Inspection on 15/01/08 for Salisbury Road

This inspection was carried out on 15th January 2008.

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

Other inspections for this house

Salisbury Road 15/01/09

Salisbury Road 10/10/06

Salisbury Road 25/02/06

Salisbury Road 07/02/05

Salisbury Road 25/11/04

Salisbury Road 22/03/04

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 Salisbury Road 22-23 Salisbury Road Leyton London E10 5RG Lead Inspector Maria Kinson Unannounced Inspection 15th January 2008 10:20 Salisbury Road DS0000007264.V357296.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 Salisbury Road DS0000007264.V357296.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. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salisbury Road Address 22-23 Salisbury Road Leyton London E10 5RG 020 8556 8147 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) r.tucker@mcch.org.uk www.mcch.co.uk MCCH Society Ltd Mr Richard Tucker Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2006 Brief Description of the Service: 23 Salisbury Road is registered to provide personal care and support for up to seven residents of either sex. The home is operated by MCCH. The home is located in a residential area of Leyton, North East London. It is close to shops, community facilities and is well served by public transport. All of the people that live in the home have complex needs and require a high level of support and supervision. Residents are encouraged to maintain family relationships and some have regular visits home, including for overnight/ weekend stays. The home charges £1441.00 per week per person. This does not include personal items, such as clothing, toiletries and activities. The commission received this information on 01/02/08. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 15th January 2008, and was unannounced. The inspector toured the home and met most of the people that use the service. Three people that use the service, three relatives and one member of staff provided written feedback about the service. During the course of the inspection the inspector spoke with two members of staff. Some of the records that were kept in the home were sampled and medication records and supplies were assessed. There were seven people living in the home at the time of this inspection. What the service does well: The home provides clear information about the facilities and support it can offer. The service user guide includes pictures to help people that have difficulty understanding written information. New people could visit the home to meet staff and service users. This helped people to decide if they wanted to move into the home. People were supported to attend health care appointments and to take their medicines. People were supported to go out, to carry out activities that they enjoyed and to stay in touch with their relatives. The food provided in the home was varied and some people were able to help plan the menu. The home was clean and tidy. People could organise and arrange their personal things how they liked. There was a varied programme of training and staff were supported to achieve care qualifications. The staffing team was stable. This meant that people were usually supported by staff that were familiar with their needs. The manager listened to people’s views and made sure that broken items were repaired and the home was safe. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some records were out of date and were not reviewed regularly. The management of medicines was good overall but the records did not show how many medicines were left over when the new supply was received. It was not possible to assess if complaints were properly investigated because records of complaints were not kept in the home. The mains electricity installation was “unsatisfactory” and some urgent work was required to improve the system. Radiators were not covered and the lock on the female bathroom door was broken. The manager asked the maintenance department to address these issues. Fire safety arrangements were good overall but staff did not receive regular fire safety training updates. The fire alarm was not always tested as frequently as it should be. The company were not sending staff to check that the home was run and managed properly. Staff did not always notify the commission about significant events that occurred in the home. Salisbury Road DS0000007264.V357296.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. Salisbury Road DS0000007264.V357296.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 Salisbury Road DS0000007264.V357296.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): 1, 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ‘Statement of Purpose’ and ‘Service User Guide’ provide useful information for people, about the home. This helps people to decide if the home can meet their needs and expectations. The admission procedure indicated that staff would assess people’s needs before confirming that they could move into the home. EVIDENCE: The registration and public liability insurance certificates were displayed. A copy of the revised Statement of Purpose and Service User Guide was supplied to the commission. The Statement of Purpose provides clear information about the home and about the company that manages the service. The Service User Guide was illustrated with relevant pictures to aid understanding. It was not possible to fully assess the arrangements and procedure followed by staff when admitting new people into the home, as all of the current service users had lived in the home for many years. Policies and procedures relating to the admission process were examined during the previous inspection. The Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 10 Statement of Purpose provides some information about the arrangements for admitting new people into the home. The Statement of Purpose indicated that people’s needs would be assessed and information would be obtained from other people such as relatives and the GP or Psychiatrist. People confirmed that they were asked if they wanted to move into the home and received information about the service. People that expressed an interest in the service were able to visit and spend time in the home. This gives the person an opportunity to ask questions and to meet staff and the other service users. Visits were arranged to meet people’s individual needs. The manager said this often included overnight stays. Salisbury Road DS0000007264.V357296.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, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records included information about people’s personal goals and hopes for the future. Some information was not reviewed and was out of date. People were encouraged to make day- to- day decisions for themselves and were supported by relatives and advocates to consider more complex issues. EVIDENCE: Two people were selected for case tracking. The first file included a pen portrait, which provided information about the person’s history and preferences, an assessment of the persons care needs and a support plan that outlined the person’s health and personal care needs. There was other guidance for staff about specific issues such as the management of challenging behaviour and epilepsy. The information recorded was detailed and related specifically to the person’s individual needs. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 12 Although support plans were detailed and individualised some of the records were not dated and a small amount of information was out of date. This included the next of kin and information about the management of epilepsy for one person. The second set of records included a pen portrait, an assessment of the persons care needs and a partially completed person centred plan. The plan was prepared during a meeting that involved the service user and other people that they wanted to attend, such as relatives and their key worker. The plan outlined the things that the person liked and wanted to do and the people that were important to their health and wellbeing. The plan indicated that the service user liked collecting and handling coins, going on bus journeys and attending clubs. The service user showed the inspector some of their coins and frequent references were made to this activity in the daily care records. Progress with the other activities that were included in the person centred plan was unclear. The person’s key worker stated that the service user often declined activities or outings. This was not reflected in the records that were viewed. Relatives said that the home was usually able to meet their family members needs and was particularly good at managing challenging behaviour, arranging advocacy services and “the provision of care”. There was evidence that people were able to contribute to care and life planning review meetings and were able to make decision for themselves where possible. Other people such as relatives and advocates that represented service users interests were consulted. Although most of the people that lived in the home had difficulty communicating they were able to make their needs known through other means such as signing or gesturing. Staff were familiar with each persons preferred method of communication. Most of the people that lived in the home had complex needs and in some cases found it difficult to follow instructions or concentrate for any length of time. Although this made it difficult for people to participate in the running of the home the records showed that staff tried to encourage and support people to undertake small tasks around the home. This included assisting staff with housework, changing their bedding, taking dirty clothing to the laundry and emptying the dishwasher. Risks were identified and the action that staff should take to maintain peoples safety was recorded. Risk assessments were seen for activities such as swimming, bus travel, shopping, holidays and cooking. Risk assessments were clear and easy to follow. The inspector was told that some assessments were new but this was difficult to evidence, as some of the assessments were not dated. Some of the other assessments were completed in 2004. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 13 Although the records did not fully meet the required standard it was evident that some progress had been made since the last inspection. Activity programmes were reviewed and updated and person centred planning was gradually being completed for all of the people that lived in the home. Further work was required to ensure that all records were up to date and reviewed regularly. See requirement 1 and 2. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to undertake activities that they enjoyed in the home and community. The menu was varied and people said they liked the food that was prepared in the home. EVIDENCE: Information about people’s personal interests and hobbies was recorded and an individual activity plan was prepared for each person. The plans had been reviewed and updated since the last inspection and now provided accurate information about how people spent their time. Some people attended local day care services for part of the week or had a structured programme of community activities. Two people required ‘one to one’ support and were assisted by a dedicated day care worker to undertake activities in the home and community. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 15 People said they could make decisions about what they did each day. Staff were familiar with people’s interests and supported people to undertake specific activities that they enjoyed such as dancing and trampolining. Activities were recorded in the daily care records. Recent entries indicated that people were supported to go bowling, for a walk in the forest, to play dominoes, attend aromatherapy sessions and visit local shopping centres and cafes. Some people received regular visitors and spent time with their family during weekends and holidays. There were good supplies of fresh and frozen food in the home and people were offered regular drinks. Access to the refrigerator and freezer was restricted because some people were at risk of eating foods that were not properly prepared or placing partially eaten foods back into the refrigerator. The menu was prepared on a weekly basis. The deputy manager was responsible for preparing the menu but service users were asked to contribute ideas. Pictures of different meals were used to help people to do this. The menu was varied and alternative dishes were listed for people that did not like the main choice. Lunch was served in the kitchen. One person said they enjoyed their lunch and liked the food provided in the home. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support was provided to meet people’s personal care needs and to identify and address health issues. The management of medication was satisfactory overall but some additional records were required to ensure that staff could account for all medicines. EVIDENCE: Records included information about health and personal care issues and provided information about the persons preferred routines, such as getting up early. Most of the people that live in the home require some form of support with personal care. This was provided in a flexible manner and people were encouraged to be independent. People were allocated a key worker who was responsible for overseeing their care. Records were maintained about medical appointments and health checks. In recent months one person had received dental treatment and staff were monitoring one persons weight. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 17 Two medication records were examined. Information about allergies was recorded and there was a photograph to help identify people. Records of receipt and administration of medicines were good. There were no gaps in the records and information was clearly recorded. The dates on the medication chart did not correspond with the dates on the blister packs. This could lead to errors. The manager agreed to address the issue with the pharmacist. Two discrepancies were noted when the amount of medication given was deducted from the amount received. This meant there were more medicines in the home than the records suggested. On discussion with the manager and staff it became apparent that this was because staff were not carrying forward medication that was left over from the previous month’s supply onto the new medication chart. See requirement 3. Good records were maintained about medicines that were no longer required and were sent to the pharmacist for disposal. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were procedures in place to protect people using the service and to ensure that their concerns were listened to and addressed. It was not possible to establish if the complaints procedure was followed. EVIDENCE: The complaints procedure was examined. The procedure was available in different formats and was easy to follow. There was clear information about the process and the timescales for responding to complaints and up to date information about who people could contact. 66 of relatives were aware of the homes complaints procedure and said staff responded appropriately when they raised concerns. One person said, “they are usually prompt in addressing issues”. The people living in the home said they knew how to make a complaint and who to speak to if they were unhappy. The home had received three complaints in the past year. It was not possible to assess complaints records during the inspection, as they were kept at the company’s head office. The manager advised the inspector that he would request copies and forward this information to the commission. The commission did not receive this information. See requirement 4. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 19 The money records for two people were examined. The records included information about money received in the home, returned to service users or paid out for items that were purchased by the service user. Receipts were kept where possible and an explanation of what the money was spent on, was recorded. Recent expenditure included chiropody, aromatherapy and personal toiletries. The inspector was told that personal money was currently kept in a joint non- interest bearing account. Work was in progress to open an individual, named account for each person. The people that live in the home also contribute to the running costs of the car that the home owns. Charges relating to this were distributed fairly and were clearly recorded. The safeguarding procedure was reviewed and updated in March 2007. The procedure includes notifying social services and CSCI about allegations of abuse and obtaining medical support for people if necessary. Staff said they would report concerns or allegations to senior staff and were confident that the management team would refer concerns to social services for investigation. Three members of staff had recently attended a safeguarding training session during their induction. The whistle blowing procedure was discussed with two members of staff. Both were aware of the procedure and said they would report concerns, if they had “enough evidence” to the manager or staff from head office. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 20 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, 25, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean and comfortable environment for the people using the service. EVIDENCE: The home consists of two terraced houses that were joined to make one home. All areas parts of the home were viewed with the assistance of staff and service users. All areas were clean, tidy and free from unpleasant odours. People said the home was always fresh and clean. Hand-washing facilities were good and waste was stored appropriately. The landlord was responsible for maintenance issues. The building and grounds were maintained to a satisfactory standard. The lock in the female Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 21 bathroom was not working properly and some of the tiles were damaged. The manager reported these issues to the maintenance department for repair. All of the people that live in the home have their own bedroom. Two people showed the inspector their bedrooms. Bedrooms were personalised with photographs, pictures, and items that reflected their personal interests and hobbies. A number of people had their own televisions and music systems. The lounge and dining room were comfortable and warm. In the period since the last inspection staff had changed the office into an activity room and the activity room into an office. The commission were notified in writing, about this change. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 22 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, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable team of staff. This provides good continuity of care for the people using the service. Staff had access to relevant training and felt supported. Staff recruitment procedures had improved. This will help to ensure that people receive safe and suitable care. EVIDENCE: 50 of staff had a vocational or equivalent qualification in care. Some of the other members of staff were also registered to complete this course. The arrangements for staffing the home had not changed. There were three support staff on duty on each daytime shift and two support staff overnight. Some people also had a dedicated day care worker. Where this was provided the staff member was supernumerary. People that use the service said staff were “nice” and treated them well. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 23 The home had developed a picture board with staff photos to so that service users would know which staff members were on duty. When people asked staff who was coming on duty they were referred to the board. Four staff had left since the last inspection and some new staff were appointed. A number of staff had worked in the home for several years and were very familiar with people’s needs. Two relatives commented that the staff group was not representative of the service user group in terms of cultural background. One person said “the culture of the three white English residents was not represented” and another person said staff required training on “issues of culture”. The commission accepts that attracting staff from different cultures can be difficult. The company should review where and how it advertises to see if this encourages applications from a more diverse group of people. See recommendation 1. The commission had agreed that staff records could be held centrally if a form that listed the documents and checks that the company had undertaken was kept in the home for inspection. The records for two new staff members were examined. Records showed that all of the necessary pre- employment checks were completed and important documents such as proof of identity, a recent photograph of the employee, a criminal record bureau disclosure (CRB) and written references were obtained. A provider relationship manager from CSCI completed a more in depth check on staff recruitment records at the company’s head office in January 2007. All of the files examined during this visit contained adequate information and documents. Staff had access to a comprehensive programme of training. During the past year some members of staff had attended induction, person centred planning (PCP), medication, moving and handling and COSHH training sessions. Staff confirmed that their induction covered everything that they needed to know and said they received regular training updates. A copy of the supervision matrix was seen. This showed that staff received supervision at least six times a year and in some in sometimes more frequently. Staff confirmed that they had regular opportunities to discuss their work and any concerns with senior staff. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 24 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, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service was well managed overall but some work was required to ensure that staff receive regular fire safety training updates. The commission were not always notified about significant events that occurred in the home. This is required to protect the people that use the service. The manager had introduced satisfaction surveys and carers meetings to obtain feedback about the service but unannounced visits to assess the conduct of the service were not taking place regularly. EVIDENCE: The manager has worked in the home for four years and is registered with the commission. The manager has the Registered Managers Award and is a NVQ assessor. The manager advised the inspector that he would be transferring to Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 25 another service. The manager was asked to notify the commission in writing about the proposed changes. Staff said that the manager was “flexible and understanding” and approachable. One staff member said, “we can say what we think here, we are listened to”. There were opportunities during handover and meetings for staff to contribute ideas and to make suggestions about the management of the service. The home had developed some systems to monitor and assess the quality of care provided in the home and to obtain feedback from the people using the service. Staff completed a weekly ‘walking route’ audit to identify maintenance and health and safety issues and head office were notified about significant events. The manager had reintroduced relatives meetings to obtain feedback about the service and to advise people about new developments. The minutes from some of the recent meetings were viewed. Satisfaction surveys were used to obtain peoples views about the service. The company is required to undertake monthly, unannounced visits to the home to assess the service. Reports for the visits that should have occurred in September, October, November and December 2007 could not be located. See requirement 5. A fire risk assessment was completed and kept in the home. Fire safety equipment was serviced at regular intervals and some ‘in house checks’, tests and drills were taking place. The fire alarm was tested regularly but this did not always occur weekly as indicated in the homes policy. See recommendation 2. Some staff had not received fire awareness training since 2004. See requirement 6. The management of health and safety issues was mostly good. Records showed that equipment such as portable electrical appliances, the mains electrical installation and gas appliances were serviced regularly and the water system was assessed. The report for the mains electricity installation stated the system was “unsatisfactory”. The manager agreed to follow this issue up with the maintenance department. Radiators were uncovered and felt hot. The risk assessment indicated that there was a ‘low’ risk of any of the current service users being harmed but stated that covers should be fitted. The manager had referred this issue to the maintenance department. See recommendation 3. It was noted during case tracking that one person sustained an injury following an exchange with another service user. This issue was not reported to CSCI. See requirement 7. The refrigerator temperature was monitored. The records indicated the refrigerator was too warm, but items that were removed from the refrigerator Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 26 felt cold. The manager advised the inspector that the thermometer was broken and has now been replaced. This issue will be reassessed at the next inspection. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X 2 2 X Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 28 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. Standard YA6 Regulation 17 Requirement The Registered Person must ensure that all records are reviewed regularly and are up to date. The responsible person must ensure that old records no longer in use must be removed from care files to avoid confusion in delivery of care. Repeated requirement. The previous timescale of 31/01/07 was not met. The Registered Person must ensure that medicines that are leftover from the previous months supply are carried forward onto the new medication chart. This will provide a clear audit trail. The Registered Person must ensure that records of complaints are kept in the home. The Registered Person must ensure that ‘regulation 26’ visits are carried out once a month and that the registered manager receives a copy of the report that is prepared in respect of the visit. The Registered Person must DS0000007264.V357296.R01.S.doc Timescale for action 29/05/08 2. YA6 15 26/06/08 3. YA20 13 01/05/08 4. 5. YA22 YA39 17 Schedule 4 26 01/05/08 29/05/08 6. YA42 23 26/06/08 Page 29 Salisbury Road Version 5.2 7. YA41 37 ensure that staff receive regular fire safety training updates. The interval between sessions should be determined by the organisation that accredits the training. The Registered Person must advise the commission in writing of all of the events listed under regulation 37 of the Care Homes Regulations 2001. 01/05/08 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 YA33 YA42 YA42 Good Practice Recommendations The registered person should endeavour to have a balanced staff team that reflects the composition of service users in terms of race and culture. The Registered Person should ensure that the fire alarm is tested once a week. The Registered Person should advise the commission about the outcome of their discussions with the landlord about the mains electricity installation report and fitting radiator covers. Salisbury Road DS0000007264.V357296.R01.S.doc Version 5.2 Page 30 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. 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