Inspection on 21/10/05 for Old Ford Road (69-71)

This inspection was carried out on 21st October 2005.

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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Ford Road (69-71) 14/10/08

Old Ford Road (69-71) 02/07/07

Old Ford Road (69-71) 27/04/06

Old Ford Road (69-71) 19/05/05

Old Ford Road (69-71) 17/11/04

Old Ford Road (69-71) 21/06/04

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 Old Ford Road (69-71) 69-71 Old Ford Road Bethnal Green London E2 9QD Lead Inspector Anne Chamberlain Unannounced Inspection 21st October 2005 10:00 Old Ford Road (69-71) DS0000010300.V261005.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 Old Ford Road (69-71) DS0000010300.V261005.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. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Ford Road (69-71) Address 69-71 Old Ford Road Bethnal Green London E2 9QD 020 8980 5631 020 8980 5631 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) Royal Mencap (Housing & Support Services) *** Post Vacant *** Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: Old Ford Road is a residential care home registered for seven service users with learning disabilities. Currently there are two vacancies. The home is situated in the Bethnal Green area close to central London. It is comprised of two terraced houses interlinked through a shared conservatory and with a shared garden. Parking in the area is restricted but there good are public transport links. The registered provider of the service is Mencap. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection this year and unannounced. The inspector inspected the standards which had resulted in requirements at the last inspection, and also a number of other key standards. The manager was not present on this day but the inspector did speak to her on the telephone. In addition the inspector was assisted by a member of the care staff, and spoke with two other members of the team. Only one resident was present in the house during the inspection and the inspector spoke with him. The inspector made a short inspection of the premises, viewed key documentation and the files of three service users. The inspector would like to take this opportunity to thank the service users and staff at Old Ford Road for their support and co-operation with the inspection. What the service does well: What has improved since the last inspection? The service user guide has been updated and now give service users better information. Annual staff appraisal is in place supporting staff to perform well. Staff to service user ratio has been improved for group community visits, making the activity safer for service users. Staff working patterns have not been changed and this has had a positive impact on staff morale. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 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. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 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 Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 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): 1,3. The home has produced documentation which helps service users to make an informed choice about placement at Old Ford Road. There remains some room for improvement in the documentation. Individuals are assured that staff will meet their needs and support their aspirations. EVIDENCE: The statement of purpose was the subject of a requirement at the last inspection. It was viewed and still fails to meet the criteria. The manager is referred to Schedule 1 of Regulation 4 of the Care Homes Regulations, which lists what should be in a statement of purpose. Items numbered ,2, 3,5,7,8,15,17 are not covered, although some of this information appears in the service user guide. The manager must ensure that the statement of purpose is amended to include the above listed information. This is a restated requirement. The service user guide has been amended and now meets requirements. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 9 Staff at the home benefit from regular training. The care worker who assisted with the inspection had been working for the home for three years and she is undertaking NVQ level 3. Other staff at the home similarly have good levels of experience. From observing them at work the inspector felt that the staff group had a good level of skills. Staff enable service users to access appropriate health care. An example which demonstrates this is that a service user has recently been started (by a specialist team) on a drug which has benefited him significantly. Old Ford Road (69-71) DS0000010300.V261005.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): 6,9,10. Individual service plans do not reflect the changing needs of service users. Information is exchanged verbally but not captured, recorded and updated on files. Service users are supported to take risks but the documentation of risk assessment is out of date. Information about service users is handled sensitively and their confidences respected. EVIDENCE: When annual reviews take place with service users and their care managers (from social services) the minutes are the responsibility of social services but are often never sent through. At the last inspection it was agreed that the home will take its own notes of reviews (whilst minutes are awaited), noting actions and updating care plans accordingly. The care worker advised that reviews have taken place since the last inspection but that no notes have been taken of them. The requirement is therefore repeated. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 11 The manager must ensure that annual reviews which take place are documented on file and the actions recorded (even if the official minutes are not received) This is a restated requirement. The inspector viewed the files of three service users. The inspector had been told by the care worker that a particular service user has started in the summer on a drug which appears to benefit him significantly. She said that his behaviour had changed markedly and positively. The inspector was not able to find (even in the section marked medical information) any indication in the file that the drug had been started or details of the consultation at which it was prescribed. In fact the Statement of Support stated that the service user was not on any medication. There was no reference to changed behaviour or needs. Another service user had no information in a section marked Spritual Needs. although he is a member and regular attender of the Church of England, and this is stated in his review. The statement of support for this service user was not signed or dated but appeared to just peter out. There was no date of updating and the dates which were included were mostly 2004. The objectives in the care plan were dated April 2003. Notwithstanding this there was a nice My Life book which had been updated in 2004. The care plan objectives for another service user had been updated in April 2004. The statement of support had been updated in November 2004. The manager must ensure that all care planning documentation is regularly updated, at least once a year but always after any significant change. This is a requirement. The manager must ensure that statements of support and plans are dated and signed and that dates of updating are clear. This is a requirement. The inspector saw an example of updating of risk assessment in one file. A risk assessment around shopping had been reviewed in June 2005. However she also viewed the file of a service user who as stated above, has had a significant change in behaviour with reduced risk and vulnerability in the community, co-inciding with starting on a new medication in July 2005. The risk assessment for community participation for this service user has not been revised and is dated March 2005. The manager must ensure that risk assessments are regularly reviewed and updated especially when the needs of service users change Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 12 This is a requirement. The care worker advised that in the past holidays have been risk assessed individually. She said that the manager and staff have decided that an at home and an abroad risk assessment will be devised each year for all holidays that year. If staff feel that for some reason any holiday activity is not covered by one or other of the assessments then it will be assessed separately. The inspector was not able to view any of the risk assessments for the upcoming holiday which is in just a couple of weeks. She was assured by the care worker that they will be done in time. The manager must ensure that risk assessments are in place for the upcoming holidays before they are taken. This is a requirement. In discussion with the care worker the inspector felt that there was a good understanding of confidentiality in the home. The worker said that information is shared on a need and right to know basis and that any discussions about service users took place in the office, behind closed doors. The inspector was advised that electronic information is password protected and she observed that paper files are kept in lockable metal cabinets. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Service users at this home have a range of social and developmental opportunities. Community, recreational and leisure activities are available and provision is culturally sensitive. A well thought out, fully supported annual holiday is provided. One service user has more specialised needs which are not currently well met and a requirement has been made. Service users have well supported contact with their families, their rights and responsibilities are respected and they enjoy privacy. Service users are offered a healthy varied diet with personal choice and enjoyable mealtimes EVIDENCE: The inspector felt that services users generally have opportunities for personal development. Four out of the five service users have quite full and varied programmes of activities. The fifth service user however has no current programme of activity. On the day of the inspection he was at home with no activities provided beyond watching TV in his room or the lounge. It is acknowledged that several resources have been tried and have not lasted more than a few weeks, also that the service user occasionally attends a football match with his keyworker. The inspector noted from his file that this service Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 14 user does have some favoured activities, for example he likes long walks and riding on buses and trains. The inspector was told the keyworker would be looking to start new activities for the service user after Christmas in the new term. This is two months away and the inspector felt that some meaningful activity should be provided before then, even if it is recreational in nature. The manager must ensure that some structured activity is provided for the service user who has none at present. This is a requirement. Four service users attend a local church. Two service users regularly visit family, one staying overnight on a weekly basis. Service users attend college, day centres which provide other outings (for example a trip to a museum) and craft classes. Service users access the community using bank and post offices. They shop, go to the pub, Gateway club, to the West end and to hairdressers. The care worker reported that the service users all watch TV and they invariably return to the ITV channel. The home has NTL television and one service user who particularly likes football has Sky TV. The home has a video. Service users are all taking a holiday together very shortly to Majorca. Six staff will be escorting them. They will be staying at an all inclusive hotel. The care worker explained that at the start of the holiday everyone sits down together with the programme of events and makes choices about which activities they particularly want to access. Every effort is made to ensure that no-one misses out on something they want to do. In addition to the above one service user is going on holiday with his sister and also with his brother to visit relatives abroad. The care worker advised that if a service user is upset about Ssomething they will call a staff member into their room and close the door to discuss the matter privately. The care worker explained that service users receive their mail unopened and generally have a look at it themselves before asking a worker to help them to read it. The inspector viewed the menus into which the service users have input. They looked varied and appetising. Proper meals are cooked from raw ingredients. Service users are offered a cooked breakfast at the weekend and one service user likes to help with the cooking at the weekend. Monday night is takeaway night. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19,20,21. Personal care support is delivered to service users sensitively and in the way they prefer. Staff are aware of emotional and health needs and do their best to meet them. The administration of medication is on sound principles, and independence in this area is supported. However medication errors are not eliminated. Ageing, illness and death would be treated with respect but the views of service users have not been sought or recorded. EVIDENCE: The inspector discussed with the care worker the way in which support is provided to individual service users. The care worker gave as an example their management of bathing for a service user who has epilepsy. The inspector was satisfied that care workers are very vigilant when the service user is bathing, but at the same time afford her the privacy she desires. The care worker also explained that personal care is fitted around the timetable of the individual and their preference. Some individuals like to have a shower before going out, others will prefer a wash and brush up and have a bath before bed, or a shower in the morning. The care workers said that agency staff are seldom used and regular relief staff are familiar with needs. Any new member of staff is thoroughly inducted into how service users prefer support to be offered. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 16 The care worker advised that the service users are all reluctant about attending hospital and other medical appointments (presumably due to past experiences) but they are always accompanied by staff. One service user is very able and verbal and conducts her own consultation although she likes the support of having her keyworker present. All service users have had a health/medication review. Two service users in the home supported to self medicate. The previous inspection required the manager to ensure that the signature of the pharmacist is obtained for returned medication and that drug errors are eliminated as far as possible. The staff member advised the inspector that the pharmacist is now signing for returned medication. The inspector checked the record and noted that the pharmacist had signed for medication returned since the last inspection. Unfortunately only initials had been used which makes it difficult to verify as by the pharmacist. It would be helpful if the name of the pharmacist were also entered on the sheet. The inspector viewed a medication administration record and balance of drugs held. There was a discrepancy with two tablets short, indicating that a medication error of some kind has occurred. The manager must ensure that drug errors are eliminated as far as possible. This is a restated requirement. The inspector felt that given the ethos of the home the death of a service user would be treated with great respect. However she found that little had been put in place in terms of ascertaining the views of service users regarding ageing, illness and death and recording them on files. The care worker advised that one service user has a family who would want to take care of all arrangements. She advised that another service user rejects all such discussion and called someone who raised the topic with her morbid. This is all she could report. In addition the organisation has a policy regarding serious illness and death. The manager must ensure that service users are given an opportunity to communicate their views on ageing illness and death. If staff feel they need additional training to approach these discussions with service users, it must be provided. Service users comments must be recorded on their files, including if they do not wish to discuss the matter. This is a requirement. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 17 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. Service users views are listened to but they may need more opportunities to express them. Service users views are not always acted upon. EVIDENCE: The home holds tenants meetings and the inspector viewed the record of these. She was pleased to see that the previous inspection report had been shared at a meeting. The content of the meetings appeared appropriate but the regularity had faltered and the meetings had been infrequent. The manager must ensure that tenants meetings take place regularly once a month. This is a requirement. At a tenants meeting in August, a service user had asked for a laminated wooden floor in his room. This is not merely a preference but is based on a care need. The care worker felt that cost would be an obstacle to providing this flooring. The manager must ensure that the above request is progressed and the floor provided. This is a requirement. The home has a user friendly complaints procedure. Information is given regarding the Commission for Social Care Inspection (CSCI) but this was not Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 18 quite correct. The inspector corrected the copy on the office of the wall to demonstrate the correct information. The manager must ensure that all copies of the complaints procedure are amended in accordance with the correction made by the inspector. The inspector viewed the complaints file. She noted that the log has not been kept up to date. The manager must ensure that the complaints log reflects all the complaints received and their processing to resolution. This is a requirement. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 19 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): 30. The home is generally clean and hygienic but the inspector has highlighted shortcomings in the environment which need to be addressed. EVIDENCE: The inspector made a short tour of the premises not inspecting most of the service user bedrooms as four were out at the time of the inspection. The inspector noted a creeper growing across the roof of the conservatory. The inspector also saw a serious damp problem in the unused second office. This appears to be being caused by the aforementioned creeper. The manager must take steps to eradicate the damp in the unused second office. This is a requirement. The inspector also noticed in the unused second office equipment unsafely stacked on top of a filing cabinet. The manager must ensure that equipment is stored safely. This is a requirement. Old Ford Road (69-71) DS0000010300.V261005.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 and 36. Service users are supported by an effective staff team whose performance is appraised. EVIDENCE: The previous inspection required the manager to cease an unsafe practice of service users being inadequately supported in the community. The inspector was pleased to hear that the practice has stopped. The staffing rota has been revisited and community visits have been rearranged to make groups smaller and to ensure that staff to service user ratio is adequate. The requirement has therefore been met. The last inspection report resulted in a recommendation that senior management engage in full consultation with staff before changing their working practices. The inspector was pleased to hear that weekend working practice has not been changed and staff are comfortable with their current work patterns. The recommendation has therefore been met. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 21 The previous inspection required the manager to ensure that staff have annual appraisal. The staff files were locked away and it was not possible to view them. However the staff member interviewed assured the inspector that she has had a PDM which is an appraisal and that last month all the staff had these meetings with the manager. The inspector was satisfied that this requirement is met. Old Ford Road (69-71) DS0000010300.V261005.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): 37, 40 and 43. The home is not run in a fully satisfactory way. The rights and best interests of service users are safeguarded by the policies and procedures of the organisation. The management of the service is competent and accountable but the budget for the home is restrictive. EVIDENCE: The previous inspection required the manager of the home to be registered with the CSCI to run the home. The managers application has now been received but the process is not complete and she is still not registered as manager of the home. The inspector spoke to the manager on the telephone and understood that the delay is in awaiting a CRB check. The manager of the home must be registered with the commission and must have a current CRB check. This is a restated requirement. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 23 On arriving at the home the inspector noted that the front door bell was not working. On the day of the inspection there was no coffee available, as the home had run out and were due to go shopping that day. Service users could be inconvenienced by both of the above shortcomings. The manager must ensure that the front door bell is repaired. This is a requirement. The manager must ensure that the home does not run out of basic commodities. This is a requirement. The organisation has produced a comprehensive manual of policies and procedures. The care worker advised that policies are updated and usually arrive electronically. They are shared with staff. The inspector noted that the care worker was able to locate all the documentation requested including policies. The worker advised that she is becoming more familiar with policies through her NVQ training. She was able to explain that policies are in some instances required by law (for example policies around health and safety) and that policies ensure conformity of practice, subject to any necessary modification from one home to another. The worker said that participating in the inspection had helped her to understand the relevance of policies. As mentioned under standard 36 it was not possible to access the staff files on the day of the inspection. They were locked away. The manager was at a considerable distance on the day of the inspection but advised the inspector on the telephone that she has a key and the other key is normally with the deputy manager. The deputy manager is on maternity leave and the key has passed to another member of staff who was also not on duty on the day of the inspection. The inspector felt that the keyholding policy was flawed as both keyholders were off duty at the same time. The manager must revisit the keyholding policy with her senior managers, to ensure a keyholder is on duty at all times. This is a requirement. The inspector viewed a business plan for the home which had been reviewed in April 2005. The plan was relevant but gave no financial information. From discussions with staff she was aware that tensions are felt in the home, in terms of staffing and the maintenance of the environment, due to a very tight budget. The inspector suggests that should management feel they have difficulty in meeting the standards of care imposed by the Care Homes Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 24 Regulations, they may wish to review the budget for the home. They may wish to approach those who commission places at Old Ford Road for a review of the fees of individuals. The inspector saw the certificate of insurance which runs until June 2006. Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Ford Road (69-71) Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 2 x x 3 x x 2 DS0000010300.V261005.R01.S.doc Version 5.0 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 YA1 Regulation 4 Requirement The manager must ensure that the statement of purpose is amended to include the list of information in the body of the report,(previous timescales of 31/8/04 and 31/01/05 and 01/09/05 not met). The manager must ensure that annual reviews which take place are documented on file and the actions recorded (even if the official minutes are not received) (previous timescale of 01/07/05 not met). The manager must ensure that all care planning documentation is regularly updated, at least once a year but always after any significant change. The manager must ensure that statements of support and plans are dated and signed and that dates of updating are clear. The manager must ensure that risk assessments are regularly reviewed and updated especially when the needs of service users change. The manager must ensure that DS0000010300.V261005.R01.S.doc Timescale for action 01/01/06 2. YA6 15 01/12/05 3. YA6 15 01/12/05 4. YA6 15 10/11/05 5 YA9 12 10/11/05 6 YA9 12 10/11/05 Page 27 Old Ford Road (69-71) Version 5.0 7 YA11 12 8 YA20 13 9 YA21 15 10 11 YA22 YA22 22 22 12 YA22 22 13 14 15 YA30 YA14 YA37 12 12 8 16 17 YA37 YA37 23 12 risk assessments are in place for the upcoming holidays before they are taken. The manager must ensure that some structured activity is provided for the service user who has none at present. The manager must ensure that drug errors are eliminated as far as possible (previous timescale of 01/07/05 not met). The manager must ensure that service users are given an opportunity to communicate their views on ageing illness and death. If staff feel they need additional training to approach these discussions with service users, it must be provided. Service users comments must be recorded on their files, including if they do not wish to discuss the matter. The manager must ensure that tenants meeting take place regularly once a month. The manager must ensure that the request outlined in the body of the report is progressed and the flooring is provided. The manager must ensure that the complaints log reflects all the complaints received and their processing to resolution. The manager must take steps to eradicate the damp in the unused second office. The manager must ensure that equipment is stored safely. The manager of the home must be registered with the commission and must have a current CRB check. The manager must ensure that the front door bell is repaired. The manager must ensure that the home does not run out of basic commodities. DS0000010300.V261005.R01.S.doc 01/12/05 01/07/05 01/01/06 01/12/05 01/02/05 01/12/05 01/02/06 10/11/05 01/12/05 01/12/05 10/11/05 Old Ford Road (69-71) Version 5.0 Page 28 18 YA43 17 The manager must revisit the keyholding policy with her senior managers, to ensure a keyholder is on duty at all times. 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Ford Road (69-71) DS0000010300.V261005.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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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