Inspection on 22/11/05 for Shalom Home

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 22 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 12/10/07

Shalom Home 05/04/06

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 Unannounced Inspection 22nd November 2005 12:00 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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 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 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 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 large staff office located on the ground floor, and each service user has their own bedroom on the first floor. There is a garden to the rear of the property. There is a large park nearby and easy access to transport links and community facilities. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection by one inspector over the course of an afternoon and evening. The main focus of the inspection was to establish progress in meeting previously made requirements and recommendations. A number of key standards were also inspected. During the course of the inspection the Inspector examined service users personal files, staff personnel records and other documentation relating to the running of the home. The Inspector spoke privately with the three service users currently residing at the home, with the staff member on duty and the registered manager. What the service does well: What has improved since the last inspection? Six requirements and one recommendation made as a result of earlier inspections were evidenced as satisfactorily addressed by the Inspector. The service users guide reflects the current situation within the home. A copy of the current staff rota was available, and service users personal files were in better order. Some individual service users plans had been developed as required by the previous inspection. One service user has been supported to transfer to a local GP and a safe deposit box has been purchased to hold another service users monies. A system to record healthcare appointments has been developed. Staffs have received training on adult protection and the recruitment and confidentiality policies have been amended. Quality assurance feedback surveys have been stakeholders and a business plan has been developed. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 6 What they could do better: As a result of this inspection 22 requirements were newly identified or restated. In addition shortfalls in 10 areas are now subject to Enforcement action. Shortfalls now subject to Enforcement Notice are not included in the requirements section of this report. Repeated inspections over previous years have identified significant shortcomings in the running of the home. This pattern was reflected in the current inspection findings. This appears to be an inspection led service with change and development occurring only as a result of statutory requirements made by the Commission for Social Care Inspection. Not all service users individual plans are being reviewed, and some areas of need are not addressed in these plans. The home does not operate a coherent risk assessment strategy that it can apply to individual service users needs. Risk assessments have not been appropriately updated in light of reviews. Service users are not being supported to develop identified activities of daily living such as cooking and there is a lack of support for service users to identify and engage with community, social or occupational activities. No information is made available to service users on local activities or resources. Service users are not receiving appropriate support to maintain their personal care. The format of service users meetings is rigid and staff led. Suggestions from service users at this forum are not acted upon. Service users want more variety in the menu offered and the inclusion of dishes that reflect their different cultural heritages. The group outings suggested are generated from staff and there is a low take up by service users. Service users want more varied opportunities for trips out, and support to identify local resources they are interested in. The homes medication administration and recording practises are poor. The home has failed to obtain a medical opinion on the frequency with which blood sugar monitoring is required for one service user. The homes health and safety practises do not meet National Minimum Standards. Appliances certified as having failed a Portable Appliance Test were left in a service users bedroom. Fridge and freezer temperatures are not recorded daily and it is not evidenced that appropriate action is taken when temperatures fall outside of acceptable parameters. Processed food items have not been labelled with a start and end date in accordance with manufacturers instructions. A number of dry foodstuffs were found to be in use when significantly past their use by date. The homes environment is in need of refurbishment and redecoration. The furniture in service users bedrooms requires is broken and in a poor state. Previous maintenance and decoration works have been carried out to a poor standard. The bathroom has a strong smell of urine. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 7 The home is not operating within current employment legislation. Rights to employment and Criminal Records Bureau checks are unsatisfactory. Once employed staff receive infrequent supervision and there is no system for staff appraisal. Some records required by regulation were not available at the time of the inspection despite the registered manager being on site. Current storage arrangements for supervision notes breach service users confidentiality. The homes confidentiality policy requires further revision. The homes policy and procedure should inform practise and must be implemented. All complaints must be logged along with details of any investigation and the action taken. The home should complete its own quality standards tool and publish the outcomes of feedback surveys. The homes petty cash should not be used to make personal purchases for the registered manager. Appropriate insurance cover must always be in place with a valid insurance certificate displayed in the communal area of the home. A summary of the areas covered by Enforcement Action is: Standard 6 – Individual service user plans Standard 9 – Risk assessment Standard 11 – Social and independent living skills Standard 19 – Healthcare needs Standard 20 – Medication administration and recording Standard 23 – Financial protection Standard 24 – Environment Standard 34 – Employment practises Standard 36 – Supervision of staff Standard 42 – Health and Safety 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. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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): 1 & 2. There is a service user guide that reflects the current situation in the home. EVIDENCE: There have been no new admissions to the home since the last inspection. The service user guide has been forwarded to the Commission for Social Care Inspection and this reflects the situation in the home. One service user who has lived at the home for five years said that the home meets their needs, as it “makes sure I have food and my medicine”. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 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, 8, 9 & 10. There have been some improvements in the maintenance and development of service users personal files and individual plans. Not all service users needs are being assessed or reviewed. Service users meetings need to be restructured and decisions of these meetings implemented. The confidentiality of service users between the two homes the responsible individual is involved with must be maintained. The home lacks a coherent risk assessment model that can be applied to individual service users needs. EVIDENCE: The Inspector looked in detail at the personal files for two service users currently living at the home. The Inspector noted that these files appeared in good order and that a new system had been introduced where information recorded on the care plans could be measured on a daily basis. The registered person had previously been required to develop individual plans to address one service users needs with regard to managing their finances and non compliance with medication and plans to address these needs were Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 11 located. It was also evidenced that an existing care plan for this service user addressing smoking in their bedroom had been reviewed and dated as required. When sampling the other service users personal file requirements from previous inspections were not evidenced as being met. The Inspector is of the view that reviews of a care plan addressing memory loss continue to focus on use of a diary to the detriment of the other elements of this plan. There was also no current care plan for this service user to address their social, educational or occupational needs. These identified shortfalls in care planning are now the subject of enforcement action. The Inspector viewed the minutes of meetings held for service users at the home. This evidenced that meetings are held on a regular basis. However the Inspector noted that the agenda for these meetings appeared fixed to the same few agenda items (menu, eating out, smoking and outings) and does not appear to be a forum in which service users have opportunities to participate in and contribute to the day to day running of the home, or the development of policy, procedure or the development of the service. At the most recent service users meeting on the 28th October 2005 a request for a more varied menu had been by two service users. It was not evidenced that this had been implemented. The Inspector noted that discussion around outings appeared led by staff with two service users clearly stating at the meeting that they did not wish to participate in two outings being arranged. There was no record of any discussion with these service users around what activities they might like to participate in. A proposed trip to the cinema agreed to by one service user had been diarised, but what was not evidenced as occurring. No reason for this was recorded. The previous inspection had identified shortfalls in the homes risk assessment process. Since then the home have completed a generic risk assessment for the home environment. However, after inspecting service users personal files the Inspector formed the view that the registered person has not developed a coherent risk assessment model that can be implemented according to service users identified needs. A variety of tools have been used to record information, some files have a risk checklist, some have risk assessment policy forms copied from the homes generic risk assessment, others have individual risk assessments. After discussion with the registered manager, the Inspector was unable to evidence that there is a methodical approach to the assessment or recording of risk. The Inspector was also unable to evidence that risk assessments were being accurately updated as a result of regular review. This was evidenced in the personal file of one service whose risk assessment had been required to be updated. The Inspector noted that inaccurate information had been scored out Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 12 on the risk assessment and a note added saying “see care plan”. It was not evidenced that the risk assessment had been appropriately updated. Some risk assessment documentation, for example the checklist on one service users personal file remain unsigned. The Inspector viewed the homes confidentiality policy. This has been revised since the last inspection. However, it is recommended that it is reviewed again to give explicit advise to staff on the circumstances when confidentiality may be breached, for example following a disclosure of abuse or other adult protection issues. The registered manager is also registered provider for another residential care home. Whilst sampling staff supervision records the Inspector noted that copies of supervision minutes recorded by the manager of this other care home and recording by name discussions relating to the other homes service user group were found on Shalom home personnel files. Standard 7 was not inspected on this occasion, but was met at the previous inspection. The Inspector noted that a previous recommendation to provide a lockable cash box to one service user had been met. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Whilst a range of entertainment is available within the home, service users are not being adequately supported and encouraged to develop fulfilling and valued occupational, social or community interests. No information is available on local activities or interests. Group outings appear to be selected by staff. The homes menu lacks variety and has not been updated to reflect service users requests, and does not reflect service users preferences or culture heritage. EVIDENCE: At the previous inspection a service user had identified that they would like staff to assist them to prepare meals. The Inspector noted that this service user had recently returned to the home after a lengthy hospital admission, however their was no evidence that this had been discussed with the service user or any plan developed for its implementation in the future. One service user at the home attends a day service and visits family members regularly. This service user told the Inspector that they would “like to go on Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 14 more outings, perhaps for lunch at a pub” and that they would also like staff to help them “find somewhere local that I can play pool”. None of the documentation or discussion with other service users evidenced that they were being supported or encouraged to identify or participate in valued activities. All service users stated that they enjoy participating in the weekly shop for the home, and for two of the service users this appeared to be either their main or sole community activity. It was not evidenced that information and advice about local activities or resources is made available to service users. The home has a stereo system and satellite television in the communal lounge. One service user told the Inspector that they particularly liked watching Hindi films on the satellite channel. The minutes of service users meetings indicate that staffs suggest outings. The focus appears to be on joint days out with, or visits to service users of another home with which the responsible individual is involved. The Inspector noted the poor take up of these opportunities by service users. From discussion with service users it was evidenced that service users choose when to be alone or in company. The minutes of service users meetings recorded that two service users had requested a more varied menu. During discussions with the Inspector all service users reported that they would like more varied food, and dishes that reflected the African Caribbean and South Asian heritage of two of the homes service users. The Inspector viewed the records of meals being provided in the home and noted that there was little variation in the menu provided from week to week and that no changes had not been made to reflect service users requests. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users are being supported to attend regular healthcare appointments. Appropriate action to clarify the blood sugar monitoring needs of one service user has not been taken. The homes medication administration and recording practises are of a poor standard. Service users are not being appropriately supported to maintain their personal care. EVIDENCE: The care plans seem by the Inspector evidence that service users require prompting to attend to their personal care, but are independent in carrying out the actual tasks. On the day of the inspection the Inspector noted that one service user was wearing a heavily soiled t-shirt. Since the last inspection the home has developed a system to record all healthcare appointments attended by service users. This indicated that service users have attended all scheduled medical appointments since the last inspection. At the last inspection one service user was travelling some distance to visit their GP and they have now transferred to a more local practise. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 16 The last inspection in July 2005 required the home to contact the diabetic clinic to establish and record the frequency with which one service use requires blood sugar monitoring. On viewing the service users personal file the Inspector noted that a letter had been sent to the GP in October 2005 seeking clarification. This letter had been sent to the service users previous GP and it was not evidenced that this letter had been responded to, or that the home had made any subsequent enquiries. The previous inspection had required the home to improve its practise regarding the administration and recording of medicines. The Inspector sampled the current MAR sheet and noted that “as required” (PRN) medication was now listed, however, the administration record was annotated “PRN medication book”. The Inspector asked to view this book and when it was produced there were no records of any PRN having been administered in it. The Inspector asked to view any records that were held for any PRN medication that the home had administered and none were produced. The Inspector sampled loaded dossett boxes and found that one of these had been incorrectly filled. A prescribed calcium supplement that had been prescribed 3 times daily was in fact being administered only once daily. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. The home does not systematically record or investigate complaints made by service users. Inappropriate withdrawals have been made from the homes petty cash supply. Staffs have received adult protection training since the last inspection and staff on duty demonstrated a good understanding in this area. EVIDENCE: The Inspector viewed the homes complaints policy. This contains details of the timescales in which complaints will be dealt with and contact details for the Commission for Social Care Inspection. The Inspector asked to see the homes complaints log, and an empty notebook was produced. The Inspector queried whether any other records of past complaints were available and was advised that they were not as no complaints had been made. During discussion with one service user they identified one occasion when in the past when they had made a complaint, and reported that they had been satisfied with how this had been dealt with and the outcome. Since the last inspection the registered manager has submitted copies of certificates to the Commission for Social Care Inspection to evidence that all staff have received training in adult protection. The staff member interviewed by the Inspector demonstrated a sound grasp and understanding of the meaning of adult protection and their responsibilities. The Inspector sampled the homes adult protection policy and noted that whilst it had been amended further revision is required. The current policy advises that all concerns must be reported to the responsible individual, who is the Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 18 same as the registered manager and does not address what should happen if the allegation is against the manager. The Inspector sampled the homes petty cash record and noted that an entry on the 9th August 2005 indicated that lunch for the manager had been bought from these funds. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30. Each service user has a private bedroom and the communal lounge has a homely atmosphere. Service users bedrooms and the communal areas are in need of refurbishment and redecoration. The furniture provided in service users bedrooms is of poor construction. Previous maintenance and decoration work has been of a poor standard. The bathroom smells strongly of urine. EVIDENCE: The home comprises a staff office, communal lounge, a kitchen with dining area and access to the rear garden and a downstairs bathroom with WC and hand basin. Access to the first floor is via a staircase in the lounge area, and three service users bedrooms are situated on this level. The Inspector toured the communal areas and the three service users bedrooms. Whilst the communal lounge did have a homely and comfortable atmosphere, the Inspector formed the view that the other shared and private spaces were somewhat austere and in need of redecoration and refurbishment. Significant shortfalls in maintenance were identified in service users bedrooms and these are now subject to enforcement action. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 20 The Inspector noted that laminate flooring had recently been fitted in one service users bedroom and observed that this had been poorly laid with gaps present between the planks. This service users bedroom had also had its hand basin removed. A range of shared and private space is accessible to service users. The Inspector viewed the homes bathroom and noted that whilst the shower curtain had been replaced as required by the previous inspection, it had not been properly hung. A strong smell of urine was also present in the bathroom. The Inspector noted that the standard of decoration in the bathroom was of a poor standard. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 & 36. The homes employment practises do not comply with current legislation. Staff supervision is irregular and there is no staff appraisal programme. New staff do complete a recorded induction programme. EVIDENCE: Standard 32 was not inspected on this occasion. It was last inspected on the 27th July 2005 and met. The Inspector sampled one of the personnel files seen at the previous inspection. This had been annotated to include the dates this person had rejoined the home as an employee. A note in this staff members file indicated that their current visa entitling them to work had expired, and that a further application had been submitted to the Immigration and Nationality Directorate. No official correspondence or receipt was on file to evidence this. A personnel file for the most recently joined member of staff was also sampled. This evidenced that two references had been obtained as well as proof of their rights to employment. The Inspector noted that this staff member is recorded as starting work on the 21st May 2005 and their Criminal Records Bureau (CRB) check is dated the 19th September 2005. There is no evidence of a Protection of Vulnerable Adults check (POVA first) being obtained in the Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 22 interim. A completed induction record was found on this staff members personnel file. Two other personnel files sampled by the Inspector did not contain current enhanced CRB checks obtained by Shalom Home or an umbrella organisation. The registered manager advised that they are currently in the process of recruiting new staff. The Inspector viewed the homes recruitment policy and procedure and noted that this had been revised since the last inspection. The registered managed must ensure that service users are supported to appropriately participate in the selection and probationary review of new staff members. Sampling of supervision records evidenced that a member of staff joining in May 2005 had been supervised on one occasion. Another staff member was recorded as having received two supervision sessions in the current inspection year. Personnel files did not evidence that staff receive an annual performance appraisal. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43. There is no clear management or leadership in the development of the service being provided. Changes in the service are driven by requirements made as the result of inspection. Management appears to lack the commitment to drive forward these changes in the long term. EVIDENCE: Repeated inspections over previous years have identified significant shortcomings in the running of the home. This pattern was reflected in the current inspection findings. The staff attendance book indicates that the number of hours spent on site by the manager have increased since the last inspection, this inspections findings do not evidence that management issues are being sufficiently grasped. Since the last inspection the home has sent quality assurance surveys to other professionals and service users family members. Responses to these were not available for the Inspector to view. The homes quality standards document Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 24 was viewed by the Inspector and was found to have substantial omissions where no information had been completed. In response to the requirements of previous inspections the home has developed a range of policies and procedures. It must ensure that these are fully implemented into practise. The Inspector asked to see the personnel file for a staff member that was sampled at the last inspection. The Inspector was advised that this staff member was no longer employed by the home and no record was available. A set of photocopied documents relating to this staff member was submitted to the Commission for Social Care Inspections offices some days later. The Inspector viewed the homes current Portable Electrical Appliance Testing certificate. It was noted that a lamp in one service users bedroom had failed the test. During the site inspection the Inspector saw that this lamp remained in the service users bedroom, and subsequently removed it and advised the registered manager to appropriately dispose of it. The Inspector sampled the log of Fridge and freezer temps. It was not evidenced that the kitchen log was being completed on a daily basis and gaps were found over the previous three months. The fridge in one service users room had a temperature recorded at 8 degrees for two consecutive days with no record of action taken to restore the fridge to a temperature within acceptable limits. The Inspector noted that a service users medication was being stored in this fridge and would have been affected by the fluctuation in temperature. An inspection of the contents of the fridge evidenced that a processed food item had not been labelled with a start date or finish date in accordance with the manufacturers instructions. An inspection of the dry foodstuffs store cupboard identified three items still in use that were significantly past their use by dates. The Inspector viewed the homes record of water temperatures and found that thee are being recorded on a daily basis. Sampling of the homes fire evacuation log indicated that a drill had been held in April 2005 and that evacuation times are recorded. During the site inspection the Inspector noted that the insurance certificate had expired. The registered manager was not able to produce documents to evidence that appropriate cover was in place. A copy of a current insurance certificate was received at the Commission for Social Care Inspection offices some days later. Since the last inspection the home has developed a business plan and submitted a copy of this to the Commission. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 25 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 1 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X 2 1 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 3 X 2 LIFESTYLES Standard No Score 11 2 12 1 13 2 14 2 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 1 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shalom Home Score 2 1 1 X Standard No 37 38 39 40 41 42 43 Score 1 2 2 2 1 1 1 DS0000022875.V268349.R01.S.doc Version 5.0 Page 27 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 YA8 Regulation 12(3) Requirement With service users participation, the structure and function of service users meetings should be reviewed and revised to ensure that these are a forum for service users to participate in the day to day running of the home and service development Suggestions and comments by service users must be appropriately and promptly responded to. Service users should be facilitated to identify outings and activities they would like organised. 2 YA10 17(1)(b) Supervision records by the Plumstead manager referring to Plumstead service users should not be held at Stratford. 28/02/06 Timescale for action 28/02/06 3 YA12 12(1) & 16(2)(m) Staff must support service 28/02/06 users to identify and participate in valued and fulfilling activities. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 28 4 YA13 16(2)(m) The registered person must ensure that information and advice are available about local activities and resources. Service users should be encouraged and supported to identify outings they would like to participate in. Service users should be supported to develop friendships with those who do not have their illness or disability. 28/02/06 5 YA14 16(2)(n) 28/02/06 6 YA15 16(2)(m) 28/02/06 7 YA17 16(2)(i) Service users must be offered a 28/02/06 choice of suitable meals that meet their dietary and cultural needs and respect their individual preferences. Service users must be given appropriate support to attend to their personal hygiene and appearance. A record must be kept of all issues raised or complaints made by service users, including details of any investigation, action taken and the outcome. The homes adult protection policy and procedure requires further revision to include procedures if an allegation is made to staff against the manager and to make appropriate reference to the whistle blowing policy. This is a restated requirement the previous target of the 27th October 2005 was not met. 28/02/06 8 YA18 12(1)(b) 9 YA22 22 28/02/06 10 YA23 13(6) 28/02/06 Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 29 11 12 YA26 YA27 23(2)(j) 23(2)(c) The largest bedroom must be fitted with a wash hand basin. The shower curtain in the bathroom must be properly fitted. The bathroom must be kept free from the smell of urine. The home must implement its revised recruitment procedure and support service users to appropriately participate in the recruitment and probationary review of new staff. Staff must receive an annual appraisal with their manager to review their performance. The Registered Person must address all management components of the National Minimum Standards as a matter of urgency. This is a restated requirement. The previous target expired on the 31/12/04 and 27/10/05. 28/02/06 28/02/06 13 14 YA30 YA34 23(2)(d) 17(2) Sch 4 28/02/06 28/02/06 15 YA36 18(2) 28/02/06 16 YA37 24 28/02/06 17 YA38 18 & 24(1) The Manager must ensure that he spends sufficient time on site each week to deal with management issues. This is a restated requirement. The previous timescale of the 31/05/05 has not been met. 28/02/06 18 YA39 24(1) The home must comprehensively complete its own quality standards tool and collate and publish the results of feedback surveys. 28/02/06 19 YA40 12(1)(a)&(b) The homes policies must comply with legislation and be DS0000022875.V268349.R01.S.doc 28/02/06 Page 30 Shalom Home Version 5.0 implemented in the homes practises. This is a restated requirement the previous target of the 27/10/05 was not met. 20 YA41 17 Individual records and home records must be up to date and in good order. This is a restated requirement the previous target of the 27/10/05 was not met. All records required by regulation and other legislation must be retained be available for inspection. 21 YA42 13(4)(c) Health and safety check and records must be completed including: (i) Fridge and freezer temperatures must be recorded on a daily basis, and this should include the action taken in the event of the reading being outside of acceptable parameters. Processed foods stored in the fridge must be labelled with a start date. Dry foodstuffs must be monitored for their use by date and disposed of when this date is reached. 28/02/06 28/02/06 (ii) (iii) Appliances that fail the Portable Appliance Test must be Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 31 appropriately disposed of. 22 YA43 25 A current insurance certificate must be displayed and be available for inspection. 31/12/05 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 YA9 Good Practice Recommendations Individual risk assessments should be reviewed and expanded to include the risk of absconding from the placement. This is a restated recommendation. 2 3 YA8 YA10 The meetings of service users meetings should be signed and dated by the minute taker. The confidentiality policy should be further reviewed to explicitly state the circumstances in which confidentiality may be breached, for example: disclosure of abuse or other adult protection issues. Shalom Home DS0000022875.V268349.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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. 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