Inspection on 12/04/05 for Keats Way, 97

This inspection was carried out on 12th April 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

Keats Way, 97 22/05/07

Keats Way, 97 04/04/06

Keats Way, 97 06/09/05

Keats Way, 97 05/07/04

Keats Way, 97 25/06/04

Keats Way, 97 18/06/03

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

CARE HOME ADULTS 18-65 97 Keats Way Greenford Middlesex UB6 9HF Lead Inspector Sarah Middleton Announced 12 April 2005. 9.40 am 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 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 Stationary 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. 97 Keats Way Version 1.10 Page 3 SERVICE INFORMATION Name of service 97 Keats Way Address Greenford, Middlesex UB6 9HF Telephone number Fax number Email 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 575 3986 0208 575 8632 Mr Rajgopal Ramanah Mr Rajgopal Ramanah Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) 97 Keats Way Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5/07/04 Brief Description of the Service: Keats way is a large end of terraced house on a corner plot in a residential area. The property is situated on the borders of Greenford and Southall. It is near to small local shops and a short distance by transport to a larger town. A bus route runs nearby providing transport to mainline railway and underground services, which are only a few miles away. There is a small front paved front garden and an enclosed back garden, with a small patio and grass area.The home is registered for four people, with an age range between 18years old to above 65 years old, with a mental disorder. There is one bedroom situated on the ground floor, which has an en-suite facilities. The other three bedrooms are located on the first floor, along with a sleeping in bedroom for staff. This means that primarily the home caters for service users who can manage the stairs. The communal rooms are located on the ground floor, where there is a separate dining room and lounge. The home is staffed twenty four hours a day and can provide personal care or assistance with personal care and supervision for people with mental health needs. 97 Keats Way Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which was undertaken in just under six hours. Currently there are three men residing at Keats Way, with one vacancy. A full tour of the premises took place and all three care plans; a sample of staff files and several maintenance records were viewed. Three service users and two support workers were spoken to as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with severe and enduring mental health needs. The pre-inspection documentation was also examined to inform the inspection. There had been several additional visits by both Regulation Inspectors and a Pharmacy Inspector in 2004, as there had been concerns about the service. These included concerns about medication, staffing and the overall management of the home. Therefore there were several requirements outstanding from these visits. A few have been met, but there are many restated requirements in this inspection report. One immediate requirement was issued to the Registered Manager/Proprietor. What the service does well: The home has recently been settling in two new service users, both with very different needs. These service users indicated they were happy living in the home and that staff were understanding of their needs. Staff are aware of their learning needs in order to promote good quality care. One service user is independent and staff support this person to make choices and decisions about their lives. 97 Keats Way Version 1.10 Page 6 What has improved since the last inspection? What they could do better: The home has had several re-stated requirements issued both at the previous inspection and at this one. Attention must be paid to the competency of all staff and their opportunity to learn and develop skills appropriate to the needs of service users. An Immediate requirement was given to the Registered Manager to act on the lack of training opportunities. Without a qualified staff team, service users needs could be unmet. There have been attempts to identify some training, but there was little evidence to prove to what extent this had been carried out. Another area of concern was the lack of activities on offer. It was not clear what is on offer for service users and the activities they can engage in. There must be sufficient numbers of staff working to enable opportunities for service users to partake in activities. Where possible service users must be consulted about their likes and dislikes and this should be evident in their individual care plans. An area also needing a review is the home décor and fixtures. Furnishings and fittings should be of a good quality, providing a homely atmosphere. While attempts to work on this have been made there are still areas of the home that need attention. The home must take care when completing risk assessments. Precautions must be taken to ensure the health and welfare of both service users and the general public are considered and noted in risk assessments to promote the best interests for all concerned. The home needs to acknowledge and act upon the requirements made at each inspection. There must be evidence for all areas of care. It is not sufficient to state that things have been said or acted upon, without evidence to support this. Standards must be kept for the home to successfully meet all the service users assessed needs. Failure to act on improving the service could result in enforcement action being taken by the CSCI. 97 Keats Way Version 1.10 Page 7 Service users needs are complex and require a dedicated staff team to be encouraging, creative and motivating for the service users. This can only be done with strong leadership and clear direction from a suitably qualified and enthusiastic Registered Manager. This is where the home falls short of meeting many of the standards, which could have a detrimental effect on service users. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 97 Keats Way Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 97 Keats Way Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Service users are provided with information about the home and are assessed prior to entering the home, so as to adequately provide staff with the information they need to satisfactorily meet service users needs. Prospective service users are encouraged to visit the home in order to make an informed decision about the move. The lack of training for staff remains an ongoing issue that must be addressed. Without relevant knowledge and skills service users needs could be unmet. EVIDENCE: Service users and their representatives are provided with information regarding the home in the form of Service Users Guide and Statement of Purpose. Both of which outline clearly the services offered in the home, thus offering the prospective service user the information about the services the home provides to meet their needs. The home had two new admissions in the last five months. Both were admitted with a full assessment and care plan outlining the service users needs. However the management of potential risk, from Social Services, with regard to one forensic service user was sparse. Without clear information on risks the service might not be able to meet the needs of a service user who presents particular risks. 97 Keats Way Version 1.10 Page 10 A pre-admission assessment form the home uses was viewed and covered sufficient details to gather information about the service user from their perspective. Through gathering detailed information the home can identify if it can suitably meet the needs of the service user and how it plans to do so. The home continues to have a staff team that have not undertaken any recent training or studying surrounding the complex issues of mental health and forensic needs. The Registered Manager, who is a Registered Mental Health Nurse, (RMN), stated they support staff in discussing relevant mental health and social care topics. This is usually carried out in supervision. There was however no evidence that this actually takes place. Without up to date training staff are unaware of current practice and how to best support a person living with a mental illness. It was noted on a service users file that they had only visited the home once before being admitted. The Registered Manager stated they are often pressured into accepting service users with little time to prepare various visits. Where possible a potential new service user needs several visits so that they are fully prepared for the admission. In addition, the service users living at the home need the opportunity to meet any new service user to have their say on whether they are happy with this new admission. Thus all concerned, including staff, have the information necessary to feel included and part of the running of the home. 97 Keats Way Version 1.10 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 Service user care plans outlined some areas of need, although these must be more detailed, to offer a full picture of a service user and their needs. Risk assessments must contain current potential risk, so that service users, staff and members of the public are protected. There must be evidence that service users have been consulted about their lives. EVIDENCE: All three individual service user care plans were viewed. Although they had detailed many areas of a person’s life, such as health and social needs. They did not offer sufficient detail on behaviour, how to respond to particular complex needs and risks surrounding the service users. There was no evidence of staff or service users being involved in the completion of care plans with staff and service users. One staff member stated the Registered Manager completes all the care plans. Only one service user had a recent review, held at the local community mental health team. This documentation was contained limited information. There was no evidence of the service holding their own reviews to ensure they were meeting the ongoing needs of the service users. 97 Keats Way Version 1.10 Page 12 Discussions took place as to the need to not only attend external reviews, but to consider within the home the needs of the service users. Activities were limited and it was not clear how time was spent occupying and supporting service users. In addition, there was no record of service users being able, or not as the case may be, of making decisions in their lives. The needs of two of the service users are complex, however attempts should be made to include them in their care plan and to try and identify any aims or objectives they may have. Service users do have the opportunity to discuss elements of the home through a service user meeting. Minutes were seen, where a variety of topics were discussed. This meeting enables service users to have a say on the home. The Registered Manager had carried out an initial risk assessment on the two new service users, however this did not include any review of potential risks since moving into the home. The potential risk surrounding the complexity of a particular service user had not been fully addressed. The Registered Manager must seek to outline possible risks and seek to minimise them. Staff must be informed about the needs and behaviours of those residing in the home, so that adequate care and support is offered. 97 Keats Way Version 1.10 Page 13 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 standard(s) 11, 12, 13, 14, 15, 16 and 17 There is a significant lack of activity and stimulation provided at the home in which to enrich service users social opportunities. Limited encouragement is given to the service users to develop daily living skills. Without activity and stimulation service users will not develop interests or feel motivated. There is the recognition of one service users independence and this is respected and promoted within the home. EVIDENCE: Staff encourage independence with the service user who has the ability to go out into the community alone. They recognise that they do not wish to go out with staff or spend much time with the other people living in the home. The needs of the other two service users are more complex, however there was little evidence that they have the opportunity to develop skills they may have. Stimulation needs to be an everyday part of the home, with staff considering what a service user likes, dislikes and areas that could be identified and worked with. 97 Keats Way Version 1.10 Page 14 If service users are unable to motivate themselves and to find occupation, staff should be considering a variety of options and offering these to the people living at the home. One service user attends an art session at the local community mental health team once a week. This person was seen to be drawing in the home. Two service users could not describe what they did during the day. One service user goes out for walks and visits the local park and golf course. However, it was not clear how, or if, the other two service users engage with the local community. One service user stated, “I should be able to go out”. Through observations on the day of the inspection, two service users stayed in the house for most of the day. Staff were seen to interact positively with the service users, taking time to listen to them, thus showing them the dignity and respect they deserve. All bedrooms can be locked, but only one service user has a key to their bedroom and front door. There was nothing noted on the other two service users care plans to indicate why they do not have a key to their bedrooms and front door. Where the home has made a decision on behalf of the service user, the reason for this must be recorded in their care plans. Menus indicate that a variety of well-balanced meals are offered, to maintain a healthy lifestyle. Fresh fruit and vegetables were seen in the kitchen. Any changes to meals are noted in a book. The service users stated they were happy with the meals. Service users are encouraged to make drinks and some snacks, but meals are mainly prepared by staff. There was no evidence that service users are encouraged to prepare main meals. Again this does not encourage service users to develop any new skills or build on their existing abilities. 97 Keats Way Version 1.10 Page 15 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 standard(s) 18, 19 and 20 The medication systems in place had improved and were being followed, therefore promoting the welfare of service users. Shortfalls in relevant staff training were identified and were to be addressed by the Registered Manager/Proprietor. Service users must be supported to attend all health appointments to ensure the home meets the complex changing needs of service users. EVIDENCE: Staff encourage service users to manage their own personal care. Two service users require an element of prompting and supervision, staff are aware of how much support service users need. Recognising limitations and abilities enables staff to appropriately support those living in the house. Service users are in contact with specialist services, such as mental health and forensic professionals. However, one service user does not feel they have any particular needs and did not attend an out patient appointment. This is crucial to ensure their mental health is stable and that the home can meet their needs. Systems must be in place in order to balance a service user’s right to refuse to attend an appointment against ensuring the care and support needed from external sources is sought on a regular basis. 97 Keats Way Version 1.10 Page 16 All service users have access to GP’s and their general health is monitored by the home. Several requirements were made at the previous inspection with regard to medication. The home has improved in the handling and dispensing of medication and the home now uses the Boots monitored dosage system. Both medication administration records were seen and correctly completed. All medications were appropriately stored. However staff must be trained in administering medication and a record of their signatures must be in place. The Registered Manager explained there had been a recent change in the Pharmacist at Boots, but they were hopeful they would be able to get staff trained as soon as possible. There were no controlled drugs in the home and no service users currently self medicate. Through the home making improvements in this area the health and welfare of service users is being protected. 97 Keats Way Version 1.10 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 standard(s) 22 and 23 The home has a clear complaints procedure and one service user was confident that their complaints would be listened to and acted upon. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has a detailed complaints procedure in place, which is freely available. There have been no recorded complaints in the past twelve months. The CSCI has not directly received any complaints since the last inspection. One service user stated if they had any concerns they would go to the Registered Manager and they knew the problem would be resolved. This service user said all the staff were approachable. They were confident that any problems would always be resolved. This indicates the home has an open policy in encouraging service users to complain if they are unhappy with something. The home has a clear procedure for the protection of vulnerable adults, (POVA). Two staff had attended a seminar on vulnerable adults. This must be offered to all staff working within the home to ensure a consistent and informed method of working which protects service users from being placed at possible risk of harm or abuse. 97 Keats Way Version 1.10 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 standard(s) 24, 25, 26, 27 and 30 There has been limited improvement to the environmental standard to the home. The home does not therefore present as a homely and comfortable environment for service users. Action to ensure carpets and lino are securely fitted must be carried out, to ensure the health and safety of service users are considered. A record must be kept, outlining reasons, if privacy and choice cannot be upheld for service users. EVIDENCE: The home has undergone some decoration, however it was difficult to identify where this had taken place. Some carpets looked worn and old. The dining room, which is a small room, was decorated in dark blue. This did not give the feeling of a bright and stimulating environment. The kitchen floor and downstairs toilet had lino that was not fitted correctly. There was also an extra piece of lino in the kitchen that someone could trip over and fall. In addition, as on a previous inspection, there was no lampshade on a bulb in the main hall, giving the impression that the service was not homely. 97 Keats Way Version 1.10 Page 19 It was not clear as to the forthcoming decoration and maintenance programme for the home. The Registered Manager stated they had recently decorated some areas and that some flooring was fairly recent. The home must ensure it provides a safe and homely atmosphere for the service users. The Registered Manager stated they would address the flooring immediately. All service users have their own bedroom, one has en-suite, and all were personalised. The home encourages service users to bring small items of personal furniture so that service users feel settled in their own room. As stated earlier, the home needs to ensure they are recording if a service user is unable to have a key to their bedroom and the reason for this, as this could be an infringement of their privacy. The home was tidy at the time of the inspection, however the kitchen lino, which will be replaced, did not look very clean, staff commented that it had been washed that day. There is sufficient space within the home for service users to spend time alone, in their bedrooms or together, in the communal areas. Two of the service users were seen to spend most of the time downstairs in the dining room. 97 Keats Way Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35 There is a lack of qualified staff working within the home. Which could have a detrimental impact on the standard of care offered within the home. Staff roles are unclear and training opportunities are limited. This confusion does not promote the welfare of the service users. Supervision takes place regularly, but records of this need to include more detail on areas of discussion. EVIDENCE: Throughout the inspection it was not clear who was working what hours. There was a rota, but as highlighted at the previous inspection, it appeared some staff worked on an ad hoc basis. As staffing rotas do not always accurately reflect the staffing arrangements in place it was not clear if there were always sufficient staff working at one time, to take service users out into the community. Staff interviewed were aware of their limited knowledge in particular areas of mental health and felt they would ask the Registered Manager if they had a query. The uncertainty of who is working or if an unskilled staff member is on shift alone, could compromise service users health and safety. 97 Keats Way Version 1.10 Page 21 One staff member is exploring studying NVQ Level 2 through open learning on the Internet, as they could not commit to the day sessions held at the local college. Discussions took place on training, as there has been little opportunity for staff to attend external training on relevant mental health issues. The Registered Manager had a programme of topics they cover, but there was no record of this information being given to staff. The need for all staff to be aware of current practice and theory is necessary to ensure service users are cared for by competent staff. There was no clear individual staff training plan in place and no system for tracking the courses attended and areas where staff would need support and guidance. If staff are unqualified or where they do not have a clear learning plan, the results could have a negative effect on service users. Staff who are not equipped to recognise individual needs, cannot meet those ever changing needs. The service users are vulnerable adults who can have unpredictable behaviour, which demands the support of competent staff. The Registered Manager, although confident the staff team are sufficiently trained to understand the service users, must invest in identifying suitable training and learning opportunities to ensure the needs of service users are met. The staff employment records viewed contained completed application forms and Criminal Record Bureau checks. Supervision notes contained minimal information, mainly these meetings looked at policies. However staff interviewed felt they were supported and supervised regularly. There must be evidence to ensure they are receiving adequate guidance and advice. 97 Keats Way Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 40, 41 and 42 The home has not reviewed its performance or consulted with service users. This must be carried out to regularly improve the support and care offered to service users. EVIDENCE: The home has an open feel and the Registered Manager attempts to lead the staff team. However, staff do not undertake a key worker role or complete care plans and risk assessments. There was no evidence that they are consulted with when these are being carried out. The home has not carried out a review of its systems or sought views of service users, their representatives and professionals. Appropriate reviews and consultations must take place to ensure that service users have a say in how the home is run and that the service meets the changing needs of service users. 97 Keats Way Version 1.10 Page 23 The home needs to reflect on its practice to improve on areas that have been identified and consider what has worked well. A sample of policies and procedures contained all of the necessary documentation to promote the welfare of the service user. Regular fire drills are carried out and samples of health and safety records contained appropriate regular checks. However, although there are safety water valves to control the water temperature, the home must take the temperature weekly to ensure the valves are working. Thus promoting the safety of the service users who use water on a daily basis. 97 Keats Way Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 1 3 1 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 2 1 2 1 3 3 3 Standard No 31 32 33 34 35 36 Score 2 1 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x 3 2 3 3 2 x 97 Keats Way Version 1.10 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 3 Regulation 18 (1) (a) (c) (i) Requirement Timescale for action 11/5/05 2. 6 3. 7 4. 5. 9 11 6. 12 The Registered Person must ensure the staff have sufficient knowledge and skill to enable them to meet assessed needs. (Previous timescale of 31/8/04 not met.) Immediate requirement issued. 15 Care plans must contain details, such as potential risks and activities. Consultation with the service user must be a part of this process. (Previous timescale of 31/8/04 not met). 12 (2) & The Registered Person must 16 (2) provide evidence that service (m) (n) users are enabled as far as possible, the opportunity to make decisions about the care they receive. (Previous timescale of 31/8/04 not met). 13 (4) (c ) Detailed risk assessments must & (6) be included in care plans and reviewed regularly. 16 (2) (g) Arrangements must be in place (h) (m) to offer opportunities to engage in daily activities to promote personal development. l 16(2) (m) There must be evidence of a (n) varied programme of activities Version 1.10 30/6/05 30/6/05 6/6/05 30/6/05 20/6/05 97 Keats Way Page 26 7. 13 8. 14 9. 19 10. 20 11. 20 12. 24 13. 31 based on consultation with service users. These must meet their individual abilities and preferences. (Previous timescale of 31/8/04 not met). 16 (m) There must be evidence that (n) service users are able and encouraged to take part in activities which promotes inclusion into the local community. (Previous timescale 31/8/04 not met). 16 (2) (n) Appropriate opportunities to engage in lesiure activities and hobbies must be available for service users. 12 (1) (b) The Registered Person must & (3) ensure, with consultation with the service user and relevant professionals, that health appointments are kept. 13 (2) The Registered Person must ensure that all staff receive appropriate training in medication. (Previous timescale of 31/8/04 not met). 13 (2) To ensure that there is an up to date list of approved signatures of staff trained to administer medication in the home. (Previous timescale of 31/8/04 not met). 23 (2) (b) The Registered Person ensures (d) that all parts of the home are kept clean and reasonably decorated. In addtion any flooring must be fitted to a safe standard. (Previous timescale of 1/9/04 not met). 18 (1) (c ) The Registered Person must ensure all staff have a clearly defined role. The rota must reflect who is working in the home. Version 1.10 30/6/05 30/6/05 2/5/05 30/6/05 12/5/05 1/6/05 12/5/05 97 Keats Way Page 27 14. 32 18 (1) (a) & (c ) (i) (ii) 15. 33 16. 34 17. 35 18. 39 19. 42 The Registered Person must ensure that all staff receive appropriate training opportunities to fufill their role. 18 (1) (a) There must be sufficient numbers of staff working to ensure service users are fully supported, both within the home and outside in the community. 19 The Registered Person must be clear who is able to work in the home, having carried out all the necessary checks. (Previous timescale of 31/8/04 not met). 18 (1) (a) Staff must have a clear & (c ) (i) individual training plan and new (ii) staff must have a clear induction plan. 24 A quality monitoring system must be put in place, which includes evidence of views obtained, surveys and outcomes. These findings must be readily available to CSCI & service users upon request. (Previous timescale of 31/8/04 not met). 13 (a) (c ) Water temperatures must be taken regularly, (not exceeding 43 degrees) and recorded to ensure the safety measures in place are working. 30/6/05 30/5/05 1/6/05 30/6/05 1/7/05) 11/5/05 20. 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 4 26 Good Practice Recommendations Where possible, prospective service users should be able to have several visits to the home to ensure they are consulted as much as possible. The home should note on care plansthe reason why a Version 1.10 Page 28 97 Keats Way 3. 36 service user cannot have a key to their bedroom or front door. Detailed notes should be used in supervision, outlining learning needs and discussions that have taken place, in order to fully support staff. 97 Keats Way Version 1.10 Page 29 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 97 Keats Way Version 1.10 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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