Inspection on 12/10/07 for Shalom Home

This inspection was carried out on 12th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shalom Home 09/04/09

Shalom Home 11/11/08

Shalom Home 16/05/08

Shalom Home 05/04/06

Shalom Home 22/11/05

Shalom Home 27/07/05

Shalom Home 04/01/05

Shalom Home 02/08/04

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

CARE HOME ADULTS 18-65 Shalom Home Shalom Home 143 Caistor Park Road Stratford London E15 3PR Lead Inspector Lea Alexander Key Unannounced Inspection 12th October 2007 10:00 DS0000022875.V345121.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 DS0000022875.V345121.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. DS0000022875.V345121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Home Address Shalom Home 143 Caistor Park Road Stratford London E15 3PR 020 8471 9533 020 8471 9533 b.fadojutimi@btinternet.com 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) Mr Bodi Fadojutimi Mr Bodi Fadojutimi Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places DS0000022875.V345121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th April 2006 Brief Description of the Service: Shalom Home is a small care provider for 3 adults with a history of mental illness. It was registered in July 1999 and the registered provider is also the registered manager. The premises are located in a terraced house on a residential street in Stratford. The accommodation comprises of a communal lounge and attached kitchen diner, bathroom with wc and garden. There is a staff office/sleep in room and two service user bedrooms located on the first floor, and a third service users bedroom located on the ground floor. There is a garden to the rear of the property and a large park nearby. The home has easy access to transport links and community facilities. DS0000022875.V345121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of a day. The Inspector had previously inspected this service on a number of occasions. The last key inspection took place on the 5th April 2006, and a random unannounced inspection was carried out on the 13th February 2007. The findings of this random inspection are included in this report. During the course of the inspection the Inspector met with the Registered Manager and spoke with privately with two people who use the service. The Inspector also interviewed the member of staff on duty. The Inspector also sampled a range of records relating to the running of the home. What the service does well: What has improved since the last inspection? The service has consolidated the progress made in three area’ s of the inspection report, and has been assessed as providing a “good” service in these. DS0000022875.V345121.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has developed a procedure for staff to follow in the event of a service user going missing. All current medication is listed on the MAR. Discontinued medications must be recorded as such and appropriately disposed of. The homes adult protection and recruitment policy and procedure has been revised and update. 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. The summary of this inspection report can be made available in other formats on request. DS0000022875.V345121.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 DS0000022875.V345121.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are not made until a full needs assessment has been undertaken. EVIDENCE: The homes service users have been in residence for some years, and there have been no recent new admissions. The Inspector sampled the personal files for two people who use the service. This evidenced that one service user was assessed by the home prior to their moving in. A similar assessment was not available for the second service user file at the time of the inspection, but a copy of this was subsequently sent to the Inspector. DS0000022875.V345121.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service involves residents in the planning of their care, and these documents are regularly reviewed. The right of residents to make their own decisions is also recognised. However, plans are not person centred and do not address all area’s have identified need or assess identified risks. EVIDENCE: The Inspector sampled the personal file of two people who currently use the service. This evidenced that the home has developed individual plans with each that address their personal, social and healthcare needs. However, the Inspector noted that the individual plans for one service user did not include information on the roles of the diabetic or continence nurse in addressing their identified needs. DS0000022875.V345121.R01.S.doc Version 5.2 Page 10 For the second person who uses the service a plan headed “Physical Health” was noted to only address diabetes, and a plan regarding substance misuse had not been updated to reflect the input of the multi disciplinary community team in addressing this need. Sampling of records, discussion with the Registered Manager and with one person who uses the service evidenced deterioration in their mobility. Whilst the home had obtained a specialist chair to assist this resident with transferring, they had not had a comprehensive Occupational Therapy assessment to review their needs for other aids and adaptations. Sampling of the available plans evidenced that people who use the service are involved in their development and that they are reviewed every six months. The Inspector noted that the available plans did not include life story work with people who use the service, or identify significant people, events or occurrences in their lives. Sampling of the plans for two people who use the service also evidenced that residents rights to make choices about their daily lives are reflected in their plans. For one service user they are supported to access the community and their family independently on a daily basis. For a second service user a plan has been developed to support them to make decisions that take account of their poor memory. The Registered Manager advised that one service user is completely independent in managing their finances. Two other service users receive some support. Whilst they each have their own bank account they hold a small amount of cash in the homes office and withdraw this as needs be. The home retains a written record of the cash held and any withdrawals. The service user and staff member on duty sign this record. Discussion with the Registered Manager and one person who uses the service identified their concerns about managing their finances and bills they had become liable for since selling their home. The Registered Manager advised that the home had supported the resident by identifying sources of emotional support within their family and requesting information from Social Services. The Inspector sampled the available risk assessments for two people who use the service. This evidenced that the home has assessed a number of identified risks for both, however one service user has impaired mobility, and the attendant risks, including falls had not been assessed. The unannounced inspection in February 2007 sampled the homes policies and procedures and this evidenced that the home had developed a policy for staff to follow in the event of a service user going missing. DS0000022875.V345121.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More able service users are involved in daytime activities of their choice. People who use the service are involved in shopping, but their views are not taken into consideration during menu planning. Residents are supported and encouraged to maintain links with their families. EVIDENCE: The home provides a service to three male service users from diverse cultural backgrounds. The Registered Manager advised the Inspector that home aims to meet cultural and diversity issues by assessing individual needs and providing them with similar opportunities. The Inspector noted that the service user with limited mobility and greater dependence upon staff did not appear to be experiencing the same equality of opportunity to access community facilities. DS0000022875.V345121.R01.S.doc Version 5.2 Page 12 Two of the homes service users are older people, one of whom has poor mobility. A third, younger service user has been engaged in discussion regarding occupational and educational activities, but has declined to follow these up. Two service users are able to spend time in the community independently. One of these spends much of his time away from the home visiting family members. The Registered Manager advised the Inspector that on the guidance of the multi disciplinary care team this service user was only allowed to participate in a weekday lunch and shopping trip for the home if they took a set number of baths in the week. The Registered Manager fedback that this approach had had little positive improvement upon their personal care but had limited their involvement in residents activities. The Inspector suggested that a system of rewards, chosen by the service user might be a less punitive and more positive system to encourage behavioural change. A second service user has limited community links, but during discussion with the Inspector advised that they preferred to spend their time within the home and were happy with their current level of activity. A third service user told the Inspector that they would like more opportunities to engage in community based activities, including the opportunity to play snooker and have more meals out. As a result of poor mobility and a lack of confidence this service user requires support to engage in community activities and may benefit from referral to a befriending service or day centre. The Registered Manager advised that two service users have their lunch out twice a week and participate in shopping for the home. The Inspector was advised that one service user also has fortnightly trips to the cinema, however the resident in question could not recall the last occasion this occurred and the home was not able to produce any records of this occurrence. Discussion with people who use the service and sampling of individual plans evidenced that the home considers the spiritual needs of people who use the service and the support they may need to access these. A previous inspection in April 2006 had identified that the television in the lounge was switched on to a religious channel by staff and played at a loud volume throughout the day. People who use the service had fedback to the Inspector that they found this intrusive. Discussion with people who use the service on this occasion evidenced that two service users continue to find this an issue, particularly as one-service users bedroom is adjacent to the lounge. On the morning of the inspection the Inspector also noted that the unattended lounge TV was left on at a very high volume on a religious TV channel by staff. During the afternoon one service user chose to watch an Asian TV channel. DS0000022875.V345121.R01.S.doc Version 5.2 Page 13 Discussion with people who use the service and sampling of records evidenced that all of the service users within the home are supported to maintain contact with their families. People who use the service can choose whom they see and when, and can see visitors in their rooms and in private. During the course of the inspection the Inspector noted that people who use the service have their own keys to their rooms. During the course of the inspection staff were observed talking to and interacting with people who use the service. Discussion with residents and sampling of records evidenced that they can choose when to join in an activity, and when to be alone. The Inspector sampled the log of meals provided and asked people who use the service for their comments on the food. The Inspector also sampled the minutes of residents meetings, where meals had been discussed over several months. These sources evidenced that people who use the service are generally satisfied, but are of the view that too much chicken is provided. Two people who use the service have repeatedly asked for more variety in the meat dishes offered, but this had not been implemented at the time of this inspection. DS0000022875.V345121.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to healthcare services and healthcare needs are addressed within individual plans. Staffs encourage residents to be independent in their personal care. However, the home needs to address shortfalls in its medication administration practise and further revise its medication policy. EVIDENCE: Discussion with people who use the service, care workers and the Registered Manager evidenced that people who use the service are independent in their personal care, and only require prompting or reminders. Times for getting up and daily routines are flexible, and residents choose their own clothes and hairstyle and their appearance reflects their personality. For both the service users case tracked, information regarding their healthcare needs was included in their individual plan. For one of these people there was a record of medical and healthcare appointments attended, although the DS0000022875.V345121.R01.S.doc Version 5.2 Page 15 outcome or follow up related to these was not recorded. For a second person that uses the service there were comprehensive records of ongoing nursing appointments but no information available in the personal file for other medical or healthcare appointments recently attended. Inspections in April 2006 and February 2007 had required the home to develop its medication administration and recording practises. Sampling of the medication records and the actual medication available evidenced that all current medications are recorded on the Medication Administration Record (MAR) and that no residents were taking “as required (PRN)” medication at the time of this inspection. However, one resident’s medication was recorded at the wrong dosage on the MAR sheet. Discussion with the Registered Manager evidenced that the dossett boxes from which medicines are dispensed are loaded by a Pharmacist, and the Inspector was therefore reassured that the medication had in fact been administered at the correct dosage. Sampling of MAR sheets evidenced that staff continue to use tippex to correct mistakes. The Inspector noted that all discontinued medications had been appropriately disposed of. Sampling of the homes medication policy evidenced that it had been updated to include information relating to self-medication, however this did not explicitly state that a risk assessment would be completed as part of the selfmedication process. DS0000022875.V345121.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed an easy to follow complaints procedure and maintains records of complaints made and their investigation. The home has also developed clear guidance for staff regarding adult protection and staffs have a good understanding of adult protection issues. EVIDENCE: The home has developed a complaints policy that includes information on how to make a complaint and the timescales within which the home aims to respond to complaints. The Inspector viewed the homes complaints log. This evidenced that two complaints had been made since the previous inspection in February 2007. These were of a minor nature, and details of appropriate actions taken and the outcome of the complaint were logged. The home has developed an adult protection policy and procedure. This has been updated since the previous inspection in April 2006 and includes information on the types of abuse vulnerable adults may experience and potential indicators. The policy gives clear guidance to staff on the steps to follow should they have any concerns. Separate multi agency adult protection guidelines were also available. Discussion with the staff member on duty evidenced a good understanding of adult protection issues. DS0000022875.V345121.R01.S.doc Version 5.2 Page 17 The Registered Manager advised that there had been no adult protection concerns since the previous inspection. DS0000022875.V345121.R01.S.doc Version 5.2 Page 18 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides comfortable accommodation that generally meets the needs of people who use the service. The home is clean and tidy, however an offensive odour in one room needs to be addressed. EVIDENCE: The home is situated in a Victorian terraced style property in a quiet residential location close to public transport links and to shopping centres at Stratford and Green Street. There is also easy access to the nearby West Ham Park. The property comprises of an entrance porch and corridor leading to a communal lounge. There is a kitchen diner to the rear, and a downstairs bathroom with WC, hand basin and bath tub with shower over. From the kitchen there are patio doors to a paved rear garden. One service users bedroom is also located on this level. Access to the first floor is via a staircase DS0000022875.V345121.R01.S.doc Version 5.2 Page 19 and a staff office/sleep in room and two further service users bedrooms are located on this level. A refurbishment programme was carried out within the home some eighteen months ago, however décor in some communal areas including the stairway, kitchen and diner would benefit from repainting. The Inspector noted that since the installation of a specialist chair for one service user the lounge is overcrowded which was observed to present an increased risk of falls to the service user with poor mobility. The inspection in February 2007 required the home to address an offensive odour present in one service users bedroom. During discussion with the Registered Manager they advised that there were ongoing continence issues that were being addressed through the individual plan and by referral to the Continence Nurse, but that the odour in the service users bedroom continued to be an issue. DS0000022875.V345121.R01.S.doc Version 5.2 Page 20 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 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using services are generally satisfied with the care they receive. However, staff do not benefit from regular supervision or a rolling core-training programme. Less than half of staff is currently studying for NVQ level qualifications. EVIDENCE: In addition to the Registered Manager the home employs four care workers. One post is currently vacant and agency staffs are deployed to cover these shifts. A singleton member of staff is on duty at all times, and the Registered Manager is on duty during the day. The Inspector sampled the personnel files for two care workers. This evidenced that the home obtains two references and a criminal records bureau (CRB) check for new employees. All staffs receive copies of their employment terms and conditions. DS0000022875.V345121.R01.S.doc Version 5.2 Page 21 The inspection in April 2006 had required the home to revise and update its recruitment policy and procedure, and sampling of this document in February 2007 evidenced that this had occurred. At the time of this inspection no staff had completed NVQ level training, however the Registered Manager advised that one staff member is currently studying for NVQ level 2 and another for NVQ level 3. The Registered Manager advised the Inspector that since April 2006 one staff member had completed Safeguarding Adults training and that Food Hygiene training was planned for the near future. Sampling of the homes induction record in February 2007 evidenced that this had been updated to reflect the companies’ practise of deploying staff to work in both of its care homes. The previous inspection in April 2006 had required the home to ensure that regular supervision is provided to staff. The Inspector sampled the supervision records for two staff members. These evidenced that a recently appointed care worker had yet to receive supervision, and that a long-standing care worker had received one supervision in the current year. This longstanding care worker had received a staff appraisal in September 2006, but there was no evidence of subsequent appraisal of their performance. DS0000022875.V345121.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is appropriately qualified and experienced. The home has developed and implemented and developed a range of policies and procedures relating to health and safety. However, food-handling practises must be improved and outcomes of the quality assurance process collated and published. EVIDENCE: The Registered Manager is also the Responsible Individual, and he has some years experience of running a care home. The Registered Manager told the Inspector that they had recently completed the NVQ level 4 award, and is awaiting the result. DS0000022875.V345121.R01.S.doc Version 5.2 Page 23 The Registered Manager advised the Inspector that a quality assurance exercise was carried out in March 2006, but that there was little response with the exception of people who use the service. The Inspector was also advised that the outcomes of this exercise were not collated or published, but that the general feedback from people who use the service was that “everything is fine”. The Registered Manager further advised that questionnaires for the 2007 quality assurance exercise had recently been distributed, but that none had yet been returned. The Inspector noted that the Registered Manager comprehensively completed the Annual Quality Assurance Assessment requested by the Commission for Social Care Inspection and submitted this with supporting evidence. During the course of the inspection the Inspector found the homes records to be secure, up to date and generally in good order. However, tippex had been used to correct the Medication Administration Record. Sampling of available records evidenced that the home maintains a log of fridge and freezer temperatures, and that these are within acceptable limits. Weekly fire alarm tests were evidenced as being carried out with no faults to the system. Sampling of the homes accident and incident reports evidenced that these are appropriately completed. A previous inspection in April 2006 had required the home to label the contents of the freezer with a name of the item and the date it was frozen. Subsequent inspections in February 2007 and the current inspection evidenced that the home had complied with this requirement. Sampling of the homes fridge contents evidenced that several started processed foods had not been date labelled, as required by the inspection in February 2007. DS0000022875.V345121.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 X 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 X 32 2 33 3 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X 3 2 X DS0000022875.V345121.R01.S.doc Version 5.2 Page 25 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 14 & 15 Requirement The home must ensure that individual plans appropriately detail the health, social and personal needs of people who use the service. Where changes in need such as deterioration mobility are identified, appropriate referrals to professionals such as the Occupational Therapist should be considered. 2. YA7 16 & 20 The home must ensure that appropriate advocacy and support are provided for service users regarding major financial decisions. The home must ensure that risks identified in the individual plan are subject to a risk assessment. 30/12/07 Timescale for action 30/12/07 3. YA9 13 30/12/07 4. YA13 16 The home must ensure that all 30/12/07 people who use the service are appropriately supported to become part of and participate in the local community. Service users should take the DS0000022875.V345121.R01.S.doc 5. YA14 16 30/12/07 Page 26 Version 5.2 lead in the choice of entertainment provided in the home, specifically the watching of TV and selecting of channels. 7. YA17 Sch 3&4 The home must ensure that a range of suitable menus that meet the dietary and cultural needs of residents are provided, and that these reflect their individual preferences A record of all healthcare and medical appointments along with the outcome must be maintained. 30/12/07 8. YA19 12 & 13 30/12/07 9. YA20 13 The home must further develop 30/12/07 its medication administration and recording practises. This is a restated requirement. Previous targets of the 31/07/06 and 30/04/07 were not met. The homes self-medication policy must be updated to state that all self-medication will be subject to risk assessment. 10. YA24 13 & 23 Communal areas such as the kitchen, stairway and bathroom would benefit from redecoration. The layout and contents of the communal lounge should be reviewed to minimise the risk of trips and falls to service users with limited mobility. 30/01/08 11. YA30 13 & 16 The home must ensure that service users bedrooms are kept free from offensive odours. This is a restated requirement. The previous target of the 30/04/07 was not met. 30/12/07 DS0000022875.V345121.R01.S.doc Version 5.2 Page 27 12. YA32 12 & 18 Care staff must hold a minimum of NVQ level 2, or be working towards one by an agreed date. The Registered Person must ensure that there is a staff training and development programme. Staff must receive an annual appraisal with their Manager to review their performance. This is a restated requirement. Previous targets of the 28/02/06 and 31/07/06 have not been met. Staff must receive a minimum of six supervision sessions per year. This is a restated requirement. The previous target of the 31/07/06 was not met. 30/03/08 13. YA35 18 30/03/08 14. YA36 12 & 18 30/03/08 15. YA39 24 The home must ensure that outcomes from the quality assurance exercise and collated, published and made available to interested parties. Prepared and started processed foods must be date labelled in accordance with good food hygiene practise and manufacturers storage instructions. This is a restated requirement. The previous target of the 30/04/07 was not met. 30/12/07 16. YA42 13 30/12/07 DS0000022875.V345121.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA7 Good Practice Recommendations In partnership with the multi disciplinary community team the home should consider different strategies to promote behaviour modification or engagement with activities of daily living by some service users. Tippex should not be used to correct records. 2. YA41 DS0000022875.V345121.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000022875.V345121.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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