Inspection on 11/10/06 for Red House Lane, 2

This inspection was carried out on 11th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Red House Lane, 2 18/09/07

Red House Lane, 2 24/01/06

Red House Lane, 2 07/07/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Red House Lane, 2 Red House Lane 2 Red House Lane Bexleyheath Kent DA6 8JD Lead Inspector Keith Izzard Key Unannounced Inspection 11th October 2006 09:30 Red House Lane, 2 DS0000062617.V308359.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 Red House Lane, 2 DS0000062617.V308359.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. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red House Lane, 2 Address Red House Lane 2 Red House Lane Bexleyheath Kent DA6 8JD 0208 523 3264 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) redhouselane@mcch.org.uk MCCH Society Ltd Mr Andrew John Fitton Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Through the CSCI inspection process, should the Commission identify the need for the home to register it’s own Manager, then they will be required to do so. 24th January 2006 Date of last inspection Brief Description of the Service: Red House Lane is a purpose refurbished detached bungalow providing long term care for two severely learning disabled people, of either gender, focussing on profound communication problems, sensory impairment, autism and challenging behaviour. The home consists of a large communal lounge, kitchen / diner, bathroom with a toilet and a separate toilet. There is also two large bedrooms, above the minimum required size, a large entrance hall and a small office. There is a garden to the rear and a driveway with garage to one side. The home is well situated for access to all local facilities and amenities and a minibus for transporting the residents. Permanent day staff and two waking night staff are employed who are well qualified and experienced to provide appropriate care and are well supported by the community services of the local Community Learning Disability Team and health services. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the third inspection of this home since registration. It was unannounced and took place on one day over a period of 6.75 hours. Both residents were at home and staff members prompted and enabled some communication from residents, as this required a sophisticated level of communication skills from staff to facilitate this. The home was clean, tidy and safe and staff members were observed to be both caring and professional in the way they related to the residents at the time of inspection. Both residents appeared to be happy and content in their home. This inspection included observation of the care provided and talking to three staff members and the acting manager. Also, inspecting records, safety systems and the premises. What the service does well: Staff and the manager communicated positively with residents to meet individual needs and provide residents with a lifestyle suited to them. Good communications existed with the local Community Learning Disability Team and other health and social service officials to enhance the quality of care provided. Staff received training and supervision to enable them to fulfil their role. Records were well maintained and care plans and risk assessments were up to date. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. Greater efforts must be made to ensure that requirements are complied with within time scales. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Red House Lane, 2 DS0000062617.V308359.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 Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures were in place to comply with these standards and service user needs assessed. Contracts have not been provided as required for residents. EVIDENCE: Standard 2. The admission procedures in place complied with this Standard. Evidence of this was seen during an examination of the records relating to both service users. The records showed that there had been good preparation in terms of the transfer arrangements from the previous home and that comprehensive documentation in respect of care plans and risk assessments were in place to support their assessed needs. However, the home needs to further develop the care plans to reflect all the areas of need listed in Standard 2.3 and how these will be met and the outcomes reviewed and recorded at each subsequent review meeting. See Standard 6 See Requirement 2 Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 9 The home must provide contracts for residents in accordance with the specification set down in Standard 5. Restated Requirement 1 Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Risk assessments viewed were up to date and comprehensive and updated on a regular basis. Care plans must reflect outcomes better in response to how need will be met Annual Care/ Life Plans were also up to date and showed that residents were involved and family or representatives and professionals involved had been invited. However care plans must be reviewed on a six monthly basis. Residents were involved in decisions about them, supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Standard 6 Care provided to both residents was tracked. Care plans were well written and were supported by up to date assessment of need. However, the home needs to further develop the care plans to reflect all the areas of need listed in Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 11 Standard 2.3 and how these will be met and the outcomes reviewed and recorded at each subsequent review meeting. See Standard 2 See Requirement 2 A previous recommendation that care files should be better indexed in order to facilitate access to the most relevant and up to date information was complied with. It was evident in the care plans that residents, a relative and an advocate were involved in care planning. However, the resident who has an advocate has no one else to advocate on his behalf and the Inspector was concerned that the involvement of the advocate was largely confined to attendance at review meetings. It is important that further efforts be made to ensure increased advocacy for this resident. See Recommendation 1 Standard 7 Two staff members interviewed said they endeavoured to involve residents in decision making based on their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of the residents and depends heavily on staff interpretation and historical knowledge of residents likes and dislikes. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner. Care plans were up to date and had been prepared in the presence of the resident and relatives or advocate, however, reviews must be held on a six monthly basis. See Requirement 3 Standard 9 Risk assessments are available in all service users’ care files and are readily available for all bank or agency staff who may be less familiar with service users’ needs and were updated in response to any changes or developments. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service users’ records examined that they are enabled to express choice in what they do and staff record these occasions. The home has an unexplained absence procedure and a current photograph of the residents to assist this process. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11-14 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standards 11-14 Evidence was available from the care files of service users that opportunities are being made available for the personal development of residents, although, owing to the level of learning and physical disability and associated Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 13 communication difficulties, none of the service users have been identified as being able to participate in employment or further education via day centres. Staff supported residents to develop daily living skills in line with their individual ability. The Inspector examined a list of activities for service users that is updated weekly and notes are recorded in the daily diary and staff communication book of those activities that are planned for service users. Valued and fulfilling activities are provided both within the home and via outings provided. A range of activities is provided for service users including shopping, using a trampoline at a local gym, bowling, swimming walks and trips out locally to pubs and restaurants and for one resident visits to his mum on a weekly basis. In house activities include games, music sessions, sensory activities, music TV and videos and supervised domestic activities in accordance with their level of ability and expressed choice. One resident has communicated his dislike of day centres and in view of this lack of provision for both residents, it was acknowledged that activities provided for both of them should continue to be carefully recorded and monitored. In a previous inspection a requirement was made that staff should attempt to identify whether any refusals to engage in activities suggested was as a result of challenging behaviour or expressed choice not to participate. This has been introduced but the Inspector recommends that this is further developed in line with recent staff discussion suggesting that these areas are recorded in a larger daily diary that would allow for more detail to be included to assist staff in monitoring this area and possibly further developing the range of experiences provided for the residents. See Recommendation 2 It was noted that two visiting professionals, one from the Speech and Language Therapy department and another from the Sensory Impairment Team have both been involved in the assessment of the residents and in providing staff with advice on how to improve both their communication skills with residents but also in how to expand their involvement in developmental activities. Following a report in June 2006 six specific recommendations were made for both service users, these must now be implemented as soon as possible. See Requirement 4 Standard 15 One resident is well supported to maintain positive relationships with his mother who is a frequent visitor to the home and he also visits her at the family home once a week. One resident has no family involvement but does have an advocate. As stated in Standard 6 it is very important that this advocacy is both retained and if possible increased for this resident. See Recommendation 1 Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 14 supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. The mother of one resident has personally decorated his room and made a fine job of it. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks; a good supply of both fresh and frozen food was seen to be available within the home. Red House Lane, 2 DS0000062617.V308359.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed EVIDENCE: Standard 18 Care plans and daily records showed how personal care was provided. Staff spoke with knowledge and confidence about residents’ individual needs and preferences, for example, around times for getting up, going to bed, whether they preferred to lie in, preferences for a bath or a shower and mood indicators. Staff also said that they are sensitive to the need for maintaining privacy and dignity for residents. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 16 Standard 19 Both residents were registered with a G.P who provided a very positive response to the CSCI questionnaire and it was evident from the records seen by the Inspector that residents were supported to access other health care such as dental, optical, dietician and chiropody speech and language therapy and sensory impairment. Specialist health care was accessed through G.P referral and other support through the local Community Learning Disability Team and a Health Facilitation officer within Bexley Council. Standard 20 Due to the level of disability, service users are not able to self medicate and would not be able to do so without a high degree of risk. Medication is stored in a locked cupboard in the hallway. Medication is the responsibility of the designated person in charge on all shifts and only permanent staff that have received training are authorised to administer medication. Both MAR sheets were examined and checked against stored medication and found to be accurate. The administration, receipt recording, handling and disposal of medicines met the Standard. Red House Lane, 2 DS0000062617.V308359.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standards 22 & 23 The home had policies and procedures showing how complaints and suspicions or any allegations of abuse would be managed. A system was in place to record complaints made about the service. Two complaints were made to the home both from the mother of one of the residents and both were in respect of medication errors. Both errors were substantiated and appropriate measures taken to prevent a reoccurrence. Both errors were reported promptly to the CSCI as required under regulation 37. No complaints have been received directly by the CSCI although the Inspector was made aware of both the above complaints to the home from the mother via a response to the questionnaire sent out by CSCI prior to the inspection. A concern was also logged about the level of activities provided and the Inspector was made aware of a meeting being set up to address this issue with the mother of the resident in the near future. Any allegations or suspicions of abuse would be referred to the Bexley Community Learning Disability Team (CLDT), for investigation under their adult protection procedures. None have been received. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 18 Robust systems were in place to safely manage residents’ personal finances and the Inspector examined the ledger and none of the staff acted as appointee for a resident. The Inspector examined the system for dealing with the personal monies of both service users within the home, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited via the programme of monthly visits undertaken on Regulation 26 visits. Red House Lane, 2 DS0000062617.V308359.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and provided a pleasant and homely environment. Equipment and furnishings provided met the residents’ needs and was maintained and serviced. One resident’s bedroom requires redecoration and attention to sensory equipment. EVIDENCE: Standard 24 The premises were suited to meeting the needs of the current residents. As residents age or develop mobility problems the suitability of the environment must be monitored to ensure it continued to meet their needs. Standards 25 & 26 One resident’s bedroom was laid out in a personalised way and it was evident that he was encouraged to have personal items in his rooms to reflect his interests and hobbies. This room had recently been decorated very well by the Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 20 resident’s mother and contained both personal possessions and appropriate sensory equipment. The other resident’s bedroom now requires similar development in order to maximise his personal space in a way that allows selfexpression and ease of use with reference to the guidance recently produced by the social worker for visual impairment. See Recommendation 3 Standard 27 The bathing and toilet facilities met the needs of the current residents. A dining/ kitchen room containing a washing machine and a lounge was also provided and all facilities are provided on one floor, as the building is a bungalow. The previous requirement made to level the path in the garden to facilitate one residents’ access had been attended to. Standard 28 Shared spaces were complementary to supplement service users’ individual rooms Standard 29 As mentioned in Standard 26 one resident requires the development of his personal space (bedroom) in respect of appropriate sensory equipment. See Recommendation 3 Standard 30 Overall, the home was clean and hygienic on the day of inspection and appropriate infection control and COSH procedures were in place. Red House Lane, 2 DS0000062617.V308359.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had the skills, support and training to meet the resident’s needs. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff, the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in activities. The home does not currently have the required 50 level of care workers trained to NVQ Level 2, the acting manager stated that this was being addressed in that two members of staff are currently undergoing NVQ Level 3 training and another member of staff will be commencing Level 2. Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 22 Standard 34 One new member of staff has joined the home from another home from within the organisation; the acting manager stated that all necessary checks had therefore been done by the previous home. Evidence was available from the three pro forma recruitment records examined that the home met this Standard. Standard 35 Staff members interviewed, presented as clear about their roles and responsibilities and had received adequate training in accordance with this Standard. A good level of training was also being planned for. However, in view of the observations made regarding care plans in comments made in respect of Standard 2 the Inspector recommends that all staff receive training in care plans. All staff members should also receive equal opportunities and disability equality training. See Requirement 1 and Recommendation 4 Red House Lane, 2 DS0000062617.V308359.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager presented as running the home in an open and inclusive manner. The position regarding the Registered Manager for the home must be clarified. Records, policies and procedures showed attention was given to ensuring the safety of residents and others. The quality review survey requires implementation. EVIDENCE: Standards 37 & 38 The acting manager has considerable experience and the necessary qualities to provide a good service, however it was never intended that she would apply to Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 24 become the Registered Manager for the home and a previous requirement that that a Registered Manager should be appointed by 01/06/06 has not been complied with. This situation must now be resolved as soon as possible in order that the Regulations and Standard are complied with. See Requirement 5 Staff members interviewed stated that the acting manager is approachable and supportive and would not hesitate to discuss any concerns about the home or the welfare of service users with her. Communication within the home was of a good standard with team meetings held regularly. The acting manager has undertaken training in order to update her own skills and knowledge. Standard 39 The home does now have a quality review system in place to record the views of residents, relatives, advocates and visiting, or involved professionals. However, this has not been implemented and must be as soon as possible, the results published and generally made available, including CSCI. See Requirement 6 The home receives regular monthly visits under Regulation 26 and produces reports as required and submits these to the CSCI. Standard 42 The policies and procedures in place ensured the safety and protection of residents were addressed. A sample of safety records including fire safety were inspected and showed systems and equipment were maintained and regularly serviced. Red House Lane, 2 DS0000062617.V308359.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 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 3 2 X X 3 X Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(3) Requirement The Registered Person must ensure that a written contract is provided for each service user and includes a copy of the service user care plan. Restated Requirement: previous timescales of 1/11/05 and 01/04/06 not met). The Registered Person must ensure that care plans are based on the criteria listed in Standard 2.3 and reflect how goals will be achieved and outcomes listed at reviews of the care plan. The Registered Person must ensure that care plans are reviewed with service user, relatives and involved professionals at least six monthly. The Registered Person must ensure that all recommendations made by involved professionals in respect of developmental activities are implemented as soon as possible. The Registered Person must ensure that a registered manager is appointed as soon as DS0000062617.V308359.R01.S.doc Timescale for action 01/01/07 2. YA6 5 01/01/07 3 YA7 12 01/01/07 4 YA14 16 01/02/07 5. YA37 8 01/02/07 Red House Lane, 2 Version 5.2 Page 27 6. YA39 24 possible. Restated Requirement: previous time scale of 01/06/06 not met. The Registered Person must ensure a system is in place to review and improve the quality of care provided in the home. Outcomes on the quality assurance reviews obtained from relatives/ advocates and involved professionals must be made available to both them and the Commission. Restated Requirement: previous timescales of 1/12/05 and 01/06/06 not met). 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA14 Good Practice Recommendations Further efforts should be made to ensure that one resident without family support should receive advocacy visits on a regular basis. Renewed efforts should be made to identify activities residents wish to participate in and the recorded in a larger daily diary as suggested by staff. These matters link with advice received from SALT and visual impairment social worker. One resident’ s room requires redecoration and liked to above recommendation, implementation of sensory equipment to maximise his environment and expression of choice. All staff should receive updated training in care planning, equal opportunities and disability equality training. 3 YA26 & YA29 4 YA35 Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Red House Lane, 2 DS0000062617.V308359.R01.S.doc Version 5.2 Page 29 - 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!