Inspection on 29/09/05 for Our House

This inspection was carried out on 29th September 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Our House 06/03/07

Our House 20/02/06

Our House 03/03/05

Our House 16/09/04

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 Our House 5 Blueberry Close Woodford Green Essex IG8 OEP Lead Inspector Jackie Date Unannounced Inspection 29 September 2005 14.00 Our House DS0000025914.V251860.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 Our House DS0000025914.V251860.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. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Our House Address 5 Blueberry Close Woodford Green Essex IG8 OEP 020 8599 7585 020 8599 7585 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) Redbridge Community Housing Limited [RCHL] Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate level of disability. Date of last inspection 3rd March 2005 Brief Description of the Service: 5 Blueberry Close, also known as Our House, is a home for five people with learning disabilities. It is one of a number of homes run by RCHL, Redbridge Community Housing Ltd. The house is in Woodford in the London Borough of Redbridge. The home was built in 1998 and was designed with the support of the parents of the residents. It is a bungalow and accessible for wheelchair users. The home has five large bedrooms, two with ensuite showers and toilets. There is a large lounge, a kitchen/dining area, a bathroom, a shower room and a laundry room. There is also a small conservatory where residents can use the computer. In addition to this there is a staff sleeping in room and an office. All of the residents have lived together since the home opened. The residents do a lot of things in the home, the day centre, and the college. They have strong links with the local Catholic Fellowship and join them for a lot of social activities. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about four and a half hours and took place during the afternoon and early evening. It was the first of the two inspections that each home must have during the inspection year. Two staff and all of the residents were spoken to. All of the communal areas and most of the residents’ rooms were seen. Care and other records were checked. In addition to this the inspector had previously visited the organisation’s head office to view staff records. What the service does well: What has improved since the last inspection? What they could do better: Health and safety checks need to be carried out regularly and more risk assessments need to be done to make sure that when residents are doing things for themselves they are being kept as safe as possible. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 6 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. Our House DS0000025914.V251860.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 Our House DS0000025914.V251860.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): 5 Residents still do not yet have an individual contract or statement of terms and conditions with the home and therefore still do not have detailed information about the service that they are entitled to. EVIDENCE: The home was purpose-built seven years ago for the five people that live there and there have not been any new admissions since then. It is therefore not possible to test Standard 2 with regard to prospective users needs being assessed. The previous three inspections have required that the organisation must provide each resident with a fully costed contract/statement of terms and conditions. At a meeting with representatives of the organisation on the 12th of September the Commission was informed that RCHL is in the process of sending out the new statement of terms and conditions, but none of the residents had yet received it. This requirement still remains outstanding and therefore residents still do not have detailed information about the service that they are entitled to. However as this work is in progress, the timescale for compliance has been extended to allow for the information to be made available to all residents. Our House DS0000025914.V251860.R01.S.doc Version 5.0 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, 8 and 9 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs safely. Residents’ needs are reviewed and care plans updated when needed. Although risk assessments are in place these need to be developed further to ensure that they cover all of the necessary areas. Residents are encouraged and supported to be involved in decisions about what they do and what happens in the home. EVIDENCE: Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 10 Each resident has a care plan. These are detailed and give clear information about each person. They include details of what they can do, what they like to and the support that they need. For example one persons plan says that they should go to the office with staff and count out the money required for fares. Another persons plan says to let them book their own opticians appointment with support from staff. Residents said that their plans were discussed with them. In one persons file there was an agreement that had been made specifically with them about their participation in chores around the home. The care plans are reviewed although some of them were a little bit behind schedule. However these were in the process of being arranged. Daily reports are made and these are now more detailed and linked to items on the care plan as required by the previous inspection. Daily notes contain details of how the person has been, what they have done, and in one case where there was concern about a resident’s behaviour and health detailed information was recorded about this. The residents are very involved in everything that happens in the home and two of them decorated their rooms with their key worker. Residents also said that they take turns to choose the menu and that some of them feed the cat and give it water. The service users guide says that residents’ meetings will be held every two weeks but they are not happening regularly and although the residents are involved in discussions about what happens at the home it is recommended that the residents’ meetings are held regularly and minutes are kept. Risk assessments are the in place. These identify risks for the residents and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. However, although the risk assessments are adequate they do not cover all the necessary areas. For example a resident was cleaning the bathroom using cleaning products. There was nothing to confirm that he could do this safely or that there are systems in place to ensure that other residents, who may not have been aware of the dangers, are kept safe. Also there was an iron on a set of drawers in one of the residents’ rooms. The resident said that they had been doing some ironing. There was no risk assessment with regard to this, or any guidelines about supporting the resident and safeguarding everyone. Risk assessments must be in place for all activities that present a risk to residents. This will ensure that residents have the opportunity to try things and to develop their skills as safely as possible. Our House DS0000025914.V251860.R01.S.doc Version 5.0 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, 14, 15, 16 and 17 Residents are encouraged and supported to do as much as possible for themselves and to be independent. All of the residents keep in contact with their friends and families. The residents take part in a variety of activities and are part of the local community. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: Residents participate in household task on a rota basis. This includes the cooking as well as domestic chores. On the day of the visit one resident was helping to cook the evening meal and another one was cleaning the bathroom. Another said that it was their job to put the rubbish out. Residents’ care plans contain lots of different ways in which they are supported to develop their skills and to be as independent as possible. For example one resident uses a bath chair and he is encouraged to work the controls himself. Also when in the bath he washes his own hair and staff just rinse it. Another resident is supported to sort out her clothes before putting them in the wash. As previously stated one Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 12 resident irons his clothes. All of the residents have a very busy life. They attend college courses and some go to day centres. In addition to this they belong to the Catholic Fellowship and United Friends and they go on lots of social activities, trips and holidays with them. They all go to church regularly and one resident said that he meets his mother there. Three of the residents were going to Yarmouth a couple of days after the inspection and said that they were looking forward to this. During the course of the visit staff were helping them to pack their cases and prepare for the holiday. As previously stated the residents’ families were involved in the setting up, planning and building of the home and they are still very much involved. They visit regularly and residents also go home for visits and short stays. One resident visits his mother every two weeks. He goes in a taxi on his own and pays his own fare. His mother phones the home to let them know when hes arrived safely. The families are invited to celebrations and barbecues. There was a letter from one of the mothers thanking everyone for the excellent party that had been organised for her son’s birthday. There was also one that said thank you for the good review and the relaxed and happy atmosphere in the home. As previously stated the residents choose the menus, they take turns to do this. There are encouraged to eat healthily and fruit and yoghurts are available. One of the residents usually has a vegetarian diet and on the evening of the inspection a different meal was cooked for her. One resident said that the food was nice and another said that he liked liver and bacon. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 13 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 and 20 When required residents receive personal care that meets their individual needs and preferences. The residents are encouraged to take their own medication with help and supervision from the staff team and this increases their independence. However the staff team must ensure that the office key cabinet is always locked so that residents do not access the keys to their medication without this necessary supervision. Residents receive support to ensure that they get the medical and health care that they need. EVIDENCE: Residents need differing amounts of help with their personal care and details of this are in their care plans. As previously stated one person needs to use a bath chair to get into the bath. This person is supported by the staff but is encouraged to work the controls himself. There are guidelines in place to enable this individual to have some privacy in the bath and to be as independent as possible even though he has epilepsy. On the day of the visit one resident was observed to go into the bathroom and bathe without assistance from the staff. Staff were observed to knock on the bathroom door and also to ask residents’ permission before entering their bedrooms. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 14 All of the residents are registered with local doctors are supported to attend appointments. Details of appointments and checks, and their outcomes are recorded in residents’ files. One resident had been unwell recently and staff noticed that this person appeared to have lost some of their motor skills. Therefore they arranged further checkups with the doctor. The cause of this has now been diagnosed and the person will be receiving the necessary treatment. The guidelines that are in place for the action to be taken in the event of the resident with epilepsy having a seizure have been updated as required by the previous inspection. It was also required that following any accident consideration must be given to how and why it happened and any action to prevent a reoccurrence must be implemented and that all accident forms must be checked and signed by the manager and line manager. This has been done. The procedure for the administration of medication has changed since the last inspection. Medication cabinets have now been fitted into each residents rooms and the keys are kept in the office. The resident comes to the office and the staff goes with them and assists them with their medication. The staff sign the medication administration record. The details of what is required are clearly explained in the guidelines, which also contain photographs of each resident. The idea of this is to give the residents an understanding about their medication and to enable them to be as independent as possible even though at present none are able to totally self medicate. This system of administering medication is adequate and suitable. However, on the day of the visit the key cabinet in the office was left unlocked and a resident was observed to come and get a key for their medication cabinet without staff supervision. This was discussed with the senior person on duty and also with the line manager and they were both clear that the key cabinet should be kept locked at all times to safeguard residents. The medication procedure has been updated to include the action to be taken in the event of a medication error occurring, as required by the previous inspection. However this was not detailed enough and what was needed was discussed with the senior person on duty to enable the necessary changes to be made. The previous inspection also required that protocol/guidelines must be in place that detail the circumstances in which prescribed “as required medication should be administered”. This has been done. The requirement from the two previous inspections that all staff must be made aware of the appropriate first aid that can be carried out and if necessary further or refresher training provided has not yet been addressed. This must be done to ensure that in the event of any accident or injury residents receive the appropriate first aid. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 There is a complaints procedure that would be followed in the event of any complaints being made. Staff are aware of issues of abuse and work to protect residents from abuse. EVIDENCE: The home does have clear policies and procedures for dealing with complaints/concerns and compliments. If residents are not happy about anything they said that they would speak to the staff about this and they would sort things out for them. There have not been any recorded complaints since 2001 but the home has had several compliments that they also record. These are mainly from the residents’ relatives and relate to the quality of care and service provided. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff spoken to were aware of the issues of abuse and aware of their responsibility to residents. The staff team appropriately dealt with a recent possible adult protection issue, not related to the service provided by the home. Issues with regard to residents’ finances were not checked during this visit and will be checked at the next inspection. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 29 The residents live in a clean and comfortable home that is suitable for their needs. EVIDENCE: The home was built in 1998 and was designed with the support of the parents of the residents. It is a bungalow and accessible for wheelchair users. The home has five large bedrooms, two with ensuite showers and toilets. There is a large lounge, a kitchen/dining area, an assisted bathroom, a shower room that is accessible to wheelchair users and a laundry room. There is also a small conservatory where residents can use the computer. The garden is well maintained and has suitable garden furniture. At the time of the visit all of the communal areas were in the process of being decorated. The residents’ rooms are all well decorated and furnished. They have been personalised with family pictures, ornaments, music centres and televisions. As previously stated two of the residents have recently helped to redecorate their own rooms with one of the staff. Bathing and showering facilities are suitable for the needs of the residents. However in the shower room the towel rail was extremely rusty and the Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 17 shower seat had some rust and mildew on it. The towel rail must be replaced and the shower seat cleaned or replaced if necessary. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 36 The Commission for Social Care Inspection (CSCI) cannot yet be confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. However, CSCI is satisfied that the organisation is actively addressing deficiencies in this area. Staffing levels are sufficient to meet residents’ current needs and provide a good service for them but the staff team are not receiving regular supervision. EVIDENCE: Two staff are on duty from 7 a.m. to 9 p.m. and then one staff is on duty until 10:30 p.m. and from 10:30 p.m. to 7 a.m. one member of staff sleeps in. Staffing levels are sufficient to meet the assessed needs of the residents. An inspection of a sample of personnel files at the organisations head office showed that not all of the required checks on staff could be demonstrated to have taken place. This was of particular concern, as many of the files inspected related to staff who have joined the organisation in the past year, and for whom the recruitment process should have been robust, as matters regarding recruitment have been discussed previously with the organisation. Since raising serious concerns about the recruitment practice with RCHL, the organisation has undertaken a detailed audit of staff files and reviewed their Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 19 recruitment procedure and practice to identify and rectify deficiencies and to safeguard service users. At a further visit to the organisations head office CSCI were informed of the changes made. However only one new member of relief staff had been recruited recently, and therefore insufficient information was available to test the new procedures fully. An extension of the timescale for compliance has been given, to allow for more evidence of staff recruitment to be available. Staff supervision has not been taking place regularly and staff meetings are not being held regularly. Although communication in the home does appear to be good it is important that staff meetings do take place and that all of the staff team are involved in these. Regular staff meetings must take place, a minimum of six per year. In addition to this all staff must receive regular recorded supervision at least six times a year with a senior/manager in addition to regular contact the day-to-day practice. This will ensure that staff have an opportunity individually and together to discuss issues, concerns and the development of the service Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41, 42 and 43 Although the home did not have a manager at the time of the inspection the staff team continue to provide good service to the residents. The organisation has not been robust in maintaining staff records. This could potentially place service users at risk. Although health and safety checks are being carried out some need to be more frequent and risk assessments need to be in place and up-to-date. EVIDENCE: At the time of the visit the home did not have a registered manager but one has since been recruited and is due to commence employment on the 24th October 2005. The organisation will then make an application for his registration. The quality of the service provided to the residents is monitored by the organisation. The service manager carries out monthly monitoring visits to Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 21 assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In addition to this the organisation carries out a quality audit each year. All of the required residents’ records are kept, but an inspection of staff records held at the head office found that staff records as required by Schedule 2 of the Care Homes Regulations 2001 were not available in all staff files. The organisation had given an undertaking that all of the staff records, in accordance with Schedule 2 will be available in the home for inspection, commencing with records relating to all newly recruited staff. Records relating to existing staff will also be available in the home, and the Commission has set 31 December 2005 as a timescale for this to be implemented. All of the necessary health and safety checks are carried out but hot water temperatures are not being tested frequently enough. They must be tested on a weekly basis to ensure that the temperature does not exceed the specified 43°C. Records show that this is not happening and this potentially places residents at risk. This requirement has been made in the two previous inspections and must be addressed. However there was a situation when the hot water was found to be too hot and the appropriate action was taken at that time to safeguard residents. The fire alarms are tested weekly but the fire risk assessment was dated 2004 and should have been reviewed in May 2005. This must be reviewed to ensure that it is up-to-date and contains the correct information to safeguard staff and residents. Standard nine give further information and a requirement regarding risk assessments. There was a problem with the oven in the kitchen in that when the door was being opened the oven would move causing a potential risk to anybody using it. The senior staff on duty was informed that this must be remedied within seven days. The two previous inspections have required that the registered manager must develop a business and financial plan for the home and a copy of this must be sent to the Commission. This still remains outstanding. However at recent meetings with the organisation the Commission has been informed that a template has been developed for this and was being distributed to the homes. The timescale for this has therefore been extended to allow for this work to be completed. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Our House Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X 2 2 2 DS0000025914.V251860.R01.S.doc Version 5.0 Page 23 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 YA5 Regulation 5 (b) (c) Requirement The registered persons must develop a costed contract for each service user together with terms and conditions. (Previous timescales of 31 March 2004, 31 December 2004 and 31 May 2005 not met). Risk assessments must be in place for all activities that present a risk to residents. All staff must be made aware of the appropriate first aid that can be carried out and if necessary further or refresher training provided. (Previous timescales of 31 December 2004 and 30 April 2005 not met). The key cabinet in the office must be kept locked all times when not in use The towel rail in the showroom must be replaced and the shower seat cleaned or replaced if necessary. Timescale for action 31/10/05 2 3 YA9 YA19 13 13 30/11/05 31/12/05 4 5 YA20 YA27 13 23 31/10/05 30/11/05 6 YA34 19 7 YA36 18 The registered persons are 30/11/05 required to ensure that their recruitment procedure is robust and in line with regulation. Regular staff meetings must take 31/12/05 DS0000025914.V251860.R01.S.doc Version 5.0 Page 24 Our House 8 YA36 18 9 YA41 17 10 YA41 17 11 YA42 13 12 13 YA42 YA42 23 13 14 YA43 25 place, a minimum of six per year. All staff must receive regular recorded supervision at least six times a year with a senior/manager in addition to regular contact the day-to-day practice. The registered persons are required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001. For new staff, before appointment. The registered persons are required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001. For existing staff an extended period for compliance has been given. Hot water temperatures must be tested on a weekly basis to ensure that the temperature does not exceed the specified 43 degrees C. (Previous timescales of 31 October 2004 & 15 April 2005 not met). The fire risk assessment must be reviewed and updated. Action must be taken to prevent the oven from moving when the door is opened. A timescale of 7 days was set at the inspection. The registered manager must ensure that there is a business and financial plan for the home and a copy of this is sent to the Commission. (Previous timescales of 31 December 2004 & 31 May 2005 not met). 31/12/05 30/11/05 31/12/05 15/11/05 15/11/05 05/10/05 31/12/05 Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 25 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 YA8 Good Practice Recommendations It is recommended that residents’ meetings are held regularly and minutes are kept. Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Our House DS0000025914.V251860.R01.S.doc Version 5.0 Page 27 - 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. 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