Inspection on 15/11/06 for Samuel Close (1, 2 & 3)

This inspection was carried out on 15th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Samuel Close (1, 2 & 3) 20/12/05

Samuel Close (1, 2 & 3) 25/05/05

Samuel Close (1, 2 & 3) 30/12/04

Samuel Close (1, 2 & 3) 26/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Samuel Close (1, 2 & 3) Samuel St Woolwich London SE18 5LR Lead Inspector Lorraine Pumford Unannounced Inspection 15th November 2006 14.00p Samuel Close (1, 2 & 3) DS0000006770.V311401.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 Samuel Close (1, 2 & 3) DS0000006770.V311401.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. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Samuel Close (1, 2 & 3) Address Samuel St Woolwich London SE18 5LR 020 8855 0322 020 8855 6261 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mr Jimmy Lendor Care Home 17 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (1) of places Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for LD(E) in respect of named service user only. Date of last inspection 20th December 2005 Brief Description of the Service: Numbers 1, 2 and 3 Samuel Close are three linked bungalows situated in a residential close in Woolwich. Each house provides board and nursing care for between five and seven adults with learning disabilities. The three houses provide services for different needs. House one is for people with learning disabilities who have challenging behaviour, house two for people with physical disabilities as well as learning disabilities and house 3 for people with learning disabilities who may also have other needs. Each house functions as a distinct group with its own front door, house leader, staff group, and communal facilities. Service users in each house eat together and share a communal lounge. There is an overall registered manager for the three houses, and some service users socialise with or visit other service users in different houses. The home is one of a group of six homes for adults with learning disabilities in the London Borough of Greenwich managed by Milbury Community Services, a National Organisation. The home has strong links with the Greenwich Community Learning Disabilities Team (C.L.D.T), a service for people with learning disability in Greenwich. The CLDT are involved in placements in the home, and the service users life plan reviews. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over two afternoon/evening visits to Samuel Close. During this time some service users and staff were spoken with and a number of documents and records examined, some specifically relating to the care of two service users and four members of staff. Additionally two of the three bungalows were inspected. Prior to this inspection taking place service users and their representatives were given the opportunity to complete questionnaires and their comments have been incorporated into this report. The home has received one other inspection in the past twelve months. This was to ascertain progress in relation to requirements made at a previous inspection regarding the decoration of the buildings and the standard of furnishings. What the service does well: The provider ensures that service users and their representatives are provided with clear information about the terms and conditions of residency and both parties’ rights and responsibilities. Service users are given the opportunity to participating in an annual holiday. Staff ensure that service users live in a relaxed and calm friendly atmosphere and ensure that service users’ privacy and dignity is maintained at all times. Service users are provided with a varied nutritional diet which is served in an appropriate way depending on the individuals needs and abilities. Staff ensure that service users access community health care professionals on a regular basis and their overall health care needs are met. Sound medication procedures were in place to protect service users. All staff working in the home have received appropriate adult protection training. Service users are provided with a clean homely environment. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 6 Staff employed hold appropriate qualifications and receive ongoing training to enable them to meet the needs of the service users accommodated. The registered provider has a system in place to monitor the care standards provide in the home. What has improved since the last inspection? What they could do better: The responsible person must ensure that service users care plans are available for staff to use as a point of reference at all times. Staff must ensure that they keep an accurate record of activities provided for service users. The responsible individual must ensure that there is a clear policy in place in relation to service users personal allowance being used to purchase furniture, curtains and bed linen etc. The responsible person must ensure that prompt action is taken to repair faulty plumbing and that an adequate supply of hot and cold water is available to maintain standards of health and hygiene in the home. A requirement made at the time the previous two inspections for work to be carried out to uneven paving at the rear of the home remains outstanding. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 7 A risk assessment must be undertaken in relation to electrical radiators used as an additional source of heating. A review of staffing levels in the home must be undertaken particularly in relation to meeting the needs of service users requiring assistance during the night. Staff recruitment practices need to be developed further to include evidence that POVA checks have been undertaken in relation to staff employed. The fridge and freezer seals to the appliances in house 3 have perished and are in need of replacement to ensure that food is stored at an appropriate temperature. Records seen indicate that fridge and freezer temperatures are not being recorded on a regular basis. 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. Samuel Close (1, 2 & 3) DS0000006770.V311401.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 Samuel Close (1, 2 & 3) DS0000006770.V311401.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home endeavours to include service users in the admission and assessment process and protects service users by providing them with a contract of residency. EVIDENCE: From information provided by staff and the majority of service users that the inspector met with it is apparent that the people accommodated have profound learning disabilities and have limited ability to make a choice regarding moving into the home. However whenever possible service users are given the opportunity to visit the home prior to admission. Staff stated service users are admitted on a trial basis to enable both parties to ascertain if the placement is appropriate and staff can meet the service user’s needs. Records seen indicate that each resident is provided with a Service User Guide and information regarding their terms and conditions of residency and both parties’ rights and responsibilities and includes information about fees and the room to be occupied. Samuel Close (1, 2 & 3) DS0000006770.V311401.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 The overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ care plans need to be up to date and accessible at all times. Risk assessments are in place which promote independence whilst safeguarding service users. EVIDENCE: A random sample of care plans including the initial assessment of two service users (one from house 2 and one from house 3) were examined. These indicated that the placing agency had provided a written assessment for each service user at the time of admission. The format of the care plan varied between the two houses which may create difficulties for staff responsible for completing documents and those responsible for monitoring the system. It was also difficult to read the text in some care plans. It was not possible for some service users’ care plans to be seen. Staff stated the manager had removed then from the house for the purpose of updating. This included the care plan of a service user who had been admitted to the home on an emergency basis. All care plans must be available for staff to use for referencing, guidance and for inspection purposes. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 11 Entries in one service user’s care plan stated that he had been demonstrating challenging behaviour all day. Discussion took place with staff regarding the need for more detailed recording to enable staff to more effectively monitor and manage the behaviour. There was evidence that staff had completed risk assessments to promote service users’ independence whilst minimising the risks involved in undertaking day to day activities. A requirement made at the time of the previous inspection to review the need of the use of bed safety rails had been addressed. There was an instance of a moving and handling assessment not being updated although the service user’s needs had changed. This was discussed with staff, who stated the matter would be addressed. However in the main there was clear evidence of reviews taking place involving appropriate agencies such as social services, day centres etc. Relative who completed questionnaires stated they were involved in the process and consulted about important matters effecting service users lives. Staff stated that all service users residing in the home needed some support in managing their finances and personal allowance and a representative of the organisation acts as service users’ advocate for this purpose. Service users personal allowances are held in individually named envelopes; the sample examined indicated that service users’ personal allowances tallied with the house records. Additionally service users’ finances are regularly audited by an administrator of Milbury Care Services Limited. Samuel Close (1, 2 & 3) DS0000006770.V311401.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): 12,13,15,16,17 The overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a varied nutritious diet and appropriate meaningful activities. Further action needs to be taken by staff to ensure that records regarding service users activities’ are fully maintained. EVIDENCE: Relatives who competed CSCI questionnaires all stated they are made to feel welcome when visiting service users. From records seen it is apparent that staff assist service users to maintain contact with relatives and friends. From information provided at the time of the inspection and discussion with staff it is apparent that service users are provided with opportunities to participate in social and leisure activates. However, there was little evidence of this information being recorded in service users’ daily records. This needs to be addressed. For example in one instance no information regarding activities had been recorded for a four month period. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 13 Staff spoken with stated they do try to involve service users in local community activities and would like to have more opportunities to take service users out but are restricted by staffing levels. Generally activities have to be planned in advance rather than being spontaneous. Service users are assisted by staff to have an annual holiday. The majority of service users attend day centre for part of the week and spend the other days having one to one time with their keyworker at home. Service users who are able were seen to walk around the houses freely. Service users dependent on staff were assisted to spend time in their bedrooms, lounge or to watch staff preparing the evening meal. The atmosphere in houses one and two felt calm, relaxed and friendly. Good interaction was seen between staff and service users. Although the majority of service users the inspector met with had very limited verbal communication skills, staff talked to service users consistently about activities going on around them and ensured that the inspector was individually introduced to each person living in the houses. Records seen indicate service users are provided with a varied nutritional diet. The inspector was in the home when the evening meal was being served and staff ensured that the food was presented in attractive and appropriate way depending on individual service users’ needs and ability. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff uphold service users’ privacy and dignity at all times and ensure that their health care needs are met. Medication practises safeguard service users’ health and wellbeing. EVIDENCE: The home operates a key worker system; staff spoken with were able to provide the inspector with a clear picture of the additional responsibilities this entails and the way in which they provide support to service users they are responsible for. Good interaction was seen between staff and service users. Staff addressed service users by their preferred name, and spoke with them in a respectful manner. Service users care plans indicated that they visit the GP when necessary and receive regular routine health checkups. Service users access community health care professionals such as dentists, chiropodists and opticians as and when required. In addition service users have access to more specialised health care professionals when needed. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 15 All service users seen were wearing clean, age appropriate clothing. It was evident that care staff provide support to service users to enable them to attain an individual and personal identity. An audit of medication was undertaken for two service users. The inspector found that medication was being safely stored and administered. A record of staff signatures was being maintained, this enables those inspecting the records to undertake an effective audit. Records seen indicate that medication no longer required is being returned to the pharmacist for safe disposal. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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. Staff are provided with comprehensive adult protection training to help ensure service users are protected from harm. EVIDENCE: Relatives who completed questionnaires stated they were pleased with the service provided and had never had need to complain regarding any aspect of the care or service. To date the CSCI has received no complaints with regard to the service. A copy of the organisation’s Whistleblowing policy is displayed in the office and the home also has a copy of the local authority joint working policy in relation to adult protection procedures in the Borough. Verbal feed back from staff indicates they have received training with regards to adult protection and whistleblowing. Further, staff attend training sessions organised by the local authority on a regular basis. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a clean homelike environment. Action is required to ensure that the service users are provided with a sound water and heating system to maintain standards of hygiene and comfort. EVIDENCE: Service users accommodation is decorated in bright and cheerful colours; both bungalows seen were clean and free from unpleasant odours. Since the last inspection the refurbishment of the kitchen in house 2 has been completed and both houses have benefited from further redecoration. A requirement made at the time the previous two inspections for work to be carried out to uneven paving at the rear of the home remains outstanding. Although service users’ bedrooms are individually personalised, a number of bedrooms seen are smaller than the current minimum room size requirement. It is apparent that it is not possible to equip all bedrooms to comply with the National Minimum Standard and staff stated it can be difficult when trying to provide personal care to some service users. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 18 From discussion with staff it is apparent that service users’ personal allowance has been used to purchase items of furniture, curtains and bed linen for bedrooms; information regarding this practise should be clearly spelt out in the organisation’s Statement of Purpose for the home. The Care Home Regulations 2002 clearly state that is the responsibility of the provider to ensure that establishments are provided with appropriate furniture and furnishings. Action must be taken to address this issue particularly in view of the fact that the majority of service users accommodated are unable to make these choices for themselves. At the time of the inspection house 3 was experiencing problems regarding the water supply; this has been an ongoing problem for a number of weeks. The home was without a hot water supply and staff were heating water in kettles and transferring it around the building. The Inspector requested that a risk assessment be completed in relation to this practice and the matter was discussed with the organisations Operations Manager who stated she would liaise with the relevant department to ensure the necessary work was completed. In spite of ongoing work the matter remains unresolved at the time of writing this report. Whilst it is acknowledged that maintenance issues arise, it is of concern the amount of time being taken to resolve this issue. A number of free standing electrical radiators were seen and staff stated that it was difficult to maintain a comfortable room temperature at night and during colder periods of weather. In the first instance a risk assessment must be undertaken in relation to these electrical radiators and further a review of the system should be undertaken to establish whether or not the heating system needs to be improved to address the problem in the long term. House 3 was also without a washing machine for a number of weeks, this issue was also discussed with the operations manager as staff were transporting foul linen to another bungalow which is not only impractical but increases the risk of the spread of infection. The tumble dryer was out of commission in House 2 and action has been taken to address both of these issues since the inspection took place. . Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are cared for by appropriately qualified and competent staff. Recruitment procedures are in place which safeguard service users but must be developed further to include POVA checks. Staff are provided with appropriate training opportunities. EVIDENCE: Relatives who completed comment cards were divided in their opinion regarding staffing levels in the home, with half perceiving there were enough staff and half stating the home needed more. Relatives expressed the opinion that they found staff to be caring and helpful. From records seen and discussion with staff it is apparent that some service users residing in house 2 require the assistance of two members of staff to help with personal care. Discussion took place with staff regarding the arrangements for providing assistance during the night when only one member of staff is awake in the house. Staff stated that colleagues working in one of the other bungalows would be found to provide assistance. The Inspector voiced concern that the current practice could result in service users being left in an uncomfortable position until an additional member of staff arrives to Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 20 provide support. In the inspectors opinion the current situation may also lead to a sole member of staff endeavouring to provide assistance to the service user rather than waiting for a colleagues support. It is recommended that the manager commence a review of service users’ night activity to ascertain if it is necessary for additional staff to be employed at night in order to maintain service users’ wellbeing and safety. The majority of staff working in the home hold either a relevant nursing qualification or an NVQ 2 in care. A sample of staff files were examined in relation to recruitment. Sound recruitment procedures were found to be in place with evidence that staff had been required to complete application forms, had attended formal interviews and provided proof of identity. CRB checks had been undertaken for all members of staff employed. However the organisation needs to provide written evidence that POVA checks have also been undertaken as part of the recruitment procedure. Records in relation to the interview process were available for inspection. Whilst the format itself was good and included written scenarios to enable prospective staff to demonstrate their key skills and knowledge, the form had not been used to its best advantage. For example, a member of staff has been employed who had no previous experience of working with the service user group; however staff interviewing the candidate had not used any of the scenarios available to provide evidence that the member of staff had been able to demonstrate relevant competencies. Records seen indicate that staff have a been provided with a job descriptions and a contract indicating their terms and conditions of employment. Staff members’ induction training records were seen. These had been signed and dated indicating the induction had been completed for each member of staff on one training day. In the inspectors opinion it would be difficult for staff to comprehend every policy, procedure and all other key information in such a short period of time. The manager is advised to prioritise tasks to be covered as part of the induction process with supervisor and employee signing and dating the document when both parties are confident that the new member of staff has understood the relevant policy or procedure, or where appropriate has been assessed as competent to undertake the task. Records seen indicate that staff are provided with appropriate and varied training opportunities to help them meet the needs of the service users accommodated. Staff are provided with statutory training such as food hygiene, health and safety, moving and handling and first aid. In addition staff have received training to enable them to meet the specific care needs of service users accommodated. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 21 From records seen and discussion with staff it is apparent that staff receive supervision on a regular basis from a senior member of staff working in the home. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 22 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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a system in place for reviewing and improving the quality of care provided. Health and safety practises and staff training protect service users and staff working in the home. EVIDENCE: The manager holds a relevant qualification in care and management and has considerable experience of working with adults with a learning disability. Staff spoken with stated they felt confident they could go to the manager or senior staff in the home if they had any concerns. Staff confirmed they have regular team meetings and the management team were receptive to their views. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 23 The operations manager visits the home regularly and undertakes a monthly audit on behalf of the registered provider in accordance with regulation 26 of the Care Standards Act 2000. A copy of this report is forwarded to the CSCI. Information provided at the time of the inspection indicates that there are regular safety and maintenance checks undertaken in relation to hoists used in the home, as well as gas and electrical appliances. Records seen indicate that there are regular checks to the fire detection system within the home and staff are provided with regular fire safety training. Staff are provided with appropriate health and safety training. The fridge and freezer seals to the appliances in house 3 have perished and are in need of replacement to ensure that food is stored at an appropriate temperature. Records seen indicate that fridge and freezer temperatures are not being recorded on a regular basis which needs to be addressed. Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 24 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 25 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 YA12 Regulation 13(m) Requirement The responsible person must be able to provide written evidence that appropriate social activities are arranged for service users. The Registered Person must ensure that the paved area to the rear of the houses is levelled to ensure the safety of service users. Restated Requirement. (Timescale of 1.06.05 not met) Timescale for action 01/02/07 2. YA24 23 01/05/07 3 YA24 4 4 YA30 23(j) 5 YA33 18 The responsible person must 01/04/07 detail in the home’s Statement of Purpose circumstances under which service users are expected to purchase standard furnishings for their bedrooms. The responsible person must 31/01/07 ensure that they are adequate supplies of hot water to meet the needs of service users and prevent the spread of infection within the home. The responsible person must 30/04/07 undertake a review of staffing in the home particularly in relation to meeting the needs of service users at night. DS0000006770.V311401.R01.S.doc Version 5.2 Page 26 Samuel Close (1, 2 & 3) 6 YA34 Care Homes Regulations 2003 7 YA42 13(4) The responsible individual must be able to provide written evidence that staff working in the home have had a satisfactory POVA check completed as part of the recruitment process. A risk assessment must be undertaken in relation to electrical radiators used as an additional source of heating. 30/03/07 30/03/07 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 YA42 Good Practice Recommendations Service users’ care plans must be available for staff to reference at all times. Action should be taken to ensure that food is stored safely and appropriately; in this instance the perished fridge and freezer seals to the equipment in house three should be replaced. It is advisable that the staff induction programme is prioritised and takes place over a period of time to enable the new member of staff to understand fully information provided. A review should be undertaken to establish whether or not the heating system needs to be improved. 3 YA35 4 YA24 Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 27 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 Samuel Close (1, 2 & 3) DS0000006770.V311401.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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