Inspection on 24/02/06 for Mawney Road

This inspection was carried out on 24th February 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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mawney Road 08/08/06

Mawney Road 27/09/05

Mawney Road 23/02/05

Mawney Road 21/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Mawney Road 89 Mawney Road Romford Essex RM7 7HX Lead Inspector Mr Roger Farrell Unannounced Inspection 24th February 2006 11:00 Mawney Road DS0000027864.V284456.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 Mawney Road DS0000027864.V284456.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 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. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mawney Road Address 89 Mawney Road Romford Essex RM7 7HX 01708 741388 01708 741 388 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mrs Brenda Netto Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: 89 Mawney Road is a care home that provides accommodation and support with daily living for six people who have profound learning disabilities, most of whom do not communicate using words. Opened in 1994, all six residents moved in during the first year. It is run by ‘Milbury Care Services Limited’ (which is part of the ‘Paragon Healthcare Group’), a company who run about two hundred and fifty care homes nationwide. This house is on large corner plot in a residential neighbourhood, set well back from one of the main roads that run into Romford town centre. Positive points are good living space - including large shared rooms, and each person having their own big bedroom; a well maintained and equipped garden; and a car park that makes it easy for residents who need wheelchairs outside to use the home’s minibus. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 11.50 and 4.15pm on 24 February 2006. The major change is that Brenda Netto, the registered manager left on 25 November 2005. She had worked at the home since it opened twelve years earlier. The deputy manager is acting as manager. The other change is that the company’s only other home in the area - Urswick Road, Dagenham - had closed six weeks earlier. Some of the staff from that home had transferred to Mawney Road. Most of the core standards were checked at the last visit. A copy of that report is available at the home, or can be seen at www.csci.org.ok. The main purpose of this recent visit was to check on compliance with the requirements set in the last report; to look at the support arrangements for those residents whose physical dependency needs have increased; to see what opportunities residents have to be involved in social and leisure activities; and to check the building, including bedrooms. The acting manager and senior support worker were both off duty. They had been part of the team who had accompanied a resident to hospital the previous day for major dental surgery. A support worker who has been at the home for four years took a lead in dealing with the inspector’s enquiries. Another support worker joined them for the feedback, and took notes on the paperwork the inspector asked to be provided. What the service does well: What has improved since the last inspection? The last report said – “Mawney Road has the three main elements that usually make a home successful – an experienced competent manager; a well-trained and enthusiastic team; and a spacious house that is well suited to the needs of the service users.” Comments from residents’ families and health care workers confirmed the consistently positive view of this service. However, all three of these key elements have been affected by change. Establishing leadership in a team that had the same highly regarded manager for twelve years is a proving to be a challenge. This is not easy as it corresponded with the introduction of Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 6 changes to the shift pattern that established staff see as problematic. Further, a couple of posts were kept vacant allowing staff to do some extra hours. Three posts have been filled by staff transferring-in following the closure of the Urswick Road home. This report also raises some issues to do with the facilities, such as using specialist equipment as dependency levels increase, and residents’ personal money being used to carry out home improvements. One particular example is of concern. A chalet with a hot-tub was installed in the side garden, paid for out of the inheritance of an elderly resident. Another of her relatives had confirmed the order, by implication giving consent for such a large purchase. This new luxury addition was said to be popular, with five residents having used it for a short period after it was installed. However, at the last visit in September 2005 it was not being used as replacement filters were needed. The inspector found that five months later it was still not working, and the chalet was being used as a storeroom for equipment and furniture from the home that had closed. This gives rise to queries about how residents are being guided on using their money. Although it was very late arriving, an action plan was received saying that the three requirements set in the last report had been tackled. This was not the case: care plans were not being kept up-to-date, and at least three residents had not had a review in the past year; medical contact sheets were still not being used consistently; and paperwork agreeing how residents’ money is used to improve the building could not be provided. 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. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 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 Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 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): 1. The use of pictures and photos show good efforts to help make main documents understandable. There have been no vacancies for over ten years, but there are guidelines that say how a new person would be helped move in if a vacancy occurred. EVIDENCE: There is a ‘statement of purpose’ folder that contains all items that need to be included. One resident is 83, and needs some assistance moving around. She has a large bedroom on the ground floor, and now spends most of her time in her room. There are good adapted bathing facilities. How this older person’s needs are met is covered in the statement of purpose. One other resident now needs greater help moving about indoors. There is also a well-produced pictorial‘ service users’ guide’ which makes good use of photos and contains comments by service users. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 9 Some staff have known the residents even before they moved to this house twelve years ago, as was the case with the former manager. Files have carried forward some assessment schedules used as part of the move-ins, but these are of little use these days given changing patterns of need. Should a vacancy occur, there is an assessment procedure that would be used to plan the transition, copies of which are available as part of the company’s policy catalogue. This says that staff would work closely with the prospective resident’s family or other representative; include trial visits and stays; and a review meeting would be held after the initial settling-in period. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Previous reports have said that a good system of recorded care planning was in place. This is no longer the case. Changes were being introduced in how personal information is arranged, but most of the examples seen at this visit were out-of-date, lacked detail, or were blank. Managers need to be concerned as this is a significant step backwards. EVIDENCE: Previous reports have said that there were well-arranged service user files giving details of individual needs and the support provided. These included ‘Individual Personal Plan (IPP) files’; the individual ‘Personal Diaries’ with three good entries made each day; The ‘Goal Sheet File’; and the ‘Daily Monitoring Sheets File’. The conclusion was that the system provided good details on the practical day-to-day support needs of individuals. The only problem was a need to make sure that the main files in the office were kept up-to-date with the working files used downstairs, such as the main care instructions being reviewed. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 11 The last report set a requirement asking that each element of service users’ care plans be reviewed at least once a year. Checking on this matter at this visit threw up a number of problems. • One individual planning review record requested was satisfactory. This was a detailed typed review with comments under a good range of headings. However, this review had been carried out ten months earlier, and that person’s needs had changed over recent months, indicating a need to call a review. More so, the most recent review record for the highest dependency resident was over two years old. That had involved contact and confirming consents with a ‘next of kin’ who had now passed away. As best as could be established, two other residents had not had reviews within the last year. Therefore, this requirement is not met, and is carried over. The detailed ‘IPP Files’ kept in the upstairs office were set up a couple of year’s ago, but it appears that there have been little worthwhile additions over recent months. The main day-to-day working files are the ‘personal folders’ kept downstairs. These were undergoing a change, there being a new index sheet saying what should be included. However, most of the sections were blank, with entries in some key sections being very basic. Daily observations are now kept in these files rather than in diaries. There were some updated risk assessments. Whilst it is accepted that the format for practice records was undergoing change, the samples seen whilst looking at specific care needs was very poor. The medical tracking sheets show how basic monitoring systems are lapsing. These are designed to be a running record of contacts with medical practitioners. A requirement was set in the last report saying these needed to be used. Some GP sheets had entries, but those for other health care were mostly blank. For instance, the last entry on the dental sheet for the resident who had surgery the previous day to extract fourteen teeth was over a year old – correspondence seen by the inspector showed that there had obviously been considerable consultations and preparations leading up to such major treatment. • • Based on the findings at this visit, it has been necessary to set further requirements on the need to have in an adequate system of care plan documentation. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 12 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 and 16. This home can no longer demonstrate that it is helping residents have opportunities to be involved in varied and worthwhile social and leisure activities. Other than the odd reference in day-to-day notes, there is no forward plan or individual programmes. A general activities programme on display promises a lot more than is provided. EVIDENCE: Enquiries about these standards also gave rise to concerns. The section covering activities in the new ‘personal folders’ were still blank. Enquiries at the visit indicated a significant reduction in chances to go out and use community facilities. In some instances this has been due to ill-health, but descriptions showed an overall reduced and more limited span of activities. The inspector asked for examples of each person’s recent opportunities. Those with the least dependant needs do go out a couple of times a week. This is mainly to shops and cafes in Romford, or for walks in a park. One person goes to bingo occasionally. Beyond this, there were no examples of activities other than one person who visits her family at weekends, and other family contacts. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 13 The inspector asked for details of any holidays and leisure activities to be sent to him, but these were not provided within a reasonable time. At the visit a description was given of each person’s contact and links with their family. This includes two residents being accompanied to visit their families at times. One resident has a home visit from a reflexologist once a month. Given the lack of records, and based on the information available the inspector is obliged to record four of these standards as not achieved. Some indications are of significant concern, such as the suggestion that women residents are not being helped go to the hairdressers as frequently as has been the case over many years. One suggestion was that the decline in helping residents go out was because of a shift change that has removed what was a generous ‘overlap’ time between the morning and afternoon shifts. Another additional reason cited was the reduction to three in the number of staff who can drive the home’s vehicle. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Inspectors have consistently found high standards in the way residents are helped with their with personal care. All residents were again well presented. Other positive signs included assistance with clothes care and how bedrooms are maintained. But the problems with keeping care records emerged as a main theme that is letting the side down. This applies to the important area of health care monitoring, which can no longer be regarded as adequate. EVIDENCE: Descriptions of the support residents receive from all health care professionals have been consistently positive over recent years. This includes the help provided by the GP practice where all residents are registered. On one occasion in the past the top ‘commendable’ score was given for the quality of the health care monitoring, including how this was recorded. This included the ‘The OK Health Check List’; the health care plan; medical letters and forms; and the health profile pictorial booklets completed by the community nurses. However, lapses were found at the last visit in September 2005, such as not using the medical contact sheets. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 15 Yet assurances were given that possible medical needs were always followed through. For instance, one resident’s periods of distress were being linked with possible pain due to dental problems. In the past he has needed extra arrangements due to his fear of medical settings. His family had praised the way the team had dealt with achieving treatment. This person had now undergone dental surgery the day before this inspection visit. A team of three, including the manager and senior had been with him through his hospital visit. Staff were attentive to monitoring him, and making sure he was not showing signs of distress. He was able to indicate to the inspector that he was comfortable. Yet the inspector was not happy with the information available on two other residents’ medical needs. An updated position could not be given on one person’s heart condition, and how this may have been implicated with the need for some short hospital admissions where a possible stroke was suspected. This person was described as remaining alert, but has experienced a loss of strength that affects her mobility. Further, details covering pressure sore prevention for another person were not adequate. It is stressed that this person was having daily visits from community nurses, and their reports gave satisfactory details on treatment and healing. Nevertheless, the home’s records and staff awareness were not up to scratch. Staff said there had been a ‘basic briefing’ on pressure sore care - but no guidance could be located; care note entries were limited to the briefest of instructions such as “Watch for pressure sores”; and understanding of the use of pressure-reliving equipment was poor. It needs to be a cause for serious concern that the rating for the medical standard has dropped from the top ‘commendable’ to the bottom ‘not met’ rating over three inspection visits. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is sufficient awareness, and guidance to make sure the right steps are taken if there is a complaint or concern. EVIDENCE: The company’s guidance and procedure on making complaints are available. Duty staff were able to locate the ‘The Milbury Complaints Book’. There is also a pictorial version of a complaints procedure attached to the service users’ guide. There has been one entry over the last year – a complaint from a neighbour that was dealt with amicably. A further note had been made about a problem with a tree at the front of the house, but this was not an issue effecting residents. There is an up-to-date policy and procedure on responding to allegations and suspicions of abuse. This makes reference to ‘No Secrets’ and the need to follow the local guidelines, a copy of which is available. In the past appropriate action was taken following a worker raising a concern. All staff have been given a copy of the ‘General Social Care Councils’ Code of Practice. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 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 and 30. This house has plenty of space, including large single bedrooms. High standards of cleanliness and safe arrangements are found at all visits. Staff have helped make this a comfortable and homely setting for residents. However, the inspector wants to see better accountability regarding how residents’ money is used on the upkeep of their bedrooms and other improvements. More thought now needs to be given to the need for aids and adaptations to help those with decreasing mobility. EVIDENCE: This home has generous space. The combined area of the kitchen/diner and large lounge considerably exceed the minimum levels. The communal rooms are well decorated and furnished. Three residents use wheelchairs for going out. There is wide ramp access with sturdy support rails at the back of the house. There is also ramped access to the front door. The inspector looked at all bedrooms. These are all big, ranging in size from 16.4sqm to 21.5sqm. They have all had tasteful makeovers, including new beds, furnishings and fittings. These have been designed to reflect the tastes and interests of each resident. This includes the person whose behaviour results in higher wear and tear. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 18 However, there are a number of problems: • Some of the furniture has not been assembled fully in line with the instructions, meaning that there are a few safety considerations such as tops of units not being secured; There are problems with two peoples’ beds. In one case the threequarter railed surround is suspected of having caused bruising, yet there were no definite plans to fit buffer cushions. Staff could not demonstrate how another resident’s specialist ‘tilt and rise’ bed worked. There was an assumption that it may have broken; whether had a ripple effect; and what were the considerations regarding its use given that resident is susceptible to pressure sores. Further, a pressure relieving mattress cover had been bought, but remained in its packaging with no indication if this was compatible or advised. Residents have paid for their bedroom upgrades, including all new fixtures and fittings, and for the decoration. At the last visit the inspector was given assurances that this personal expenditure was discussed and agreed with a suitable representative on behalf of each resident. He said that he wanted to see evidence of this on each person’s file, such as in the minutes of reviews. No such evidence was readily available at this visit. There is also an issue about landlord/tenancy expectations regarding paying for, or contributing to normal ’wear and tear’ redecoration and replacement. The inspector is also concerned about another areas where a resident’s money was used to pay for a hot-tub chalet, as raised in earlier in this report. • • • There is good attention to safety, such as radiator covers; thermostatic safety valves on wash-hand basins; and first floor window openings are restricted. All bedrooms have suitable locks, but no resident is able to use a key. The bathrooms are also large, there being one on the ground floor, and two on the first floor. The ground floor bathroom has a fixed electric chair hoist. There is ceiling tracking in this bathroom, but this is not needed at present. As with other parts of the house, staff have added homemaking touches and there is a consistently good attention to detail. There is a well maintained garden with features such as swing benches; raised flower beds; a vegetable area; and plenty of seating including a delightful ivy clad pagoda covering the outside dining area. The neglect involving the whirlpool detracts from this record of providing such good facilities. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 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): 0. These standards were covered at the last inspection. They will be checked at the next visit. EVIDENCE: At this visit it was fond that the pattern of cover had changed. The generous hour and a half overlap between the early and late shifts has been stopped; and the handover period at the start and end of the day have been cut. Cover is still three people on each of the early and late shifts (now 7.15am to 9.15pm); night cover being one person awake, and one on sleeping-in. How the shift changes have affected the total care hours, formally 479, including 20 hours of the manager’s time, will be discussed with managers. Recent rota’s showed the occasional ‘long-day’. Staff said that these are always voluntary, and now must involve taking an hour lunch break. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 20 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 and 42. It was not possible to cover all the core standards in this section at this visit as there was not a manager on site. EVIDENCE: Some of the safety records and certificates the inspector asked to see were available. This included the fire log showing the weekly and contractor tests of equipment and a recent drill; and electrical safety certificates. The inspector asked for copies of other paperwork to be sent - such as gas and water certificates and the last visit by an EHO – but these were not received ahead of this report being issued. The same high level of cleanliness and general household standards were again found. Safety issues pointed out are those already raised above, including completing the assembly of bedroom furniture, and better attention to making sure that beds are safe for their purpose. Some safety records are being maintained, such as temperature monitoring in the kitchen, but the main monthly health and safety checklists had not been done since August 2005. The company’s operations manager does a monitoring visit, and sends a copy of her report to the Commission. Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 21 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 X X 2 X X X X X 2 Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes – Items 1 to 3 are carried forward from the last report. 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 14; 15 Requirement Make sure that there is a record that each element of service users’ care plans are reviewed at least once a year. (Original date to achieve compliance was 28/11/05) It is advised that the medical tracking sheets for each type of practitioner are reintroduced, and as appropriate, monitoring sheets such as weight charts are kept up-to-date. (Original date to achieve compliance was 28/11/05) Double check that there is documentation that confirms consent for residents’ own money to be spent on items such as new furniture, bedroom fittings, and covering the cost of redecoration. (Original date to achieve compliance was 28/11/05) Have available an up-to-date care plan for each service user. Include in care plans opportunities to assist residents develop and retain life skills, including those provided at skills and education centres. DS0000027864.V284456.R01.S.doc Timescale for action 24/04/06 2. YA6 15 24/04/06 3. YA7 15(2)(c) 24/04/06 4 5 YA6 YA11YA12 15 12(1)(b) 24/04/06 24/04/06 Mawney Road Version 5.1 Page 23 6 YA13 16(2)(m) 7 YA14 16(2)(n) 8 YA19 13(1)(b); 15 9 10 YA26 YA29 12(1)(a) 23(2)(n) 11 12 YA37 YA42 8; 9 12 13 YA42 12 Include in care plans the support to be provided to help residents use a range of community facilities. Have available a record that sets out how residents are supported to be involved in social and leisure activities. Include in care plans sufficient information on physical health, including details of any additional support and treatments. As appropriate, this must include monitoring of skin viability, and prevention arrangements such as the use of equipment. Make sure furniture in bedrooms is assembled correctly and safely. Make sure residents are provided with beds that are appropriate to their needs. This must involve written instructions and providing staff with instruction on the safe use and operation of special features. Provide an application to register a manager. Have available for inspection the required range of safety certificates and records, including: • A gas safety certificate; • Water safety tests; • Reports provided by EHOs. Carry out the regular health and safety checks of the building, rounds and vehicle - and keep a record, including the action taken to deal with defects. 24/04/06 24/04/06 24/04/06 24/04/06 24/04/06 10/04/06 10/04/06 10/04/06 Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mawney Road DS0000027864.V284456.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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