Inspection on 12/10/05 for Prema House

This inspection was carried out on 12th 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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Prema House 20/04/06

Prema House 04/05/05

Prema House 28/10/04

Prema House 27/05/04

Prema House 03/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Prema House 45-47 Gleneagle Road Streatham London SW16 6AY Lead Inspector Lynn Hampton Unannounced Inspection 12/10/05 08:20 DS0000022749.V252382.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 DS0000022749.V252382.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. DS0000022749.V252382.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Prema House Address 45-47 Gleneagle Road Streatham London SW16 6AY 0208-677-2302 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Sam Vindalon Mrs C Vindalon Patrick Chibagu Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) DS0000022749.V252382.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. up to five persons only aged 65 years and above Date of last inspection 4th May 2005 Brief Description of the Service: Prema House is a 24-bedded private home for adults with mental health problems, one of two homes in the Streatham area owned by the same proprietors. It is situated within easy walking distance of transport links, and all amenities offered in Streatham High Street. The building is made up of two large Victorian houses, converted to interconnect internally. There are 16 single and four double bedrooms, two of which are almost completely divided by a wall providing a high level of privacy. The Registered Providers plan to phase out the double rooms as service users vacate them, and convert them into single rooms with en-suite facilities. The home has a range of communal areas that includes two main sitting rooms, a small kitchen for residents to make drinks, and a number of small smoking rooms. There is a large and attractive paved rear garden. There are a number of internal stairs, and the home is not suitable for people with mobility problems. Prema Houses mainly accommodates people over the age of 45 who have enduring mental health problems, and it provides long-stay accommodation and support for them. The home employs a cook and a cleaner, as well as care staff who prompt and support residents in personal care and activities of daily living. DS0000022749.V252382.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place during the early morning of a weekday, and lasted five hours. The inspection methods included a tour of the building; meeting service users, (and discussions with approximately six of them); meeting members of staff, (and discussions with four of them, including the Registered Manager); discussion with Director of Operations; and examination of a number of records held at the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000022749.V252382.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000022749.V252382.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A These standards were not assessed at this inspection. The finding of the previous inspection was that the standards were being met. EVIDENCE: DS0000022749.V252382.R01.S.doc Version 5.0 Page 8 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 Service users have individual care plans, and are involved in making decisions about their lives. Service users, relevant care professionals and their family (where appropriate) are consulted in planning and reviewing care. Records need to be kept fully up-to-date with notes of discussions and meetings that have taken place, and Risk Assessments updated when people’s needs or health changes. EVIDENCE: The inspector spoke to several residents, who confirmed that they were able to make choices about their life, with support from staff. Each service user has a key to the front room as well as their bedroom, and can enter and leave the home freely. Where service users need assistance, staff were seen to arrange transport or offer to accompany people to appointments. Service users explained that they were consulted about aspects of life in the home in the House Meetings, and could choose to participate in chores such as cooking and cleaning (see Lifestyle, below). DS0000022749.V252382.R01.S.doc Version 5.0 Page 9 Case files seen by the inspector were very well organised, and clearly showed that care plans were agreed between staff and service users, with specific ‘Agreements’ being drawn up that are signed by the staff and the service user, which set out how problems will be addressed by the staff and resident together. Case files showed that regular Reviews were held, attended by the user and the multi-disciplinary team involved in their care. Care Plans and Risk assessments were reviewed and updated, and regular Key Worker Meetings held and recorded, which showed how staff consult with residents about progress. One service user had just had a Review, and the manager was able to talk knowledgeably about issues that were discussed, although this was not recorded on the person’s file. The manager explained that the Social Worker was responsible for taking notes and producing the official Minutes, which they were awaiting. The home should ensure that there is some record of important meetings and decision-making in place, to prevent gaps in information while awaiting this. It was identified during the inspection that this service user, and one other resident, had physical health problems that were effecting their mobility and ability to use stairs. Due to the layout of the home, and the number of stairs leading to all areas, this could present problems for them, or for other service users as they get older and frailer. The manager reported that he was reviewing the situation, in consultation with the users effected. Consideration was being given to addressing concerns as to whether the home could continue to meet the service users’ needs, balanced against the users’ clearly stated wishes to remain. It is positive that the manager is giving due consideration to the situation, and consulting with users, but this was not clearly recorded on their files. There were no records of discussions about this issue that had taken place, although one file showed that the user had spoken about looking for alternative placements. Records should indicate whether service users require input from Advocacy services. It was also noted that the individuals’ Risk Assessments needed to be updated in light of these changing physical needs, with specific reference to environmental factors such as managing stairs, and whether assistance could be sought from Occupational Therapists. See Requirements. DS0000022749.V252382.R01.S.doc Version 5.0 Page 10 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 have individual programmes of activities that reflect their interests and wishes. They are offered some opportunities to participate in routines in the home as well as in activities outside, although many choose not to take up these options. Rights and responsibilities are respected. Meals at the home are of a very high standard. EVIDENCE: Service users that the inspector spoke to were able to clearly state that they had control of their finances, were registered to vote, and had a strong say in how they lived their lives. They were well aware of their rights and benefit entitlements. They understood the role of the inspector and inspection, and were happy to give their views on the home. All the service users that the inspector spoke to were positive and warm in their comments about the home, and had no complaints or criticisms. Interaction between residents, and between staff and residents, was warm and friendly, and there was a relaxed and sociable atmosphere in the home. A social evening was being planned for the following Friday evening, which service users were looking forward to. DS0000022749.V252382.R01.S.doc Version 5.0 Page 11 Some service users had activity programmes that included attending college or Day Centres. At the time of this inspection, approximately 12 service users were spending the morning at home. Two residents were seen to plan attending appointments that day, with staff escort or transport being arranged. Others spent time out in the local community, going to shops or for walks. The home is set up to provide long-term support rather than rehabilitation, and residents are prompted, rather than required, to participate in cooking or cleaning communal areas. Service users told the inspector that they were encouraged to take part in some food preparation and communal cleaning chores, although only some residents actually did this. The home employs a cleaner who cleans all communal areas as well as users’ rooms, and a Cook/catering manager, who prepares a communal cooked lunch and dinner daily. Meals are served, ready plated, by staff. This arrangement, and the physical layout of the kitchen and dining area, does not allow for a lot of participation by service users, although the service users generally seemed very happy to have all these services supplied for them. The Catering manager described how some residents were supported in cooking for themselves, if they requested this. This often related to service users who wished to prepare individual meals that reflect their culture/ethnicity. It was reported that some residents went out shopping for ingredients and needed minimal support; the home provided some ingredients such as salt fish and ackee, which one person made while the cook was preparing the main meal. Consideration should be given to promoting service user choice and participation further, and should include review of whether service users could serve themselves at mealtimes. A Requirement made in the report of the previous inspection (May 2005), that the menu should be more varied and reviewed to include service users’ individual preferences. Residents confirmed that this had been discussed in the House Meetings, and all the residents that the inspector spoke to said that they liked the food at the home and had a choice of what to eat. The record of menus indicated that a choice of two main courses were on offer each mealtime (one is always vegetarian). The Catering Manager described how she consults with service users and ensures that they are able to make special requests. The meal served at lunchtime consisted of mince, ham omelette, boiled potatoes, broccoli and cauliflower, followed by apple crumble and custard. The meal was well presented and looked very appetising. As the inspector arrived early in the morning, service users were seen having breakfast. The kitchen was not open, as the cook arrives later to prepare lunch. Bowls of porridge with individual names on were left out, which residents could ask to be re-heated in the microwave, cereal and juice was available. When asked, some service users said that they would on occasion like a cooked breakfast. The manager reported that this used to be provided, but was stopped at the residents’ request. Service users’ choice is to be kept under review on an on-going basis. DS0000022749.V252382.R01.S.doc Version 5.0 Page 12 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 Service users receive personal support in the way that they prefer and require, and this is undertaken in a respectful and professional manner. Medication administration is of a good standard, and health care needs are well met. EVIDENCE: All service users are prompted by staff to maintain a good level of personal hygiene, to do laundry, and to keep their rooms clean and tidy. The inspector saw the Team Leader prompt individual residents in an entirely appropriate and professional way. The home has a routine in which a house check is undertaken every hour, to ensure that smoking areas are safe, and to make contact with individual service users to prompt them to have showers, clean their rooms, or to undertake other activities relating to their individual care plan. This practice, and the way it was undertaken, is to be commended. It promotes contact with service users and ensures continuity of care. Its effectiveness, and the good care practice of staff, could be seen in the high standard of personal hygiene of service users and their rooms. Staff were seen to consult with residents about their preferences, and to knock on their bedroom doors before entering. DS0000022749.V252382.R01.S.doc Version 5.0 Page 13 Case files showed that health issues are assessed and followed up in collaboration with the relevant health care professionals. However, some Risk Assessments and Care plans had not been updated following recent changes in physical health (See Individual Choices, above). Service users reported that staff arrange appointments with G.P.s and chiropody. Administration of medication was observed, and was of a good standard, with the member of staff ensuring that service users had a drink to take with their medication. DS0000022749.V252382.R01.S.doc Version 5.0 Page 14 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): 23 The manager was responding to a complaint received appropriately. EVIDENCE: The manager informed the inspector that one complaint had been received since the last inspection. This was from a neighbour, who was complaining about a service user making a lot of noise at unreasonable hours. The manager explained what action he had taken to investigate and respond to this, which including discussion with the user, and requesting a meeting with the neighbour. The manager was aware of the need to work towards a resolution that would be sensitive to the needs of neighbours, but not undermine the rights of the individual service user. This was to include reviewing staff interaction with the user at key times, to assess, monitor and resolve the situation. This complaint was not entered into the home’s Complaints Book. The manager reported that this was because it had been received while he was on holiday. The Complaints Book must be kept up-to-date. DS0000022749.V252382.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 Service users live in a home that they find comfortable. Bedrooms are personalised. There are numerous communal areas for service users to use, including lounges, bathrooms and toilets. Improvements have been undertaken in the home, but some repairs and redecoration is still needed. It is intended to phase out shared rooms. The home is clean. EVIDENCE: The inspector had a tour of the home, and saw four residents’ bedrooms. The home was clean throughout. The home has a Maintenance person, and repairs and redecorations are undertaken on a rolling programme. At the last inspection visit, the inspector had been told that there were plans to relocate the laundry to a more suitable area, and this had been carried out. Some carpets had been replaced. Equipment and furniture were in a good state of repair throughout the home. DS0000022749.V252382.R01.S.doc Version 5.0 Page 16 The lower ground floor consists entirely of communal areas; dining room, kitchen, a smoking- and a non-smoking T.V. lounge; a small kitchenette for making drinks; access to a large and attractive paved garden area, which houses an out-building for a Maintenance Room and a Laundry. Lounge areas were domestic in style and furnishings, but the dining area is much less so. The layout and furnishings are in the style of a canteen rather than a domestic home. The manager was aware of this and reported that he hoped to be able to make changes in the décor and furniture. The Ground level floor accommodates staff offices, as well as a service user bedroom, a shower room and a toilet. The shower has steps up to it, so is not mobility accessible. Access to the lower ground floor and upper floors is via flights of stairs, which are narrow but have hand-rails (See Individual Needs regarding mobility issues). The stair carpets were showing signs of wear in areas, and in one part, were coming loose and had been taped down at the edges. This portion of carpeting must be made secure to prevent risk of tripping, and a programme for replacing stair carpets throughout must be put in place. There were a total of three shower rooms, two bathrooms, and seven toilets for residents’ use. This does not meet National Minimum Standards recommendations, but the owner reports that there are plans in hand to reduce the number of double rooms to create en-suite facilities. This, and the ensuing reduction in numbers of residents, will bring the ratio of bathrooms and toilets to service users into line with National Minimum Standards. It is noted that, where the owner has undertaken similar work at the ‘sister’ home to Prema House, this has been done to a high standard. Plans for this work, with approximate timescales, in respect of Prema, are to be submitted to the Commission. The service users who showed the inspector their bedrooms said that they were happy with them, and that they had everything that they needed and wanted. Each was personalised to reflect their own tastes and interests: one room had no pictures on the walls, but the service user said that she didn’t want or like things on the wall. At the time of the inspection, an electrician and a drainage engineer both arrived to carry out routine maintenance work. DS0000022749.V252382.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 Staff are supported by an effective staff team, who have access to training. Policy relating to the recruitment of staff is good, but records of checks were incomplete. EVIDENCE: During the inspection, the inspector met the Registered Manager, the Team Leader, two care staff, a Night Wake staff, the cook/catering manager, and the cleaner. The Director of Operations also attended the home to meet the inspector and discuss future plans for the organisation. Staff were observed to interact professionally and in a caring manner with service users. They were able to talk knowledgeably about residents’ individual needs. One member of staff had started at the home six months earlier, and had enrolled for an NVQ Level II award. The inspector examined two staff records held at the home; both showed that each person had been interviewed, with references taken up. However, there was no evidence that POVA checks had been undertaken (to ensure that people were not listed as unsuitable to work with vulnerable adults), and on one file, there was no evidence that a CRB (police) check had been undertaken. The manager reported that these checks were routinely done, and previous inspections had noted POVA/CRB checks on file. Evidence of this DS0000022749.V252382.R01.S.doc Version 5.0 Page 18 is to be confirmed to the Commission, and placed on file. It was clarified with the manager and Operations Director that staff must not be employed until a POVA check has been undertaken and found to be satisfactory. A new CRB check must be requested for each new member of staff joining the organisation, although staff may start work if they produce evidence of a recent clear CRB check, at the manager’s discretion and with appropriate supervision. One person’s references had not been fully completed by the referee. The manager must ensure that this is followed up and efforts made to establish the suitability of candidates before they start work at the home. The manager must also ensure that there is proof of identity and a photograph of staff on file. There was evidence of training available to staff on file. The organisation pays for training, although a request is made for staff to contribute to half of the fees, payable if the member of staff leaves within twelve months of the training date. The manager was actively seeking courses that he feels would be appropriate for the staff of the home, but was unsure what would be considered equivalent to NVQ training. This is to be clarified with the GSCC who oversees care staff qualification and registration. The manager reported that he undertook supervision and appraisal of the care staff. There were no copies of Job Descriptions or contracts on staff files, which would help ensure clarity of roles and responsibilities. These, including the Job Description for the manager, are to be forwarded to the Commission DS0000022749.V252382.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, 38, 39, 41, 43 Service users benefit from a well run home. Senior management roles in the organisation are being reviewed to promote clarity, accountability and promote the best interests of users. Issues around registration need to be clarified. EVIDENCE: Prema House is owned by Mr & Mrs Vindalon, who own a second registered care home called Deepdene. They have formed a company, Deepdene Limited. During the inspection, the Director of Operations for the company arrived to speak to the inspector, having been informed that there was an unannounced inspection taking place. She explained that the company was undergoing some review. The Director of Operations is a new post, and she is responsible for reviewing all aspects of operation of both homes, and is developing a new Business Plan. An issue discussed with the Director of Operations following this inspection, is that the home’s Operational Policy and Registration details need to be reviewed and updated to reflect recent changes including the status of the organisation (Deepdene Ltd, rather than individual proprietors). Relevant information will be sent to the proprietors by the Commission in respect of registration issues. DS0000022749.V252382.R01.S.doc Version 5.0 Page 20 The Director outlined that the Company’s aim is to build on the good foundations of the service, but to modernise and possibly expand. The organisation has already identified areas in which they feel positive developments could be made, and this assessment was in agreement with the view of the manager as well as with evidence found in inspections. A priority is to ensure stability in management for the home, and to clarify and consolidate the role of the registered manager. The manager is involved in developing the Business Plan for Prema, and has been able to implement changes to address staffing issues and care planning processes. The direction of travel outlined by the Director of Operations and the manager was very positive. The updated Business Plans are to be submitted to the Commission. It is recommended that this includes quality assurance monitoring, based on service user surveys or feedback, (as outlined in NMS 39). Also, details of the organisational structure and roles of the senior management team/Directors are to be submitted. Following a Requirement made in the report of the last inspection, May 2005, the Director has submitted copies of monthly visits undertaken in accordance with Regulation 26, for the period June – September inclusive. The Director or the Personnel Manager carried these out. The reports are thorough and comprehensive. Out-of-hours on-call management of the home is provided by the manager of Prema and the manager of Deepdene, on a one-week-on/one-week-off rotational basis. Due to the nature of the two services, there is a reasonable likelihood that on-call managers will be contacted. This relatively high level of cover provided, could lead to fatigue. This is to be monitored and reviewed, particularly as the manager of Deepdene is due to leave in the near future. The Responsible Individual is to inform the Commission of what systems will be in place to cover this absence. A sample of records held at the home were examined by the inspector, and were mostly found to be in good order, and up-to-date. However, the Visitor’s book was full and needed replacing. As noted above, one recent complaint had not been logged. Finally, although the home maintained full and accurate records of accidents and incidents, not all of these had been notified to the Commission. See Requirements. DS0000022749.V252382.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 X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 2 4 X 4 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score 2 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 2 3 X 2 X 2 DS0000022749.V252382.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA66 Regulation 15(2), 17(3)a Requirement The Registered Manager must ensure that there is a record of important meetings and decision-making on service users’ files, to prevent gaps in information while awaiting minutes or other records from care professionals. The Registered Manager must ensure that service users are offered advocacy support, particularly when making decisions that may effect their future placement, and that this is recorded on their files. The Registered Manager must ensure that Risk Assessments are updated when service users needs or health changes. This is to be undertaken specifically for those service users whose physical health is changing, with reference to the layout of the home. Consideration should be given to arranging for Occupational Health input in this assessment. Timescale for action 10/11/05 2 YA7 12(2)(3) 10/11/05 3 YA9 13(4) 15(2) 01/02/06 DS0000022749.V252382.R01.S.doc Version 5.0 Page 23 4 YA17 12(2)(3) 16(2)h 5 YA24 23(2)d, f 6 YA24 13(4)a,c The Registered Manager must ensure that a review is undertaken on the mealtime arrangements in the home, with a view to maximising service user involvement in meal selection, food preparation and serving. This is to include all meals, and a system put in place to ensure that this is reviewed at regular intervals thereafter. The outcome of the review, with timescales for any action agreed, to be notified to the Commission in writing. The Registered Person must review the layout, décor and furnishings of the dining area, with a view to making the area more homely and domestic in appearance. The outcome of the review, with timescales for any action agreed, to be notified to the Commission in writing. The Registered Person must ensure that stair carpets are made secure to prevent risk of tripping, and that a programme for replacing stair carpets is put in place. The Registered Person must submit a written plan for refurbishment of the home, in respect of converting double rooms into en-suite single rooms. This is to indicate timescales for action. The Registered Manager must ensure that staff records kept at the home contain copies of Job Descriptions and contracts, which contain information specified in Schedule 4(6). A Job Description for each role is to be copied to the Commission. 01/04/06 01/04/06 10/11/05 7 YA27 23(2)j 01/02/06 8 YA31 17(2) Sch4(6) 01/02/06 DS0000022749.V252382.R01.S.doc Version 5.0 Page 24 9 YA34 19 Sch.2 10 YA38 10(1) 12(1) 18(1)(2) 10 YA41 17 Sch 3 &4 11 YA43 10, 24 12 YA43 6, 39 The Registered Person must ensure that information and documents as specified in Schedule 2 are in place for each person working at the home. The Registered Manager is to confirm to the Commission in writing that satisfactory POVA, CRB and reference checks have been undertaken for each member of staff, and this is evidenced on staff files. The Registered Person must review and monitor the on-call rota, and out-of-hours support to the home, to ensure that this is adequate, appropriate, and avoids staff fatigue. The outcome of the review, with timescales for any action agreed, to be notified to the Commission in writing. The Registered Person must ensure that a new Visitors Book is in place; that all Complaints are promptly logged; and that all events relevant to Schedule 4 are notified to the Commission. The Registered Person must submit revised Business Plans to the Commission, with information relating to any changes in organisation or operation. This is to include details of the organisational structure and roles of the senior management team and Directors. The Registered Person must ensure that the Operational Policy and Statement of Purpose are updated, and that contact is maintained with the Commission regarding any amendments to Registration that may be necessary. 10/11/05 10/11/05 10/11/05 10/01/06 10/01/06 DS0000022749.V252382.R01.S.doc Version 5.0 Page 25 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 YA39 Good Practice Recommendations The Registered Person should ensure that quality assurance monitoring, based on service users views, and are included in the updated Business Plans being developed. DS0000022749.V252382.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022749.V252382.R01.S.doc Version 5.0 Page 27 - 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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