, due to the home being charged for this service, the registered manager now chaired these meetings. The decision to revert back to the registered manager had been discussed with the service users, who stated that they were satisfied that their meetings would be facilitated in an open and fair manner. Each of the care plans read by the inspector contained risk assessments, which demonstrated an individualised approach to assessing and planning for potential and actual risks. John Kirk House DS0000067464.V309574.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are assisted to pursue fulfilling activities, utilise recreational and other community facilities and maintain their external friendships and relationships. Service users are offered a good food service, with specific support for any identified feeding needs. The home must ensure that fresh fruits are widely available throughout the day. EVIDENCE: The inspector reviewed the activities, including therapeutic employment (where applicable) for all of the service users. Each service user possessed an individualised programme, which took into account their interests, needs and abilities. The home organised entertainments such as regular trips to the cinema, bowling, swimming, barbeques, birthday parties and banger racing. Service users and staff informed the inspector that a trip to an air show was planned for the forthcoming weekend. Service users attended local day centres and some people engaged in parttime occupational work (one service user worked at a stable and another John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 12 service user was employed in the kitchen at a sheltered housing scheme). The inspector spoke to one of the service users who undertook therapeutic employment; this was described as a very fulfilling and enjoyable activity. Service users were offered opportunities to help with gardening at the home, attend college courses, shop at the local supermarket, undertake food preparation and play in-house bingo. A recommendation was made in the last inspection report for the home to ensure that a wide range of cultural activities was offered to service users. The inspector noted that a discussion to identify and meet cultural needs was now incorporated in the monthly service users meetings. Some of the service users attended specific resources such as mosques, Indian restaurants and Asian cinema. Holidays had been arranged for all service users who expressed an interest. Some of the service users regularly took holidays and day trips with the day centres and clubs that they attended. Holiday destinations included the ‘Center Parcs’ in Elvedon Forest and Sherwood Forest, Butlins and a residential holiday centre at Epping Forest. The inspector was informed that the home hoped to arrange a trip to Blackpool to see the illuminations, as some service users had stated an interest in this. Via discussions with service users and staff, the inspector found that service users were enabled to maintain external relationships and friendships. During the inspection, a friend visited one service user and the key worker for a service user described how she supported an individual to visit their family and attend events such as weddings. Specific examples of how the home have respected the wishes of service users have not been recorded in this report, in order to maintain the confidentiality of individuals. However, the inspector was satisfied that staff provided a empathetic response to the changing needs and wishes of service users (for example, if a service user wished to move on to more independent living accommodation). The inspector observed the serving of one meal (evening meal). Some of the service users required support with feeding; it was noted that the home had been closely working with speech and language therapists for advice regarding how to support people with swallowing difficulties. It was observed that the home provided a varied menu and a good range of food was available (for example, choices of cereals, biscuits and snacks). The inspector found a limited availability of fresh fruits; one of the units had a bowl of apples but the main kitchen did not have any fresh fruits. Via later discussion with the registered manager, the inspector was informed that there had been a variety of fruit available in the home prior to the inspector’s arrival, but this fruit had been quickly consumed. The registered manager has been advised to ensure the availability of a selection of fruit throughout the day and evening; for example, John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 13 through staff storing some fruit in a locked area and replenishing the fruit bowls at regular intervals. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home demonstrated that the personal and health care needs of service users were promptly and sensitively responded to; however, there is a need to produce health care plans for all service users in a timely manner. The new training for staff in medication practices has been a good initiative; some issues for improvement in medication practices have been identified, including a more rigorous monitoring system for ensuring the safe storage of medications for self-medicating service users. EVIDENCE: The care plans satisfactorily identified the personal care needs of service users, and outlined how these needs should be met. The personal care needs of the service users were quite variable, taking into account that the home provided care for people who are wheelchair users and individuals who are fully mobile. The inspector reviewed the individual health needs of all of the service users. No specific concerns were identified in regard to service users access to medical and health services (for example, General Practitioners, district nurses, chiropodists and opticians). The documentation within the care plans indicated that staff were prompt in their recognition of any changes and/or deterioration in the well being of an individual, which was then reported to the John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 15 General Practitioner for further investigation/specialist referrals. One of the service users reported to the inspector that they were receiving medical and nursing interventions for a current health problem, and that staff at the home were very supportive and understanding. The inspector observed that a member of staff was very discrete in their approach to this person’s health care needs. The inspector observed that there was a noticeable degree of work still to be done in order to ensure that all service users possessed an individualised health care plan, although the commenced work on these plans was of a promising standard. As previously stated, some of the service users had been referred to speech and language therapists for protocols for feeding. The inspector was consulted as to whether the individual guidelines for these service users should be displayed in a communal area; it has been advised that this information should be held in an easily accessible file within the kitchen/dining area (or any other rooms that staff support people with their feeding needs). Some of the service users attended weekly physiotherapy sessions, which were provided for their healthcare and social needs. The recreational activities offered by the home included activities to promote good health via exercise, for example, swimming, bowling, walks to the park and local shops. The home supported service users to take their own medication if they wished to, subject to staff guidance, supervision and risk assessments. At the time of this inspection, two service users maintained responsibility for their own medications and one service user was partly self-medicating. The inspector found that one self- medicating service user had a medication in their bedroom that expired in 2004 (this was a non-prescribed medication that they had bought over the counter). It was also observed that two service users were not remembering to keep their prescribed respiratory inhalers within a lockable cabinet in bedrooms that were not locked. Via later discussion with the registered manager, the inspector was informed that staff monitored the storage of the inhalers when carrying out the medication rounds and give gentle reminders on the importance of locking medications away. The inspector observed part of the evening medication round, which was satisfactorily undertaken. It was noted that the medication administration records did not always clearly state where a prescribed cream or lotion should be applied and this information was not consistently provided on the pharmacy label. The registered manager must speak to the dispensing pharmacist to request that specific instructions are recorded on the pharmacy labels and that this information is also documented on the medication administration charts. The inspector was shown the recent medication training programme that staff have undertaken, which appeared to be of a detailed standard. The member of staff conducting the medication round discussed the issues covered in this training, such as ethical considerations (for example, circumstances when a medical decision is made to conceal medications in food). John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 16 John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected through appropriate policies, staff training and service user consultation; however, the home needs to develop a pictorial style complaints procedure. EVIDENCE: A recommendation was made in the previous inspection report for the home to introduce a pictorial style complaints procedure for the use of service users; this recommendation was not met and has been repeated in this report. The home’s written complaints procedure was satisfactorily presented. The minutes of the service users meetings demonstrated that service users were informed of how to make a complaint. The inspector found that some service users were able to verbally state how they would complain but it was not clear how other service users would express any issues of concern. Staff had received training related to the protection of vulnerable adults from Newham Social Services Adult Protection team; this was in conjunction with training provided by the service provider. The home’s Adult Protection procedure and whistle-blowing policy were satisfactorily presented. John Kirk House DS0000067464.V309574.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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The premises provided a comfortable, hygienic and homely environment, although improvements are needed to the small communal lounges and kitchens. EVIDENCE: The inspector toured the premises with a member of staff. The home was proposing to convert the former sensory room into a dining room for people who need support with feeding; the speech and language therapists had suggested this in order to provide a quieter environment for these service users. The inspector was concerned that the absence of a sensory room might impact upon the needs of some service users; this needs to be explored by the registered manager via discussion with other health and social care professionals (for example, psychology services). The home might need to consider providing a sensory area within another part of the premises (staff suggested that a music room might be developed into a sensory room). The home had implemented improvements in the bathing/shower facilities and further developments were planned in this area. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 19 It was noted that the monthly- unannounced visits by the service provider addressed any environmental problems, such as uneven paving outside of the building and the concerns of staff that the office safe was visible to passers-by. The inspector looked at some of the bedrooms whilst chatting to service users. It was noted that service users were encouraged to personalise their rooms; there was good evidence to demonstrate that service users purchased music, magazines and other personal effects of their choice. The inspector noted that some decorative improvements were needed in the small communal lounges and unit kitchens, in order to make these facilities more welcoming, stylish and homely. It was observed that a Christmas tree was on display in one of the small lounges. The home was clean and free from any offensive odours. John Kirk House DS0000067464.V309574.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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff were provided with training that was applicable to the needs of the service users. The home needs to review its staffing levels and obtain documentary evidence to verify that references have been checked. EVIDENCE: The inspector was pleased to find that staff had made good progress with National Vocational Qualifications (NVQ) training. Due to the absence of the registered manager, the inspector was unable to gather exact information but discussions with staff indicated that approximately two-thirds of staff had either completed an NVQ level 2 in Care or were undertaking this qualification. Senior staff progressed to NVQ level 3 qualifications. The staffing rotas demonstrated that four staff were on duty on the early shift and four staff were on duty on the late shift (this figure does not include the registered manager’s hours). The inspector observed that there were particularly busy times during the day, such as meal times. The home’s active approach to enabling people to use local leisure facilities was very good; however, the inspector was concerned that some scheduled evening activities (such as trips to the cinema) left the home short-staffed at busy times. A requirement has been issued for the home to review its staffing levels, taking into account individual service users dependency levels. John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 21 The inspector looked at the recruitment documents for four members of staff. The recruitment practices were satisfactory; however, the inspector could not track how the service provider had verified one of the references. The member of staff on duty stated that this process is undertaken by a central human resources department; documentary evidence that references are checked upon should be supplied to the home. John Kirk House DS0000067464.V309574.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users expressed that the home met their needs and their views were listened to. Some health and safety practices have been identified for improvement. EVIDENCE: Via discussion with service users and staff, and through observations, the inspector found that the home was suitably managed. Some strengths were identified, such as the involvement of service users in fulfilling activities, links with the local community and consultation with service users. The requirements and recommendations within this report have identified areas for improvement; for example, care planning, some medication practices, and availability of fresh fruits and refurbishment of communal areas. As previously stated in this report, service users views were sought via their monthly meetings. The home also produced ‘newsletters’ to inform service users and their representatives of any new developments. The John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 23 recommendations for more pictorial documents (contracts and complaints procedure) have been issued to enable service users with learning disabilities to understand more about their home so that they are in a better position to contribute their views on how their service can be improved. The inspector noted that the monthly- unannounced visits by the service provider were of a good quality; service users were consulted and a realistic account of any problems or areas for improvement were documented. The inspector looked at the home’s health and safety records and practices. It was noted that two items in the main refrigerator had not been labelled with the dates of opening (packets of ham and cheese). The employer’s public liability certificate produced at this inspection had expired in May 2006; a requirement has been issued in this report for the home to send a copy of the current insurance cover. Refrigerator and freezer temperatures were provided for the all equipment apart from the medication refrigerator. All other health and safety practices were found to be satisfactory. John Kirk House DS0000067464.V309574.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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X John Kirk House DS0000067464.V309574.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 YA6 Regulation 15 Requirement The Registered Manager must ensure that all of the care plans are regularly reviewed. Review dates must be clearly documented. The Registered Manager must ensure that an adequate amount of fresh fruit is offered daily. The Registered Manager must ensure that all service users possess a ‘health care plan’. The Registered Manager must ensure that all expired medications are disposed of, including the medications of selfadministering service users. The Registered Manager must ensure the safe storage of prescribed respiratory inhalers. The Registered Manager must ensure that there are clearly recorded guidelines for the administration of prescribed topical creams and lotions. The Registered Manager must ensure the refurbishment of the small communal lounges and kitchens. The Registered Manager must ensure that the daily monitoring DS0000067464.V309574.R01.S.doc Timescale for action 31/01/07 2. 3. 4. YA17 YA19 YA20 16(2)(i) 15 13(2) 30/09/06 28/02/07 30/09/06 5. 6. YA20 YA20 13(2) 13(2) 30/09/06 30/09/06 7. YA28 23(2) 30/04/07 8. YA42 13(4)(a) 30/09/06 John Kirk House Version 5.2 Page 26 9. YA42 13(4)(a) 10. YA42 13(4)(c) of the medication refrigerator temperatures. The Registered Manager must supply evidence of the following document: Public liability insurance The Registered Manager must ensure that opened food items are labelled with the date of opening. 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA6 Good Practice Recommendations The Registered Manager should develop pictorial contracts. The Registered Manager should develop a timed programme for service users to be in receipt of person centred planning care plans. The refusal of a service user to be involved in person centred planning needs to be documented. The Registered Manager should develop pictorial complaints procedures. The Registered Manager should undertake a review of staffing levels. The Registered Manager should obtain documented evidence from the Human Resources department in order to verify that telephone and/or other checks have been made to ensure the authenticity and reliability of written references. 3. 4. 5. YA22 YA32 YA34 John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 John Kirk House DS0000067464.V309574.R01.S.doc Version 5.2 Page 28 - 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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