Inspection on 31/08/05 for Little Haven

This inspection was carried out on 31st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Little Haven 01/08/07

Little Haven 30/10/06

Little Haven 27/01/06

Little Haven 01/12/04

Little Haven 06/07/04

Little Haven 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Littlehaven 66 Laleham Road Catford London SE6 2HX Lead Inspector Kate Matson Unannounced 31 August 2005, 11:00am st 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 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. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Littlehaven Address 66 Laleham Road, Catford, London, SE6 2HX 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) 020 86974246 020 84650230 littlehaven@elizabethpeters.co.uk Elizabeth Peters Care Homes Limited Mr Martin Muriuki CRH Care Home PC Care Home Only 4 Category(ies) of MD Mental Disorder registration, with number MD(E) Mental Disorder-over 65 of places Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users admitted in the MD category must be between the ages of 55 and 65 years Date of last inspection 1st December 2004 Brief Description of the Service: Little Haven is a care home for four people who have mental health problems and are aged 55 or over. The home is one of four owned by a local provider, Elizabeth Peters Care Homes Ltd. The home is an older terraced property and is not identifiable as a care home. It is located within a short walking distance of Catford town centre, although there are smaller shops available locally. There are four single rooms over three floors. The home could accommodate a wheelchair user on the ground floor. There were no vacancies on the day of the inspection. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was conducted over 6.5 hours. The inspection included speaking with three of the service users, two staff members and the registered provider, a tour of the premises and examination of care plans, staff records and other records. The manager was not present at this inspection. What the service does well: What has improved since the last inspection? What they could do better: There is a lack of clarity about the age range to who care is provided and this must be clarified and made narrower to ensure that service users live with other service users of a similar age. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 6 Consistency is needed in care planning to ensure that all of service users’ needs are met The homes medication system was largely in order but homely remedies were not available and procedures were not being followed leading to the administration of supplements not being recorded and one dose of medication had been missed. One of the service users stated that sometimes things “get a bit monotonous” and two service users stated that staff were often too busy to spend time with them. None of the service users’ care plans detailed times spent with service users on an individual or group basis. One bedroom carpet was badly marked and the edges of the kitchen floor and the cooker were dirty. Service users exercise control over most aspects of their lives though a restriction in the use of the kitchen needs to be supported by a risk assessment. A previous requirement regarding staff duty rota remains unmet, as on the day of the inspection the rota did not reflect the situation in the home. Also the number of staff on duty had been reduced leaving some service users’ needs only partially met. A letter of serious concern was sent to the provider immediately following the inspection. Three staff on the duty rota did not have records in the home as required by previous inspections. The home continues to appoint staff before the receipt of appropriate checks placing service users at risk of abuse. A letter of serious concern was sent to the provider immediately following the inspection. Although a range of training is undertaken at the home, training records had not been updated; there continues to be no training plan and no evidence available that the homes training meets the National Training Organisation’s (NTO) workforce training targets. The manager is not at the home sufficiently often in order to run the home effectively. This is of serious concern and the registered provider must address this issue as a matter of urgency and ensure that the home has a manager at the home, who is fit to do the job and is able to work at the home on a full time basis. Reports of quality monitoring visits are not kept at the home or sent to CSCI in order to ensure that the home is run in the best interests of service users. A business and financial plan is not available to evidence that service users are safeguarded by the accounting and financial procedures of the home. Although evidence of some supervision was available it does not show that staff are supervised regularly enough. This issue has persisted over many inspections and enforcement action is now being considered. Some of the homes record keeping, policies and procedures do not safeguard service users rights and best interests. The health safety and welfare of service users are largely protected though evidence of the safety of the electrical installation of the premises has not been provided since the last inspection. Before the final publication of this report, a meeting was held with the provider. An action plan was agreed and compliance will be monitored over the coming months. Please contact the provider for advice of actions taken in response to this Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1 and 3 Prospective service users are provided with good information about the home; however, the age range to who care is provided needs to be clearer and narrower. The needs of service users are fully assessed before being offered a place to ensure that they can be met. EVIDENCE: It was noted at previous inspections that the Statement of Purpose and service user guide lacked some of the information required for service users to be able to make an informed choice about where they live. At this inspection it was noted that both documents had been reviewed and they included all of the information required as well as some other useful information. However, it was noted that the age range was quoted differently in the two documents and this must be addressed to ensure that service users receive clear information. The statement of purpose stated that the age range is over 50yrs and the service user guide states that it is over 40yrs. As the eldest of the current service users is 73 yrs and the youngest is aged 57 it would be inappropriate to take service users younger than 55 yrs and the documents must be reviewed to state this. The newest service user was admitted in February 2005 and their personal file contained a full care management assessment and supporting documentation Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 10 in addition to an assessment completed by the home to ensure that their needs could be met. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7 and 9 All service users needs are not set out in their care plans. Recording of medication administration requires improvement. EVIDENCE: All four of the service users’ personal files and care plans were examined. The home uses a well-known care planning system. It had been noted at previous inspections that although care plans were in place, risk assessments had only partially been completed. At this inspection it was noted that the newest service users had a comprehensive care plan in place that was signed by the service user, regularly reviewed and covered all of the required areas. However, although the other three service users had care plans in place that were also regularly reviewed and statements to indicate that service users were invited to take part in the process, the care plans covered only limited areas. In order to ensure that all service users’ needs are addressed they must be reflected in the care plan. All four of the service users had risk assessments that identified risk indicators to ensure that staff are alerted to potential risk behaviours in order for them to be managed safely. The medication supply and records were examined. All of the medication is supplied in blister packs. These were largely in order though it was noted that one dose of medication had been missed though it was recorded as given and it was also noted that dietary supplements were not being recorded. This is of Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 12 concern because it is not possible to know that service users are getting the medications that they need. Also there were no homely remedies available, meaning that service users do not have easy access to medications for minor ailments. It is recommended that the home obtain a copy of the guidance “Administration and control of medicines in care homes and children’s service” produced by the Royal Pharmaceutical Society of Great Britain in order to improve medication practice. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 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 standard(s) 12, 14 and 15 Two service users indicated that staff did not have time to spend with them and this needs to be addressed to ensure that their needs for stimulation are met. Service users exercise control over most aspects of their lives though a restriction in the use of the kitchen needs to be supported by a risk assessment to evidence its necessity. Service users are provided with meals that suit their needs and preferences. EVIDENCE: It was found at previous inspections that most of the service users tend to prefer activities in the home such as watching television, playing games, or listening to music rather than organised activities. Organised activities are offered, however, including barbeques and parties at the home in addition to those held at one of the larger homes in the Elizabeth Peters Group. It was positive to note that service users had been offered a holiday and one had enjoyed seven days away from the home. One of the service users stated that sometimes things “get a bit monotonous” and two service users stated that staff were often too busy to spend time with them. None of the service users’ care plans detailed times spent with service users on an individual or group basis and staff provision must be provided to meet those needs. It was clear that service users make their own decisions in most areas including daily routines, activities they take part in and relationships. Service users are supported to be as independent as possible in managing their financial affairs. Only one of the service users is supported in managing their Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 14 money. Service users are able to bring their own possessions into the home and the newest service user had brought several items of furniture. It was found that the kitchen is locked at night but there was no risk assessment to explain the necessity for this. This must be addressed, as any restrictions on service users must be fully evidenced. Service users were mainly positive about food provided at the home. They all confirmed that meals were flexible and records showed that service users were regularly provided with food that was different to what was on the menu in accordance with their personal preferences. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 Service users had not made complaints but were confident to do so if necessary. Policies and procedures at the home largely protect service users from abuse though recruitment practice places them at risk. EVIDENCE: There were no complaints in the home’s record of complaints. Three of the service users spoken to stated that they had not made any complaints. They confirmed that they would be happy to do so if necessary and one said they felt “able to raise any concerns with the staff”. The home has appropriate policies and procedures in place to protect service users from abuse. The registered provider confirmed that most staff had now completed training in adult protection. It was noted at a previous inspection that the home’s policy on dealing with aggressive incidents was inadequate and it was found that this had been reviewed and an appropriate policy was now in place. However, the home’s recruitment practices potentially places service users at risk of abuse and this is discussed further under Standard 29. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 20, 24 and 26 The home is safe and generally well maintained. It offers sufficient communal and individual space and is decorated and furnished in a comfortable and homely way. Service users were content with their bedrooms though one carpet was in need of cleaning or replacement. The home was largely clean though parts of the kitchen were dirty. EVIDENCE: The home is a two storey terraced property in a residential area in Catford and it is not identifiable as a care home. The home consists of four single bedrooms and communal space including a lounge at the front that also is used as the office and staff sleeping in room, a dining room with sitting area at the rear of the property and a small yard outside with a picnic table. Previous inspections had noted that the kitchen was in need of renewal and it was found at this inspection that this had been done. All of the service users’ rooms were seen and service users reported to be happy with them. The home is generally well maintained and furnished in a comfortable and homely way. However, it was noted that a carpet in one of the service user’s rooms was badly marked and detracted from the overall well maintained environment. It needs to be cleaned Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 17 or replaced in order to ensure that service users feel that they are valued. The home was generally clean though the edges of the kitchen floor and the cooker were dirty. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The number of staff on duty had been reduced leaving some service users needs only partially met. Continued shortcomings in the home’s recruitment practices potentially place service users at risk of abuse. Although most staff are completing appropriate qualifications there is no evidence available to show that the home’s training meets the needs of service users. EVIDENCE: At the previous inspection a duty rota was not available to inspect to ensure that sufficient staff were on duty, though the inspector was informed that there were two care staff on duty from 8am until 8pm and one care staff sleeping in from 8pm until 8am. At this inspection rotas were available; however, they did raise several concerns. They did not accurately reflect the situation in the home at the time, they did not show the manager on the rota or any staff working at night and they showed that only one staff was on duty after 5pm and at the weekends. Service users confirmed that there were always staff on duty but two stated that they were often busy and didn’t have time to spend with them. The provider must ensure that there are adequate numbers of staff on duty and a letter of serious concern was sent to the provider immediately after the inspection regarding this. The issue regarding the manager is discussed further under Standard 31. The registered provider stated that seven of the eight staff are completing or have completed NVQ qualifications and the Statement of Purpose confirms this. This ensures that staff are competent to meet the needs of service users. It was noted at previous inspections that staff were allowed to commence employment before appropriate checks had been received from the Criminal Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 19 Records Bureau (CRB). Also at the last inspection staff files were not available to ensure that appropriate checks had been made. At this inspection it was found that although some staff files were available for inspection, there were three staff names on the rota who did not have records at the home and one person on duty who was not on the rota. Continued failure to comply will lead to enforcement action being considered. Out of the six files examined, one had no photograph and one had no photograph or proof of identity. One had only one reference and one had no references. Three of the staff did not have a CRB check on file including one new member of staff who had started work without a check against the list of people considered unsuitable of working with vulnerable adults (POVA). The registered provider stated that all staff had two references in place but they were probably in their files kept at the other homes. She stated that one of the staff without a CRB definitely had one and the other had ongoing difficulties. An application for a new CRB check had been made for the new staff member who had an existing CRB when she started but the inspector clarified again that this is not acceptable, as a check against the POVA list must be made in these circumstances. Continued failure to comply will lead to enforcement action being considered. A letter of serious concern was sent to the provider immediately following the inspection. It was noted at previous inspections that an overall training record was available that indicated the training that each staff member had completed. Although a range of training was undertaken there was no evidence that the homes training met the National Training Organisation’s (NTO) workforce training targets. The registered provider was required to ensure that it was. At this inspection the registered provider confirmed that she had been in touch with the Skills for Care office in London and was trying to ensure that training at the home complied with their requirements. However, the record of training completed was not up to date; there was no evidence available that induction and foundation training were to NTO specifications and there was no training plan available based on mandatory requirements, the needs of staff and the needs of service users. Continued failure to comply will lead to enforcement action being considered. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 36, 37 and 38 The manager is not at the home sufficiently often in order to run the home effectively. The home consults with service users but reports of quality monitoring visits are not kept at the home or sent to CSCI in order to ensure that the home is run in the best interests of service users. A business and financial plan is not available to evidence that service users are safeguarded by the accounting and financial procedures of the home. Staff continue to not be appropriately supervised. Some of the home’s record keeping, policies and procedures do not safeguard service users rights and best interests. The health safety and welfare of service users are largely protected though evidence of the safety of the electrical installation of the premises is still overdue. EVIDENCE: It was noted at a previous inspection that the manager had over ten years experience of residential care and had managed Little Haven for four years. He was due to commence the NVQ level 4 Registered Managers Award in September 2004 and was also planning on doing NVQ level 4 in Mental Health Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 21 Care. At this inspection it was noted that the manager’s name was not on the rota though the inspectors were informed that he usually works around three days per week. However, when service users were asked how often they saw Martin, some did not know who he was and none knew that he was the manager of the home. This is of serious concern and the registered provider must address this issue as a matter of urgency and ensure that the home has a manager at the home, who is fit to do the job and is able to work at the home on a full time basis. Previous inspections had noted that although the registered provider carried out monthly monitoring visits to the home, reports were not always completed and kept at the home and reports were not sent to CSCI. It was also noted that although quality assurance surveys were completed, service users did not retain anonymity and the results of these were not published. At this inspection the registered provider was unable to show the inspectors any reports of monitoring visits and none had been sent to CSCI. This situation has remained unchanged over several inspections and must be addressed in order to evidence effective monitoring of the service. Continued failure to comply will lead to enforcement action being considered. However, it was pleasing to note that further quality assurance surveys had been completed and the results of the latest surveys were anonymous and summarised in the service user guide. Although it was noted that the home uses a different form for visiting professionals, it was noted that the same form is given to service users and their relatives. It is recommended that separate survey forms be developed for service users and relatives to reflect their different needs. Although evidence was seen at previous inspections that the home’s insurance was adequate and that the home is financially viable, a business and financial plan, including an annual development plan was required. At this inspection the registered provider stated that this had been done but was not available at the home. Continued failure to comply will lead to enforcement action being considered. Previous inspections had found that although there was some evidence of staff supervision and appraisal in staff files, it did not show that staff were being supervised at least six times per year as required. At this inspection, again there was evidence of supervision but these were not dated and some were not signed by the supervisor and the supervisee. This requirement has remained in place over several inspections and enforcement action is now being considered. Some of the records required by regulation to be kept by the home were examined including service users records, medication administration, record of food provided, complaints, staff files and record of fire drills and were found to be up to date and accurate, unless commented on specifically in other areas of this report. At previous inspections requirements were made that the registered provider must ensure that the home is registered with the Information Commissioner’s Office for the storage of confidential information and that all staff files contain proof of identity and a recent photograph. At this inspection the registered provider stated that the home was registered with the Information Commissioners Office but was unable to provide evidence of this. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 22 As already stated under Standard 29 staff files did not all include proof of identity and photographs and these requirements are restated in this report. Continued failure to comply will lead to enforcement action being considered. At the last inspection certificates of gas safety, electrical installation and portable electrical appliances were not available and the registered provider was required to send these to CSCI. These were not received but at this inspection an up to date gas certificate and proof of electrical appliance testing was available. However, although the inspector was assured that the electrical installation was tested the previous year, evidence was not available to support this. Continued failure to comply will lead to enforcement action being considered. Other evidence of measures taken to protect the health, safety and welfare of service users was available at the inspection for example, testing of fire alarm, fire equipment, fire drills and a satisfactory food hygiene inspection. Fire extinguishers were being serviced on the day of the inspection. It was noted that although fire drills were held at appropriate intervals, the times of the drills were not recorded as required. This must be addressed to ensure that they are held at different times of day. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 2 x 2 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 1 x 1 1 x 1 1 2 Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 24 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 1 Regulation 4 and 5 Requirement The registered provider must ensure that the statement of purpose and service user guide are reviewed to state that the age range for whom care is provided is 55yrs and over. The registered provider must ensure that service users care plans cover all areas of need including mental health. The registered provider must ensure that medications are administered in accordance with the homes policies and procedures. Also the administration of food supplements must be recorded. The registered provider must ensure that homely remedies are available in the home supported by written approval from the GP detailing names of service users, homely remedies and doses of medication approved. The registered provider must ensure that service users are provided with more opportunities for individual and group activity with staff and care plans detail time spent on these activities and provide sufficient staff to Timescale for action 30/11/05 2. 7 15 (1) 30/11/05 3. 9 13 (2) 30/09/05 4. 9 13 (2) 30/11/05 5. 12 16 (2) (m) and (n) 30/11/05 Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 25 cover them. 6. 14 17 (1) (a) Schedule 3 (3) (q) 16 (2) (c) The registered provider must ensure that the need for any restrictions in the home is regularly reviewed and written evidence provided. The registered provider must ensure that the carpet in the downstairs bedroom is cleaned or replaced. The registered provider must ensure that all parts of the home, including the kitchen floor and cooker are kept clean to an acceptable standard. The registered provider must ensure that a duty rota is kept at the home showing which staff are on duty at any time during the day and night (previous timescale of 30/01/05 not met) The registered provider must ensure that there are two staff members on duty at all times during the day until 8pm at night until approval for a reduction in staffing has been given by CSCI The registered provider must ensure that no new staff commence employment in the home until a satisfactory CRB disclosure has been received (previous timescales of 31/08/04 and 31/01/05 not met) The registered provider must ensure that no staff commence work in the home until satisfactory checks have been made with CRB and the POVA list. A risk assessment must be conducted regarding the staff member who has not yet received these checks back and sent to CSCI Southwark office The registered provider must ensure that staff records listed in schedule 4 are kept at the home 30/11/05 7. 24 31/12/05 8. 26 23 (2) (d) 30/11/05 9. 27 17 (2) and 17 (3) 30/09/05 10. 27 18 (1) (a) 31/08/05 11. 29 19 (1) (b) 31/08/05 12. 29 19 (1) (b) 31/08/05 13. 29 17 (2) 31/10/05 Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 26 14. 29 19 (1) (b) 15. 30 18 (1) (c) (i) 16. 17. 30 31 17 (2) 8 (1) (a) 18. 33 26 19. 34 24 and 25 and evidence of information listed under schedule 2 is available for inspection (previous timescale of 31/01/05 not met) The registered provider must more actively pursue outstanding CRB checks and submit a new application where neccessary. The registered provider must ensure that the homes training and development programme meets the NTO workforce training targets (previous timescales of 31/10/04 and 31/03/05 not met) The registered provider must ensure that the record of staff training is kept up to date. The registered provider must ensure that the home has a manager at the home, who is fit to do the job and is able to work at the home on a full time basis. If the existing manager is unable to do this the provider must urgently commence the recruitment process for a new manager in order to meet the given timescale. The registered manager must ensure that reports of visits conducted in accordance with Regulation 26 of the Care Homes Regulations also include service user interviews and are sent to CSCI, Southwark Office (previous timescales of 31/10/04 and 31/01/05 not met) The registered provider must ensure that there is a business and financial plan for the home including an annual development plan reflecting aims and outcomes for service users (previous timescales of 31/10/04 and 31/01/05 not met) 30/09/05 31/12/05 30/11/05 31/12/05 31/10/05 30/11/05 Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 27 20. 36 18 (2) 21. 37 12 (4) (a) 22. 37 19 (1) (b) (i) and 17 (2) 23. 38 23 (2) (b) and 23 (2) (c) 24. 38 23 (4) (e) Formal staff supervision must be increased to a minimum of six times a year (previous timescales of 01/01/03, 31/03/04, 31/10/04 and 31/03/05 not met) The registered provider must ensure that the home is registered with the Information Commissioner’s Office for the storage of confidential information (previous timescales of 31/10/04 and 31/03/05 not met) The registered provider must ensure that all staff files contain proof of identity and a recent photograph (previous timescales of 31/10/04 and 31/01/05 not met) The registered provider must ensure that copies of safety certificates for gas, electrical installation and portable electrical appliances are sent to CSCI, Southwark Office on receipt of the draft report (previous timescale of 31/12/04 not met though evidence of gas safety and portable electrical appliance testing seen at this inspection - electrical installation still outstanding) The registered provider must ensure that records of fire drills include the time of the drill. 30/11/05 30/11/05 31/10/05 30/09/05 30/11/05 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 9 Good Practice Recommendations It is recommended that the home obtain a copy of the guidance “Administration and control of medicines in care G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 28 Littlehaven 2. 33 homes and children’s service” produced by the Royal Pharmaceutical Society of Great Britain in order to improve medication practice. It is recommended that separate survey forms be developed for service users and relatives to reflect their different needs. Littlehaven G52-G02 S25598 Littlehaven V244510 310805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 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. 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