Inspection on 23/05/06 for Positive Community Care

This inspection was carried out on 23rd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Positive Community Care 09/01/07

Positive Community Care 13/12/05

Positive Community Care 07/07/05

Positive Community Care 30/09/04

Positive Community Care 11/05/04

Positive Community Care 01/12/03

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 Positive Community Care 174 Petts Hill Northolt Middlesex UB5 4NW Lead Inspector Robert Bond Unannounced Inspection 23rd May 2006 10:00 Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 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 Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 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. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 174 Petts Hill Northolt Middlesex UB5 4NW 0208 621 1724 0208 248 8496 pcc707@aol.com 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) Ms Charmaine Watson-Mattis Ms Charmaine Watson-Mattis Care Home 9 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Positive Community Care (PCC) is a care home for nine adults with mental health needs and/or a learning disability. The overall aim of the service is to support service users in maintaining and developing their independence and integrating into the community as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. The home was established in 1997, was initially two small homes operating side by side, which were later combined into one. A third house (166 Petts Hill which is next to 170) is operated by PCC as a supported living scheme (SLS). There is a throughput from the Care Home to the SLS, residents of the later are supported by staff from the care home, and residents often visit the care home where their medication and money may be kept. The care home’s bedrooms are all singles but containing double beds. One bedroom is en-suite. Two additional bedrooms have been created within the loft space. The home has adequate communal areas including a conservatory and large rear garden in which a ‘social activities centre’ has been built. The home is in a residential area, next to a convenience store/petrol station, and is on a bus route. The home has its own small mini-bus, but this is not used at present. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous full inspection took place on 13th December 2005 but the Inspector undertook an additional visit inspection on 27th February 2006, the outcomes of which are included in this inspection report. It was found during the additional visit inspection that most of the requirements of the previous inspection had been or were about to be met, but due to concerns about the health and safety of service users and staff present whilst the building work was on-going, three new requirements were made, two of them being immediate requirements. This current inspection was a ‘key inspection’ during which the expected outcomes of all the key National Minimum Standards for Care Homes for Younger Adults were assessed, and some other standards besides. The Inspector found that 20 of the outcomes were fully met, whereas 10 outcomes were only partly met. This led to the Inspector making 16 requirements (two of which are restated from the previous inspection report) and 2 recommendations. During this inspection, the Inspector met one of the Proprietors, interviewed the Manager Designate, and talked to all the service users present, all the staff present, and spoke in depth to a service user’s relative. The Inspector inspected the premises, including the new loft bedrooms, and examined a variety of records including case-tracking the records of the two new service users. Over the past few months the CSCI has received a number of complaints about the operation of the care home from the Chairperson of the local Residents Association. The CSCI has investigated some aspects of the complaints directly and has referred other aspects to the Proprietors for them to investigate. Some aspects of the complaints have been upheld by the CSCI, some have not been upheld. The situation is complicated by the fact that some aspects of the complaints refer to residents of 166 Petts Hill which as a supported living scheme is not regulated by the CSCI. Those aspects have therefore been considered by Ealing Primary Care Trust who are the purchasing body for that scheme. What the service does well: A personalised individual service is provided to service users in a way that promotes their independence. Some service users benefit from rehabilitation to Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 6 the extent that they are able to move next door into the supported living scheme there, which is also operated by PCC. The managers and staff communicate well with service users who feel able to come to them with their concerns knowing that they will where possible be assisted. The Statement of Purpose and Service Users’ Guide are well produced. The care plan format is sufficiently detailed and a thorough assessment was undertaken before one of the most recent service users moved in. Staffing levels have been increased and staff are properly recruited. A four day induction training is undertaken by new staff. What has improved since the last inspection? What they could do better: The Statement of purpose and the Service users guide must be revised. Written contracts between the care home and service users must not have correction fluid on them, and the documents must be signed by both parties. Individual service user plans for new service users should be completed within one month of the service user moving in. The creation of an activity centre, external environmental improvements and upgrading of the bathrooms should be completed as soon as possible. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 7 The home must have sufficient managers on the staff, and sufficient staff who are trained to be key-workers, for the benefit of service users. Additional effort must be put into finding day centre places and therapeutic and leisure activities for service users. In order for more service users to go on more outings, the home should have the use of a larger vehicle. Systems for auditing the quantity of medication in stock must be improved. Greater care must be taken when returning unused medication to the pharmacist. Replacement of furniture and light bulbs within the conservatory is necessary. Replacement of light bulbs and redecoration within the lounge is necessary. Redecoration of the kitchen is required. Paint on windows must be removed. Bedrooms must be furnished to the minimum standard. 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. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective service users do not yet have the correct information on which to base an informed choice about where to live. Prospective service users’ individual aspirations and needs are mostly fully assessed. Cultural linguistic and religious needs are fully considered. Staged visits are undertaken prior to a service user moving in. Service User Contracts are in use but must be improved. EVIDENCE: The Inspector noted that the home was displaying the updated version of the CSCI registration certificate showing that the registration is now for 9 service users. The Manager Designate reported that updated versions of the Statement of Purpose and the Service Users’ Guide had not yet been produced. Requirements 1 and 2. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 10 The Inspector examined in detail (case-tracked) the care files of the two new service users. He found that one had had a full and detailed assessment undertaken by the Manager Designate that led to the creation on an excellent care plan. The assessment of the second service user and his care plan were however only adequate. The Manager Designate explained that he was the key worker for both service users but that he had needed to leave the country for two weeks during the process of assessing the second service user. The Manager Designate did not think a similar difficulty would arise in the future as a permanent part-time Deputy Manager was being considered. See Requirement 3. One assessment and care plan in particular identified ways of meeting the assessed cultural, religious and ethnic needs of the service user. The Inspector noted evidence that the new service users had had a full introduction to the home including trial visits to see if they liked it and fitted in. The file of one service user contained a Contract of Care that was signed by the service user but not by the Care Home, and the form used was that used for another service user with his name covered over by correcting fluid. Requirement 4. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 11 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users know that their assessed and changing needs are reflected in their individual plan. Service users are involved in decision making about their lives. Service users are encouraged to be independent EVIDENCE: The Inspector examined in detail two care plans. One was excellent, the other was not complete despite the service user having been resident for over a month. Requirement 5. Both care plans had been signed by the relevant service user. The Manager Designate is key worker for both new service users until such time as support workers have been trained to undertake the key worker role. Requirement 6. A schedule of dates for formal reviews to be undertaken was seen by the Inspector. Reviews of care plans are undertaken internally on a monthly basis. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 12 The Manager Designate reported that most of the service users have a close relative to assist in looking after their best interests. The Manager Designate added that all the service users need support with their finances. One of the proprietors of the home is the Appointee for two service users. The Inspector examined a sample of financial records. The Inspector noted that risk assessing is an integral part of the assessment and care planning process. Independence is promoted including responsible risk taking. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Opportunities for personal development should be extended. Service users are able to engage in culturally appropriate leisure activities but some do not do so sufficiently. Further effort is required to engage with the local community. Most service users have family links. Service users rights are respected and responsibilities recognised. Service users enjoy a reasonably healthy diet. EVIDENCE: The Manager Designate reported that none of the service users have paid employment but one service user and his mother told the Inspector that he cleans cars at Ealing Hospital as part of his rehabilitation, for which he does receive a small amount of money. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 14 Five of the nine service users have day centre places. The Manager Designate agreed to make the appropriate day centre place referrals for those not currently with places. The activity/rehabilitation centre that has been built in the garden is still occupied by the builders whilst they finish off their work. Requirement 7 The Inspector examined the home’s activity programme. The Manager Designate reported that additional outings were planned but that the home’s minibus was not being made available to him as he only had the use of a car. Requirement 8 The range of activities and the involvement of service users in activities and outings must be increased. This view was endorsed by the relative that the Inspector spoke to. The Manager Designate reported that one service user attends a mosque each week. The Inspector noted that the home has a cleaning rota for service users. The Inspector talked to a resident from the supported living scheme next door who said she and her fellow residents generally visit the care home once a day. The Inspector examined the home’s current food menu. He observed service users eating a hearty lunch of meat pie, baked beans and coleslaw. The mother of one service user reported that the quality and quantity of food served at lunch times had improved substantially. Service users are always offered a vegetarian choice. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional needs are met. Service users are not adequately protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The Inspector observed in practice and noted from the care pans examined that routines are flexible and individually based. Additional support services are arranged as necessary, such as an occupational therapist assessment, or alcohol treatment centre attendance. The Inspector ascertained that the two new service users had been registered with a nearby General Practitioner. Medication reviews are undertaken, and community psychiatric nurses and consultant psychiatrists are involved as appropriate. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 16 The Inspector examined the homes records of the administration of medication. He found that one service user had had a particular medication stopped by his doctor and the home’s record showed that the medication was ‘discontinued’. What the records did not show, and what the Manager Designate was not able to answer, was whether there remained any stock of unused medication on the date when the doctor said it was to be discontinued. The medication auditing system within the home requires modification in order that on any particular date exact stocks of all medication can be determined. Requirement 9. The Inspector examined the records and the stock of medication awaiting collection by the pharmacist. He found that medication signed for by the home’s representative and the pharmacist’s representative had not in fact been handed over to the pharmacist. This error had not been recorded in any way. Requirement 10. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and relatives feel that their views are listened to and acted on. Service users are protected form abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints record. The only complaints recorded are those made by the Chairperson of the Danemead and Petts Hill Residents Association. These complaints have been addressed to the CSCI and a variety of other agencies as opposed to directly to the management of the home. The CSCI has investigated some aspects of the complaints directly and has referred other aspects to the Proprietors for them to investigate. Some aspects of the complaints have been upheld by the CSCI, some have not been upheld. The situation is complicated by the fact that some aspects of the complaints refer to residents of 166 Petts Hill which as a support living scheme is not regulated by the CSCI. Those aspects have therefore been considered by Ealing Primary Care Trust who are the purchasing body for that scheme. None of the service users or their relatives had any complaint to make to the Inspector. In relation to training in the Protection of Vulnerable Adults, the Inspector noted that two staff had been trained in the procedure by the London Borough of Ealing, and further POVA training was scheduled to take place on 13th June 2006. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 18 Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 19 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home is not yet sufficiently homely or well decorated. Bathrooms remain unfinished. Bedrooms are not sufficiently furnished to promote service user independence. The home is adequately clean and hygienic. EVIDENCE: On the day of the inspection, the builders were seen to be working on the porch roof of the next door supported living scheme. Similar porches are being created at the front of the care home, the pebble-dashed walls of which have been repainted. The front gardens have been paved to enable off street parking to take place, and refuse is now stored within a large ‘wheely-bin’. Now that the refurbishment work is almost finished, the exterior appearance of the care home, front and back is much enhanced. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 20 The back garden has been landscaped, and a level access way created from the back garden to the front of the property. The activity centre has not yet been brought into use as the builders are using it for their storage. Internally, the loft extension bedrooms are complete and are occupied, but some work remains to be done in the two bathrooms. Requirement 11. It was noted that the conservatory has been made a no-smoking zone and that service users have to go into the back garden if they wish to smoke. Two light bulbs were seen to be missing from a fitting in the conservatory. The Manager designate reported that damaged chairs in the conservatory are to be replaced. Requirement 12. The lounge area is still in need of further decoration, the wooden ramp between it and the dining room remained unpainted or otherwise improved, and two light bulbs were non-operational in the lounge. Sufficient stocks of replacement light bulbs should be kept at the care home. Requirement 13 is a restatement from the previous inspection report. The kitchen area was also seen to be in need of redecoration. Requirement 14. The window on the stairs of number 170 was seen to be badly splattered by paint and must be cleaned. Requirement 15 is a restatement from the previous inspection report. With the permission of the service users concerned, the Inspector entered the two bedrooms that had been created in the loft spaces. He found that each bedroom only contained one chair and no table, contrary to NMS 26.2. The Manager designate reported that similar shortfalls in furnishing existed in other bedrooms. Additional furniture must be provided as a means of encouraging service user’s independence and pursuance of their own interests and hobbies. The only exception is if it is agreed that it is in the service user’s best interest not to have this minimum level of furnishing, which must be agreed in writing by all concerned and recorded in the individual plan of care. Requirement 16. Overall the home was seen to be adequately clean and hygienic. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 21 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported by competent and qualified staff. Service users are protected by the home’s recruitment policy and practices. Service users benefit from well supported and supervised staff. EVIDENCE: The Inspector examined the home’s current staffing rota. The Manager Designate reported that during the mornings, three staff are on duty including himself, during the afternoon and evening, two staff are on duty until midnight, with one then sleeping on the premises. At weekends two staff are always on duty during the day. A senior support worker is acting as deputy manager. The Manager Designate said that the Proprietors are considering appointing a permanent part-time deputy manager to cover weekends. See Requirement 3. The home is also in the process of recruiting an additional senior support worker. Three of the nine support worker staff are professionally qualified. Whereas this is 33 , the national target for every care home is 50 . Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 22 The relative spoken to by the Inspector reported that she considered the staff to be hard working. The Inspector examined two staff recruitment files and found that satisfactory checks had been undertaken. The Inspector noted that the home has a training plan, and that new staff undertake a four day induction training programme. The Inspector noted that staff supervision records were up to date, formal supervision was taking place monthly, and staff appraisals were six monthly. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home, service users; views`are taken into account, and the health, safety and welfare of service users are promoted and protected. EVIDENCE: The Manager Designate is currently applying to the CSCI to become the Registered Manager. He is also undertaking the Registered Manager Award. The Inspector examined records of service user group meetings that take place on a regular basis. The Inspector saw the summary that had been written concerning the findings of the last Quality Assurance survey. The Proprietors have begun to undertake and submit to the CSCI monthly Regulation 26 visits and reports. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 24 The Inspector examined records of fridge and freezer temperatures kept in the home. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 2 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 2 25 x 26 2 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 26 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. 2. 3. Standard YA1 YA1 YA37 Regulation 4 5 18(1) Requirement A Statement of Purpose is required that meets the Regulations. A Service users’ guide is required that meets the Regulations. The registered person shall ensure that sufficient management staff are employed appropriate to the health and welfare needs of service users. A signed contract terms and conditions document must be issued to each service user. Service user plans for new service users must be completed sooner. Additional staff must be recruited or trained to become key workers. The registered person must provide or arrange sufficient leisure, recreational facilities and therapeutic activities for the service users. The registered person must promote social inclusion, and activities away from the DS0000027713.V288999.R01.S.doc Timescale for action 01/07/06 01/07/06 01/08/06 4. YA5 5(3) 01/07/06 5. 6. 7. YA6 YA32 15(1) 18(1)(a) 01/07/06 01/07/06 01/07/06 YA14YA12YA11 16(2)(n) 8. YA13 16(2)(n) 01/07/06 Positive Community Care Version 5.1 Page 27 9. 10. YA20 YA20 13(2) 13(2) 11. 12. YA24 YA24 23(2)(b) 23(2)© 13. YA24 23(2)(d) home by the provision of suitable transport. The medication stock auditing system must be improved. The correct procedure for returning unused medication to the pharmacist must be followed. The bathroom refurbishment must be completed quickly. Furniture and equipment in the conservatory must be operational and of good quality The decoration and ambience of the nonsmoking lounge must be improved. THIS IS RESTATED FROM THE PREVIOUS INSPECTION AS THE TIMESCALE HAS NOT BEEN MET. The kitchen must be redecorated. All the windows in the care home must be kept clean. THIS IS RESTATED FROM THE PREVIOUS INSPECTION AS THE TIMESCALE HAS NOT BEEN MET. Adequate furniture must be provided in service users’ bedrooms. 01/07/06 01/06/06 01/07/06 01/07/06 01/07/06 14. 15. YA24 YA30 23(2)(d) 23(2)(d) 01/09/06 01/07/06 16 YA26 16(2)© 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000027713.V288999.R01.S.doc Version 5.1 Page 28 Positive Community Care 1. 2. Standard YA13 YA13 Further efforts should be made to achieve integration of the home and its service users into the local community. The management of the home must remain alert to what neighbours may perceive as threatening behaviour or antisocial behaviour by services users, whether in the home, its gardens, or in the street, and take appropriate action to avoid or minimise distress to all concerned. Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection West London Area Office 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Positive Community Care DS0000027713.V288999.R01.S.doc Version 5.1 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!