Inspection on 09/08/06 for Pathways

This inspection was carried out on 9th August 2006.

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

Other inspections for this house

Pathways 30/08/07

Pathways 07/03/06

Pathways 07/09/05

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 Pathways 11 Gloucester Drive Hackney London N4 2LE Lead Inspector Kristen Judd Unannounced Inspection 9th August 2006 09:50 Pathways DS0000065292.V306724.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 Pathways DS0000065292.V306724.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. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pathways Address 11 Gloucester Drive Hackney London N4 2LE 020 8800 2619 020 8802 6862 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.pathwayscare.net Care Support Service Ltd trading as `Pathways` Ms Joanna Mary Brunt Care Home 8 Category(ies) of Learning disability (9) registration, with number of places Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service user with a Learning Disability aged 16-60 years, can be accommodated within the home. 7th March 2006 Date of last inspection Brief Description of the Service: 11 Gloucester Rd is registered with the Commission for Social Care Inspection to provide care and accommodation for eight young adults who have learning disabilities and was registered in July 2004.From 27th July 2005 the home is known as Pathways. The home is a quite residential road in Frinsbury Park area of the London Borough of Hackney and is well positioned to access a range of community amenities, local parks and transport links. The aim of the home is to provide a specialised service in working with service users with complex needs, in particular challenging behaviour and autism. It is a large house on four floors, which provides adequate communal areas. There is a small courtyard area. At the time of inspection there were five service users placed. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which started at 9.50 am. Two inspectors Kristen Judd and Yemi Adegbite conducted this inspection, which was conducted over seven and half hours. This inspection followed up the requirements made at the unannounced visit held on 3rd March 2006. The inspectors spoke with a service user, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There have been 17 requirements and 3 recommendations made following this inspection. Verbal feedback was given to the registered manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? 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. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 6 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 Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 7 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): 2 ,3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are clear about the service provision and what assistance is expected to be provided to service users. The service users are comprehensively assessed prior to admission to ensure that needs can be met. EVIDENCE: Service users are provided with a statement of purpose and service user guide, which provides all the relevant information. The service users guide is also in a pictorial format. The inspectors tracked the assessment process of one service user who was admitted into the home in June 2006.There was evidence of a comprehensive assessment being completed prior to service users being admitted to the home which clearly indicated behavioral issues. The assessments seen were comprehensive and specific to the needs of the service user. The inspectors were informed that the prospective service user was given the opportunity to visit the home prior to admission. Through discussion, the inspector was satisfied that the registered manager was able to demonstrate that the home has the capacity to meet the service users’ needs. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 8 Evidence was seen during the inspection that confirmed that the registered manager liaises closely with health professionals with regard to accessing specialised services in relation to learning disability. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. However all service users needs must be clearly assessed to ensure those needs can be met. EVIDENCE: Care plans examined contained some information about the service users daily routines, personal care and daily living issues in addition to behavioural issues and guidelines for dealing with individual service users The inspectors examined the care plan of the service user who was admitted in June 2006 the care plan was very basis covering three aspects, personal care, preparing own meal and community safety. The inspector raised concern that during the first month many key aspects of the service users care had not been included into the care plan. Whilst the inspector acknowledges that care plan have to been developed generally over a six week period and amended on an ongoing basis, however clear identified needs must be addressed, for example communication, physical aggression to others and health needs are all important issues and should be assessed to ensure that staff are well aware of how those needs are to be met. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 10 Through cross-tracking of relevant information concern was raised that incidents that occurred shortly after one of the service users had moved to the home lacked evidence of monitoring and evaluation of the incidents. The incidents involved other service users in the home, physical aggression to others had been indicated in the pre admission assessment as a possible incidents however even following incidents this was not included in the care planning. Additionally the inspectors cross-reference the risk assessments in place and there was no evidence of then being updated following incidents. Risk Assessments are in place which highlight the risks to service users, others and staff. The actions to be taken are detailed and provide clear direction to staff with strategies are in place in case of incidents. The strategies in place are clear and the process of dealing with situations is indicated. However there was little evidence to inform staff of any ‘triggers’ for example an increase in agitation. There was evidence to suggest that service users are involved in the day-today running of the home, participation in activities of daily living and involvement in choice of daily activities. The daily recordings include a document known as “How has your day been”. Service users are supported to indicate how they have felt and details of activities that they have participated on a daily basis. The format is in pictorial format. The inspectors cross reference information and were satisfied that service users were being supported to access the community and undertake a variety of activities. The inspector saw good evidence to suggest that service users were encouraged to participate in the decision making process. There was clear written information on files outlining the service users likes and dislikes in relation to many aspects of their daily living such as food and what clothes they like to wear. Service users are encouraged to preparation of drinks or assist with making a snack dependent on their ability. This was observed during the inspection. The interaction between service users and staff during the inspection was observed as being positive and sensitive to their needs. All records in regards to the service users are kept secure and confidential in a locked office. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspectors observed and were satisfied that staff provide service users with support to make choices and provide them the opportunity to lead independent lives. EVIDENCE: Service users’ are involved in the day-to-day routines of the home. Service users are offered a key to their own bedroom dependant on their needs. Through observation and discussion with the registered manager, it evident that daily routines and house rules do promote independence and individual choice for the service users in line with individual assessed needs. All of the service users are encouraged by staff to participate in a range of activities. Service users have good access to the local community. The care plans and daily records reflect evidence of the service users going out to various local places. During the inspection most of the service users were taken out to various venues. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 12 There was clear evidence of staff seeking a suitable college place for one service. Staff were actively following up a programme that would develop social skills, travelling training and other aspects of independent living. Risk assessments support decisions to ensure that both the service users and others are not put at unnecessary risk when accessing the community or undertaking activities. Risk assessments indicated what level of staffing service users need, this may to one to one or more. All but one of the service users had a holiday planned to ‘Centerparks’. On the day of the inspection two of the service users were having a ‘massage’ in the home The inspector was satisfied that service users largely maintain a good contact with family and friends and that their rights were well respected. Details of family and friends were evidenced on the individual service user files. The inspector was informed that family and friends are always welcome in the care home. There were relatives seen in the home of the day of inspection. There are three meals offered daily when service users are present in the home, with additional drinks and snacks. The home was found to have ample food supplies. On Friday’s service users have take away and are able to choose from a range of options. The sample of menus seen appeared to be balanced and nutritious. The inspector saw the food storage facilities; dry stocks were appropriately stored. The freezer was seen which needed to be defrosted. The inspectors were informed that the registered manager was in the process of ordering a new appliance. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 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 &20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The liaison with health professionals is good however there must be clear guidance in place for all users of the service when dealing with issue that may affect others. EVIDENCE: Service users’ require a range of support with personal care from prompting and supervision to assistance with regards to bathing. The inspectors saw evidence of the wishes of service users who are supported by staff with personal care tasks on service users files. Written guidance/guidelines in place were clear in identifying which tasks staff needed to be completed, supervised or prompted only. The inspector continues to be satisfied through indirect observation and records seen that the staff are very flexible with regards to meal times, bedtimes and activities. Service users are able to choose their clothes and other personal belongings that reflect their own individual personalities. Individual files contained good information regarding the physical and healthcare needs of service users; all service users were registered with a GP and medical and health care appointments. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 14 Although the registered manager had responded appropriately to a recent heath issue within the home appropriately however it is the inspectors’ view that there should be guidelines in place for visitors to the home. Additionally through discussion with staff it was clear that it was a concern that the service user affected may not have completed the treatment in line with direction. The staff must ensure that this is clarified to ensure that there are no further outbreaks. Medication is provided by the chemist in blister packs. The inspector was informed that most staff are now up-to-date with medication training. At the time of inspection two service users were prescribed medication. Medication records were seen and were deemed correct at the time of inspection. However a medication ‘Fexodenadine’ that had been discontinued as of the 27th July 2006 was still being entered on the MAR sheets. The registered manager must ensure that only prescribed medication are entered. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate judgement has been made using available evidence including a visit to this service. All complaint must be dealt with in line with procedure to provide a degree of confidence in the complaints system for those who may wish to have complaints investigated. EVIDENCE: The complaints procedure is in place and the information is available in pictorial format. The inspector saw the complaints log, and there was evidence that complaints are appropriately logged. However a complaint made on 15/6/06 had been logged however there was no evidence of an investigation or outcome. The inspectors were informed that the past Managing Director had dealt with the complaint. The registered manager must respond to this complain in line with procedures and the outcome must be appropriately recorded. Adult protection policies and procedures are in place. The registered manager was aware of procedures and was very clear about her responsibilities to follow procedures. A recent incident in the home was reported without delay to the local authority in line with procedure. However the registered manager indicated that not all staff have received adult protection training. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 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): 24,26,27 &30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were serious concerns with regard to the condition of the environment, which must be addressed as a matter of urgency. EVIDENCE: The service users have access to the entire home with the exception of the individual rooms of others. There is a dining area situated next to the kitchen and small courtyard. There is also a multi-sensory room off the dinning room, which is not in use at this time due to the repairs being undertaken following the leak in two of the bathrooms. Due to recent changes within the organisation the inspectors were informed that none of the previous requirements made with regard to the environment had been addressed. During the tour of the environment many issues were noted requiring attention it was noted that many areas required plaster to be replaced and cracks to be filled in particular around doorframes. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 17 There are many window coverings broken or not in place. In particular the service users bedrooms and the bathroom at the front of the house which although has frosted glass with the lights on in the evening it will lack privacy. This is currently the only bathroom available for service user use. All windows should have suitable coverings to ensure that the privacy and dignity of service users is preserved. Service users rooms seen also had damage to the walls; one room on the first floor had been affected by a recent leak and required total refurbishment. This room cannot be occupied until it reaches the NMS. It was noted that carpet was worm and loose on the stairs. Carpet in room one is very heavily stained; the registered manager was advised to change carpet if cannot be cleaned professionally. Bedroom 5 had a severely stained carpet; the odour in this was extremely strong. This was a previous requirement. The registered manager stated that new washable flooring had been ordered. During there inspection, the inspectors observed a staff member mopping up urine in the downstairs lounge with the bucket that clearly had no water in it. The staff member was observed to be spreading the urine across the floor area and did not use any disinfectant. This practise is unacceptable; the registered manger was advised to ensure that all staff are fully aware of how to deal with such incidents to ensure that there is no risk of cross infection. In the kitchen the inspectors noted a cupboard door was missing; areas such as worktops and cupboard doors were ‘sticky’ and required cleaning. It was noted that there were a lot of flies during the inspection the registered manager stated that a fly screen was about to be fitted. The inspector also noted that the oven and the fan extractor were dirty and in need of urgent cleaning. There are currently two bathrooms out of service following leaks of which the Commission had been notified. The third bathroom is in need of a deep clean and concerns were raised with regard to the continental toilet and the connections that have caused an overflow of faeces. This has raised concern with regard to health and safety. An immediate requirement notice was issued with regard to this matter. At the time of writing this report the inspector was satisfied that this was being actioned. All of the bathrooms required attention to crack floor tiles; bath panels required securing and were generally looking ‘tired’ and unwelcoming. There is domestic support provided daily, however this is a large home that cares for service users with unpredictable behaviour. The home had been Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 18 cleaned on the morning of the inspection however attention needs to be taken to walls, carpets and woodwork throughout the home. Additionally the inspectors were very concerned about the strong odours throughout areas of the home. It was noted that much of the wooden floors had gaps, which could be harbouring urine and possible cause a spread of infection. In particular the first floor landing. Additionally there was an extremely strong smell of urine from two service users bedrooms on this floor. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 19 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 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service fails to protect service users by not undertaking adequate checks before staff work in the home. EVIDENCE: The inspector was satisfied through discussions and observations made during the inspection that the registered manager and staff are aware of their roles and responsibilities. There are currently four-service users in placement and there is always a minimum of two staff on duty with an additional staff on duty between 11.007.00pm throughout the day and one waking night plus a sleep in. In addition there is a manager and administrator. Rotas seen at the time of inspection accurately reflected the staff on duty. There is an on call emergency procedure in place. A sample of three staff files, the inspector raised concern as all three staff were have been working for some time in the home as agency staff had been employed without all relevant documentation being in place. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 20 The concerns were: File 1 contained one reference (which was brief and part completed) and no Criminal Bureau Records (CRB) check. File 2 contained two reference but they were applied for from the organisation. File 3 contained one reference. Did contain a CRB however it had not been received prior to the staff member commencing employment. It is recommended that an audit of the staff files be undertaken to ensure all relevant documentation is present. The inspectors were provided with information of training completed by staff. Staff have completed some mandatory training however the registered manager was unable to establish exactly what training staff had achieved. It is recommended that an audit be undertaken to identify any mandatory training that staff required. A random selection of staff files evidenced that staff are receiving supervision at least six times a year. The inspector also noted that one staff member who was affected by a recent incident was provided with additional support/debriefing on a one two one basis by the registered manager. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 21 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, 41 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. However action must be taken to address outstanding requirements from previous inspections. EVIDENCE: The inspector is satisfied that the registered manager has knowledge of the National Minimum Standards and is satisfied that the home is managed in an open and positive way. The inspector continues to be satisfied that the registered manager is competent and experienced to run the care home in line with its stated purpose. As previously stated due to recent changes within the organisation the inspectors were informed that none of the previous requirements made with regard to the environment had been addressed. Through feedback during the inspection the inspectors were satisfied that this issue was to be addressed by the current management team. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 22 There was a lack of evidence of the monthly monitoring visits being undertaken regularly. The last report available was dated March 2006. This issue remains an outstanding requirement. Through the tracking of incidents and accidents it was noted that an incident that occurred on the 30/06/06 was not notified to the Commission. The registered manager had however updated the risk assessments appropriately and care plan appropriately, which were clear and detailed. The following health and safety checks have been evidenced: The last recorded fire drill is recorded as 10/7/06 Emergency lighting checked 26/06/06 Gas certificates were seen dated 05/06 valid for one year. The electric certificate 11/04 valid for 5 years. Portable Appliance Test were completed 09/05 Fire extinguishers were last checked 9/5/06 Insurance certificate valid until 10/10/06 Fire alarm was last serviced 26/6/06 A ‘care of the environment’ checklist is completed weekly. Staff highlight repairs needed and entry them into the maintenance book. Staff also record areas that may need cleaning however staff do not record whether it has been actioned. Given the concerns in this report it is recommended that this be formalised. Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 x 26 1 27 1 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 3 33 x 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x 2 3 x Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 24 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 15.2 Requirement The registered manager must ensure that care plans are updated following review to clearly identify service users needs and how those needs are to be met. (Timescale of 31/05/06 not met) 2 YA6 15.1 The registered manager must ensure that when care plans are developed they clearly identify key needs . The registered manger must ensure that all unnecessary risks to the healthy and safety of service users are identified are so far as eliminated. (Timescale 31/10/05 not met) 4 YA9 13.4 The registered manager must 31/10/06 ensure that risk assessments are updated following incidents in involving service users. The registered manager must 15/09/06 ensure that appropriate guidance is in place for service users, staff DS0000065292.V306724.R01.S.doc Version 5.2 Page 25 Timescale for action 31/10/06 31/10/06 3 YA9 13.4 (c) 31/10/06 5 YA19 13.1 Pathways 6 YA19 13.1 7 8 YA20 YA22 13.2 22.3 9 10 YA23 YA24 13.6 23.2 and visitors to the home for any situation that potentially puts them at risk. The registered manager must ensure that service users received the correct treatments as state by the health professionals. The registered manager must ensure that medication records are accurately maintained. The registered manager must respond to this complaint as stated in this report in line with procedures and the outcome must be appropriately recorded. The registered manager must ensure that all staff received adult protection training. The registered manager must ensure that all of the damaged areas of the home be repaired and decorated. (Timescale 24/12/05 not met) 15/09/06 15/09/06 15/09/06 31/10/06 30/11/06 11 YA26 16.2(c) The carpet in SR room must be cleaned thoroughly to remove stains or replaced. (Timescale 31/10/05 not met) 30/11/06 12 YA27 23 The ground floor bathroom is not 10/08/06 to be used until deemed safe. Evidence of the bathroom being thoroughly cleaned and free from any cross infection to be forwarded to the commission. The registered manager must 30/09/06 ensure that all areas of the home be kept clean (Timescale 30/09/05 not met) 13 YA30 23.1 Pathways DS0000065292.V306724.R01.S.doc Version 5.2 Page 26 14 YA34 19.1(b)(i) 15 YA34 19.1 16 YA39 26 The registered person to ensure that no person works in the home unless a satisfactory CRB disclosure has been obtained by the organisation. The registered manager must ensure that all staff files are maintained in line with Schedule 2. The responsible individual must ensure that visits be completed and recorded monthly. The reports must be available for inspection. (Timescale 30/04/06 not met) 30/09/06 30/09/06 31/10/06 17 YA41 17 The registered manager must ensure that all incidents that are notifable be forwarded to the Commission without delay. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations It is recommended that the registered manager monitor the usage with the current service users, as the home gains full occupancy there may be a need to reconsider the position of these machines. It is recommended that any cleaning issues noted in the weekly care of the environment check be formally actioned. It is recommended that an audit be undertaken to identify any mandatory training that staff required. 2. 3. 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