Inspection on 11/07/06 for 10 Love Walk

This inspection was carried out on 11th July 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Love Walk 25/06/08

10 Love Walk 18/10/07

10 Love Walk 15/12/05

10 Love Walk 25/04/05

10 Love Walk 25/10/04

10 Love Walk 20/05/04

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

CARE HOME ADULTS 18-65 Love Walk, 10 London SE5 8AE Lead Inspector Ms Alison Pritchard Unannounced Inspection 11 & 22nd July 2006 1:15pm th Love Walk, 10 DS0000007105.V299311.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 Love Walk, 10 DS0000007105.V299311.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. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Love Walk, 10 Address London SE5 8AE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company Name of registered manager Type of registration No. of places registered (if applicable) 0207 703 3632 0207 252 4958 jmacy@missioncare.org.uk Mission Care Mr Jonathan Macy Care Home 22 Category(ies) of Physical disability (0) registration, with number of places Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 (twenty two) people with physical disability, some of whom may be over 65 years old. 15th December 2005 Date of last inspection Brief Description of the Service: 10 Love Walk is a 22-bedded care home for people with a range of physical disabilities. It is located in a quiet residential road in Camberwell. The home is situated close to local shops, public transport and services and has a small car park. The home was purpose built and each of the bedrooms is single and has a large en-suite toilet /bathing facility. There is a lift to enable residents who use wheelchairs to access the first floor. In July 2006 there were 21 residents. The Registered Manager informed CSCI that information about the service is available in a written brochure and guide which are given to potential service users. In addition the Registered Manager or another senior member of staff will meet and answer potential service users’ queries about the home. Potential service users may visit the home, be shown around the building and have a meal. Copies of the most recent CSCI inspection report are available in the home for residents and visitors to read. In late July 2006 the Registered Manager said that the current fee charged is £685 a week. Additional charges may be considered if the person has significant extra needs. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over two separate days in July 2006. The inspection methods included discussion with service users, staff and the Registered Manager of the home, inspection of service user and staff files, as well as a range of records and policy documents. Service users and involved professionals were sent survey forms so that they could contribute to the inspection process. Responses were received from six service users and a health care professional. These responses have been taken into account in this report and the Inspector is grateful for the contributions. The CSCI also has access to information about the home gathered through notifications from the home. All of this information has been taken into account in compiling this report. The inspection was well facilitated by the residents, staff and the Registered Manager of the home who were helpful and courteous throughout the process. What the service does well: What has improved since the last inspection? Recruitment to the Deputy Manager post was underway during the inspection and the newly recruited post holder was due to start work at the home shortly after the inspection. This is a significant improvement as the post had been vacant for a long time. Visits by representatives of the managing organisation have resumed after a long gap so the residents and staff are able to make their views known as part of the overall monitoring of the quality of care provided. Love Walk, 10 DS0000007105.V299311.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. Love Walk, 10 DS0000007105.V299311.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 Love Walk, 10 DS0000007105.V299311.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, 3, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home ensures that both they and the potential resident are supplied with as much information as possible. This ensures that the resident and the home can make an informed judgement about whether the resident’s needs can be met at Love Walk. EVIDENCE: The home ensures that they are supplied with as much information as possible about a potential residents’ needs, including requesting copies of the person’s assessment by a social worker. Assessments by senior staff from the home are also carried out. In recent months additional unforeseen needs have come to light after a person’s admission to the home. In these instances the home has made significant efforts to accommodate the person’s needs and to seek the additional help required. The home has been realistic about when they are unable to meet the person’s needs and has used the appropriate systems in these cases, such as the review of placement and the trial period. Residents who recently came to live at the home confirmed that they visited before their admission, had the opportunity to ask questions, have a meal and look around the building. Love Walk, 10 DS0000007105.V299311.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, 8, 9, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The newly devised care plan system is being implemented although, the process is not yet complete. It is anticipated that the new plans will reflect residents’ needs more fully than those previously used. EVIDENCE: The Registered Manager is in the process of introducing a new format for care plans. Three care plans were examined in detail. Of these one had been partly completed in the new format, but the Registered Manager had many completed documents relevant to the implementation of the new formats for many of the residents. These documents were not in current operation but were part of the process of implementing the format. The new format includes information on residents’ social history, communication needs, information on cognition and care guidelines. There remains a substantial amount of work to be undertaken to achieve a care plan for each resident which reflects their assessed needs and goals. It is anticipated that when the management team is complete there will be a higher level of input which will assist with achieving this goal. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 10 Reviews of care plans and the placements have been taking place. In addition there were notes to show that key-workers and residents met at approximately monthly intervals to discuss their satisfaction with the way in which care is provided and with the placement generally. These are useful meetings and the records provide confirmation of the involvement of the resident in the process. These meetings and the monthly meetings of the residents’ forum are important opportunities for residents to contribute their views to the running of the home. The residents’ forum was attended by the Chief Executive of Mission Care recently and the minutes showed that residents had the opportunity to range issues of concern with him. Documents relating to risk were seen on residents’ files but some did not give adequate information on the implications for care practice of the assessed risk. For example, visual and mobility problems as sources of risk for one resident but there was no further information on how these risks would be managed or minimised. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to join in a range of activities, outings and there is consideration of their spiritual needs. EVIDENCE: Residents take part in a range of activities in the home. These include an art class; bingo games; musical entertainment and barbecues. In addition there are three televisions available for residents to watch, one in the smoking room, and the others in the two lounges. A trip to Worthing was planned for a few days after the first day of the inspection. Residents said how much they had enjoyed the trip. The number of activities in the home has increased, but some feedback was received that suggested that residents would like more activities to be arranged. Some residents attend churches in the local area and arrangements are being made for a local clergyman to come to the home to run services. Some people Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 12 attend day centres in the borough, one of which reflects the members’ cultural backgrounds. Residents confirmed that they are able to receive visits from their friends at all reasonable times. Many of the residents have telephones fitted in their bedrooms so they are able to keep in touch with people away from the home. Other residents have access to the pay phone located in a private room on the ground floor (see Environment section below). In addition there is a post box located next to the front door so residents can easily keep in touch by mail. The routines of the home are flexible. Residents can choose when to rise from and retire to bed. Some residents choose to have breakfast in their rooms rather than joining the main group in the dining room. One resident to who the inspector spoke had no key to his bedroom, nor was there a lockable space available in the room. Some others do have keys so it is recommended that an audit is conducted to ensure that all residents who are able to use, and wish to have, a key and a lockable space in their rooms are supplied with them. Residents confirmed that their privacy is respected and they can choose whether or not to join in the group activities. It was noted in minutes of a residents’ meeting that arrangements were made to assist residents to access the polling station at the most recent election in May 2006. Residents were positive about the food provided. The usual cook was unavailable for work at the time of the inspection and while there was satisfaction with the temporary arrangements residents were missing the permanent cook who, they said, knows their tastes and preferences well. There is a set menu which the cook amends to reflect residents’ preferences, cultural and dietary needs. It was noted that residents had requested at their forum meeting that a wider range of diabetic puddings be provided. The Registered Manager expressed in the meeting his commitment to ensuring that this request is made to the catering staff. Consideration of whether the menu should be changed to reflect seasonal variations was discussed with the manager and he agreed to follow this up with the catering firm. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Written information did not reflect staff knowledge of residents’ medical needs. Staff need to be sure that they carry out recommendations regarding residents’ health care needs. There has been effective involvement of health professional in residents’ care. EVIDENCE: Residents expressed satisfaction with the way that their care is provided. Some residents made particular reference to their key workers who they are fond of, trust and know well. The home has made appropriate referrals to health care professionals including community psychiatric services, optical services and podiatry services. As the care planning system is not yet fully implemented it was found that in some instances staff knowledge of residents’ medical needs was not reflected adequately in the written information in use at the time of the inspection. The information was being collated by the Registered Manager and will contribute towards the full implementation of the new care planning system. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 14 Two days before the second day of the inspection a multi-disciplinary meeting had been held about the specialist needs of one of the residents. The meeting had made a number of recommendations to monitor the on-going health of the person concerned. One of these recommendations required twice daily monitoring. On checking, it was found that this recommendation had not been carried out properly despite the minutes of the meeting being referred to during the staff handover meeting. On another file the person’s weight was being monitored using the BMI measurements (body mass index). The recording of one of the measurements was made incorrectly and the error had not been noticed by staff. On another file pressure care assessments were, in one case incomplete, in another undated. These issues indicated that staff would benefit from training in how to use the risk monitoring systems. There was positive feedback from a healthcare professional about the way in which the home manages the health care needs of residents. The main medication stocks are stored securely. Some residents are supported to manage their own medication. The GP is aware that these people do so and is in agreement with this. In one of these instances the person did not have a key with which to lock their bedroom so this compromised safe storage. In one case an instruction from a hospital about a change in a person’s medication had not been adequately implemented and recorded. This was passed on to staff for follow up. Some of the codes used on the medication administration record did not use the key stated on the sheet and this could lead to confusion. Checks of medication arrangements are carried out by senior care staff. They should record their checks to verify that they have been conducted. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were confident that their complaints and concerns are taken seriously by the home. Although complaints were recorded in residents’ meeting minutes a central record of complaints must be put in place. More regular checks of the safe contents are required. EVIDENCE: Feedback from residents was that they feel confident that their concerns are listened to and they find the staff and the Registered Manager approachable. There were no new complaints recorded in the complaints book. Some issues had been raised as concerns in the residents’ meeting. A formal record of these issues and complaints must be made along with details of any investigation, the action taken and the outcome. This record will allow management monitoring. There are procedures in place to ensure that residents are protected from abuse but there are some areas in which these could be strengthened. For example there had been no spot checks or audits of the contents of the safe (in which valuable items are held for residents) since February 2005. In addition the records of one residents’ finances, for whom, money is collected on his behalf, were not included in the manager’s usual checks of finances. There have been no matters investigated under vulnerable adults procedures over the last year. Staff were clear about the need to report issues of concern to senior staff and were clear that the manager would listen to their concerns. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 16 Information on the training received by staff in adult abuse issues, along with the adult protection procedure, should be forwarded to the CSCI for comments to be included in the final report. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The building remains in need of substantial redecoration and refurbishment. EVIDENCE: The building is suitably clean and hygienic but needs redecoration and refurbishment to improve conditions for the residents. There is an outstanding requirement that the Registered Person forward to the CSCI the plans for redecoration and refurbishment. The target date for this to be met was 1st April 2006. The need for the decorative state of the building to be improved has frequently been noted in the reports of visits to the home made by senior managers but this has not resulted in any changes or improvements being made. Of the bedrooms seen residents had personalised the rooms to varying degrees, but some would benefit from decoration. An audit should be conducted to ensure that each has lamp shades, cooling fans and that curtains are properly attached to the rails. In addition some bathrooms did not have lidded bins Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 18 It was noted on the first day of the inspection that some work had begun on the redecoration of the telephone room on the ground floor but there had been minimal progress by the time of the next visit eleven days later. The indications of this inspection were that the frequency with which maintenance staff available to work at Love Walk needs to be increased so that redecoration can be completed more quickly. There is specialist equipment available for residents’ use and this aids their development and maintenance of independence skills. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are sufficient staff to meet residents’ needs. Although the formal supervision session is not yet implemented staff report feeling well supported. EVIDENCE: The majority of care staff hold NVQ level 2 or 3. Observation and feedback from residents confirmed that staff are accessible to residents who find them approachable. There are sufficient numbers of staff on duty to meet the residents’ needs. There are five staff on duty in the morning and in the afternoon and evening there are four staff on duty. At night time there are two staff on waking night duty. On each shift a member of staff is designated to be in charge so that there is clarity about responsibilities even if a senior staff member is not on duty. At the time of the inspection there were three vacancies on the staff team, one as a Deputy Manager and two care staff. The vacancies are covered through the use of bank staff or by permanent staff working additional hours. This helps to ensure that staff are familiar with the residents and the routines, policies and procedures of the home. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 20 Staff meetings take place each month meetings showed that both residents and Executive of Mission Care attended one useful for staff to have a forum to raise organisation. and are recorded. Minutes of the staff issues are discussed. The Chief of the meetings recently and it is issues with senior managers of the In addition to the Manager and the care staff there are staff who cover the cleaning, catering and administrative duties. The maintenance team is employed to work in all of the Mission Care homes, most of which are located in the Bromley area. Staff recruitment records overall were in good order, but one file did not contain the Enhanced Criminal Record Bureau check, nor did it include a ‘POVA First’ check. The administrator agreed to follow this up as the checks were taken up by the Head Office of the managing organisation. Residents are involved in staff selection by contributing their views about potential staff members who visit the home prior to confirmation of appointment. The report of the visit by a representative of the Registered Person stated that the requirement for staff to be issued with the General Social Care Council Code of Conduct is to be followed up. Staff are issued with statements of terms and conditions. Staff training records were not examined on this occasion and a copy of the training programme for the home should be sent to the CSCI for comment in the final report. Induction is carried out by senior staff although the format for the induction programme is not documented. This is recommended. Staff said that they feel well supported and that they can approach senior staff and the manager as necessary. However the formal supervision system has not been implemented. It is anticipated that this situation will be resolved when the Deputy Manager post is filled. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 21 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, 38, 39, 42, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The management arrangements will be strengthened when the management team is full. Visits by the representative of the managing organisation have resumed. Some aspects of health and safety need improvement. EVIDENCE: The Registered Manager has been in post since June 2005. The post of Deputy Manager was being recruited to during the inspection after a significant period when the post was unfilled. This is a welcome development which should help to consolidate the management of the home. The feedback about the management style within the home was positive and the manager’s approach was described as ‘hands on’. This confirms the findings of the inspection that the manager is knowledgeable about the Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 22 residents and their needs and supportive to staff in helping them to provide appropriate care. Visits carried out on behalf of the Registered Provider have now resumed after a significant length of time. Reports of visits were seen on this inspection and copies are sent to the Commission as required. It is noted that the report format uses standards applicable for older people’s home and this omits some standards. The Registered Person may wish to consider amending the report format so that it is relevant to the standards applicable to Love Walk. Residents have access to their records and some written reports of meetings are signed by them. As noted under the appropriate standards some records need improvement, for example the complaints records, care plans and health monitoring systems. Health and safety records were examined. Maintenance staff carry out checks of the fire alarm system and conduct fire drills. The records that they complete were inconsistent and although staff and the manager have confirmed that a drill has been carried out recently this was not recorded properly. An antiseptic hand-wash called Hibiscrub is used in the home and is kept in places accessible to residents. There could be circumstances when this is dangerous to residents so it is judged that a risk assessment is required to support its use and the arrangements for its storage. There have been intruders in the building on more than one occasion over recent months. On one occasion they entered the building through a window on the upper floor which was open to provide ventilation during the hot weather. There must be a review of security arrangements to ensure that this risk is reduced. Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 23 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 3 X 2 X X Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement The Registered Person must ensure that care planning systems are improved by the recording of service users’ aims and goals and strategies employed by the home to support them to achieve them. Although action has begun to comply with this requirement it is not yet met and a new date for compliance is set. 2. YA19 18(1)(c) (i)&(2) The Registered Person must ensure that staff receive management input on the purpose and value of recording systems, and that these are monitored through supervisory and other quality control systems. The previous timescale of 01/06/06 is not met. A new date for compliance is set. 01/10/06 Timescale for action 01/01/07 Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 25 3. YA30 23(2)(b)(d) The Registered Person must forward to the CSCI the plans for redecoration and refurbishment for the next year. This requirement was to be met by 01/04/06, this was not met, a new date for compliance is set. 01/10/06 4. YA36 18(2) The Registered Person must ensure that all staff are appropriately supervised. This requirement was to be met by 01/04/06, this was not met, a new date for compliance is set. 01/10/06 5. YA9 13(4)(b) The Registered Person must 01/10/06 ensure that there are for the resident for whom visual and mobility problems were identified as sources of risk for that a risk assessment is carried out detailing how these risks would be managed or minimised. 6. YA19 7. YA20 12(3) & 13(1)(b) The Registered Person must 01/10/06 ensure that health monitoring is carried out properly and any necessary training provided for staff. 13(2) The Registered Person must 01/10/06 ensure that checks of medication stocks and records are recorded. 17(2)sch4para11 The Registered Person must 01/10/06 ensure that a formal record of complaints is kept along with details of any investigation, the action taken and the outcome. 8. YA22 Love Walk, 10 DS0000007105.V299311.R01.S.doc Version 5.2 Page 26 9. YA42 23(4)(e) 10. YA42 13(4)(a) 11. YA42 13(4)(a) The Registered Person must 01/10/06 ensure that fire drills are recorded accurately and fully. The Registered Person must 01/10/06 ensure that a risk assessment is conducted and documented to support the use of Hibiscrub and the arrangements for its storage. The Registered Person 01/10/06 must ensure that a review of security arrangements is carried out to ensure that the risk of intruders is reduced. The Registered Person must 01/10/06 ensure that spot checks or audits of the contents of the safe are carried out and the manager’s checks of finances include all matters in which staff are involved. 12. YA23 13(6) 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 YA16 Good Practice Recommendations The Registered Person should ensure that an audit is conducted to ensure that all residents who are able to use a key and a lockable space in their rooms are supplied with them. The Registered Person should consider taking steps to ensure that the format for the induction programme is documented. The Registered Person should consider amending the report format used for visits made under Regulation 26 of the Care Homes Regulations so that it is relevant to the standards applicable to Love Walk. DS0000007105.V299311.R01.S.doc Version 5.2 Page 27 2. 3. YA35 YA39 Love Walk, 10 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Love Walk, 10 DS0000007105.V299311.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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