Inspection on 20/11/07 for Prudential Care Home Limited

This inspection was carried out on 20th November 2007.

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

Other inspections for this house

Prudential Care Home Limited 14/10/08

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

CARE HOME ADULTS 18-65 Prudential Care Home Limited 23 Ivatt Way London N17 6PF Lead Inspector Susan Shamash Key Unannounced Inspection 20th November 2007 11:00 Prudential Care Home Limited DS0000069944.V353904.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 Prudential Care Home Limited DS0000069944.V353904.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. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prudential Care Home Limited Address 23 Ivatt Way London N17 6PF 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) 020 8245 2859 020 8211 7406 Prudential Care Home Ltd Karl Graham Dicks Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 5 N/A Date of last inspection Brief Description of the Service: 23 Ivatt Way provides support for up to five adults with mental health needs including those subject to conditions of Section 37/41 of the 1983 Mental Health Act. The home is run by Prudential Care Home Ltd, a private provider that owns other residential services in the area. The property is a large two storey building with five bedrooms for residents with a separate toilet and bath/shower room, and a staff office on the first floor and a lounge, kitchen/diner and toilet on the ground floor. The stated aim of the home is ‘to provide the high quality residential support for adults with mental health needs who are not yet ready to live independently’. The home is approximately 10 minutes walk from Turnpike Lane Underground Station, and is served by local buses. It is close to shops, pubs and other public amenities. In November 2007 the weekly fees charged are £550 - £1400 depending on level of need. Current CSCI inspection reports can be obtained directly from the home and can also be viewed on www.csci.org.uk Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately six hours. This was the home’s first inspection undertaken by the Commission for Social Care Inspection since it opened this year. There were two people living at the home at the time of the visit, with three vacancies at the home. The registered manager assisted with the majority of the inspection. I conducted a tour of the home and I had the opportunity to speak to both people living at the home. I also spoke to the three support workers on duty and observed routines within the home. A variety of records, including care plans, staff files and health & safety documents, were examined. Information provided by the home in the Annual Quality Assurance Assessment, was also taken into account as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The home’s statement of purpose needs to be updated to include some further details to ensure that people are being provided with sufficient information about the service. The contracts between residents and the home need to be updated to ensure that people’s rights are protected as far as possible. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 6 People living at the home must be supported to attend regular healthcare appointments including dentists and opticians, to safeguard their health and welfare. Medication cabinets must be kept locked at all times when not in use and the storage temperature of medicines must also be monitored to ensure that the medication needs of people living at the home are met safely. The adult protection policies for the home’s local authority and the placing authorities of all people living at the home must be obtained for the protection of people living at the home from abuse. Lockable storage facilities must be provided in each person’s bedroom for the safe storage of their valuables. Staff files for all people working at the home must be kept on the premises including evidence of safe recruitment practices and adequate training to meet people’s needs safely. Monthly unannounced inspection visits must be made to the home on behalf of the provider organisation to ensure adequate quality monitoring for people living at the home. The fire prevention authority must be consulted regarding the home’s fire risk assessment, and a number of safety certificates must be obtained for the home for the safety of people living and working at the home. It is recommended that the garden area at the rear of the home be developed into a more attractive and comfortable area. Consideration should be given to relocating the washing machine away from the kitchen area and providing disposable towels or air dryers for hand drying in toilets, to improve hygiene for people living at the home. It is also recommended that all policies for the home should be dated and reviewed at least annually. 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. The summary of this inspection report can be made available in other formats on request. Prudential Care Home Limited DS0000069944.V353904.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 Prudential Care Home Limited DS0000069944.V353904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home feel that they are provided with adequate information and their needs and wishes are assessed so that the home can be sure that it can meet their needs and preferences. Their rights could be better protected by more specific terms and conditions with the home. EVIDENCE: I had the opportunity to speak with two people living at the home, although only briefly to one of them. They told me that they enjoyed living at the home and thought that all their needs were being met. Detailed assessments were available in each person’s care file indicating that a comprehensive assessment is undertaken prior to any person being admitted to the home. A statement of purpose and service users guide were available for the home, and those people spoken to advised that they had been given sufficient information about the home prior to moving in. The statement of purpose indicates that the home will take all steps necessary to combat discrimination and take positive action to promote equal opportunities while appreciating the benefits of diversity. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 9 The home’s statement of purpose needs to be updated to include the sizes of all rooms in the home and a copy of the current service users guide for the home should also be sent to the local CSCI area office. People living at the home advised that they had had opportunities to visit the home for short visits, overnight and weekend stays prior to moving in. This was confirmed by staff spoken to and recordings in each person’s daily notes. People’s files included statements of terms and conditions between the home and people living at the home. However these need to be further updated to include the room to be occupied and specify the care home at which the person lives, to ensure that people’s rights are protected as far as possible. Prudential Care Home Limited DS0000069944.V353904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home assesses and responds to the needs of residents whilst helping them to make decisions for themselves. People living at the home are supported to take appropriately calculated risks in order to develop their independence skills as far as possible. EVIDENCE: I looked at the care plans of both people living at the home, which identified their primary needs and how these were being met. I also spoke to both residents about the support that they receive, and three staff members told me how they assisted residents to achieve the aims set out in their care plans. Both care files contained an up to date care plan and risk assessments, reflecting a person-centred approach to supporting residents. These were based on detailed assessments undertaken by the home and obtained as part of the admission information for each person, and were signed by the relevant Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 11 resident. The minutes of recent Care Programme Approach reviews were also available. & psychiatric Care staff interviewed were aware of the need to provide guidance and support to residents where necessary, whilst letting them decide for themselves as much as possible how they lead their lives. The residents said they could decide when they wanted to have their meals and what they had to eat. Risk assessments indicated that staff support residents to take risks as part of a more independent lifestyle, and this was confirmed by staff and residents spoken to. Observation of interactions in the home indicated that staff had formed supportive relationships with residents, enabling them to make choices about how they spent their time. Prudential Care Home Limited DS0000069944.V353904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is good at enabling people to get out and about and lead lives of their choices. Residents enjoy a better quality of life because they have good links with the local community and close contact with friends and family. People are supported to make choices for themselves about how they spend their time. They are encouraged to help prepare meals at the home and consulted about the menus so that their preferences are taken into account, and a varied and nutritious diet is provided to them. EVIDENCE: Despite both residents being quite new to the home, they advised that they were satisfied with activities available to them. One attends a local gym regularly, and is looking to undertake a plastering course at college. Both go out independently and make use of local shops and amenities. Other activities Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 13 enjoyed by residents include playing football, a picnic in Epping Forest, reading daily newspapers and going clubbing. Within the home they are supported to be involved in cooking their own meals and undertake housework in order to develop their independence skills. Two evenings weekly are scheduled for cooking lessons with an identified staff member. Staff were aware of people’s cultural needs, including dietary preferences and religious observance. Foods on the home’s menu took account of the cultural diversity of people living at the home. In the Annual Quality Assurance Assessment for the home, the manager advised that Ramadan and Eid had been respected at the home and a Christmas activity was being planned. People said they could have visitors when they wanted and spoke positively about how staff members respect their rights and give them responsibility. Both are in contact with family members and see them regularly. Both residents have their own keys to the home and their rooms and staff have no access to personal/private space unless permission is received. Restrictions are kept to a minimum and where they are in place they are stated in the home’s brochure or the contract. I observed that residents and staff related well to each other in a relaxed way. The home was well stocked with food including fresh fruit and vegetables. People that I spoke to advised that they were consulted on menu choices and evidence within one person’s care plan indicated that they were receiving support and advice around managing their diabetes. Prudential Care Home Limited DS0000069944.V353904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff team is good at providing physical and emotional support to residents in a way that they are comfortable with. However it is not clear whether they receive sufficient support to attend regular healthcare appointments. Residents are generally protected by the medication arrangements in place in the home, however there is room for improvement in the storage arrangements to further protect them from harm. EVIDENCE: Staff were observed to interact appropriately with residents and in a way that recognised their individual needs and preferences. They told me that their needs were being met and that staff were easy to talk to. However there was insufficient evidence that the people living at the home are prompted and supported to attend regular healthcare appointments including dentists and opticians. These must be clearly recorded in order to safeguard their health and welfare. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 15 Neither resident was self-medicating at the time of the inspection, and a detailed medication administration policy was in place for the home. The records relating to the administration of medication to residents were up to date and accurate. Medicines were stored within a separate small cabinet for each person. At the time of the inspection the keys for each cabinet were left in the cabinets when not in use. Staff indicated that this was not unusual. Despite having lockable cabinets, leaving keys in the locks undermines the security of medication stored at the home. A requirement is made accordingly. The storage temperature of medicines stored at room temperature should also be monitored to ensure that it does not exceed 25°C, to ensure that the medication needs of people living at the home are met safely. Prudential Care Home Limited DS0000069944.V353904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system so that people can be confident that their complaints and concerns will be listened to and acted on. Adult protection procedures are in place to protect people from abusive practices, however it is not clear that people are safeguarded by the local authority policy and procedures. EVIDENCE: The home has policies and procedures in place in relation to reporting and investigating complaints with each resident given a copy of the complaints policy as part of the service users guide. No complaint had been made as yet, but a format for recording concerns and complaints was in place. Residents said they felt able to make complaints and raise issues if they needed to. There had been no incidents in relation to adult protection in the home. Staff had had training in this area and the staff members on duty were aware of how to respond to incidents or allegations. Although the home has a detailed adult protection policy, it did not have a copy of the adult protection policies and procedures for the host local authority (Haringey). The local authority’s policy alongside those of the placing authorities of all people living at the home must be obtained. These must be easily accessible within the home and the manager must ensure that the home’s policy complies with these, for the protection of people living at the home from abuse. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a homely, clean and comfortable environment although there are a small number of improvements needed to further ensure the comfort of people living at the home. EVIDENCE: Inspection of the premises showed that it was comfortably furnished and well decorated, providing a homely environment for residents. Residents commented that it was a nice environment to live in. The home was clean, and staff advised that they supported residents to keep their home clean and tidy. Bedrooms had been personalised, considering that residents had not been living there long. Each bedroom had a sink, radiator, bed, wardrobe, chest of drawers, table and chairs, bedside lamp, television, telephone and refrigerator provided by the home, exceeding the provision specified by the national minimum standards. However they did not include lockable storage facilities, Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 18 and these must be provided in each person’s bedroom for the safe storage of their valuables. The garden area whilst clear and well maintained, was rather sparse, and it is recommended that this area (at the rear of the home) be developed into a more attractive and comfortable area. The kitchen was well equipped, and staff and residents advised that all equipment was functioning well. The washing machine is currently located in the kitchen area, which is not a problem given the needs of the existing people living at the home. However it is recommended that the registered persons consider relocating the washing machine away from the kitchen area to facilitate better infection control procedures within the home. This may become necessary in the future, depending on the needs of future people admitted to the home. At the time of the inspection, cloth towels were being used in the communal bathrooms/toilets for hand drying by people living at the home. This is satisfactory as the two people living at the home currently have one bathroom each. However this will need to be reviewed when more people move into the home, in order to ensure safe hygiene procedures to prevent the spread of infection within the home. The provisions of disposable towels or air dryers should be considered to improve hygiene for people living at the home. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from an experienced team of staff who support them appropriately. They are protected by the home’s recruitment procedures, however insufficient staff information maintained within the home means that this cannot be fully verified. It is unclear whether all staff members have the relevant training needed to meet residents’ needs. EVIDENCE: I had the opportunity to speak to three staff members and the registered manager. Most staff at the home have worked at another home belonging to the registered provider and are therefore experienced at meeting the needs of people with mental health problems. Positive feedback was received from both residents, indicating that they felt well supported by staff at the home. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 20 Not all staff files were available for inspection within the home. The manager advised that this was because several staff members had been working at another home owned by the provider, and their files were therefore kept at that home. I inspected three staff files that were available. They contained sufficient information to evidence the staff members had the appropriate checks made to protect residents from having unsuitable staff working in the home. These checks included two written references, identity documents and enhanced CRB disclosures. Discussion with the manager indicated that he was aware of the appropriate procedures to follow when recruiting staff. However it is required that the staff files for all people working regularly in the home must be stored at the home to evidence that residents are fully protected by thorough recruitment checks for all staff members. Records and certificates maintained in one staff file indicated that the staff member had undertaken a thorough induction including basic counselling skills and mental health awareness. Other training courses undertaken included control and restraint, dual diagnosis, breakaway techniques, health and safety, food hygiene, first aid, fire safety and adult protection. The training records for other staff members were not available, however discussion with them indicated that they had undertaken the majority of mandatory training courses as appropriate. The training records including training certificates of all staff members must be kept at the home, alongside a matrix of staff training to ensure that all staff are appropriately trained to meet the needs of people living at the home. In the Annual Quality Assurance Assessment the manager advised that a series of staff seminars are planned for 2008 including the history of Mental Health, Basic Counselling skills, Diagnoses of Mental Health/ Learning Difficulty and Forensic Mental Health. He also advised that he would be planning and implementing staff training seminars to address the need for a sound working knowledge in the area of equality and diversity. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally well run so that people living there benefit from having their individual needs and preferences responded to. Residents contribute to the way in which the home is run, however there is room for improvement in quality control procedures for the home to ensure that high standards of care and support are maintained at all times. Although a large number of safeguards are in place, people living at the home would be better protected from harm by more rigorous health and safety record keeping. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager for the home had been working in social care since 1984, and is a Registered Mental Health Nurse, and Learning Disability Nurse. He has a diploma in counselling and National Vocational Qualification level 4 in management and level 5 in Operational Management. The manager advised that regular staff meetings are held at the home during which people can put forward their ideas and suggestions on how the home is run. Meeting minutes indicated that they were used for consultation about the way the home is run as appropriate. The manager advised that resident meetings had recently commenced and are expected to take place on a fortnightly basis. Although the manager advised that monthly quality assurance visits were being undertaken by a representative of the provider organisation, there were no reports of these visits available, to evidence this. Nor had monthly reports been sent to the local CSCI area office, and this is required. Clear policies were in place for supporting residents with their finances, and the manager explained the current procedures, and showed me current records as appropriate. A detailed selection of policies and procedures were available for the home. It is recommended that these should be dated and that these must be reviewed at least annually. Health and safety records were looked at, including fire safety, accident reports and daily refrigerator and freezer temperatures, which were current and complete. Inspection of safety certificates for the home showed that current gas and electrical installation certificates were in place. However it is required that a current portable appliances testing certificate, emergency lighting certificate, fire extinguishers servicing certificate, and Legionella testing certificate be obtained for the home for the safety of people living and working at the home. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 3 X 2 X Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 4, 5 Timescale for action The registered persons must 01/02/08 ensure that the home’s statement of purpose is updated to include the sizes of all rooms in the home. A copy of the current service users guide for the home should also be sent to the local CSCI area office to evidence that people are being provided with sufficient information about the service. The registered persons must 18/01/08 ensure that statements of terms and conditions between the home and people living at the home are updated to include the room to be occupied and specify the care home at which the person will live, to ensure that people’s rights are protected as far as possible. The registered persons must 11/01/08 ensure that people living at the home are prompted and supported to attend regular healthcare appointments including dentists and opticians, and that these are recorded to DS0000069944.V353904.R01.S.doc Version 5.2 Page 25 Requirement 2. YA5 5(1b) 3. YA19 12(1) Prudential Care Home Limited 4. YA20 13(2) safeguard their health and welfare. The registered persons must 20/11/07 ensure that the medication cabinets are kept locked at all times when not in use and that the keys are kept securely. The storage temperature of medicines stored at room temperature should also be monitored to ensure that it does not exceed 25°C to ensure that the medication needs of people living at the home are met safely. The registered persons must 28/12/07 ensure that the adult protection policies for the host local authority and the placing authorities of all people living at the home are easily accessible within the home and that the home’s policy complies with these, for the protection of people living at the home from abuse. The registered persons must 14/03/08 ensure that lockable storage facilities are provided in each person’s bedroom and that they are issued with keys for these facilities, for the safe storage of their valuables. The registered persons must 18/01/08 ensure that staff files for all people working at the home on a regular basis are kept securely on the premises and that these include all relevant recruitment documents and staff training certificates to evidence that safe recruitment practices are in place to protect people living at the home from harm. A matrix of staff training must also be produced to ensure that 5. YA23 13(6) 6. YA24 23(2m) 7. YA34 17(2) Sched 4 19 Sched 2 Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 26 8. YA39 26 9. YA42 13(4) 23(4) 10. YA42 13(4) all staff undertake training necessary to meet the needs of people living at the home safely. The registered persons must 18/01/08 ensure that monthly unannounced inspection visits are carried out on behalf of the provider organisation, and that reports of these visits are sent to the local CSCI area office and to the home. The registered persons must 01/02/08 ensure that the local fire prevention authority is consulted regarding the home’s fire risk assessment, and that this is dated, and reviewed at least sixmonthly to ensure the safety of people living and working at the home. The registered persons must 18/01/08 ensure that - a current portable appliances testing certificate, - emergency lighting certificate, - fire extinguishers certificate, and servicing - Legionella testing certificate are obtained for the home for the safety of people living and working at the home. Copies of these certificates must be sent to the local CSCI area office. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 27 No. 1. 2. Refer to Standard YA24 Good Practice Recommendations It is recommended that the garden area at the rear of the home be developed into a more attractive and comfortable area. It is recommended that the registered persons consider relocating the washing machine away from the kitchen area to facilitate better infection control procedures within the home. It is recommended that the use of cloth towels for handdrying in bathrooms and toilets be reviewed when more people move into the home. The provisions of disposable towels or air dryers should be considered to improve hygiene for people living at the homes. It is recommended that all policies for the home should be dated and that these must be reviewed at least annually. YA24 3. YA30 4. YA40 Prudential Care Home Limited DS0000069944.V353904.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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