Inspection on 07/11/06 for Pengarth Road (57)

This inspection was carried out on 7th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pengarth Road (57) 24/01/06

Pengarth Road (57) 06/07/05

Pengarth Road (57) 09/02/05

Pengarth Road (57) 31/08/04

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 Pengarth Road (57) 57 Pengarth Road Bexleyheath Kent DA5 1DS Lead Inspector Keith Izzard Key Unannounced Inspection 7th November 2006 11:30 Pengarth Road (57) DS0000037816.V304493.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 Pengarth Road (57) DS0000037816.V304493.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. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pengarth Road (57) Address 57 Pengarth Road Bexleyheath Kent DA5 1DS 01622769100 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) MCCH Society Limited Mr Andrew John Fitton Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: The home provides a long term care service for four men with a severe learning disability, who, for the most part, have challenging behaviour and autism. O Briens five accomplishments of community services are used as a set of standards that the home aims to provide for service users. The home provides 24 hour support with waking night staff provision. Daytime opportunities/ are provided both through day centres operated by Bexley Council and within the home. The home receives extensive input from the community learning disability team, around the area of challenging behaviour. Over the past year the home has reduced the number of residents accommodated by one and the registration certificate will be amended accordingly. The home is now jointly managed with another home for two severely learning disabled residents that is very close by. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visits for this unannounced inspection were completed over two separate days on the 7th and 16th November 2006 over a period of 7.00 hours. The acting manager was on duty and both he and the staff assisted with the inspection on both occasions. All four residents were seen as they were home at the time of the inspections. The service was last inspected on the 24th January 2006. Two long outstanding requirements were still outstanding as was the requirement to provide a full time Registered manager. Any non compliance with requirements will be closely monitored. The inspection included a review of information received about the service, a tour of the premises, inspection of records, talking to residents, and members of the staff team. Following the inspection contact was made with relatives and other interested parties to get their views of the service. There was a happy and positive atmosphere in the home on the days of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: Records seen were well maintained and care plans were up to date. Care plans reflected resident needs and showed how these were to be met. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. The home had access to a mini-bus, which helped with outings and transport in general for the residents. Attention was given to ensuring the environment and equipment provided was safely maintained. All bedrooms were used for single occupancy, which afforded the residents privacy. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 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. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 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 Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures were in place to comply with Standard 2. Contracts have not been provided as required for residents. EVIDENCE: Standard 2 There have not been any admissions to the home since the last inspection. The home would require an assessment of need from the Community Learning Disability Team and all referrals are made to the home through a joint health and social services panel at which the home would be represented. The manager stated that this Standard would be met if there were any new admissions in the future. The home has a written procedure for admissions to the home as stated in Appendix 2 and Schedule 1, Care Homes Regulations Younger Adults. The care plans of two service users were examined and were seen to reflect all the areas of need listed in Standard 2.3 and how these will be met and the outcomes reviewed and recorded at each subsequent review meeting. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 9 Standard 5 The home must provide contracts for residents in accordance with the specification set down in Standard 5. Restated Requirement 1 Pengarth Road (57) DS0000037816.V304493.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments viewed were mostly up to date and comprehensive and reviewed on a regular basis. Annual Life Plans were also up to date and showed that residents were involved, and family or representatives and professionals involved had been invited. Staff members do their best to involve residents in decisions about them; they are supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality EVIDENCE: Standard 6 Two care files and individual plans were examined in respect of two service users. Individual plans were comprehensive and involved service users and their representatives, including family or advocates and other professionals Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 11 involved. These plans are reviewed with outcomes clearly stated and agreed by all participants. Records seen were comprehensive and up to date. Residents’ records included risk assessments. In view of the dependency of the residents in the home they required staff to assist them with all aspects of their lives. Where risks were identified procedures and care plans reflected how these were being managed. Additionally, clinical meetings with CLDT are also taking place when specialist individual support with complex health problems such as challenging behaviour are dealt with. Standard 7 Interaction between staff and service users, observed by the Inspector, demonstrated choice being encouraged by staff members in relation to activities taking place. The level of disability and communication difficulty of service users is such that staff members find it very difficult to meaningfully engage service users in participating in the running of the home and contribute to policies and procedures. On a daily basis staff do make attempts to involve service users and this was evidenced in the daily diaries, the activities file and within tasks for staff listed in the shift planners. Two staff members interviewed said they endeavoured to involve residents in decision making based on their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of the residents and depends heavily on staff interpretation and historical knowledge of residents’ likes and dislikes. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner. Standard 9 Risk assessments are available in all service user’s care files and are readily available for all bank or agency staff who may be less familiar with service user’s needs. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service user’s records examined that they are enabled to express choice in what they do and staff record these occasions. Pengarth Road (57) DS0000037816.V304493.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): 11-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents but further efforts are required in respect of increasing the level of activities provided. Residents’ rights and responsibilities were recognised in their daily lives. Meals provided were varied and planned to meet the residents’ choice and preferences. EVIDENCE: Standards 11-14 Evidence was available from the care files of service users that opportunities are being made available for the personal development of residents, although, owing to the level of learning and physical disability and associated communication difficulties, none of the service users have been identified as being able to participate in employment or further education via day centres. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 13 Staff supported residents to develop daily living skills in line with their individual ability. The Inspector examined a list of activities for service users that is updated weekly and notes are recorded in the daily diary and staff communication book of those activities that are planned for service users. Extensive support is available to the home from Psychiatry, Psychology, Specialist Community Nursing, CLDT, Speech and Language therapy and also from Occupational Therapy, Physiotherapy, Chiropody and Aromatherapy. Much of this input is focussed on responding to challenging behaviour and other complex health needs. Service users are encouraged to participate in household tasks when identified as safe to do so in terms of possible challenging behaviour and in accordance with guidance in their individual risk assessments. None of the service users in the home have been identified as having any specific spiritual needs. The Inspector recommends that further thought is given to increasing the level of activities provided and that there is some scope for linking some of these for example to shopping trips to obtain clothing or other personal items. See Recommendation 1 Standard 15 Staff members actively support and encourage family contact; two residents have advocates as well as parental involvement is decreasing. Through the various activities and outings provided residents are provided with some opportunity for meeting with other people. However, staff report that there are no relationships of significance other than family, staff or advocates for any of the residents. It was also reported that there are no issues in respect of expressed sexuality that need to be addressed, as such areas are already known to staff members within the care planning process. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping trips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise, in activities of their own choosing. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. The home has the advantage of the services of a ”Homemaker” who largely attends to the cooking of meals and other domestic areas. Unfortunately at the time of inspection she was off sick but arrangements were being adequately managed by care staff in her absence. A new cooker was about to be delivered following the development of faults on the existing oven. The likes dislikes and special requirements of all residents were recorded and staff members well aware of them. Pengarth Road (57) DS0000037816.V304493.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s physical and emotional health needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. It was not possible for all residents to comment on whether this suited them or not. None of the residents in the home were able to give feedback about any aspect of the service, owing to the their individual communication difficulties. Daily records were kept to show the care provided and activities the residents were involved with. All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 15 with the community learning disability team to support staff with meeting resident needs. Standard 19 Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example OT’s Physiotherapists, Speech and Language Therapists, Psychiatrist and Dietician. Any nursing care needs would be commissioned via the GP from the local District Nursing service or Community Psychiatric Nurse. All service users require considerable assistance with their personal care needs. On the day of inspection service users appeared adequately and tidily dressed in age appropriate clothing. Personal appearance had been attended to and staff were observed to be sensitive and respectful to service users. Standard 20 Due to the level of disability, service users are not able to self medicate and would not be able to do so without a high degree of risk. Medication is stored in a locked cupboard in the hallway. Medication is the responsibility of the designated person in charge on all shifts and only permanent staff that have received training are authorised to administer medication. Both MAR sheets for the two service users case tracked were examined and checked against stored medication and found to be accurate. The administration, receipt recording, handling and disposal of medicines met the Standard. The home has a controlled drug for one service year; it was noted that this drug was retained within a separate locked box within the lockable medicine cabinet and that a separate log was retained for the administration of the medication signed by two people, as required. Pengarth Road (57) DS0000037816.V304493.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 &23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service and a book provided in the entrance area for the purpose of encouraging visitors to the home to register any concerns or compliments in writing. No complaints had been made to the provider or the Commission since the last inspection. None of the residents have the ability to raise concerns, and when spoken to by the Inspector one individual indicated that he was happy within the home and had no complaints. Standard 23 The home had policies and procedures in relation to adult protection. No allegations of abuse had been made to the provider or the Commission since the last inspection. The home had copies of the London Borough of Bexley Adult Protection Procedures and a whistle-blowing policy. Staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. Since the last inspection some staff had Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 17 attended training on adult protection, however, it is recommended that all staff members have the opportunity to receive updated training in this area. See Recommendation 2 Robust systems were in place to safely manage residents’ personal finances and the Inspector examined the ledger. The Inspector examined the system for dealing with the personal monies of two service users within the home, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited via the programme of monthly visits undertaken on Regulation 26 visits. Pengarth Road (57) DS0000037816.V304493.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, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable environment that is safe clean and hygienic. Bedrooms suited residents’ needs and promoted their independence. The home was clean and hygienic on both days of inspection. EVIDENCE: Standard 24 Service users live in a homely and comfortable environment that is safe clean and hygienic. The Inspector was informed that the lounge/ dining area was due to be decorated shortly and it was agreed by the acting manager that an area of faulty plastering should be attended in one corner at the same time. Standard 25 The bedrooms of residents suited their lifestyles and it was noted that one had been redecorated and personalised, in response to a previous requirement. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 19 Standard 26 The home was clean and tidy throughout and policies and procedures in respect of infection control available and implemented by staff members. Pengarth Road (57) DS0000037816.V304493.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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. From the evidence available the staff team had the ability to meet the residents needs and received relevant training and supervision. Recruitment procedures were good with all the information required by regulation being included on the employee files seen. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff, the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in activities. The home does not currently have the required 50 minimum of care workers trained to NVQ Level 2. The acting manager stated that this would be achieved by March 2007. However, The Registered Provider must monitor this Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 21 and report any shortfall to CSCI, should this target not be achieved in this timescale. Restated Requirement 2 Standard 34 Four personnel files were examined and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Standard 35 Staff members interviewed, presented as clear about their roles and responsibilities and had received adequate training in accordance with this Standard. Evidence was available from the training records examined within four staff members personal files that training had been provided in Medication, Health and Safety, Fire training, Adult Protection, Epilepsy, Person Centred Planning, SCIP training and communication A good level of training was also being planned for and a group study day for all the staff members. Pengarth Road (57) DS0000037816.V304493.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, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager presented as running the home in an open and inclusive manner. The position regarding the continued lack of a Registered Manager for the home must be addressed as a matter of priority. Records, policies and procedures showed attention was given to ensuring the safety of residents and others. The quality review survey requires implementation. The Registered Provider must clarify the position regarding the possibility of the home being split into two separate units. EVIDENCE: Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 23 Standards 37 & 38 The acting manager has considerable experience and the necessary qualities to provide a good service, however it was never intended that he would apply to become the Registered Manager for the home and a previous requirement that a Registered Manager should be appointed by 01/06/06 has not been complied with. This situation must now be resolved as soon as possible in order that the Regulations and Standard are complied with. See Restated Requirement 3 Staff members interviewed stated that the acting manager is approachable and supportive and would not hesitate to discuss any concerns about the home or the welfare of service users with her. Communication within the home was of a good standard with team meetings held regularly. The acting manager has undertaken training in order to update his own skills and knowledge. Standard 39 The home does now have a quality review system in place to record the views of residents, relatives, advocates and visiting, or involved professionals. However, this has not been implemented and must be as soon as possible, the results published and generally made available, including CSCI. See Requirement 4 The home receives regular monthly visits under Regulation 26 and produces reports as required and submits these to the CSCI. Standard 42 The policies and procedures in place ensured the safety and protection of residents were addressed. A previous requirement made to ensure that automatic door closures were fitted to service users’ bedroom doors had been complied with. A sample of safety records including fire safety were inspected and showed systems and equipment were maintained and regularly serviced. Evidence provided in the pre inspection questionnaire regarding the various checks required were found to be accurate when examined by the Inspector. Standard 43 The Inspector has been made aware of the possibility of the home being split into two separate units in the future. The Registered Provider must inform the CSCI in writing, the rationale for this development and the proposed timescale for implementation and how the necessary consultation with service users, their relatives advocates and CSCI will be conducted. See Requirement 5 Pengarth Road (57) DS0000037816.V304493.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 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 3 2 Pengarth Road (57) DS0000037816.V304493.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 YA5 Regulation 5 Requirement The Registered Person must ensure that a written contract is provided for each service user and includes a copy of the service user care plan. Restated Requirement: previous timescales of 1.06.04, 1.12.04, 1.05.05, 1.11.05 and 01/04/06 not met. The Registered Person must ensure that an action plan is submitted to the CSCI clarifying when the required 50 NVQ level 2 staffing will be achieved. Restated Requirement: previous timescale of 1.11.05 and 01/04/06 not met. The Registered Person must ensure that a Registered Manager is appointed as soon as possible. Restated requirement: Previous timescale of 01/06/06 not met. The Registered Person must ensure a system is in place to review and improve the quality DS0000037816.V304493.R01.S.doc Timescale for action 01/01/07 2. YA32 18 01/01/07 3. YA37 8 01/01/07 4. YA39 24 01/01/07 Pengarth Road (57) Version 5.2 Page 26 of care provided in the home. Outcomes on the quality assurance reviews must be made available to residents, relatives the Commission and others. Restated requirement: previous timescales of 1/11/05 and 01/04/06 not met 5 YA43 39 h The Registered Provider must inform the CSCI in writing, the rationale for this development and the proposed timescale for implementation and how the necessary consultation with service users, their relatives advocates and CSCI will be conducted. 01/01/07 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 YA14 YA35 Good Practice Recommendations The Registered Person should increase the level of activities provided for residents. Any staff members who have not had updated training in adult protection should receive this as soon as possible. Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Pengarth Road (57) DS0000037816.V304493.R01.S.doc Version 5.2 Page 28 - 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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