Inspection on 05/01/06 for Millenium Care (Old Park Road)

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millenium Care (Old Park Road) 23/10/06

Millenium Care (Old Park Road) 19/07/05

Millenium Care (Old Park Road) 20/12/04

Millenium Care (Old Park Road) 06/04/04

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 Millenium Care (Old Park Road) 1 Old Park Road London N13 4RG Lead Inspector Rebecca Bauers Unannounced Inspection 5th January 2006 10:00 Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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 Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Millenium Care (Old Park Road) Address 1 Old Park Road London N13 4RG 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) 020 8447 8897 Millenium Care Mr Lalith Katugampola Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who is now a wheelchair user may remain accommodated in the home. The home must advise the registering authority at such times as the specified service user vacates the home. 19th July 2005 Date of last inspection Brief Description of the Service: This home is registered for ten adults who have a learning disability. At the time of the inspection there were no vacancies at the home. Millenium Care operates this and another local home for adults with learning disabilities. The home is situated close to local shops, public transport and other local amenities, including Palmers Green station and Broomfield Park. The home has ten single bedrooms, none of which have en-suite facilities. There is an adequate number of communal areas and bathrooms. The home has a large garden, which is used by service users. There is a programme of daytime activities provided by the home for service users not attending local day services. Significant use is made by service users of the local community resources. The stated aims of the home are: 1 Old Park Road provides 24-hour care and support to ten adults with learning disabilities from 18-65 years of either sex. Our goal is to promote independence and to ensure that privacy and dignity are maintained at all times. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 5th of January 2006 as part of the annual inspection programme to identify progress with previous requirements and to check standards of care against the core standards. The inspection took four hours to complete. A partial tour of the home took place; three service users were spoken to individually. No relatives visited the home on the day of the inspection. Care records including medication, staff records and health and safety records were examined. Two staff were spoken to, the registered manager was present throughout the inspection. Further information was obtained from the pre-inspection questionnaire sent out routinely to registered services and the surveys distributed to service users by the Commission. Positive comments were given with regard to the care received by service users, some commented that they would like more involvement in the running of the home. What the service does well: The service users benefit from annual reviews and person centred individual plans ensuring that their needs are met and that staff are supporting them in the way they prefer to promote independence. Service users continue to benefit from fulfilling activities to enhance their lives and meet their aspirations all within the guidelines of measured risk. Service users continue to benefit from the experience of multidisciplinary working to ensure that their personal care, social and emotional health needs are met. Service users are protected by the homes robust recruitment procedures The home ensures that service users, relatives and other professional’s views are listened to and addressed to improve service provision. Service users benefit from a consistent stable staff team and an open approach to the management of the service. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Six requirements and two recommendations were made during this inspection. Requirements were made for the service users individual plans to be reviewed and updated following a six monthly in house review and for the individual profiles to be updated to reflect the changes in preferred activities since the summer. A requirement was also made for each service user to have an individual plan covering issues of sexuality. Changes to service users financial support needs must be updated in individual plans to reflect the current situation and support required by service users. Requirements were made concerning the need to investigate the reason for staff using tippex on a medication administration sheet and to ensure that all staff follow the homes medication policy and procedure to protect service users from possible misadministration of medication. A recommendation was made for additional monitoring to take place of the support given to service users with regard to their oral hygiene. Further requirements were made for all fire doors to be kept shut and for advice to be sought from the fire safety team with regard to appropriate closing devices being fitted to fire doors. This must be prioritised to ensure the safety of service users and staff. A recommendation was made for the 1to1 supervision format to be revised so that sufficient information can be recorded to indicate the discussion that had taken place, the detail of the actions agreed and the progress with actions since the last meeting. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 7 All staff must undertake all mandatory training and the training records must reflect this to safeguard the service users and to ensure the competency of the staff. 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. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Good detailed assessments are in place for each service user to ensure that their assessed needs are met. The needs of a service user who has lived in the home for several years have changed and the homes registration category now enables them to continue to support the service user. EVIDENCE: There have been no new admissions to the home since the last inspection. However the three service users plans examined contained up-to-date assessments of need, which included clear objectives for each service user. Service users can be assured that that home will consistently review and meet their needs. A requirement made at the last inspection for the registered person to apply to the Commission for a minor variation to the conditions of registration with supporting evidence of the continued suitability of the home to meet the needs of the service user who now uses a wheelchair had been fully complied with. The new certificate of registration had been issued on the 3/8/05 and was displayed appropriately. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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): 6,7,8,9 Each service user has a detailed person centred care plan however these are not always updated to reflect changes in support needs. Service users make clear decisions about what they want to do and when and appropriate risk assessments are in place to facilitate this. Service users say that they feel they are consulted on and participate in all aspects of the home although this feeling should be checked periodically. EVIDENCE: Service user files are well organised; contain assessments of need and individual profiles including a personal history so that staff can understand and know the issues for individuals. The personal profiles are good and have been developed in a person centred way. However through discussion it was identified that in some cases, since the summer there had been changes in the interests service users wished to pursue and changes with regard to managing finances. Important omissions with regard to sexuality and some evidence of sexualised behaviour had not been included in the individual plans to enable staff to consistently support the service user to safeguard staff and the service users alike. Service users therefore cannot always be sure that their assessed and changing needs and personal goals are reflected in their individual plans. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 11 The three individual plans seen had been reviewed monthly although recent changes had not been reflected. There was evidence that service users placement had been reviewed annually involving their social worker and significant others. Although there was no evidence that six monthly in house reviews were taking place this must be rectified to ensure that all changes for service users support needs are documented to aid consistency in support provided by the staff. There continued to be evidence in the daily notes that service users make decisions about their lives, service users spoken to discussed the choices they had made recently with regard to meal times, activities and arrangements for Christmas that they prefer and which are appropriate to them. For example, one service user explained that she likes to go out shopping but that she also likes to watch T.V and that she usually plans her day around her favourite programmes. During the inspection several of the service users had chosen to have a leisurely day and spend time in their own rooms, some had decided to go out locally and others were sat in the lounge chatting or watching TV. The three feedback questionnaires returned by service users stated that they would like to be consulted on and participate in more aspects of the home. The inspector spoke to the service users individually who expressed that they do participate in the running of the home when they feel like it. One had recently arranged a Christmas party; others help out with household chores. Service user meetings, which occur monthly, also demonstrated that service users have a real say in the running of the home. It was difficult to ascertain if this was still an issue, but could be an area in which the registered manager checks out with individuals regularly. Appropriate risk assessments continue to be in place for all service user files seen; they had all been reviewed in the last three months and included accessing the community, daily living skills and finances. Several of the service users had detailed behaviour management plans in place; they had been reviewed during the service users meeting with the consultant psychologist and on a monthly basis within the home. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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): 15,16,17 Service users benefit from a staff team that understand their rights and know how to promote dignity and respect. Service users are encouraged and do develop positive relationships with family and friends although issues of sexuality are not yet being documented in individual plans. Service users are offered and enjoy a healthy diet. Service users dictate meal times. EVIDENCE: All four service users spoken to stated that they were supported to see their families and or friends if they wished. Some service users see their family several times a week this had also been documented in their daily notes and had been recognised as important parts of their lives in their individual profiles. The issue of sexuality and personal relationships had been explored during reviews although this was not part of the individual plans. Some service users spoke of close friendships with other service users living in other homes at college or daycentres. A recent adult protection issue involving one service users privacy and dignity being neglected following an epileptic seizure had been addressed satisfactorily Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 13 following actions made during a strategy meeting held in November. During a team meeting held on the 7/11/05 the incident that occurred on the 31st of October was discussed. The discussion was constructed in such a way as to identify what had been learned from the mistakes made with regard to not protecting the service users privacy and dignity during and after administering rectal diazepam. A training session was held on the 12/11/05, which involved all staff working through the homes ‘six values’ policy and procedure. The policy covered privacy, dignity, respect, rights, choice and independence. Following this staff worked through typical scenarios that could occur and were asked in each case how they would ensure that the individual’s privacy, dignity and rights were protected. In addition to this all staff have received refresher training from the community nurse on the 14/11/05 with regard to the administration of rectal diazepam. The registered manager and group manager expressed their confidence in the staffs ability to respond appropriately in the event of an emergency and knowing how to protect service users rights to dignity and respect. Staff spoken to confirmed this. Evidence from the minutes of the monthly meetings held for service users demonstrated that menus in the home are regularly reviewed and that there is much flexibility around meal times. The fridge and freezer was well stocked. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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): 19,20 Service users receive a range of services from health professionals to ensure that their emotional and physical health needs are met. Medication policies and procedures are robust and generally protect service users although these are not been fully followed by staff to safeguard service users. EVIDENCE: Service users personal support needs and preferences had been fully documented in the care plans. Service users say ‘ staff are helpful and know what I need and like’. It was noted through discussion with service users that oral hygiene can sometimes prove to be a difficult task for staff to effectively support service users with. It is recommended that oral hygiene is further encouraged and monitored more closely to benefit service users individually and within the wider community. All receive annual dental check ups. Service users continue to receive regular input from psychologists with regard to addressing their emotional needs and there was evidence in the health records that service users have regular contact with GP’s, dentists and chiropodists. There was evidence in the health records that all service users had recently had medication reviews, it was also evident from the daily notes that staff were confident and competent at identifying any side effects as a result of changes in medication and responded appropriately. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 15 Medication records were examined, nine out of ten Mar Sheets demonstrated that staff are following the homes medication policy and procedure to protect service users. However one of the MAR sheets had been written on by hand and tippex had been used on three occasions. Twice to block out a signature written by a medication that had been discontinued and once to eradicate a hand written medication and dose that had already been printed on the MAR sheet by the pharmacist. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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): 22,23 Service users state that they continue to feel that their views are listened to and acted upon. Complaints are dealt with appropriately and satisfactorily. Service users are protected from abuse, neglect and self-harm. EVIDENCE: Service users spoken to felt that their views and opinions are listened to and acted upon, there was evidence of this in the service users meeting minutes. Service users also expressed that they had wanted to arrange a Christmas party and a birthday party just after Christmas which, they organised with staff support. Service users were familiar with who their key worker was and had developed good relationships with them, enough to feel able to express any concerns they may have. Four complaints had been logged in the complaints book since the last inspection three concerned the same relative and had been resolved within the 28 days. One complaint had been received from the ambulance service following a call out to the home on the 31/10/05. An adult protection strategy meeting was called to discuss the complaint and concerns raised by the ambulance crew at the time. All issues raised at the strategy meeting had been addressed during a team meeting on the 7/11/05, training sessions and one to one discussions. The registered manager is now confident that all staff are fully aware of how to respond in an emergency situation, they know that additional staff are available if necessary and how to protect service users dignity and respect. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 17 The three individual files examined showed that in one file the arrangements for supporting a service user with finances had according to the letter received had changed on the 17/5/05. The exact information had not been transferred to her individual plan, this must be rectified to ensure that all staff are aware that all finances are protected and managed by a ward of court. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Service users live in a homely environment; all minor maintenance work had been completed to benefit the service users living environment. Service users safety is being compromised by the poor practice of propping fire doors open with door wedges. The home is clean and hygienic. EVIDENCE: Requirements made at the last inspection for minor repairs to be addressed had been complied with to promote a more homely environment for service users. One of the bedrooms highlighted as being tired, in need of redecoration and the replacement of furniture had been progressed slightly and continues to be an ongoing piece of work with the service user. The furniture that was seen to be a safety risk had been removed. Although it is the service user choice to have what furniture he wants in his room the staff are keen to ensure that he has a full choice with regard to the colours and alternative furnishings. Other bedrooms seen were bright and airy with good quality furniture to suit the service users needs. Some of the service users had had new bedroom furniture fitted and some had been more personalised with pictures. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 19 The sealant around the kitchen work surfaces had been renewed and a brighter light bulb had been put in the laundry room, making it brighter. The service users are now benefiting from having a choice of coffee table to put drinks on. The home is generally well maintained and homely. The service users expressed their satisfaction with living in the home. The home is clean and hygienic. Most of the fire doors in the home had been propped open with door wedges. This is not an acceptable practice and does not protect service users in the event of a fire. The registered manager informed the inspector that many of the service users are unable to push the doors open as they are too heavy and this is why they are propped open. The inspector advised that the registered manager contact the fire safety team to seek advice about closing devices being fitted to the doors in the home so that service users can move freely about the home and feel confident that they would be safe in the knowledge that in the event of a fire the doors would close automatically. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 33,34,35,36 Service users are supported by sufficient numbers of effective staff and are protected by the homes recruitment procedures. Staff are now being supported regularly through supervision to ensure continuity in care although the detail of the meetings require development. Not all staff have undertaken all statutory training this includes the registered manager to safeguard service users. EVIDENCE: The rota reflected the staff on duty at the time and indicated that there are sufficient staff on duty t meet the number and needs of the service users. Three staff files were examined. The staff files were well maintained and contained all information relevant to the protection of service users, which demonstrated robust recruitment procedures. A requirement made at the last inspection for staff to receive 1to 1 supervision every two months had been progressed all files examined contained up-to date records of supervision. The records were not detailed enough to clarify the actual work practice discussions that had occurred, the actions listed were vague and there was no evidence of following up on previous actions and progress so far. In some cases where verbal warnings had been issued these had not been documented in the supervision records, this should be rectified to Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 21 ensure that useful and clear information is in place for each member of staff with regard to practice issues and how these are supported and managed. Service users continue to benefit from a stable staff team who are well informed with regard to their needs through the use of the comprehensive individual plans, life histories and training. The training records on this occasion demonstrated that not all staff had received all mandatory training such as first aid, fire safety, health and safety and manual handling to safeguard service users and staff. All staff have however received refresher training in the administration of rectal diazepam and NAPPI training has been planned for 17/1/05. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 38,40,42 Service users benefit from a consistent open management approach to the running of the home. Policies and procedures are reviewed and updated annually to safeguard service users and the health, safety and welfare of service users is promoted. EVIDENCE: Service users benefit from a consistent management approach and the welfare of service users are protected by the homes polices and procedures that are reviewed regularly, the last review took place during September 2005. Service users participate in the running of the home through regular meetings and through having clear individual plans and activities that they choose and enjoy during the week. All health and safety records were checked and were found to be up-to-date and appropriate to meet the health, safety and welfare of service users. As mentioned previously the fire safety team must be contacted with regard to identifying the safest way to hold fire doors open for service users that do not Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 23 impinge on their safety in the event of a fire. In the meantime all fire doors must remain closed. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Millenium Care (Old Park Road) Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X 3 X DS0000010633.V265136.R01.S.doc Version 5.0 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1) Requirement The registered person must ensure that each service user has an individual plan that refers to their sexuality. These plans must be specific for service users that exhibit expressions of sexualised behaviour so that clear guidance is in place for staff in the support required. The registered person must ensure that service users have six monthly reviews and ensure that the individual plans and profiles are updated to reflect changes in need or interest. The registered person must ensure that the homes medication policies and procedures are followed and that tippex is not used on the MAR sheets at anytime. This incident must be investigated and the outcome must be forwarded to the CSCI. All discontinued medicines must be returned to the pharmacist. The registered person must ensure that the individual plans concerning service users finances and the arrangements DS0000010633.V265136.R01.S.doc Timescale for action 01/03/06 2 YA6 15(2)(b) 01/03/06 3 YA20 13(2) 28/02/06 4 YA23 15(2)(b) 01/03/06 Millenium Care (Old Park Road) Version 5.0 Page 26 5 YA24 6 YA32 for support are reviewed and updated. 23(4) The registered person must ensure that all fire doors are kept shut. Advice must be sought from the London fire safety team with regard to door closing devices. 18(1)(c)(i) The registered person must ensure that all staff including the registered manager undertake mandatory training on an annual basis and that training records are updated to reflect this. 06/01/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA36 Good Practice Recommendations The registered person should encourage close monitoring by the registered manager in the support provided to service users to promote good oral hygiene. The registered person should develop the supervision format to enable clear identification of the discussion taking place, detailed actions taken and follow up on actions at the next supervision. Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Millenium Care (Old Park Road) DS0000010633.V265136.R01.S.doc Version 5.0 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. 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