Inspection on 31/07/07 for Rachel House

This inspection was carried out on 31st July 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 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rachel House 06/08/08

Rachel House 11/01/08

Rachel House 06/04/06

Rachel House 21/10/05

Rachel House 06/05/05

Rachel House 02/12/04

Rachel House 09/06/04

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

CARE HOME ADULTS 18-65 Rachel House Rachel House 103 Sixth Avenue Manor Park London E12 5PS Lead Inspector Lea Alexander Key Unannounced Inspection 31st July 2007 1:00 DS0000022872.V345116.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 DS0000022872.V345116.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. DS0000022872.V345116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rachel House Address Rachel House 103 Sixth Avenue Manor Park London E12 5PS 020 8514 2556 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) rachellhouse@hotmail.com Ms Estelle Moyo Ms Estelle Moyo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places DS0000022872.V345116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th April 2006 Brief Description of the Service: Rachel House is a three-bedded care home for people with mental health support needs. A private individual Estelle Moyo owns the home and is also the Registered Manager. Newham Registration and Inspection Unit initially registered Rachel House in August 2000. The home offers 24-hour care and accepts emergency placements. The premises are a terraced property in a residential area of Manor Park, with easy access to Ilford shopping area. A range of culturally diverse services and amenities are located in the Romford Road, which is within walking distance. The home is well served by several bus routes, which includes the 25 and 86. Ilford, Manor Park and Woodgrange Park British Rail stations are approximately a mile away. Unrestricted car parking is available. All service users have their own room. Each service user is provided with his or her own room key. Service users are able to personalise their rooms to reflect their individuality. There are no placement vacancies. Currently two African Caribbean females and one White British male reside at the home DS0000022872.V345116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of two visits on the 30th July and 7th August 2007. This was the Inspectors first visit to the home. During the course of the inspection the Inspector met with the Registered Manager and spoke privately with a care worker and with people who live at the home. The Inspector also sampled the personal records of people who use the service, personnel files and other relevant documentation relating to the running of the home. What the service does well: What has improved since the last inspection? What they could do better: DS0000022872.V345116.R01.S.doc Version 5.2 Page 6 The Inspector discussed with the Registered Manager how the home promotes equality and diversity issues. The Inspector was advised that the home aims to “promote independence” and use assessment of needs to identify individual issues. The Registered Manager advised that the home also aims to provide culturally appropriate foods. The Inspector formed the view that the home does not comprehensively assess needs or develop person centred plans that include resident’s life histories. The current plans and entries in the daily logs were not found to evidence service users being promoted to be independent. The lack of a log to evidence the meals provided meant that the Inspector was unable to evidence that the home provides a range of culturally appropriate meals. Twenty requirements are made as a result of this inspection, a number of which have been restated over several inspections. The home was not evidenced as carrying out its own assessments of people who use the service prior to their moving in, or supporting potential residents to “test drive” the home. The home produces poor quality individual plans that do not adequately reflect the personal, health and social care needs of people who use the service. These plans are not person centred and the home does not produce appropriate risk assessments. There is no evidence of key working and people who use the service are not supported to access advocacy services. Some needs identified by other professionals have not been followed up by the home, and there is little evidence that people who use the service are appropriately supported to access appropriate community, occupational and leisure activities. There was no evidence of variation in the meals provided or evidence of how meals meet the dietary and cultural needs of service users. People who use the service also receive inadequate support in maintaining appropriate personal care. The homes complaint, whistle blowing and Safeguarding Adults policies all require revision and update, and the home must ensure that the complaints log is available for inspection. Only one staff member has completed NVQ level 2 studies, and not all staffs have appropriate checks in place prior to starting their employment. There is no annual training plan and only limited training has been provided since the last inspection. Not all staffs are on target to receive a minimum of six supervision sessions in a year. A range of maintenance issues requires addressing, particularly in the homes bathroom. The homes quality assurance process requires further development to include the views of families, professionals and other interested parties. The results must be collated and published. The home has yet to complete a fire risk assessment or a business plan. DS0000022872.V345116.R01.S.doc Version 5.2 Page 7 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. DS0000022872.V345116.R01.S.doc Version 5.2 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 DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not properly assess resident’s prior to their admission and cannot clearly evidenced that prospective residents are given the opportunity to visit the home. EVIDENCE: There have been no recent admissions to the home, and the three people who currently live there have been in residence for some years. The Inspector sampled the personal records for two of the people currently living at the home. It was not evidenced that the home had carried out its own assessment or obtained the views of other professionals prior to either person moving in. Sampling of the personal records did evidence that a care worker had completed a tick box assessment document in January 2007 for both service users. Archived records also did not evidence that either of these service users had been given the opportunity to test drive the home, although the Registered Manager told the Inspector that although it was not recorded each person who uses the service had visited the home at least once. The service users in DS0000022872.V345116.R01.S.doc Version 5.2 Page 10 question were unable to recall whether they had visited the home before moving in as it had been some years previously. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes care plans are poorly developed and do not reflect the person. There is no key worker system in place and little evidence of risk assessments. EVIDENCE: The Inspector sampled the individual plans for two people who currently use the service. This evidenced that each had an individual plan and that these are reviewed on a six monthly basis. However, the Inspector noted that whilst a plan for one service user dated the 4/12/6 was fairly comprehensive, successive plans dated the 20/1/7 and 3/7/7 each carried notably less information. The current plan dated the 3/7/7 was noted as only addressing three areas, mental health, blood sugar monitoring and community activities. The Inspector noted that this person who uses the service suffers from diabetes, however, this was not adequately addressed in the available plans, DS0000022872.V345116.R01.S.doc Version 5.2 Page 12 for example only blood sugar monitoring was addressed, with no information on dietary management or the arrangements for insulin administration. A similar deterioration in the quality and quantity of information recorded in the individual plan was also evidenced in the second service users personal file. The Inspector also noted that there was little evidence of person centred planning, and that there was little information on their life histories, past interests or other culturally relevant information. For example, during the Inspectors discussion with one person who uses the service they stated that they have an interest in music, and would be interested in attending local music events, particularly those arranged in local parks during the course of the summer. This interest was not reflected in their individual plan. There was no evidence of key working sessions or other input to evidence that the home is proactively working with people who use the service to address their individual needs and goals. The personal records for service users sampled by the Inspector evidenced that the home provides varying levels of support with finances for people who use the service. One person sampled retains their own bankbooks, card and monies, and only requires assistance in attending the bank and actually withdrawing their own money. A second person that uses the service requires higher levels of support. The home retains their weekly allowance and this is released throughout the course of the week. Each transaction is recorded and signed for by staff and the person who uses the service. Details of the date, amount and nature of transaction are also recorded. The Inspector sampled the records and actual cash available for this person and found that they corresponded. During the course of the inspection one service user stated that they would like support in obtaining an advocate and this information was passed on to the home manager for follow up. Sampling of the personal file for one person who uses the service evidenced that they have a current risk assessment. However, this only addresses a potential vulnerability to abuse as a result of visual impairment and does not link with areas identified in the individual plan. A second person that uses the service was not evidenced as having a current risk assessment. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not support residents to become involved in community activities, education or training. There is no reflection of the cultural or specific dietary needs of people who use the service. However, staffs do interact with people who use the service and they are supported to maintain contact with their families. EVIDENCE: A previous inspection had required the home to follow up on rehabilitation work the local Social Services Department had identified in its own assessment. Sampling of this resident’s personal file did not evidence that the home had done this. DS0000022872.V345116.R01.S.doc Version 5.2 Page 14 The Inspector noted that one person who uses the service did not have community, leisure or occupational activities addressed in their individual plan. The Registered Manager advised that they “popped in out to the local shops”. The Inspector sampled the daily logs and these evidenced that in the previous two and half weeks the service user was evidenced as having two visits to a local shop and one fifteen minute walk. The only other activities recorded were four occasions when this service user cleaned their room. The second resident sampled by the Inspector did have an individual plan that aimed to address their community activities. However, the only activity identified was attendance at a local day service which it was recorded the person had been declining to attend for several weeks. Sampling of the daily logs evidenced that this person does attend church once per week, but this was not reflected in their individual plan. The Inspector noted that the homes assessment undertaken in January 2007 had been annotated under the heading Education and Occupation “cannot meet due to sight impairment”. Neither of the individual plans sampled provided any information on whether the people they relate to have contact with friends or family, or the nature of this. Discussion with people who use the service and the Registered Manager evidenced that residents are supported to maintain contact with family through the phone and face-to-face visits, where they live locally. Throughout the course of the Inspectors two visits to the home staff were observed talking and interacting with people who use the service. Discussion with people who use the service evidenced that they can choose when to be alone or in company and when not to join in an activity. One service user spoken to by the Inspector said that the meals were “fine”. The homes own quality assurance surveys evidence that generally people who use the service are satisfied with the meals provided. The Inspector asked to see the log of meals provided and was advised by the Registered Manager that the home does not maintain such a log. The Inspector was shown a standard weekly menu, but the Registered Manager was not able to confirm how regularly this was changed, or how people who use the service participate in the selection of meals for the menu. The Inspector noted that the specialist dietary requirements of one service user were not reflected in the sample menu, or their individual plan. The Registered Manager stated that staffs “knows what to give and what not to give”. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to healthcare services and their health is monitored. Medication records are up to date. However, the personal care needs of some people who use the service have been assessed as not being met over several inspections. EVIDENCE: One of the service users sampled by the Inspector was identified in their individual plan as requiring support to maintain their personal care. A previous inspection had noted that this service user was wearing soiled clothing during the visit to the home, and on this occasion the Inspector saw that this resident was again wearing heavily soiled garments. Sampling of the personal records for two people who use the service evidenced that the home supports residents to attend medical appointments and retains copies of medical correspondence. Information relating to residents healthcare needs was also recorded in the individual plans. DS0000022872.V345116.R01.S.doc Version 5.2 Page 16 The home has developed a medication policy, and the Inspector viewed this. It contains guidance for staff on the steps to take when administering medication, and also allows scope for people who use the service to self medicate within a risk assessment framework. The Inspector was advised that at present no residents are self-medicating. The Inspector viewed the homes Medication Administration Records and sampled the actual medications available. This evidenced that the medications available correspond with those listed on the Medication Administration Record. These records were accurately completed. The Inspector did however note that two medications require storage at below a specified temperature, and the home is therefore recommended to purchase a thermometer and monitor the temperature of the medicine cabinet. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have an up to date complaints policy and does not maintain a record of complaints that have been received. However, the home has obtained Safeguarding Adults protocols from the local authority and staffs demonstrate a good understanding of adult protection issues. EVIDENCE: The home has produced a complaints policy, and the Inspector viewed this. The policy clearly states that the home aims to deal with complaints within a 28-day timescale. The Inspector did however note that the policy had not been updated to include the current contact details for the Commission for Social Care Inspection. The Inspector asked to view the homes complaints log, but was told by the Registered Manager that they were unable to locate it. Discussion with people who use the service evidenced that if they were unhappy with the service they received they would feel confident raising this with staff. A previous inspection had required the home to obtain copies of the local authorities safeguarding adult’s procedure, and the Inspector noted that these had been obtained. The home had also been required to update its whistle blowing policy to included up to date contact details for the Commission for Social Care Inspection and this remains outstanding. DS0000022872.V345116.R01.S.doc Version 5.2 Page 18 The Inspector sampled the homes adult protection policy. This was found to be very brief. It included a short statement on what abuse is and did give some guidance to staff on the steps to follow should they have concerns. However the policy did not make appropriate reference to the local safeguarding adults protocols. The Registered Manager advised the Inspector that there had been no adult protection referrals since the last inspection. Discussion with the care worker on duty evidenced that they had a good understanding of the types of abuse people who services may experience and understood their responsibilities should they have any concerns. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally comfortable, clean and tidy. Residents have their own rooms that they can personalise. However, there is a number of maintenance and repair issues that need addressing. EVIDENCE: The home is situated in a three bed-roomed terraced property in a residential area. There is a long downstairs hallway and from this there is a communal lounge with a range of comfortable seating and a television. One service users bedroom is also located on the ground floor, as is a kitchen diner. This has a range of fitted units and a dining table and chairs. To the rear of the kitchen there is a bathroom. Access to the first floor is via a staircase and on this level two service users bedrooms, a staff office and a WC are located. DS0000022872.V345116.R01.S.doc Version 5.2 Page 20 Some minor repairs in the upstairs WC were identified at a previous inspection, and these have been satisfactorily carried out. However a number of further maintenance and repair issues were identified during this inspection and these are detailed in the requirements section of this report. Over the duration of the Inspectors two visits to the home, the premises were noted to be clean and free from offensive odours. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The training the home provides is infrequent and there is no comprehensive training plan. Staffs are not encouraged to pursue NVQ level 2 training, and some staff start work without all the necessary checks being completed. EVIDENCE: During the course of the inspection care workers were observed to be accessible to and approachable by people who use the service. At the time of this inspection the home employs three care workers in addition to the Registered Manager. The Inspector was advised that at present only one staff member has obtained NVQ level 2, and the remaining staffs have yet to enrol for NVQ training. A current staffing roster was displayed at the time of the inspection, and this was found to accurately reflect the situation found in the home. DS0000022872.V345116.R01.S.doc Version 5.2 Page 22 The Inspector sampled the personnel records for two care workers. These evidenced that all staff have completed an application form and that two satisfactory references and an Enhanced level Criminal Records Bureau (CRB) check has been obtained by the home. However, sampling of the personnel records and discussion with the Registered Manager evidenced that one staff member had been employed by the home to provide bank cover before their CRB check had been obtained. There was no evidence that the home had obtained a “POVA first” check to cover this period of employment. Both staff members were evidenced as having received copies of their employment terms and conditions. The home had also obtained proofs of identity for both staff. However, the Inspector noted that the visa for one staff member appeared to indicate that permission was required from the Secretary of State for their employment, and it was not evidenced that his had been obtained. From training records located in care workers personnel files the Inspector was able to evidence that since the last inspection the home has provided two training courses for staff, the administration of medicines and first aid. The Registered Manager advised that there are at present no additional training courses planned and that the home does not have a training plan. Both of the sampled personnel files contained evidence of care workers receiving an induction to the home. The Inspector viewed the supervision records available for both of the sampled care workers. A longstanding member of staff had already received four supervisions in the current year and was on target to receive a minimum of six sessions over the year. However, the second member of staff had commenced work in March 2007 and was evidenced as having received one supervision session in the intervening period. DS0000022872.V345116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is suitably experienced although they have not yet obtained their NVQ level 4. The home has implemented a basic quality assurance system and carries out many of the checks required by health and safety. EVIDENCE: The Registered Manager is also the proprietor of the home. They are a qualified Registered Mental Health Nurse and are currently studying for their NVQ level 4. DS0000022872.V345116.R01.S.doc Version 5.2 Page 24 The Registered Manager advised the Inspector that the home carries out regular quality assurance surveys with people who use the service. This was evidenced by the completed surveys found in resident’s personal files. However, the home does not at present survey the families, professionals or other interested parties to obtain their views on the service provided. The home at present does not collate or publish the results of its quality assurance exercise. A previous inspection had required the home to develop a fire risk assessment. The Registered Manager advised the Inspector that they were not sure what this was, and that they had not therefore undertaken one. Sampling of the homes other fire records evidenced that weekly fire alarm call point tests are carried out and regular fire evacuation drills. The Inspector sampled a range of health and safety records maintained by the home. These evidenced that a current portable electrical appliance-testing certificate had been obtained and that regular fridge and freezer temperatures are recorded. However, the Inspector noted that the homes recording sheet states that the freezer temperature must be below –18 degrees, and the actual temperature recorded was frequently –17 degrees with no record of any action taken to restore the temperature to within acceptable parameters. A previous inspection had required the home to develop and forward to the Commission a business and financial plan. The Registered Manager advised the Inspector that this remained outstanding. DS0000022872.V345116.R01.S.doc Version 5.2 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 X 2 1 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 2 12 1 13 1 14 1 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 3 X 3 X 2 X X 2 2 DS0000022872.V345116.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. 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. Standard YA2 YA6 Regulation 14 15 Requirement People competent to do so must properly assess people who use the service. Care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. These are restated requirements. The previous timescales of the 01/01/06 and 01/06/06 were not met. The home must develop a risk assessment and management plan for each person who uses the service that relates to the activities identified in the individual plan. The home must actively pursue the necessary rehabilitation work with Social Services for the identified service user. This is a restated requirement. The previous target of the 01/08/06 was not met. DS0000022872.V345116.R01.S.doc Version 5.2 Page 27 Timescale for action 30/12/07 30/12/07 3. YA9 13 30/12/07 4. YA11 12 30/12/07 5. YA12 16 6. YA13 16 7. YA14 16 8. YA15 23 9. YA17 13 & 16 10. YA18 12 Staffs help people who use the service to engage in fulfilling activities, education and training or work. Staffs support people who use the service to become part of and participate in the local community. Staffs ensure that people who use the service have access to and can choose from a range of appropriate leisure activities. The arrangements for contact with family and any support required with facilitating this must be detailed in the individual plan. The home must evidence that a variety of meals that meet the dietary and cultural needs of people who use the service are provided. Service users must be encouraged and supported to maintain their personal appearance. This is a restated requirement. The previous targets of the 01/12/05 and 01/05/06 were not met. The home must maintain a record of all complaints, and this must be available for inspection. The homes complaints policy must be updated to include the current contact details for the Commission. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. This is a restated requirement. Previous targets of the 01/01/06 and 01/06/06 were not met. 30/12/07 30/12/07 30/12/07 30/12/07 30/12/07 30/12/07 11. YA22 22 30/12/07 12. YA23 13 30/12/07 DS0000022872.V345116.R01.S.doc Version 5.2 Page 28 13. YA24 23 The missing and broken tiles in the downstairs bathroom must be replaced. This is a restated requirement. The previous targets of the 01/02/06 and 01/08/06 were not met. Worn furniture and soft furnishings in the communal lounge must be replaced. Soiled carpets in residents bedrooms must be cleaned or replaced. Damp patches on the cornice of one resident’s bedroom ceiling must be repaired and made good. Floor tiles must be properly fitted to prevent trip hazards. In the downstairs bathroom the following additional works must be undertaken: (i) The poorly fitting flooring must be made good to prevent a trip hazard The split doorframe must be repaired or replaced. Mouldy grout must be replaced. Damp peeling walls and side panels must be repaired and made good. Damaged handrails must be replaced. A blind must be fitted to the rear window. 30/12/07 (ii) (iii) (iv) (v) (vi) DS0000022872.V345116.R01.S.doc Version 5.2 Page 29 14. 15. YA32 YA34 12 & 18 19 16. YA35 18 The home must ensure that 50 of care workers are qualified to NVQ level 2 standard. The home must ensure that appropriate Criminal Records checks are carried out prior to staff commencing employment. The home must develop a staff training and development plan. All care workers must receive a minimum of five days training each year. Staff must receive regular, recorded supervision sessions, a minimum of six per year. The home should expand its quality assurance exercise to include the views of families, professionals and other interested parties. The outcome of the quality assurance exercise should be collated, published and made available for interested parties including the Commission for Social Care Inspection. A fire risk assessment must be developed. This is a restated requirement. Previous timescales of the 01/09/05, 01/12/05 and 01/05/06 were not met. Freezer temperatures must be maintained within acceptable parameters. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. This is a restated requirement. The previous targets of the 01/02/06 and DS0000022872.V345116.R01.S.doc 30/12/07 30/12/07 30/12/07 17. 18. YA36 YA39 18 24 30/12/07 30/12/07 19. YA42 23 30/12/07 20. YA43 25 30/12/07 Version 5.2 Page 30 01/07/06 were not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA7 YA20 YA34 Good Practice Recommendations The home must support people who use the service to access local advocacy services. The home should purchase a thermometer for its medicine cabinet and monitor the temperature to ensure that medicines are kept within their required temperature. The home should ensure that it complies with employment legislation by evidencing care workers entitlement to work. DS0000022872.V345116.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000022872.V345116.R01.S.doc Version 5.2 Page 32 - 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!