Inspection on 30/01/06 for Manor Green Road (62)

This inspection was carried out on 30th January 2006.

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 no outstanding requirements from the previous inspection report, but made 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Green Road (62) 18/01/07

Manor Green Road (62) 20/09/05

Manor Green Road (62) 05/10/04

Manor Green Road (62) 12/05/04

Similar services:

Southfields

Thorndene

Insight - Eastchurch

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Manor Green Road (62) 62 Manor Green Road Epsom Surrey KT19 8RN Lead Inspector Suzanne Magnier Unannounced Inspection 30th January 2006 13:20 Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 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 Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manor Green Road (62) Address 62 Manor Green Road Epsom Surrey KT19 8RN 01372 726131 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CMG Homes Ltd Mrs Rosaleen Ann Leen Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 29 - 65 YEARS One person may be over the age of 65 years Date of last inspection 20th September 2005 Brief Description of the Service: 62 Manor Green Road is a converted detached property providing accommodation for five service users with a learning disability. The home is located in a quiet residential area of Epsom and has easy access to shops, public transport and other local amenities. The accommodation is provided over two floors. All bedrooms are single rooms with two rooms with en-suite facilities. The communal areas consist of a medium sized lounge, dining room and kitchen/diner area. There are suitable bathroom facilities provided and the home has a large, secure garden to the rear of the property. There is space for one car to park off-street at the front of the property and ample on-street parking. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 3 hours and was conducted with a senior support worker on duty. One resident was at home during the inspection and their comments have been included within the report. A tour of the premises took place and documents inspected included one care plan, risk assessments, menus, medication administration records, health and safety records, and staff records including the staffing rotas. The inspector would like to thank the resident who assisted with the inspection and the member of staff on duty for their time, assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: It is required that the Statement of Purpose be updated to reflect the current staffing arrangements in the home. A requirement has been made that all resident’s files are stored to respect the individual’s rights to privacy and confidentiality and ensure that resident’s risk assessments related to their achievements and goals are reviewed and updated. During the tour of the premises the inspector observed that the bed for staff sleep in duties was permanently situated in the resident’s dining room. The Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 6 inspector raised serious concern and an immediate requirement was made regarding this arrangement, which infringes the rights for residents to have choice in their home and does not provide a suitable and appropriate dining area, separate from the resident’s private accommodation. The Registered Person must give notice to the C.S.C.I without delay of any event in the care home, which adversely affects the well-being, or safety of any resident and risk assessments must be implemented and regularly reviewed where hazards to the health and safety of residents or their belongings have been identified. It has been required that the home is conducted so as to encourage and assist staff to maintain professional conduct and observe safe practice regarding health and safety in the workplace. The inspector noted that the kitchen was in a state of disrepair with drawers broken, kick boards and kitchen cupboards damaged. A requirement has been made that the kitchen units are repaired or replaced in order to ensure the safety and well being of all people using the kitchen. Immediate requirements were made that the Registered Person must submit a documented plan of action to CSCI local Eashing office detailing the proposed day-to-day management arrangements, staffing levels and details of the practice of staff working excessively long hours must be reviewed immediately to ensure both the welfare of staff and residents. Several requirements have been made regarding health and safety in the home which include that all food must be stored and handled appropriately and in accordance with Food Safety Hygiene Regulations and all cleaning materials must be stored in a locked facility at all times in line with the ‘Control of Substances Hazardous to Health Regulations’ (COSHH) guidance. 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. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Prospective residents wishing to live at the home are offered support to visit and stay at the home prior to moving and a full assessment of the person’s needs and lifestyles are assessed and documented. It is required that the Statement of Purpose be updated to reflect the current staffing arrangements in the home. EVIDENCE: The home currently has one vacancy as a resident had recently moved to live more independently within the Care Management Group (CMG) Supported Living services. The inspector sampled the statement of purpose which clearly detailed that prospective residents will know that the home they choose will meet their aspirations through a thorough assessment of their lifestyle and needs. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 9 The senior member of staff advised the inspector that any resident wishing to move to the home would be supported to visit the home, have meals and also stay overnight and weekends if they choose to. Whilst sampling the Statement of Purpose the inspector noted that it indicated that two members of staff were on duty on each shift. The senior member of staff told the inspector that the home does not have two staff on duty at one time. It is required that the Statement of purpose be updated to include the current staffing arrangements in the home. During the inspection the inspector raised concern regarding the staffing arrangements, which are further examined in Standard 33 of this report. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10. It was evident that the home supports and encourages residents to have their say about their home and residents are encouraged to achieve specific goals in their lives. A requirement has been made that all resident’s files are stored to respect the individual’s rights to privacy and confidentiality. EVIDENCE: The resident at home during the inspection told the inspector that they have meetings to discuss ‘things’ in the home, the resident said she did not like to attend so doesn’t join in but is told all about things afterwards. The inspector noted that the resident moved freely around her home and cooked her own ready meal, using the microwave. She told the inspector that Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 11 she has roast chicken, vegetable and roast potatoes every day and cooks it herself. During the course of the inspection the inspector noted that residents personal files and daily records were left in the kitchen and in the dining room on the table. A requirement has been made that all resident’s files are stored to respect the individual’s rights to privacy and confidentiality. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. The home must review the current staff sleeping in arrangements as currently the residents dining room is being used for staff sleep in duties and infringes the rights of residents in their home. It is recommended that the current dual Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 13 documentation of menus be revised in order to offer clarity regarding meals served. EVIDENCE: The senior member of staff showed the inspector a menu book, which described the date, type of meals, which had been prepared, served and temperatures checked by staff. The inspector noted that the menu on a board in the kitchen stated the day of the week but not the date. It is recommended that the dual system for recording meals is reviewed in order that any person inspecting the records are able to determine whether the diet is satisfactory in relation to nutrition and if any special diets are prepared for residents. The senior staff member told the inspector that two residents have a set menu, and despite encouragement to change and experience different food the residents have chosen to keep their current menu. During the tour of the premises the inspector observed that the bed for staff sleep in duties was permanently situated in the resident’s dining room. The staff member explained that only one resident uses the dining room to eat their meals whilst the other residents use the kitchen. It was noted that the table in the kitchen could accommodate 2 residents if they chose to eat their meal there. The inspector raised serious concern and an immediate requirement was made regarding this arrangement, which infringes the rights for residents to have choice in their home and does not provide suitable and appropriate dining space, separate from the resident’s private accommodation. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The inspector observed that staff promote residents personal achievements. It is required that resident’s risk assessments related to their achievements and goals are reviewed and updated. EVIDENCE: The resident explained to the inspector that recently she had started taking her own medication with staff support and was excited about the responsibility and achieving this goal. The inspector sampled the residents care plan which clearly indicated that staff were assisting the resident and risk assessments had been completed in order to ensure the safety and well being of the resident. It has been required that the risk assessment is reviewed and updated as the inspector noted the document had not been reviewed since it began in March 2005. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. The Registered Person must give notice to the C.S.C.I without delay of any event in the care home, which adversely affects the well-being, or safety of any resident and risk assessments must be implemented where hazards to the health and safety of residents or their belongings have been identified. EVIDENCE: Whilst sampling a residents financial records and in discussion with the senior staff member the inspector was advised that one resident prefers staff to look after their money due to another resident, in the past stealing their money. The staff member explained that staff were able to retrieve the money stolen. The inspector was advised that the incident had not been reported to the residents Care Manager or the Commission for Social Care Inspection (CSCI) to clarify if a referral should be made under the Local Authority (i.e. Surrey County Council) Multi Agency Procedures for the Protection of Vulnerable Adults. The inspector has advised that the Registered Manager contact the residents Care Manager and CSCI to retrospectively advise them of the incident which occurred in September/October 2005 and risk assessments be documented and regularly reviewed regarding the safekeeping of residents money. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 16 The inspector was told that all staff were aware that there was a potential for one resident to steal another residents money. No risk assessment had been documented regarding this identified hazard and a requirement has been made that this is implemented within the timescales set in order to ensure the safety and protection of resident’s property. The inspector sampled two resident’s financial transaction sheets and the homes petty cash system. The recording of transactions was of an appropriate standard and no discrepancies were found. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,30. The home is clean, homely and tidy. Several requirements have been made regarding issues of health and safety and repairs in the kitchen. EVIDENCE: On arrival at the home the inspector noted that the senior staff member in charge of the home was inappropriately dressed as she not wearing anything on her feet (i.e. was bare foot). It has been required that the home is conducted so as to encourage and assist staff to maintain professional conduct and observe safe practice regarding health and safety in the workplace. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 18 The home was noted to be clean and hygienic. New carpet and curtains had been purchased for the dining room, which the resident told the inspector they liked in the room. The resident at home told the inspector that they liked their bedroom and had got new bedding and curtains, which they had chosen. A vacant room was seen by the inspector, which included all the furnishings to meet the standards. The toilets and bathrooms seen by the inspector were clean and hygienic and currently suitable for the needs of the residents. As previously documented concern was raised regarding the current use of the residents dining room as a staff sleep over room. The resident’s lounge was clean, bright, homely and well decorated. Leisure activities included TV, music systems and comfortable furnishings, framed pictures and ornaments. The kitchen was observed to be clean yet the planned refurbishment had not taken place in October 2005. The inspector noted that the kitchen was in a state of disrepair with drawers broken, kick boards and kitchen cupboards damaged. A requirement has been made that the kitchen units are repaired or replaced in order to ensure the safety and well being of all people using the kitchen. The inspector sampled fridge and freezer temperature charts which staff are documenting and were within the appropriate limits. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36. Immediate requirements were made that the Registered Person must review the present staffing levels and the practice of staff working excessively long hours be reviewed immediately to ensure both the welfare of staff and residents. Records indicated that the Deputy Manager undertakes effective staff support and supervision. EVIDENCE: The Registered Manager was not present during the inspection at the home. The one resident in the home identified that the senior support worker was in charge of the home and was available if the resident needed any assistance or support. The inspector observed a relaxed and supportive response between Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 20 the staff member and the resident. The resident told the inspector ‘the staff are kind, they are my friends and I get the newspaper for them’. The inspector asked the senior support worker to clarify the staffing arrangements of the home and was advised that she was on her own on duty with an on call person available. The inspector sampled the staffing rosters, which reflected the practice of staff being on duty for a continual period of up to 43 hours, for example commencing duty on 29.1.06 at 14.00hrs and ceasing duty on 1.2.06 (the shifts also included 2 sleep over duties). It was noted that the week commencing 9.1.06 the Deputy Manager had worked 58.5 hours including several sleep over shifts in one week. The member of staff on duty explained that the long shifts were being worked to cover a staff members special leave. It was also noted that staff contracted hours were not recorded on the rosters. Immediate requirements were made that the Registered Person must review the present staffing levels and the practice of staff working excessively long hours be reviewed immediately to ensure both the welfare of staff and residents. The senior support worker told the inspector that the Deputy Manager supervised her work and offered support, which was appreciated by the member of staff. The inspector sampled the staff member’s file and noted that supervisions were regularly attended and the staff member’s mandatory training was all up to date Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,42. The Registered Person must submit a documented plan of action to CSCI local Eashing office detailing the proposed day-to-day management arrangements of the home. Several requirements have been made regarding health and safety in the home. EVIDENCE: Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 22 The staff rosters sampled by the inspector did not include the hours worked in the home by the Registered Manager. The inspector was advised that the Registered Manager has additional responsibilities and works in another Care Management Group (CMG) Registered Care Home and visits 62 Manor Green Road. An immediate requirement has been made that the Registered Person must submit a documented plan of action to CSCI local Eashing office detailing the proposed day-to-day management arrangements and staffing of the home in order to ensure the safety and wellbeing of all the persons within the care home. It was observed by the inspector that chemicals had been left unattended on the worktop in the kitchen presenting a potential hazard to the safety and well being of service users. An immediate requirement was made that the Registered Person must ensure that all cleaning materials must be stored in a locked facility at all times in line with the ‘Control of Substances Hazardous to Health Regulations’ (COSHH) guidance. Fresh fruit and vegetables were available in the kitchen for the residents. Whilst sampling the fridge contents the inspector noted that several packages of food in the refrigerator had been opened and not labelled and one opened packet of sliced meat had passed the use by date. Am immediate requirement has been made that all food must be stored and handled appropriately and in accordance with Food Safety Hygiene Regulations. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 2 2 X 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 X 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 2 29 N/A 30 2 STAFFING Standard No Score 31 3 32 X 33 1 34 X 35 X 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 X 38 2 39 X 40 X 41 X 42 1 43 X X 3 3 X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Green Road (62) Score X X 2 X DS0000013524.V276173.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA1OP1 Regulation 4&5 Sch1 Requirement The Registered Person must ensure that the homes Statement of Purpose is updated to reflect the current staffing arrangements in the home. The Registered Person must ensure that all resident’s files are stored to respect the individual’s rights to privacy and confidentiality. The Registered Person must review the current use of the residents dining room for staff sleep in arrangements and take into account the residents rights to choice, dignity and respect in their home. The Registered Person must ensure that resident’s risk assessments related to their achievements and goals are updated. The Registered Person must give notice to the C.S.C.I without delay of the occurrence of any event in the care home which adversely affects the well-being or safety of any resident and DS0000013524.V276173.R01.S.doc Timescale for action 14/02/06 2. YA10OP37 12.(4)(a) 14/02/06 3. YA17 OP15 23(2)g) 2(1)(34)a) 30/01/06 4. YA20OP9 13.(4)(b) 30/01/06 5. YA23OP35 OP18 37(1)(e) &13(6) 30/01/06 Manor Green Road (62) Version 5.1 Page 25 6. YA23OP35 OP18 13(4)c 8. YA24OP26 12(5)(b) 9 YA28OP19 13(4)(a) 10 YA33OP27 18(1a) 17(2)4(67)e) 13(4)c 17(2) 6(e) 11 YA33OP27 12 YA38OP32 38(2)(ae) make arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered Person must ensure that where an identified hazard i.e. financial abuse is recognised the current risk assessment must be reviewed in order to ensure that risk is managed as far as reasonably practicable and staff have clear procedures of reporting any incidents. The Registered Person must ensure that the home is conducted so as to encourage and assist staff to maintain professional conduct and observe safe practice regarding health and safety in the workplace. The Registered Person must ensure that the kitchen units are repaired or replaced in order to ensure the safety and well being of all people using the kitchen. The Registered Person must review the present staffing levels to ensure both the welfare of staff and residents. The Registered Person must ensure that the practice of staff working excessively long hours be reviewed immediately to ensure both the welfare of staff and residents. The Registered Person must submit a documented plan of action to CSCI local Eashing office detailing the proposed day-to-day management arrangements and staffing of the home in order to ensure the safety and wellbeing of all the persons within the care home. DS0000013524.V276173.R01.S.doc 30/01/06 30/01/06 30/02/06 30/01/06 30/01/06 30/01/06 Manor Green Road (62) Version 5.1 Page 26 13 YA42OP38 13 (4) 14 YA42OP38 13(4)(a) (c) The Registered Person must 30/01/06 ensure that all cleaning materials must be stored in a locked facility at all times in line with the ‘Control of Substances Hazardous to Health Regulations’ (COSHH) guidance. The Registered Person must 30/01/06 ensure that as far as reasonably practicable the home is free from hazards to residents safety and unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. All food must be stored and handled appropriately and in accordance with Food Safety Hygiene Regulations. 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 YA17OP15 Good Practice Recommendations It is recommended that the current dual documentation of menus be revised in order to offer clarity regarding meals served. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Manor Green Road (62) DS0000013524.V276173.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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