Inspection on 16/06/06 for Park House

This inspection was carried out on 16th June 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park House 20/09/07

Park House 25/10/05

Park House 06/07/05

Park House 10/03/05

Park House 15/07/04

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 Park House 157 Park Lane Hornchurch Essex RM11 1EH Lead Inspector Ms Rhona Crosse Unannounced Inspection 16th June 2006 09:15 DS0000027870.V300527.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000027870.V300527.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000027870.V300527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park House Address 157 Park Lane Hornchurch Essex RM11 1EH 01708 707370 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) Mr Michael Joseph Prior Mrs Harjinder Kaur Prior Mrs Harjinder Kaur Prior Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000027870.V300527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Park House is a semidetached property in a residential area of Hornchurch. Service users (all female) are accommodated in 5 single bedrooms. The home is not suitable for anyone with a physical disability. The home is close to local shops and amenities. Romford market town is in walking distance of the home. There are two parking spaces at the side of the home in front of the garage. There are no restrictions about parking in the road in front of the home and in the road to the side of the home. DS0000027870.V300527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection this means the home did not know the inspector was coming. The inspector arrived at approximately 09.15 Two staff were on duty and the manager/proprietor arrived shortly afterwards. The atmosphere in the home was very good. Staff had a good rapport with service users. All of the service users were at home. One service user was waiting for transport to take her to the day centre. Service uses were spoken with and their views on the home were gained. The staff team on duty is 2 staff. One staff took 2 service users out in the morning. The inspector spoke with the remaining staff member. No relatives were visiting the home at the time of the inspection. There have been improvements in the operation of the home since the last inspection. Service users now have goals of achievement set. This will benefit the service users by increasing their daily living skills.. What the service does well: What has improved since the last inspection? Two new sofas have been provided by the home. Service users said that they liked them and that they were comfortable. New flooring in the kitchen has been provided and also new flooring in the downstairs bathroom has been fitted. DS0000027870.V300527.R01.S.doc Version 5.2 Page 6 There is now a cross over of staff ensuring that the waking day is covered by two staff for the first ½ hour in the morning at the change over of night staff to day staff. Each service user now has a programme of goals set for them to achieve that will make a difference to their daily lives if achieved. Some staff training has taken place with staff attending basic food hygiene and health and safety training. Formal staff supervision is also taking place. The manager is continuing to undertake the Registered Managers Award and should have completed this later this year. What they could do better: The home has now set goals for service users to achieve to enable them to reach their potential. However these goals are recorded on a tick box scoring record. There must be an accompanying document provided to assess the progress being made. The fact that requirements set for the maintenance of the building have not been achieved means that in these standards the home scored only an adequate rating as there are some strengths but particular areas of weakness in these standards that reflect on the well being of the service users. Medication practice needs to be more thorough as medication administered on a ‘when necessary’ basis was not appropriately recorded when it was carried over on the medication administration record for the current month. The medication, the dosage and the amount of medication held must always be recorded when carried forward to the next month. Menus did not record the puddings eaten by service users this must be recorded to show the diet of service users at any time. Certain staff training was required to be undertaken. This training in basic first aid, challenging behaviour and POVA (protection of vulnerable adults) training has not taken place. This reflects poorly on the operation of the home as they should be achieving these requirements. These outstanding requirements will be re stated in this report and a shorter timescale will be given for achievement. Any further failure to meet these requirements may result in formal action being taken against the home. The home failed to protect vulnerable service users as they did not undertake a POVA first check on a new staff member who is already working with service users. This check must be undertaken by the timescale given. The home must ensure that this staff member does not work unsupervised with service users until the POVA check is received. DS0000027870.V300527.R01.S.doc Version 5.2 Page 7 The home must introduce a quality assurance system. The manager is doing this as part of her NVQ level 4 training. However the quality assurance questionnaires must be sent out and the information when returned analysed and added to the new Service Users Guide to enable any new service users to see what it is like living in the home. 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. DS0000027870.V300527.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000027870.V300527.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home endeavours to ensure that anyone wishing to live at the home has the appropriate information prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and a Service user Guide these documents are currently being reviewed. It was noted that there is reference to the NCSC this needs to be removed and the CSCI (Commission for Social Care Inspection) stated in it’s place. There have been no vacancies at the home for some time. However the home has an admission policy and service users are encouraged to visit the home prior to admission (this may be a visit and a meal or an overnight stay dependent on the service user involved). This is to get to know the service users who already live there an see what it is like living at Park House. Prior to admission the home receives an assessment by the placing authority and then the proprietor/manager will carry out their own assessment of the needs of the service users to ensure that the home can meet their needs. All service users have contracts complete by the placing authorities. DS0000027870.V300527.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 The quality in this outcome area is good therefore there are more strengths that weaknesses. In general information held was of a good standard with staff being aware of particular needs and wishes, evidencing that the needs and wishes of service users are met as far as possible enhancing their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place for all service users and theses were observed to have been updated. The inspector noted that some changes had not been made to two service users plans who’s needs had changed, this needs to be addressed. Risk assessments are drawn up as necessary and these are reviewed in line with the care plan. Since the last inspection reviews by the placing authorities have taken place. A further review for one service user is booked to take place on the 23/6/06. Since the last inspection goals have been set for service uses to achieve. These are individual goals that relate to each of the service users. A table identifies the goal and to what standard the task/goal has been achieved on any DS0000027870.V300527.R01.S.doc Version 5.2 Page 11 particular day. However there must be a corresponding record to show when the goal is reviewed and whether this goal is achieved. This must be put into place. Service users are able to make decisions about what they do and how the daily routine is undertaken. A service user asked to go out to Romford and another service users asked to accompany her. One member of staff took them out shopping to Romford and they returned later in the afternoon having had lunch at the ‘sister’ home Sycamores, which is about ½ way between Park House and Romford. The other three service users stayed at home. One service user loves to do jigsaw puzzles as was seen to start a very difficult puzzle. The other service users wanted to watch television. One service user helped hang up the days laundry on the washing line. No one at present wishes to use an advocacy service but there is information held relating to advocacy services. Two service users manage their own finances with minimal support from staff. One of the goals set is for one service user to manage her money more appropriately to ensure she has money set aside for activities she wants to take part in. The home has policies and procedures in relation to confidentiality. Service users are aware that records are written and the staff speak to them about their daily reports. It is doubtful that they have a clear understanding of the need for confidentiality, as one service user is quick to tell you everything that has happened in the home herself. However should service users raise an issue that was related to poor practice the staff would explain why they would have to pass this information on to the manager thus breaking their confidentiality. DS0000027870.V300527.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. The quality in this outcome area is good therefore there are more strengths that weaknesses. Service users needs are being well met and this enhances their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users undertake educational and supported work projects. One service user goes to a local college once a week to undertake literacy classes. Another service user goes to a supported work project 4 days a week. Activities take place and services users attend a local Church on a Sunday. One service uses told the inspector ‘I do the collection every week’. The Local Clubs are used which take place on Monday, Wednesday and Saturday. Service users have a presence in the local community using the local post office and shops. A trip to Hastings is to take place on the 21/5/06. A trip to Clacton is arranged for the 1/7/06 and to Aylesford on the 9/7/06. These trips are arranged DS0000027870.V300527.R01.S.doc Version 5.2 Page 13 through the clubs that the service users attend. A boat trip is to take place but a date is to be set in August/September. The annual holiday has not been discussed as yet, but this is usually a holiday abroad. Trips out to local restaurants and cafes take place. One service user is to go out with the manager/proprietor as she likes a one to one outing. This is part of the monitoring of behaviour that is taking place and the service user’s response to having to take responsibility for her actions. It was observed by the inspector to be working well as the service user ‘self harms,’ but the instances of this taking place have been greatly reduced. The home should be congratulated as they have effectively reduced this practice. Links with families and friends are encouraged and there are no restrictions placed on visiting times. No relatives were visiting at the time of the inspection. Meals and meal times are generally arranged around the daily activities that are taking place. The main evening meal is when all service users and staff sit down together. Menus are generally kept to unless service users make requests for something different. This is then recorded on the menu. From inspection of the menu it made reference to choices of puddings over leaf. However there were no choices recorded and no record of what service users had eaten. This must be addressed with a record always kept of all meals service users eat. Food stocks were inspected these were found to be appropriate for the service users accommodated. It was stated that the ‘big’ shop always take place on a Monday. The meal on the menu for the evening of the inspection was a stir fry chicken dish (chicken was thawing out for this meal). DS0000027870.V300527.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. The quality in this outcome area is good therefore there are more strengths that weaknesses. Greater care needs to be taken when carrying forward medication held onto the new medication administration record. This is to ensure a clear audit trail and ensure that medication is administered in line with the prescribing requirements for the protection of vulnerable service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal care of service users being in an all female establishment works well. During the inspection one of the staff was attending to a service users feet cutting her nails. Choices of when to rise and when to go to bed are recorded in the care plans. As the majority of the staff team have worked at the home for a long time, the needs and wishes of the service users are well known and continuity of care is provided. Service users clothing is very individual and when staff assist with any clothing purchases they always ensure that the clothing is the appropriate size and is in keeping with the individual. From an inspection of records it was observed that health care needs are being addressed appropriately with trips to the GP, dentist, optician and hospital DS0000027870.V300527.R01.S.doc Version 5.2 Page 15 appointments as necessary. One service user stated ‘I am going into hospital soon to have my teeth sorted’. Another service users who will refuse to eat is monitored and has ‘snacks’ at certain times of the day and also an enriched food supplement. The weight of the service user has risen to a reasonable standard and staff are keeping a record of her weight. Annual health checks for some service users have taken place. The home has policies and procedures for the safe administration of medication (including covert administration). Staff have undertaken training in the administration of medication on 21/7/05 and 25/3/06. For one service users there is no written information about when the PRN medication should be administered only a reference to make contact with the manager/proprietor is recorded before administering this medication. Clear guide lines must be drawn up for the administration of this medication. The medication held and the medication administration records were inspected. It was observed for two medications (Risperdal and Ibuprofen) that are administered ‘PRN’ (when necessary) had not had the quantity of medication or the dosage recorded and carried forward onto the new medication administration sheet. The home has to be able to show a clear audit trail of all medication administered. At the commencement of each month any medication that is to be carried forward to the next month must have the medication the dosage and the amount of medication held at that time recorded on the new sheet. DS0000027870.V300527.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is adequate therefore there are some strengths but particular areas of weakness. All staff must have training in the protection of vulnerable adults to ensure that they are aware of any poor practice and the process that has to be taken should any allegation of abuse be made. This is a restated requirement from the last inspection. If requirements have to be restated the home is not ensuring the well being of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures for dealing with complaints. It holds the Havering Complaints procedure and the ‘No Secrets’ document. Some staff have attended training in how to deal with any suspected abuse. However the home must ensure that all other staff receive training in the protection of vulnerable adults. This is a restated requirement that has not been complied with. There have been no formal complaints from either the service users or the relatives. The only complaint received was from the house next door as new owners moved in and they were not aware that the care home existed next door to them. The home should record this in the complaints register as the person went on to raise some complaints. These were addressed as necessary by the manager/proprietor. DS0000027870.V300527.R01.S.doc Version 5.2 Page 17 An allegation of abuse was made by a service user. This was dealt with appropriately with the police, relatives, social services and the commission being informed. The outcome of the allegation was that the incident reported did not take place. A review of the needs of the service user is to take place this week. Service users money held in safekeeping was inspected. All money held corresponded with the receipts held and the expenditure made. DS0000027870.V300527.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30 Standard 29 does not apply to the home. The quality in this outcome area is adequate therefore there are some strengths, but there are areas of particular weakness that need to be dealt with. Some requirements set at the last inspection in October 2005 relating to the maintenance of the building have not been complied with. This reflects on the well being of service users as the facilities they use are not being maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and tidy and free from odours throughout. Standard 29 does not relate to this home, as the home is not suitable for anyone with a physical disability. All bedrooms are suitable for the needs of the service users. Service users are able to bring small pieces of furniture with them the rooms were very individual and were filled with ornaments and other personal possessions. The laundry room was clean and tidy. A new washing machine had been purchased since the last inspection. DS0000027870.V300527.R01.S.doc Version 5.2 Page 19 At the last inspection a requirement was made that the ‘blown’ tiles in the downstairs bathroom be replaced as they were no longer impervious to water getting behind them. This requirement has not been complied with and will therefore be restated with a shorter timescale for compliance. The bath panel is broken and requires replacing. New flooring has been recently fitted to this bathroom. The upstairs shower room was also required to be refurbished. Holes remain in the ceiling where an electrician had made alterations to the lights. The shower is out of order and the shower cubicle requires attention. The shower room requires redecoration. This requirement has not been complied with and will therefore be restated with a shorter timescale for compliance. There was a large crack by the door at the top of the stairs this requires making good and painting. The remainder of the house was well maintained. The garden was well maintained with garden furniture available. DS0000027870.V300527.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is adequate therefore there are some strengths but there are areas of particular weakness that need to be dealt with. One member of staff did not have a current CRB disclosure returned and the home had not carried out a POVA first check to ensure that the staff member was suitable to work with vulnerable adults. The home in this instance has failed to protect the vulnerable adults in it’s care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a recruitment and selection policy and procedure. Only two new staff have been recruited since the last inspection. The majority of the staff employed are now long standing and offer continuity of care to service users. An inspection of the information held was made. Both staff had application forms and 2 written references taken up prior to employment. One staff had a CRB disclosure form returned, the other member of staff had an enhanced CRB applied for but it had not been returned. The home had not carried out a POVA first check on this member of staff and must do so to ensure that the staff member is suitable to work with vulnerable service users. Both staff had completed an induction programme. Staff have a 3 month probationary period DS0000027870.V300527.R01.S.doc Version 5.2 Page 21 when after this time a contract will be issued of the terms and conditions of employment. Staff training was inspected. 50 of the staff team must hold NVQ level 2 qualifications. Of the current staff team (14) 6 staff hold NVQ level 2 qualifications. The home must ensure that they meet this requirement. Recent training provided is Food hygiene on the 4/2/06 and 13/3/06, health and safety training also took place on those dates. It was a requirement at the last inspection that basic first aid, challenging behaviour and the POVA (protection of vulnerable adults) training take place. These requirements have not been complied with and are therefore restated in this inspection with shorter timescale for compliance. Any further failure to ensure compliance within the timescales set may result in formal action being taken against the home. The home must complete a training and development plan for each member of staff Formal supervision is taking place with staff and a record of this is kept. DS0000027870.V300527.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. The quality in this outcome area is good therefore there are more strengths that weaknesses. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager/proprietor has nearly completed her NVQ level 4 qualification and will be suitably qualified once this is achieved. The staff are aware of the lines of accountability within the home and were clear about their roles and responsibilities for the day. The home is an equal opportunities employer. The home has not yet commenced a quality assurance questionnaire. This is being looked into as part of the managers NVQ level 4 qualification. A questionnaire has been drawn up and is to be sent to service users relatives and visiting professionals. Once this information is returned an analysis of the DS0000027870.V300527.R01.S.doc Version 5.2 Page 23 findings should be made and the result should form part of the new Service Users Guide that this being reviewed at present. The home must be able to evidence the year on year development of each service user. Now goals have been set with the review of these the home will be able to monitor and report on the achievements made by service users. Staff meetings take place and the last staff meeting was on the 16/3/06. Service uses meetings are not taking place. These should be reinstated to evidence that the home is taking into consideration the wishes and requests of service users. The homes policies and procedures are currently under review and changes will be made as necessary. Staff have access to policies and procedures to refer to at any time. Health and safety records were in place and up to date. The annual portable appliance test was due to be carried out on the 17/6/06. Fire drills are taking place the last drill took place on the 21/9/06. The home must ensure that fire drills take place 4 times a year. DS0000027870.V300527.R01.S.doc Version 5.2 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 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 1 28 3 29 N/A 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 2 x 3 3 x DS0000027870.V300527.R01.S.doc Version 5.2 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 YA1 Regulation 4&5 Requirement Timescale for action 30/09/06 2 YA6 3 YA11 4 5 YA17 YA20 6 YA20 7 YA23 Provide an up to date Statement of Purpose and Service Users Guide. This should include the views of the quality assurance questionnaire. 15(1) & Care plans must reflect the (2) current needs of the service users and the changes should be documented as they occur. 15(1) & A reviewing document must be (2) drawn up to evidence progress (or not) of the Goals set for achievement to evidence the potential being reached by service users. 17(2) Menus must record the meals schedule 4 provided to service users. 13 13(2) Guide lines to be written for the administration of one service users PRN (when necessary) medication should be administered. 13(2) Any medication carried forward must have the name, dosage and remaining medication held in stock recorded onto the new medication administration sheet each month. 13(4)(c) All staff should be provided with DS0000027870.V300527.R01.S.doc 30/07/06 30/07/06 30/06/06 30/06/06 30/06/06 30/08/06 Page 26 Version 5.2 training in dealing with challenging behaviour. This is a restated requirement. 8 YA27 23(2)(b) The ceramic tiles on the walls in 30/07/06 the downstairs bathroom need to be replaced as they have ‘blown’ and are standing proud of the walls surface. This is a restated requirement. 30/09/06 9 YA27 10 11 12 13 14 YA27 YA27 YA32 YA32 YA34 15 YA35 16 17 YA38 YA39 23(2)(b) & The upstairs shower room needs 23(2)(d) refurbishment, the shower requires maintenance to the sealed edges of the shower door and the room requires painting and decorating. This is a restated requirement. 23(2)(b) Repair/replace the ceiling of the shower room. 23(2)(c) Replace the broken bath panel in the downstairs bathroom. 13(6) Staff must have POVA training. This is a restated requirement. 18(1)(c)(i) Staff must have training in basic first aid. This is a restated requirement. 19 1-8 The home must urgently undertake a POVA first check on the newly recruited member of staff. 18(1)(c)(i) All staff must have a training and development plan drawn up to ensure they have the skills and qualifications to meet the needs of service users. 12(3) Service users meetings must recommence. 24(1)(a) The home must have a quality &(b) assurance system in place. 30/07/06 30/07/06 30/08/06 30/08/06 18/06/06 30/08/06 30/07/06 30/09/06 DS0000027870.V300527.R01.S.doc Version 5.2 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 2 Refer to Standard YA32 YA36 Good Practice Recommendations Ensure that 50 of the staff group have undertaken the NVQ level 2 qualification. It is recommended that a chart identifying the times that supervision takes place is drawn up to assist the manager to monitor that 6 supervision sessions per year have taken place with all staff. Ensure that the minimum of 4 fire drills take place in a year. 3 YA42 DS0000027870.V300527.R01.S.doc Version 5.2 Page 28 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 DS0000027870.V300527.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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