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

This inspection was carried out on 27th April 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 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 12 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) 21/10/05

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 27th April 2006 10:00 Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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) www.mencap.org.uk Royal Mencap Society Mrs Margaret Udofot Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 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.V290954.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced initially and was carried out over two half days. All key standards were inspected as well as those which had requirements at the previous inspection. At the time of the inspection the manager and deputy were both on leave and the inspector was assisted by staff members, and a manager from another nearby Mencap home. The inspector selected three service users and viewed their files, medication, financial records etc. She spoke with two of them and she inspected the staff files for their keyworkers, and also spoke with two of them. This process is termed case tracking. In addition the inspector spoke with relatives of one service user who was case tracked and one who was not. The inspector toured the premises and inspected key documentation. Since last inspecton the home has had a burglary and the inspector discussed with staff issues arising from this. The inspector would like to thank the service users and staff at Old ford Road for their assistance and co-operation with the inspection. What the service does well: What has improved since the last inspection? A number of requirements from the last inspection have been met and there is a general improvement in documentation in service users files. The home benefited from the recent redecoration and refurbishment. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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.V290954.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. The overall judgement for this outcome group is adequate. EVIDENCE: The statement of purpose has been amended according to the requirement of the previous inspection and now meets the standards of regulation. However the inspector noted that the numbering on the contents page of the document does not match the actual contents and is therefore rather confusing. The service users files contained a wealth of assessment information about them. However the inspector over recent inspections has formed the view that the service user most recently placed in the in the home has needs which are incompatible with the others. A relative who spoke to the inspector expressed this view and said that his relative has been at times very scared of the other person. It is acknowledged that some aspects of the placement have improved but the view of the inspector is that the assessment of need was not adequate and led to an inappropriate placement. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. The judgement for this outcome group is adequate. EVIDENCE: There was a requirement at the previous inspection that all care planning documentation be regularly updated and always after any significant change. On inspecting the files there was evidence of updating of service user plans. However in one case a plan did not record a recent change of medication for a service user. There was also a medication pen picture dated 18/1/05 which was out of date. A behaviour plan dated August 2004 had a review date of August 2005 but this had not been undertaken. The requirement is therefore repeated. There was evidence of annual reviews on the three files inspected. These were arranged by the home but none appear to have been attended by social workers. The inspector recommends that the manager invite social workers to reviews by letter, giving them sufficient notice, and record their apologies on the review minutes if they do not attend. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 10 A relative told the inspector that more notice of reviews and perhaps a time set in the afternoon would make it easier for him to attend. The inspector noted that service users had Personal Care Plans (PCPs) started on their files and the staff said they had all had training in completing these. The inspector was told that service users make decisions and choices wherever possible in their lives. For example one service user had opted to use a local Art Group having had information and a taster session. The inspector was shown the takeaway folder where the menus for local restaurants are kept. Service users choose their weekly takeaway meal from these. Breakfast is always a meal of choice and the inspector was shown an array of cereals and juices available each day. The inspector was told that service users are supported to transact financial business by visiting the bank on Saturday mornings. Unfortunately this could not be verified in the daily logs. The previous inspection made a requirement in relation to the review and update of risk assessments. The inspector viewed risk assessments. A risk assessment on medication dated 22/4/06 failed to state the name of the medication being risk assessed. The inspector was told that one service users needs have changed significantly in terms of accessing the community, however his risk assessment had not been updated since 4/11/05. The review was planned for 8/2/06 but had not been done. The requirement in relation to risk assessments has been restated. One service user is at risk from epileptic absences which her documentation states should be recorded in the medication file. On checking the medication file the inspector noted that although quite regular before 22/2/06 no absences had been recorded for the service user since. On checking this with staff they said that they have not witnessed any seizures since that date. In this case it would be prudent to make some entry in the record to that effect. The manager must ensure that the record of seizures is kept up to date, at least monthly, if appropriate recording that there have been no seizures observed. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 and 17. The overall judgement for this outcome group is adequate. One requirement and three recommendations have been made. EVIDENCE: Four of the service users attend day centres. Their programmes include activities like horseriding and swimming. One service user attends Poetry in Wood classes and there are various attractive wooden artefacts around the home, which testify to this. Some of the service users attend Gateway and other social clubs. The inspector was concerned about one individual. He does not attend a day centre or clubs and there was a requirement at the last inspection that some structured activity be provided for him. On the first day of the inspection the inspector was told that the individual had started attending art and gym classes twice a week (the latter because he is overweight and borderline diabetic). It is acknowledged that in this respect the requirement has been partially addressed. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 12 However on the second day of the inspection the inspector was told that due to a staff shortage the service user would not be able to attend art class or gym that day. As the inspector had been told that the service user was quite motivated about the art class and in the middle of creating a portrait over three weeks, she knew that he would be disappointed and his motivation undermined. The inspector viewed the daily log for the individual discussed above, going back for two weeks. During that time the service user had attended art class and gym twice and spent one overnight at home. Apart from this he did not appear to have left the house, and spent most days getting up very late in the day and then watching television, although there is occasional reference to room tidying. This service user has a poor sleep pattern, often not going to sleep until the middle of the night. He is described as roaming around the house and at times is disruptive knocking on the doors of other service users when they are trying to sleep. The inspector felt that the lack of outdoor exercise would exacerbate the situation and the service user could at the very least be supported to take a walk each day. The manager must ensure that the service user who has no regular programme of activity, is given opportunities to get out of the house for recreation and to take some exercise. The inspector was told by staff that service users are regularly supported to undertake their own shopping needs and to help with the house shopping. She inspected the daily logs for recent weeks for all the service users and found one reference to shopping. The records on the daily logs for each Saturday start p.m. As previously mentioned the inspector was told that service users access the community on Saturday a.m.s, but this could not be confirmed in the daily logs. The impression gained by the inspector from the daily logs is that when service users are at home they undertake some domestic tasks, but mainly watch television. A comment from a relative was that when he visits he never sees staff around. It would be nice to see service users being encouraged by staff to develop individual interests and activities which they can pursue at home. This is recommended. The inspector was told that one service user has regular visits from family and they engage with everyone, leading games sessions in the conservatory. Another service user has occasional overnights at home. Another has a friend in a local care home and she speaks to him on the telephone regularly. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 13 The inspector was satisfied from her observation of the interaction in the home that service users are treated with respect. They appeared relaxed with staff. The inspector was told that the rights of individuals are respected. For example their mail is given to them unopened, their doors are knocked upon before anyone enters. The inspector was satisfied that service users enjoy their meals and eat them in pleasant surroundings. She was told that a flexible menu is in place for evening meals and that service users eat together. The inspector noted ready meals in the personal fridge of a service user and felt there might be some reliance on these, especially during the week when people need to get out to clubs in the evenings. The inspector was told by a worker that meals from scratch using fresh ingredients are also cooked, particularly at the weekend. A relative mentioned that with different staff on duty each day he felt there was the possibility that service users might eat a limited diet and this might not be noticed. The inspector recommends that the manager keep a monitoring eye on the use of convenience food ensuring that there is a balance with meals cooked from scratch, using fresh ingredients including fruit and vegetables. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 and 21. The overall judgement for this outcome group is good, although two requirements have been made. EVIDENCE: The inspector was told by staff that the statement of support is the main guidance for personal care. She was told that every worker goes through this document to thoroughly understand the needs of the service user they keywork. For example the service user who has epilepsy is independent in personal care but staff stay within calling distance when she is having a bath. One service user is taking part in a research project to assess the benefits of taking multivitamins. The inspector was told that staff have observed an improvement in his wintertime health. One service user was supported to attend an appointment with a health specialist during the course of the inspection and the inspector was told about a mental health assessment another individual had had. A relative told the inspector she was pleased with the way her sons health was being supported. The inspector formed the view that the healthcare needs of individuals are met in the home. Medications are no longer stored with cleaning materials, which is a significant improvement. The inspector viewed the arrangements for the administration of medication and attempted to balance some medications. Each service user Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 15 has a section in a medication file. This contains a photograph of them and a pen picture of their medication and a MAR sheet. The inspector noted that in one instance the medications listed in the pen picture and the MAR sheet did not match. The MAR sheet does not give the balance of medication at any starting point so it is more difficult to check for any discrepancies. However there is a record of medications ordered and received. The inspector found that of 60 tablets dispensed on 6/4/06 (3 boxes of 20), 34 remained, whereas 39 should have remained. The worker agreed therewas a discrepancy and was not able to explain it. The inspector was told that medications are audited weekly on a Monday, if so this error does not seem to have been picked up. The service is going over to bubble pack dispensing and this should make the checking of medications easier and reduce the risk of error. There was a previous restated requirement that the manager eliminate drug errors as far as possible. This is restated for a third time. There was a previous requirement that service users be given an opportunity to communicate their views on ageing, illness and death, including that service users comments be recorded on their files, including if they do not wish to discuss the matter. The inspector noted on one file that family would make necessary arrangements but there was no information on the two other files inspected. The requirement is therefore restated. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The overall judgement for this outcome group is adequate. EVIDENCE: There was a previous requirement relating to the logging of complaints. The inspector viewed the complaints file and noted the last complaint logged was in 2004. However there was information in the folder relating to a complaint from a service user on 19/01/06 and to a recent complaint from a neighbour. The requirement is therefore restated. The manager must ensure that the complaints log reflects all the complaints received and their processing to resolution. There was a previous requirement that tenants meetings take place regularly once a month. The inspector viewed the record of tenants meetings which showed that meetings had taken place in January and February this year. The requirement is therefore restated. The inspector viewed the policy for the protection of vulnerable adults and discussed its implementation with the member of staff. She was clear that any allegation or suspicion of abuse should be immediately reported to her senior. The service also holds a copy of the Tower Hamlets adult protection policy and the department of health guidance No Secrets. The inspector also discussed whistle blowing with the staff member. She was clear about her responsibility with regard to whistle blowing. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 17 The inspector viewed the arrangements for the handling of service users finances. She checked the cash balances, bank books, transcash receipts for the payment of rent, and rent payment record for the three service users case tracked. She found no discrepancies. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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 and 30. The overall judgement for this outcome group is good. EVIDENCE: The inspector undertook a partial tour of the premises (she could not see the bedrooms of service users who were not home). There were two requirements at the previous inspection relating to the condition of the house. These are both met. It has been redecorated and newly carpeted and was looking fresh and pleasant. There are however a few improvements required: lampshades need to be fitted on the lamp in the sitting room and also the ceiling light, also lampshade is also needed for the ceiling light in the office. The cupboard in the downstairs bedroom was damaged in the burglary and needs to be replaced. The sitting room at number 71 lacks a TV set (stolen in the burglary) and this must be replaced. The windows throughout the home are dirty and need to be cleaned inside and out. There is a missing cover on a meter at the front of the property and this should be replaced. There was a curtain pole box laying on the frontage of the property which should have been folded up and put in the dustbin. The rear garden is looking well. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 19 The house has no unpleasant odours. Laundry facilities are located in a kitchen but the inspector was told by staff that this is not an issue as there is no foul laundry to wash. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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): 32, 34 , 35 and 36 The overall judgement for this outcome group is adequate but the inspector was particularly concerned about the extended lack of management support at the home. EVIDENCE: The inspector was told by a member of staff that his NVQ course had been suspended. He had not been able to contact his assessor and he did not know the reason. The inspector was informed by the manager of the other local Mencap home that Mencap had severed arrangements with their NVQ provider, and have appointed their own assessors. The inspector was shown a letter advising staff of this. There seems to have been poor communication on the topic and staff morale appears to have been undermined. Another member of staff told the inspector that she had paid for her own NVQ 3 course. Notwithstanding the above and based on her interviews with them the inspector believes that staff group between them have substantial experience. Recruitment appears to be generally safe and robust. Staff told the inspector that they received regular relevant training, although this tends to be offered more in the second half of the year. However staff files did not contain training profiles, so the inspector could not form a view as Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 21 to whether training is adequate. She did note that supervision records inspected did not explore training or identify future needs adequately. The manager must ensure that staff training profiles are available for inspection. At the time of the inspection the manager was away on four weeks annual leave. The deputy manager for the service is on maternity leave. The inspector was told that a support worker had been approached by management a couple of days before the manager had gone on leave, to act as team leader but had declined. She told the inspector that she had had not training or experience for such a role. The inspector learned that the manager of another Mencap service which is very close by was also on annual leave for the foregoing week. The staff at the home have been reliant upon armslength supervision from the service manager. The inspector felt that the staff had not been adequately supported or supervised. The registered person must ensure that in future more robust arrangements are made to support and supervise the staff in the absence of their manager. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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, 39, 42 and 43. The overall judgement for this outcome group is adequate. EVIDENCE: The manager is now registered with the Commission for Social Care Inspection (CSCI), to manage the service. The certificate of registration is displayed on the wall of the office. One of the staff interviewed was very positive about the manager saying that she had a gift for diffusing difficult situations. Another staff said that he felt there were not enough shifts which allow for the completion of paperwork. He also said he would like to see all staff getting involved in a wider range of tasks. Person in control visits are made to the home and the reports are forwarded to CSCI. The inspector also viewed the business plan for the home. Staff stated Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 23 that service users have the opportunity to attend forums twice a year where they can express their views about their service. The inspector viewed the fire protection records. There is a risk assessment in place which is dated 22/4/05 and is therefore due for updated. There was evidence of fire alarm testing, the most recent occasion being 27/4/06, and the outside contractor visited the premises on 4th January this year. The last planned fire drill was on 14/6/05 and the last unplanned on 2/1/06. Fire drill is therefore now due. The inspector viewed the arrangements for the COSHH. There is a COSHH folder with a list of products kept, data sheets and product information, and a COSH cupboard. Several products were checked but there was only one match between the information in the folder and the products in the cupboard. The cupboard contained products which had been in the main purchased at a particular supermarket. The information held mainly related to products from another supermarket. One of the products in the cupboard looked to the inspector to have been bought at a pound shop and she doubted if it would be possible to track down any information on it. The COSHH situation needs to be completely overhauled. It would probably be best to start the whole system again because most of the information held is likely to be out of date. The manager must ensure compliance with the COSHH legislation, having safe storage of items and comprehensive information about them. The previous inspection required the manager to revisit the keyholding policy as it was impossible for the inspector to view the staff records on the day of the inspection. The manager has complied with the requirement in that a key is now held at the previously mention nearby Mencap service. However on the first day of the inspection the manager of the other service was herself on annual leave. On the second day of the inspection she was unavailable in the morning although she did come to the service with the necessary key in the afternoon. The manager (from the other service) and the staff on duty agreed that should they need to they would not be able to contact the next of kin of staff, as the contact information is locked away. The inspector recommends that a separate file of contact details for the next of kin of staff be maintained in an accessible place. Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 x 3 x x 2 3 Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 15 Requirement The manager must ensure that all care planning documentation is regularly updated, at least once a year but always after any significant change (previous timescales of 01/07/05 and 01/12/05 not met). The manager must ensure that risk assessments are regularly reviewed and updated especially when the needs of service users change (previous timescale 10/11/05 not met). The manager must ensure that the record of seizures is kept up to date, at least monthly, if appropriate recording that there have been no seizures observed. The manager must ensure that the service user who has no regular programme of activity is given opportunities to get out of the house for recreation and to take some exercise. The manager must ensure drug errors are eliminated as far as possible (previous timescales of 01/07/05 and 01/07/05 not met). Timescale for action 01/06/06 2 YA9 12 01/06/06 3 YA9 12 01/06/06 4 YA11 12 01/06/06 5 YA20 13 01/06/06 Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 26 6 YA21 15 7 YA22 22 8 YA22 22 9 YA30 12 10 11 YA35 YA36 18 (1) (c) (i) 18 (2) 12 YA42 13 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 (previous timescale of 01/01/06 not met). The manager must ensure that the complaints log reflects all the complaints received and their processing to resolution (previous timescale of 01/12/05 not met). The manager must ensure that tenants meetings take place regularly once a month (previous timescale of 01/12/05 not met). The manager must ensure that the improvements listed in the body of the report are undertaken. The manager must ensure that staff training profiles are available for inspection. The registered person must ensure that in future more robust arrangements are made to support and supervise staff in the absence of their manager. The manager must ensure compliance with the COSHH legislation, having safe storage of items and comprehensive information about them. 01/06/06 01/06/06 01/06/06 01/06/06 01/08/06 01/06/06 01/09/06 Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 27 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 YA6 Good Practice Recommendations The inspector recommends that the manager invite social workers to reviews by letter, giving them sufficient notice, and record their apologies on the review if they do not attend. The manager should ensure that service users are encouraged to develop individual hobbies and activities which they can pursue at home. The inspector recommends that the manager keep a monitoring eye on the use of convenience food ensuring that there is a balance with meals cooked from scratch, using fresh ingredients including fruit and vegetables. The inspector recommends that a separate file of contact details for the next of kin of staff be maintained in an accessible place. 2 3 YA11 YA17 4 YA17 Old Ford Road (69-71) DS0000010300.V290954.R01.S.doc Version 5.1 Page 28 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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