Inspection on 02/01/07 for Montbelle Road, 88

This inspection was carried out on 2nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Montbelle Road, 88 22/12/08

Montbelle Road, 88 09/11/05

Montbelle Road, 88 04/05/05

Montbelle Road, 88 04/11/04

Montbelle Road, 88 25/05/04

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 Montbelle Road, 88 88 Montbelle Road New Eltham London SE9 3NY Lead Inspector Keith Izzard Unannounced Inspection 2 January 2007 10:20 nd DS0000006878.V291647.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000006878.V291647.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000006878.V291647.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montbelle Road, 88 Address 88 Montbelle Road New Eltham London SE9 3NY 020 8851 5999 H/O 0208 297 1207 Janw@Plusservices.org 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) LINC Ms Janet Woolnough Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000006878.V291647.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: Montbelle is a large, semi-detached house in a quiet residential street in New Eltham. The Home caters for five younger adults with mild to moderate learning disabilities. The residents have their own bedrooms, furnished and decorated to their own tastes, and use of communal facilities that include a lounge/diner, kitchen, laundry room, conservatory (which doubles as a staff office) and a large garden. There is a toilet and bathroom on the first floor, a shower room and toilet and a separate toilet on the ground floor. There is unrestricted parking in the road at the front of the house, and close by are bus routes to Catford, Bromley or Lewisham. Residents are supported to live as independently as possible. There is a Manager, Deputy manager and up to six support workers, and there is 24-hour cover in the Home. DS0000006878.V291647.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection within the inspection year 01/04/0631/03/07, and took place over six hours. The manager and three members of staff were spoken to and four of the five service users were present for most of the inspection. Two service users showed the Inspector their bedrooms, and the others were seen in the presence of the manager. All the communal areas were viewed. Two care plans were looked at, and documentation was seen in respect of complaints, accidents, incidents, fire regulations, staffing and supervision records. What the service does well: What has improved since the last inspection? Following a previous requirement the home now has brand new patio and retaining wall finished to a high standard and providing a very pleasant outdoor area for service users. Most requirements and recommendations made at the previous inspection were complied with. DS0000006878.V291647.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000006878.V291647.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000006878.V291647.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1-5 were not assessed as the same group of service users have resided at the home for a number of years and all of the Standards have already been assessed as met, and this still applies for this inspection year April 1/04/06 – 31/03/07. DS0000006878.V291647.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments viewed were up to date and comprehensive, and reviewed on a regular basis. Staff members do their best to involve residents in decisions about them, they are supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality EVIDENCE: Standard 6 Two residents’ files were viewed. Both were well maintained and up to date, with a clearly printed recent profile and photograph of the resident at the front of the file. The residents at Montbelle are viewed as individuals and they each have their own goals and wishes recorded. Guidelines and risk assessments were in place to cover situations that might arise, and advice was sought appropriately from other professionals such as the psychiatrist or the speech DS0000006878.V291647.R01.S.doc Version 5.2 Page 10 and language therapist. Staff members are responsive to changing needs. For example, one resident has difficulties attending his review of care unless they are made very formal occasions, and the service area director of care has been invited to conduct the next review in order that the resident will be encouraged to take part in a more productive way. Standard 7 Residents are encouraged to make decisions wherever possible in respect of activities, food, domestic tasks, the décor and layout of their rooms, their personal appearance and clothes they choose to wear. At least two residents had input into new flooring in their rooms in recent weeks and one had just selected the colour she wanted her room to be redecorated in. Residents choose and, with support, cook a meal one day each week. Standard 8 Service users at Montbelle Road are involved in all aspects of the running of the home. The menu for each day is worked out between them daily in order to allow flexibility and a more spontaneous choice rather than planning too far in advance. On the day of the inspection the staff members took one of the residents out with her to do the shopping. Service users take it in turns to cook a meal for the others. At lunch-time those present were asked what they would like for lunch, were given a choice and it was noted that one resident was provided with a supplementary food drink in order to ensure that her food intake was satisfactory; this was in accordance with her care plan. The recorded minutes taken of residents’ meetings were seen by the inspector and showed that all residents are encouraged to take part in decisions about the running of the home. All the residents have jobs to do in the home and one of the service users had been cleaning her room on the morning of the inspection. Service users have also contributed their views as to what characteristics new staff members should have prior to interviews being arranged. Standard 9 Independence is promoted where possible. Risk assessments are available in all service users’ care files and are readily available for all bank or agency staff who may be less familiar with service users’ needs. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service users’ records examined that they are enabled to express choice in what they do and staff record these occasions. DS0000006878.V291647.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users at Montbelle Road enjoy a fulfilling and stimulating life. Residents’ rights and responsibilities were recognised in their daily lives. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standards 11- 14 Service users at Montbelle Road are supported with a range of training and employment opportunities. One resident attends classes and two jobs, one paid, and one voluntary. The service users engage in a whole raft of activities DS0000006878.V291647.R01.S.doc Version 5.2 Page 12 over the course of the week, with event such as horse riding, visits to the pub to play snooker and day trips, keeping them very busy indeed. The quarterly report produced by the manager clearly lists the activities provided for each of the service users in order that this area can be monitored by the organisation. Last year three service users enjoyed a holiday together in Holland with a group of other service users from other homes and who were well known to them through other joint events run by the organisation. Another service user went on a week’s holiday with his brother and sister-inlaw in Cornwall. Indoors, service users play board games, do craft activities or listen to music. Standard 15 Staff members at the Home have considerable contact with the families of the service users, and the visitors’ book showed a great many family visitors to the Home. Relatives of the service users are routinely involved in reviews and care planning and all receive a summary of their son or daughter’s progress from the quarterly reports produced by the manager. One service user has recently been reunited with her mother, through the combined efforts of the manager and the mother’s social worker and this led to her spending time at her mother’s home over Christmas for the first time in many years. This was a commendable achievement, and demonstrates the efforts made by staff members in trying to promote family contact and the best interests of service users. A telephone with big buttons is available in the hallway for residents to take or receive calls. Family and friends, including residents from other Homes who were known to the service users, attended a barbecue at the Home in the summer. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. Standard 17 At the last inspection before last it was recommended to introduce more culturally varied meals, given that three of the five service users are black. The menu for the week showed a good variety of dishes and service users had contributed to the choices being made. The manager stated that whilst culturally variable meals were provided on occasions, the individual service users had not been inclined to have them on a regular basis as their tastes were quite cosmopolitan and they were content with the variety provided. The home provides a good supply of fresh ingredients as well as some frozen food DS0000006878.V291647.R01.S.doc Version 5.2 Page 13 for convenience. A set of recipe cards was available for reference in the kitchen to give some ideas for meals. One of the residents has an NVQ in catering and he likes to cook without any help from staff. DS0000006878.V291647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s physical and emotional health needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. Three service users commented that they were content with the way care staff assisted them. Daily records were kept to show the care provided and those tasks performed by service users for themselves. All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained with the community learning disability team to support staff with meeting resident needs. DS0000006878.V291647.R01.S.doc Version 5.2 Page 15 Standard 19 Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about residents’ individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example OT’s Physiotherapists, Speech and Language Therapists, Psychiatrist and Dietician. Each service user needs a varying degree of support with their personal care. One service user has a bath aid that gives her more independence in getting in and out of the bath. One service user has been supported to join a bone-fide dating agency, in view of an expressed desire to meet somebody of the opposite sex and establish a relationship. The manager stated that if this proves successful then a similar approach will be under consideration for two other service users in the future. Another service user with an eating disorder and associated issues had appropriately been referred to a Psychologist and Dietician. Standard 20 The system for medication was examined and was generally well managed. None of the service users are able to deal with their own medication and all staff members who deal with it are trained to do so and the training is recorded. Medicines were examined were examined and tallied with those recorded on the MAR sheets and were retained in a lockable cabinet. External medication was stored separately. The home had recently received a visit and advice regarding managing medication and the recommendations made by the Pharmacist had been implemented. The Inspector noted two areas for improvement; that medicinal creams should be dated when opened and that any handwritten MAR sheets should be signed by two staff members to eliminate potential errors. See Requirement 1 DS0000006878.V291647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: A copy of the complaints procedure is by the front door and a copy is available in the Service User’s Guide. There have been no complaints since the last inspection. Most minor issues raised are resolved easily through discussion with family members. However, following a previous recommendation the Home has produced a log to record all compliments, complaints and suggestions, and these will be numbered to correspond with letters in the complaints file. The log will now contain record of who investigated, what action was taken, the complaint resolution, whether the complainant was satisfied and be signed and dated as a true record. All staff members have received training in adult protection, following a recommendation previously made. The home also has a policy and procedure in relation to this to guide staff in the event of any incidents although none have ever occurred within this home. Service users’ money is checked at each handover, and both incoming and outgoing staff members sign the record. The home has successfully trialled the idea of service users having their tin of money in their own room, and this has now been achieved with three of the service users. The two remaining service users need more assistance in this area and staff members retain their individual cash boxes in a secure area. DS0000006878.V291647.R01.S.doc Version 5.2 Page 17 Both of these were examined by the Inspector and found to be accountable with amounts tallying both in respect of the ongoing ledger and the amount of cash remaining in the box. Overall, the system was well organised and provided an clear audit trail. At the previous inspection a requirement was made that any valuables deposited with staff members should be recorded on a log with date of deposit recorded and signatures recorded from both the service user and the receiving member of staff. This had been implemented. DS0000006878.V291647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable environment that is safe clean and hygienic. Bedrooms suited residents’ needs and promoted their independence. The home was clean and hygienic on the day of inspection. EVIDENCE: Standard 24 An inspection of the building was undertaken and included service user bedrooms and communal areas. A previous requirement made to relay the garden patio and make the retaining wall safe had been complied with and had made a very attractive and safe sitting area for service users in good weather. It was noted that a shower screen needs replacement as it was in poor condition. The kitchen units now require replacement and provision made for a DS0000006878.V291647.R01.S.doc Version 5.2 Page 19 dishwasher to be installed. In the bathroom a crack needs repair around the door area and a new blind should be provided for the window. A new sofa is required in the sitting room area. See Requirements 2, 3 & 4 Standard 30 The Home was clean and tidy on the day of the inspection, and liquid soap and towels was available in the bathrooms, toilets and laundry. The kitchen work surfaces were clean and tidy with utensils and equipment appropriately stored. All cleaning materials were locked away and the Inspector noted one service users, who had been risk assessed, safely locking away such items away after cleaning her room. DS0000006878.V291647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and cared for by competent and qualified staff members who act as a team to meet their needs and receive appropriate training. Recruitment practice must be evidenced and signed by senior management on checklists retained within the home. EVIDENCE: Standard 32 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of DS0000006878.V291647.R01.S.doc Version 5.2 Page 21 skills and experience and that those staff who were observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in their daily activities. Staff spoken to on the day of the inspection said they enjoyed their work and spoke of the happy atmosphere in the Home. Standard 33 It is recommended that permanent staff are appointed to the current vacancies and that a male staff member is appointed as one has just left and there are three male service users within the home. Standard 34 At the previous inspection a requirement was made in respect of shortfalls in relation to recruitment documentation held at the head office. It was recommended, as a minimum, that the Provider devise a record in the form of a checklist to be held at Montbelle Road to evidence the person’s suitability to work at the Home. This should provide basic information about the staff member, including a photograph, their address, date of birth and an emergency contact number. In addition it could usefully show signed and dated verification that the information contained in Schedule 2 of the Care Homes Regulations 2001 has been obtained in respect of that member of staff. This was partially complied with as checklists were produced and are now retained in the home; however from staffing details examined some did not include confirmation of receipt of two references or up to date photographs of staff. A restated requirement is now made that evidence of all the documentation required, and as specified in Schedules 2 and 4, specifically the records relating to all persons employed in the Home, must be kept in the Home on fully completed checklists that are signed to evidence that all of the required checks have been completed. See Restated Requirement 5 Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this. Overall, a comprehensive spread of training had been provided for staff members and included the annual updates in fire training and moving and handling, as required. Each member of staff has a training and development assessment and profile and a training matrix had been developed for the team as a whole. DS0000006878.V291647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home, and, are involved in how it is run and contribute their views towards this. Regular monthly visits to assess how the home is running and checking the welfare of service users must be conducted and the reports retained within the home. The health and welfare of service users are promoted and protected. EVIDENCE: DS0000006878.V291647.R01.S.doc Version 5.2 Page 23 Standard 37 The manager was registered with the Commission in August 2006 and a new certificate issued, which was displayed in the Home. She confirmed that she has completed her Registered Managers’ Award and NVQ4 in Health and Social Care. The manager has worked in the Home since it opened, and knows the residents well. She has adapted readily to the role, and has produced quarterly monitoring reports, which are well written and also provided comprehensive but succinct information regarding the service users and the running of the home. The manager said that the Home’s computer will not be updated, and she has been told to work from another office or handwrite reports if required. This does not give a very professional impression of the organization and is likely to impede her work; a restated recommendation is therefore made in relation to this. Restated Recommendation 1 The Home is organized in a calm and orderly way, and the manager has a good knowledge of the systems and procedures. Staff members interviewed stated that she is approachable and supportive and would not hesitate to discuss any concerns about the home or the welfare of service users with her. Communication within the home was of a good standard with team meetings held regularly and the manager, overall, complies with the requirements of Standard 37. The manager has undertaken training in order to update her own skills and knowledge. Standard 39 Quarterly service reports are produced giving comprehensive information on the development of services within the home. Service users are regularly involved in service user meetings and contribute their views on the appointment of new staff. Regular service user reviews take place that reflect and record outcomes and aims for service users. However, there is an ongoing shortfall in that Regulation 26 visits, to assess the running of the home and check the welfare of service users, have not been conducted on a regular monthly basis and the reports of those visits must be retained within the home. See Requirement 6 Standard 42 A number of records to do with safety and maintenance were seen by the Inspector and were found to be up to date and well recorded. The manager confirmed that all staff had annually updated fire training over the past year. In respect of other checks the implementation of fire drills, alarm tests and checking of fire prevention equipment was recorded and up to date. Evidence was available that routine servicing and testing had taken place on the electric, gas and water systems. The manager had also provided a comprehensive DS0000006878.V291647.R01.S.doc Version 5.2 Page 24 checklist within the pre-inspection questionnaire. Overall, health and safety requirements had been well attended to. One call point for the fire alarm system requires repair and must be attended to as soon as possible. See Requirement 7 DS0000006878.V291647.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 3 X DS0000006878.V291647.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement The Registered Person must ensure that medicinal creams should be dated when opened and that any handwritten MAR sheets should be signed by two staff members to eliminate potential errors. The Registered Person must ensure that the shower screen is replaced. The kitchen units now require replacement and provision made for a dishwasher to be installed. The Registered Person must ensure the crack on the wall around the door is repaired and a new blind provided in the bathroom. The Registered Person must ensure that a new sofa is provided in the sitting room. A fully completed checklist of the Records, as specified in Schedules 2 & 4, specifically the records relating to all persons employed in the home, must be kept in the home. Restated Requirement as previous timescale of 30/12/05 not DS0000006878.V291647.R01.S.doc Timescale for action 01/03/07 2. YA24 23 01/07/07 3. YA24 23 01/07/07 4. 5. YA24 YA34 23 17(2) 01/07/07 01/03/07 Version 5.2 Page 27 fully complied with. 6. YA39 26(5)(a) Regular monthly visits must be maintained to the home in, accordance, with Regulation 26 by the Person in control. Copies of all Person in Control reports must be sent to the Commission and also retained within the home. 01/03/07 7 YA42 23 (4) The call point in the conservatory 01/03/07 area must be repaired. 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 YA37 Good Practice Recommendations It is recommended that the registered person ensure that the Home has adequate IT support within the home to enable the manager to carry out her role effectively. DS0000006878.V291647.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000006878.V291647.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!