Inspection on 05/10/05 for Peel Way

This inspection was carried out on 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peel Way 18/09/07

Peel Way 15/12/06

Peel Way 14/06/05

Peel Way 15/05/05

Peel Way 24/02/05

Peel Way 26/08/04

Peel Way 19/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Peel Way 6 Peel Way Harold Wood Romford Essex RM3 OPD Lead Inspector Ms Edi O`Farrell Unannounced Inspection 5 October 2005 10:50 Peel Way DS0000015599.V254342.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 Peel Way DS0000015599.V254342.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. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peel Way Address 6 Peel Way Harold Wood Romford Essex RM3 OPD 01708 386 478 01708 345 478 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) The Avenues Trust Limited Mrs Beverley Deleth Pace Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. MINIMUM STAFFING NOTICE Date of last inspection 14th June 2005 Brief Description of the Service: 6 Peel Way is a purpose built home for six adults with learning disabilities, situated in Harold Wood, Romford. It is a detached, two storey, house, with parking space to the side, and an enclosed garden to the rear. There is an open plan lounge/dining area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, both of which have ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each have an ensuite toilet, and share a bathroom. There is a ramp to both front and back entrance, but no lift to the upper floor. The Avenues Trust, a company that has similar homes, both locally and in Kent, runs the home. There are good local transport links, and the home has its own minibus. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, or staff accompanying service users to appointments. The home uses a Person Centred Planning system, in line with central government policy in relation to people with learning disabilities, as outlined in ‘Valuing People’. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from mid morning to mid afternoon. All six service users were at home and some were able to give their views on some aspects of care. Care records were examined, and crossreferenced with other documents such as accident reports, menus, and the staff rota. The findings were discussed with some of the staff, who were also asked about staff meetings, supervision and morale. The Registered Manager was on annual leave, so the results of the inspection were discussed with the Service Manager, who visited the home during the inspection. Eleven Requirements were set at the previous inspection and for three of these the timescale has not yet been reached, so these have been taken forward with the original timescale. Three have been partly met; so new Requirements have been set to take account of this. A further three have not yet been met and have been restated in this report with a new timescale for compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet Requirements can be found in the relevant standard. Unmet Requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. This was the second statutory inspection for 2005/6, and across the two visits all core Standards have been assessed. Service users, staff, and the service manager, are thanked for their in-put to the inspection. What the service does well: The house is bright, airy, and well decorated and furnished. It is domestic in nature providing a pleasant place to live. All the bedrooms are single and have an ensuite toilet, with two also having an ensuite bath. The house is in keeping with others in the area, and on good transport links. Five of the people living there, and many of the staff have known each other for a long time, so know each others moods, and ways of communicating. Staff know the needs of each service user, and how these should be met on a day-to-day basis. They also quickly notice changes in the health of service users, and take prompt action to refer them to specialists. All service users have an annual holiday, some as a group, and others by themselves with staff. The menu is balanced, and includes regular fresh fruit and vegetables. Staff cook many meals, such as lasagne, from fresh. Service users help with domestic tasks as much as they are able. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 6 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. Peel Way DS0000015599.V254342.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 Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 The Statement of Purpose is not fully accurate, and needs amending. Service users’ needs are assessed prior to admission, and they have an opportunity to visit and test drive the home. Each service user has a written contract. EVIDENCE: The Statement of Purpose needs to be reviewed and amendments made as the staffing numbers vary in different sections, and do not agree with other documents seen in the home, such as the staff rota. It also still refers to the previous Commission, and does not include our contact details. The inspection report it contains is not the last one. This is Requirement 1. The Service User Guide has been produced using symbols, which makes it more accessible to the residents, than the written version. The home should consider producing this document in other formats, such as video/DVD, in order to make it even more accessible. This is Recommendation 1 One service user has been admitted since the last inspection, and the preadmission assessments were examined. These included in-depth reports from members of the specialist multi-disciplinary team for people with learning disabilities. The manager had also carried out a pre-admission assessment, using the company’s standard format. This information had been used to draw up a care plan. Peel Way DS0000015599.V254342.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, 9 & 10 Service users’ assessed and changing needs and personal goals are reflected in their individual plans, but are not always being met on a day-to-day basis. They are consulted on, and participate in the life of the home, to the level that their disabilities allow. They are supported to take risks, but some aspects of control and restraint need closer monitoring and review. Information about service users is not being stored confidentially. EVIDENCE: Four case files were examined, and cross-referenced with other documents, such as the staff rota. Staff have very obviously worked hard since the last inspection to implement the new PCP system. The system being used is very comprehensive, and includes lots of things that are considered to be best practice in learning disability services, such as use of first tense, circles of support, and short, medium, and long term goals. It was therefore disappointing to find that some of the basic goals, such as regular walks, had not always been able to be met due to lack of staff. In one case the care plan had been changed because of this, so that it included in-house activity instead, yet the assessed need for regular walks, as a preferred activity, remains. This is the total opposite of the principle of PCP, which is that the plan is based on Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 10 the needs and wishes of the service user, not on the needs of the service. Comparing the staff rota over the past few months with the four care plans showed that it was not possible to meet the identified needs, for example one service user has to have two members of staff at times in the community, whilst another has to have two in the house, and there are usually only three staff members, and sometimes only two, on duty. This is Requirement 2. Requirements have been set at previous inspections in relation to risk assessment, and management of aggressive or self-harming behaviour. These have now been acted upon, but further work is needed. For example, since the last inspection the home had sent three notifications of use of restraint to the Commission. In response the, then, lead inspector rang the home to request further information, such as a copy of the care plan, and minutes of multi-disciplinary meetings where the restraints were agreed, and reviewed. She also informed the home that the Commission would need to be formally informed via a Regulation 37 notification each time restraint was used. As no further documentation had been received a further phone call was made to the home approximately one month later, again asking for this information. To date it has not been supplied. On inspecting the file during this visit the three notifications were still on the file, and staff confirmed that one, the use of a body suit on a 24-hour basis, was still being used. Written records showed that another, the use of physical restraint whilst out in the community, also has to be used at times. The manager, during the second phone conversation, and staff, during the inspection, reported that both methods of restraint had been in use for many years, and had been agreed by medical staff, and the nearest relative. Whilst this may be the case there was no evidence of this on file, nor was there any evidence to show that these practices are kept under constant review, with alternative options being explored. This is Requirement 3. These matters were discussed with the service manager. There was evidence in the written records, and via observation during the visit, that service users are involved in the life of the house, taking account of each person’s level of disability. This includes accompanying staff to the supermarket for food shopping, helping with communal domestic chores, and doing laundry and simple cooking. The care files contain confidential information, such as medical diagnosis, but they are not locked away, simply stored on the top of filing cabinets in the staff office. The office door was open for the whole of the visit. Confidential information about service users must be stored securely. This is Requirement 4. Peel Way DS0000015599.V254342.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 & 17 Service users’ opportunities for personal development are sometimes curtailed by the lack of staff, as are opportunities for them to be involved in the local community and leisure activities. This also affects their rights. The setting up of the Communication group is an excellent initiative by staff. Service users are encouraged to have appropriate personal and family relationships. Service users’ rights are respected by staff. Only partial records are being kept of the food offered and taken by each service user. EVIDENCE: The comments made in the preceding section of this report are also applicable to this set of Standards. Many of the above Standards cannot be met whilst activities assessed as being needed get cancelled due to staffing levels. The activities in care plans are fairly basic, i.e. going for walks, bus rides, out in the minibus, shopping, or for meals. Due to the level of disability, and type of Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 12 behaviour of some of the service users, these activities are very staff intensive. Sufficient staff must be provided for the care plans to be adhered to. Refer to Requirement 2. Staff have recently set up a Communication Group, which is attended by three of the service users. The notes from this group were examined, and one service user was asked about the group. He said that he liked it, and staff reported that he had taken an active part. The group is using a combination of discussion of recent events, such as outings, and craft type activities. Staff also reported that they were doing other in-house activities, such as puzzles and colouring books. One service user said that he enjoyed doing crosswords as he can now read and write. Relatives are encouraged to be involved, to visit, and to take service users out. A Requirement was set at the previous inspection that all food offered and taken by service users must be recorded, so that it is possible to see if a balanced and nutritious diet is being taken. This has not yet been actioned for all service users, so has been restated as Requirement 5, with a new timescale. Peel Way DS0000015599.V254342.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, 20 & 21 Generally service user’s personal, emotional, and health needs are being met, but some record keeping means that it is not possible to say that this is always the case. Staff are not always following the home’s policy and procedure for the administration of medication, placing service users at risk. The use of covert means to administer medication needs to be reviewed. The wishes of service users in the event of their death have been established. EVIDENCE: Care plans were examined, along with accident/incident records and Medication Administration Charts (MAR). A spot check of the medicine cupboard against some of the MAR charts was carried out. Personal care and medication administration was discussed with two staff members, and with the service manager. The PCP system clearly identifies each person’s personal and health needs, including emotional needs. There were some good examples of prompt referral to clinicians, and of close working with specialists from the Community Team for Learning Disability. The care plans state how personal care needs, such as baths, should be carried out for each person, including how to Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 14 communicate, and what sort of toiletries have to be used. Staff demonstrated a high level of knowledge of how these needs should be met. One service user wears pads, and the care plan states that this should be changed a minimum of five times during waking hours, and that the chart should then be filled in. The chart states two changes am, two pm and one at night if awake, whereas the care plan states not to change at night because he finds it distressing. On checking the chart there were wide variations, with no entries some days, and on others one, two, three or four entries. Where charts are used as part of the care plan they must be fully, and accurately, completed, so that they form a reliable record of the care provided. This is Requirement 6. Medication, including PRN (as necessary) is supplied in blister packs, and those checked corresponded to the MAR charts. The accident/incident reports showed that there were two incidents in August where medication had been found in the blister pack, but had been signed as given. Neither of these two incidents had been reported to the Commission, as they should have been. Medication administration mistakes in care homes are significant incidents, which must always be reported to the Commission as a Regulation 37 notification. This is Requirement 7. Two scripts had been handwritten but were not signed or dated, as they must be. Bottles of liquid medication are not being dated when opened. These points are covered in Requirement 8. One service user’s care plan for medication includes the use of covert medication administration, when other steps have failed. When questioned, staff reported that this had not been necessary for some years. If this is the case, then review of this practice should have meant that it no longer appears in the care plan. This is Requirement 9. Steps have been taken to find out the wishes of the service users in the event of their death, including contacting relatives where the service user is unable to express their views. Peel Way DS0000015599.V254342.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 The complaint procedure is in a format suitable for the service users, but it does not include the contact details for the Commission. As there are no recent complaints recorded in the log, fully assessing this Standard is not possible. Some staff have attended adult protection training, and others are due to. Staff demonstrated sound knowledge of correct adult protection procedures, and do all that they can to protect service users from abuse. EVIDENCE: A Requirement was set at the previous inspection that the complaint procedure and leaflet be updated to include the contact details for the Commission. Checking the document showed that this has not yet been done, so the Requirement has been restated in this report as Requirement 10 with a new timescale. A Requirement set at the previous two inspections was that all staff must have adult protection training. As the new timescale set at the last inspection has not yet been reached this has been taken forward in this report as Requirement 11, with the previously set timescale. The comments set out earlier in this report in relation to restraint and restrictions impacts on adult protection, as without constant review it is possible for those practices to become a form of punishment and abuse. Whilst the Commission has no reason to suspect that this is the case in this home, and staff demonstrated in discussion a knowledge of abuse procedures, the Registered Manager, and her supervisor, must be aware of this possibility at all times. Peel Way DS0000015599.V254342.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): These Standards were not assessed at this inspection. All but one environmental Standard were assessed as fully met at the last inspection, so were not covered on this visit. The service user to whom one Requirement related has since moved out, and the home has not repeated the practice of using service users’ money to purchase fixtures and fittings that they should be providing. EVIDENCE: The home was clean, bright, and airy, with no offensive odours noted during the visit. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33, 34, 35 & 36 Service users are supported, in the main, by staff who know them well, and are competent to meet their needs. At times there are insufficient staff to meet the assessed needs of the service users. The Responsible Person has not provided confirmation that all staff have had a CRB and proof of identity check, as required at the last inspection. It was not possible to fully judge if the home will meet targets in terms of NVQ training by the end of 2005. EVIDENCE: Comments made in early sections of this report about staffing levels are relevant to these Standards. Please refer to Requirement 2. There must be sufficient staff on duty at all times to meet the assessed needs of the service users. Staff who were on duty during this visit demonstrated a sound knowledge of the needs of each service users, and were able to describe how they try to meet these on a daily basis. The service user who has recently been admitted has very different needs to the established residents, as he is much more independent. Staff would benefit from specific training in the recognition of severe mental health problems. This is Requirement 12. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 18 At the last inspection a Requirement was set that the Responsible Person confirm to the Commission, in writing, that all existing staff have an up-to-date CRB and proof of identity check. This has not been complied with, so has been restated, with a new timescale, as Requirement 13 in this report. This is important as staff files are held at the company’s head office in Kent, so are not available at an unannounced inspection for examination. Some staff training records were examined, and training was discussed with some staff. Training appears to have been given a lower priority over recent months, which might again be due to staff shortages. Requirement 14 has been brought forward from previous reports as the timescale has not yet been reached. Staff reported that they receive regular supervision, and separate discussions about their keyworker roles. The service manager reported that he is going to be involved with individual supervision sessions with all staff in the coming weeks, in order to gain a greater knowledge of the workings of the home. Staff also confirmed that there are regular staff meetings. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 19 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, 40 & 41 The fact that there are insufficient staff to always follow each service user’s care plan reflects negatively on the management of the home. It is not clear if this is due to in-house management failures or inappropriate staffing levels. The Registered Manager is not reporting significant incidents to the Commission. EVIDENCE: Comments made earlier in this report in relation to staffing levels also relate to these Standards. Refer to Requirement 2. Legislation requires the registered Manager to report significant events to the Commission. A check on the accident/incident report held at the home, crossreferenced with those held by the Commission, demonstrated that this is not happening. This is Requirement 15. The Requirement set at the previous inspection for the Registered Manager to acquire NVQ level 4 in management and care, or the Registered Managers Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 20 award, has been brought forward as the timescale has not yet been reached. This is Requirement 16. The Commission has recently met with senior managers of the company, and agreed that the monthly reports, produced by the Responsible Individual, following monitoring of care visits to their homes, will look at particular issues. That meeting was focused on concerns about other homes, but three of the issues of concern that the Commission raised are also raised in this report, i.e. medication, care planning, and risk assessment. Requirement 17 has been set so that the Commission can monitor compliance with this agreement. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X 3 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 3 2 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Peel Way Score 2 2 2 3 Standard No 37 38 39 40 41 42 43 Score 2 X 2 2 X X X DS0000015599.V254342.R01.S.doc Version 5.0 Page 22 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. Standard 1 YA1 Regulation 5&6 Requirement The Statement of Purpose must be reviewed so that it is accurate, and includes all the required documents and information. On completion a copy must be forwarded to the Commission. Where service users’ needs are identified via assessment arrangements must be made for these to be met on a day-to-day basis. Staffing levels must be set based on the individual care plans and assessed needs. Where restraint and/or restrictions form a part of a service user’s care plan there must be evidence that this has been agreed by professionals who have responsibility for that person, such as a GP or clinical member of the multi-disciplinary team. There must also be evidence of the agreement of the next of kin. The Registered Manager must be able to demonstrate that the use of restraint and restrictions is kept under regular review, and that alternative interventions are considered on an on-going basis. DS0000015599.V254342.R01.S.doc Version 5.0 Timescale for action 31/12/05 2 YA6YA11YA1 2YA13YA14Y A16YA33 15 & 18 30/11/05 3 YA6YA9 15 & 13 (7) & (8) 30/11/05 Peel Way Page 23 4 5 YA10YA40 YA17 6 YA18YA19 Confidential information about service users must be stored securely. 16 (2) (i) & The Registered Manager must 17 (2) keep an accurate record of all food provided to service users. Previous timescale of 31/08/05 not met. 12 Where charts are used as part of the care plan they must be fully, and accurately, completed, so that they form a reliable record of the care provided. 13 (2) & 37 The Registered Manager must ensure that all medication administration mistakes are reported to the Commission as a Regulation 37 notification. All scripts handwritten on MAR charts must be signed and dated by the person entering them and all bottles of liquid medication must have the date of opening written on them. Where the covert administration of medication is considered, or used, there must be regular review, monitoring, and recording. The complaint procedure and leaflet must be updated to include contact details of the Commission. Previous timescale of 30/09/05 not met. All staff must receive adult protection training. Previous timescale of 25/05/05 not met, but new timescale set at the last inspection not yet reached. The Registered Manager must ensure that all staff have training in recognising the on-set of severe mental illness. The Responsible Person must confirm in writing that all staff files contain CRB checks and DS0000015599.V254342.R01.S.doc Version 5.0 17 30/11/05 30/11/0 5 30/11/05 7 YA20 30/11/05 8 YA20 13 (2) 30/11/05 9 YA20 13 (2) 30/11/05 10 YA22 22 (7) 31/12/0 5 11 YA23 13 (6) 31/10/0 5 12 YA32YA33 18 31/01/05 13 YA34 9 & 19 Schedule 2 31/10/0 5 Page 24 Peel Way 14 YA35 18 15 YA37 37 16 YA37 9 17 YA39 26 proof of identity. This must include the name of each staff member and the documents that have been accepted as proof of identity. Previous timescale of 30/09/05 not met. 50 of care staff at the home must achieve NVQ level 2 in care by the end of 2005. Timescale set at previous inspections not yet reached. The Registered Manager must report all significant incidents to the Commission, in line with legislation. The manager must acquire NVQ level 4 in management and care or the Registered Managers award. Timescale set at previous inspections not yet reached. The monthly report by the responsible Individual must include how the home is improving practice in the administration of medication, risk assessment, and care planning. It must also address how the home is taking steps to meet all the Requirements set in this report, within the set timescales. 31/12/05 30/10/05 31/12/05 30/10/05 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 YA1 Good Practice Recommendations The home should consider producing the Service User Guide in other formats, such as video/DVD, so that it is even more accessible. Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 25 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 Peel Way DS0000015599.V254342.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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