Inspection on 27/07/05 for Shalom Home

This inspection was carried out on 27th July 2005.

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 but made no statutory requirements on the home.

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 22/11/05

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 143 Caistor Park Road Stratford London E15 3PR Lead Inspector Lea Alexander Unannounced Inspection 27th July 2005 at 12.45 pm 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 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 Stationary 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 G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shalom Home Address 143 Caistor Park Road, Stratford, London, E15 3PR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8471 9533 020 8471 9533 bodefadojutimi@aol.com 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 G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 4th January 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 closeby and easy access to transport links and community facilities. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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. The main focus of the inspection was to establish progress in meeting requirements and recommendations previously made. The previous inspection in January 2005 had made twenty requirements and one recommendation and a complaint investigation in April 2005 concluded with the making of a further twelve requirements During the course of the inspection the Inspector spoke individually with the registered manager, the support worker on duty and one service user. In addition service user personal files and staff personnel files were sampled, as were key policies and other documentation. What the service does well: What has improved since the last inspection? What they could do better: Several requirements have been restated and shortfalls in new areas identified. To promote service users safety and choice a number of documents and policies including the statement of purpose, service user guide, confidentiality policy, adult protection and recruitment policies must be reviewed and amended. To promote service users independence the home should develop its service user plans so that they are systematic, holistic and fully integrate risk assessment and management plans. The home should develop its practises in supporting service users to acquire and maintain independent living skills and promote their well being through the appropriate monitoring and support to attend healthcare appointments. To ensure service users health and safety medication administration practises Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 6 must be developed. The homes standard of record keeping must improve and an up to date duty rota should always be available. Petty cash should only be used to purchase items for the home or service users. The homes employment practises must comply with all relevant legislation and staff must be regularly supervised. The home needs clear management and guidance to develop in these identified areas and to develop its quality assurance systems and development plans. As a result of shortfalls and restated requirements made as a result of this inspection the Commission for Social Care Inspection may be minded to consider Enforcement action. 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 G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1. The home has developed a statement of purpose and service user guide to promote service users independence and choice. These require revision to comply with regulations and accurately reflect the situation in the home. EVIDENCE: The Inspector viewed the homes statement of purpose and service user guide. The service user guide has been revised as required by the previous inspection and each service user is in receipt of a copy. The Inspector noted that the service user guide states that the home has a full time manager. The Inspector cross-referenced to the staff attendance register and noted that entries in this register evidence that the manager is not in attendance at the home on a full time basis. The service user guide should be amended to accurately reflect the situation. The previous inspection had required the home to review its statement of purpose to include room sizes and be dated. A revised copy of the statement of purpose had been sent to the Commission for Social Care Inspection to evidence the inclusion of the required information. The Inspector noted that the statement of purpose was not available in the home on the day of the inspection. There have been no new admissions to the home since the previous inspection. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 & 10. The home is promoting service user well being by developing individual care plans for service users that are regularly reviewed and by attending multi disciplinary care planning meetings. The homes practise with regard to evidencing service users participation in reviews needs development. The homes current individual planning system does not give an overview of the users needs and risk assessments are not integrated into this process. The home also needs to develop its recording practises in these areas. EVIDENCE: The Inspector sampled personal files for two service users. These evidenced that individual service user plans have been developed and are being reviewed with service users on at least a six monthly basis. It was also evidenced that regular Care Programme meetings with Community Mental Health Team professionals are regularly convened and that the home attend and participate in these meetings. The Inspector noted that each care plan covered a particular area of need, and that these care plans are individually reviewed at different times. To ensure that that an overall picture of care needs is established and reassessed it is Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 10 recommended that the home develop a system where all care planning documentation is reviewed as part of the same process. The Inspector also noted that service user files were in a muddled state with some care plans not labelled as such, and being filed in separate sections of the personal file with no apparent system. In some cases the handwritten review notes appeared to be filed in a section with an unrelated care plan. The Inspector noted that one care plan addressing a particular service users smoking in his room was undated with no evidence of review. Another service users personal file had an opening sheet headed “Personal Needs” it did not state the name of the service user, who had completed it or the date it had been completed. This service users file contained a care plan addressing their needs regarding the monitoring of blood sugar levels. Whilst is it was evidenced that this plan had been regularly reviewed, it was not signed by the service user to evidence their participation and agreement with the review. The Inspector noted that an Occupational Therapist (OT) had assessed one service user with regard to their memory loss. Whilst an individual care plan had been developed incorporating guidance from the OT the Inspector noted that the reviews of the care plan had solely focused on the use of a diary and did not include the other elements outlined in the plan. The Inspector also noted that records had been kept on the reverse of a Medication Administration Record that indicated that one service user had refused medication on a number of occasions. There was no care plan or risk assessment in the service users personal file to address this as had been required by the complaint investigation report. The Inspector reviewed the homes risk assessment and management practises as evidenced in two service uses personal files. It was noted that the home has a risk assessment checklist for each service user and individual risk assessments for each area of need. The Inspector found that the checklist had not been dated or signed for one service user and was not found on the others personal file. A risk assessment for a service user addressing potential risk to others and self-harm was not dated or signed. Another risk assessment for this service user that was headed self-harm had actually been completed to address drug misuse and associated aggressive behaviours and did not address self-harm at all. A third risk assessment for this service user addressing aggression towards staff had been completed in March of this year; the Inspector noted that the current Community Mental Health Team plan from June 2005 highlighted an Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 11 improvement in behaviour. It was not evidenced that the homes risk assessment had been reviewed to reflect these developments. The previous inspection had identified the need for one service user to be risk assessed with regard to absconding from the home. This remains outstanding. The Inspector viewed the homes confidentiality policy. This needs revision to include the circumstances in which confidentiality may need to broken to ensure service users wellbeing, and the procedure that staff should follow in these circumstances. Service users have their own bank or building society accounts and are encouraged to be as independent as possible in managing their finances. One service user receives high levels of support in managing his finances and this is detailed in a later section of this report. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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 standard(s) 11. The home must develop its practise to ensure that service users have opportunities for personal development and to take part in appropriate leisure and community activities. EVIDENCE: One service user spoken to by the Inspector identified that he would benefit from support in developing his personal skills. He identified that he would like support with shopping for personal items. This service user identified that previously staff had supported service users to prepare meals, but that this practise had stopped and staff now prepare meals for service users. The service user reported that he had enjoyed and appreciated staff support in preparing meals and was sorry that this practise had ended. The same service user identified that he had stopped going to local day services, as he did not enjoy them. This service user identified that he would also to be supported by the home to have day trips and outings. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19 & 20. Service users are safeguarded by the homes medication policy. To promote service users wellbeing the home must address shortfalls in its medication administration recording. The home must also improve its current practises to ensure that it adequately supports service users to attend all healthcare appointments and that these appointments and their outcomes are appropriately recorded and monitored. EVIDENCE: A previous inspection had required the home to regularly monitor and record the blood sugar levels of a diabetic service user. The Inspector viewed the log and noted that this is now happening on a weekly basis. The Inspector noted that this was less frequently than was being recorded at the time of the previous inspection and queried the rationale behind this. The Inspector was advised that the diabetic nurse had advised that weekly recording was sufficient, however there was no written record of this conversation or advice. The Inspector viewed the homes appointments diary and activity record. These indicated that one service user had missed a medical appointment in January 2005, as he had no shoes to wear. The Inspector noted that the diary identified several medical appointments for service users over recent months. There was however no entry in the Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 14 appointments diary, activity schedule or personal file to record whether these appointments had been kept and the outcome. The Inspector noted that one service user is travelling to East Ham to see their GP. The complaint investigation in April 2005 had required the home to explore with this service user their preference between continuing to travel to see their current GP and transferring to a local practise. The service user advised that this discussion had not occurred. The registered manager advised that local GP surgeries had been contacted but were not taking new patients at the time. No record had been made in the service users personal file to evidence these enquiries. The service user in question advised the Inspector that they would welcome the opportunity to explore the benefits and disadvantages of moving GP before making a decision. The Inspector viewed the homes policy relating to medication. It was noted that these have been amended to include self-medication and a protocol regarding controlled drugs. This policy now meets the requirements of National Minimum Standards. The Inspector viewed the homes medication administration records (MAR) and the medication currently available. It was noted that two “as required (PRN)” medications were not listed on the MAR. One service user had an eye drop medication that was not listed on the MAR and was not marked as discontinued in the records seen. One service users dossett box was not labelled with his name. The Inspector noted that the loaded dossett boxes did correspond with the list of medications on the MAR. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 23. Service users are protected by the homes adult protection policy and practise in managing individual service user finances. The training of all staff in adult protection and the separation of the homes petty cash from the manager’s personal financial expenditure would further enhance service users protection. EVIDENCE: The Inspector viewed the homes adult protection policy and procedure. This advises staff to report all concerns or allegations of abuse to the Manager. The policy does not advise what steps should be taken if the allegation is against the manager or make reference to the whistle blowing policy. The Inspector spoke with the Registered Manager who advised that since the last inspection one staff member had attended adult protection training. The previous inspection had required all staff to undertake adult protection training and the Registered Manager advised that funding is being sought to facilitate this. The staff member on duty at the time of the inspection was able to identify different types of adult abuse and advised the inspector this was an area that had been covered in his NVQ studies. The staff member was aware of the homes adult protection and whistle blowing policies. One service user receives high levels of support with his finances and his monies are retained with his agreement by staff. The Inspector viewed the record of monies deposited and withdrawn and found this to be signed by both the service user and staff. The written record of monies available tallied with the monies actually available. The service users monies are kept separately from other monies in the home. At present monies are stored in an envelope in the service users personal file. The Inspector recommends purchase of a separate safe deposit box to ensure safekeeping of money. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 16 The Inspector noted that this service users needs with regard to budgeting were recorded in an individual care plan. An assessment addressing risks associated with managing personal finances for this service user was not available. The Inspector viewed the homes petty cash box and ledger. This indicated that petty cash is used to buy essential items for service users and the home. The Inspector did however note an entry where a food item is recorded as being purchased for the Manager from petty cash. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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 standard(s) 27 & 30. The home has undertaken outstanding maintenance work and cleaning is carried out to an appropriate standard. EVIDENCE: The home has a single WC and bathroom used by service users and staff. The Inspector viewed the facilities and noted that some repairs and maintenance had been carried out since the last inspection. The Inspector noted that a shower curtain should be fitted in order for service users to use the shower fitted over the bath. The non-slip shower mat had fungus growing on it and this must be replaced. The Inspector noted that the premises were generally clean and free from offensive odours. Extractor fans in the kitchen and bathroom had been cleaned to an appropriate standard. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 36. Staffing documents required by regulation must be available to staff in the home. The homes recruitment policy and procedure is aimed at protecting service users. The home must comply with relevant legislation in the recruitment and supervision of staff. EVIDENCE: The Inspector noted that staff on duty at the time of the inspection appeared accessible to, approachable by and comfortable with service users. The staff member on duty who was interviewed by the Inspector had previously nursing and care work experience prior to taking up this post and had successfully completed NVQ level III earlier this year. The staff member has been in post approximately one year and has received training in food hygiene and first aid. The staff member advised that they had received training on medication administration as part of the induction process. The staff member also confirmed that supervision occurred on a monthly basis and copies of the minutes were given to both parties. The staff member advised the Inspector that they felt supported and enabled to carry out their work with service users. The Inspector noted that the current staffing rota had expired several days previously. A request was made to view the current rota but this was not available. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 19 The Inspector viewed the homes recruitment policy and noted that this does not detail how service users will be involved in the selection of staff and does not clearly state that staff must have a satisfactory Criminal Records Bureau check carried out by the home prior to taking up appointment. The service user interviewed by the Inspector was not aware of being asked to be involved in staff selection. He expressed an interest in being involved in future recruitment. The Inspector sampled two staff personnel files. These indicated that two satisfactory references are obtained as part of the recruitment process. Completed and signed off induction checklists were also on file. The Inspector noted that photocopied Criminal Record Bureau checks were kept on file and that some information had not been copied, on one the date of the check was not complete. The Inspector also noted that one member of staff had given an overseas nationality on their application form. A photocopy of a passport photo page was included in their file but this did not state the nationality. No copies of a visa or Immigration or Nationality Directorate letter were found on the file detailing the person’s rights to work. The Inspector looked at staff supervision records for two employees. The Inspector noted that for one staff member the supervision is recorded as having occurred only once this year. The Registered Manager advised the Inspector that this staff member had left the home and subsequently rejoined. This was not reflected in the records available to the Inspector. In a second personnel file the Inspector noted that supervision sessions were recorded as having taken place until the 15th May 05 when the next supervision session was noted to be the 14th June 05. There was no record of this having occurred or arrangements for an alternative date. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 & 43. Whilst some progress has been made since the last inspection service users would benefit from a full time manager on site to address ongoing shortfalls in the management of the home. EVIDENCE: Previous inspections have highlighted the need for the management components of National Minimum Standards to be addressed as a matter of urgency. Whilst it was evidenced during this inspection that some steps have been made towards this, requirements regarding the management of the home remain. The Inspector viewed the staff register and noted that the Registered Manager had signed himself as attending the home for approximately 50 hours over the preceding four-week period. The Inspector raised with the manager the issue of quality monitoring systems. The Inspector was advised that the home is developing “quality standards” a Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 21 self-assessment process addressing all aspects of the service. The Inspector noted that this document is not complete, and was presented during inspections in January 2005 and August 2004. The home does ask service users to complete feedback questionnaires, and completed copies of these were found on personal files. General feedback seemed to be that service users were generally happy with the service they received. There is no system in place at present to systematically obtain feedback from relatives, other representatives and other professionals and stakeholders on the quality of the service provided. The Inspector noted that policies and procedures required by National Minimum Standards are now available in the home. Most of the policies viewed during this inspection require further review and amendment to meet National Minimum Standards. The home must ensure that these policies are implemented in the homes practise. The Inspector viewed the homes fire alarm test record and this indicated that weekly fire alarm tests are carried out on a weekly basis. Previous inspections have required the home to implement a generic risk assessment to maintain a safe environment. This should address all activities service users are involved in and all areas of the home and should include the use of kitchen equipment, laundry machinery, steps and pathways and security of service users based on their vulnerability. These assessments were not available on service users personal files during this inspection. The Inspector viewed the fridge and freezer temperatures are being recorded daily and are within acceptable limits. The Inspection process identified the need for the home to improve its record keeping practises. This is an ongoing issue identified at earlier inspections. The Inspector noted that the Registered Person had submitted a financial report and accounts to June 2004 to the Commission for Social Care Inspection. This information did not however contain a business or development plan as required by the previous inspection. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 22 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 2 x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 1 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x 2 x x 3 Standard No 11 12 13 14 15 16 17 2 x x x x x x Standard No 31 32 33 34 35 36 Score x 3 2 1 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shalom Home Score x 1 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 2 2 2 G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Schedule 1 15(1) & 15(2)b Requirement Timescale for action 27/10/05 2. 6 3. 9 13(4)b The registered person must ensure that the service user guide must be amended to accurately reflect the managers attendance status at the home. 27/10/05 The home must develop its individual service user planning to: (1) Review care plans together to ensure the whole picture of need and strengths is established and recorded. (2) Written care plans must be kept in good order by storing them and any related review notes together in a systematic way. (3) Care plans must be dated and signed and a review date identified. (4) All components of need recorded on the care plan must be fully addressed and reviewed. (5) All areas of need must be recorded on an individual plan and reviewed. The home must develop its risk 27/10/05 assessment practises. (1) All identified areas of potential risk must be assessed and appropriately recorded. (2) Risk assessments must be dated and signed. (3) Risk assessments must be regularly reviewed. Version 1.40 Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Page 24 4. 10 17(1)b 5. 11 16(2)m & 16(2)n 6. 19 13(1)a & 13(1) b 7. 20 13(2) 8. 23 13(6) The homes confidentiality policy requires revision to include the circumstances in which service user confidentiality may need to be broken and the procedure to follow in these circumstances. The home must ensure that service users have the opportunity to learn, maintain and develop social and independent living skills by supporting service users to cook, shop and have day trips. The registered person must ensure that the home is conducted so as to promote and make proper provision for the health and welfare of service users. This is a restated requirement. Previous timescales of 31/08/04 and 28/02/05 have not been met. (1) The home must contact the diabetic clinic and establish and record the frequency for blood sugar monitoring tests. (2) The home must develop a system to record medical appts, whether they were attended and the outcome. (3) The home must ensure that service users are adequately supported to attend medical appointments. The home must improve its practises regarding the administration and recording of medication. (1) PRN medication must be listed on the MAR. (2) Medications discontinued or completed must be marked as such on the MAR sheet. (3) Dossett boxes must be clearly labelled with the service users name. (1) The homes adult protection policy and procedure must be amended to include procedures if an allegation is made to staff 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 25 9. 10. 27 33 23(2)c 18(1)a 11. 34 19 12. 34 19 against the manager and to make appropriate reference to the whistleblowing policy. (2) All staff must receive training in the protection of vulnerable adults. This is a restated requirement. Previous timescales of the 31/08/04 and 28/02/05 have not been met. A shower curtain must be fitted in the bathroom and the non slip shower mat replaced. The Registered Person must ensure that a copy of the duty roster of persons working is available in the home. This is a restated requirement. The previous timescale of the 10/01/05 has not been met. The homes recruitment policy and practise requires development to include: (1) The involvement of service users in the selection of staff. (2) Staff appointments must be subject to a satisfactory CRB check carried out by the home or their umbrella organisation. (3) New appointees must be subject to a three month probationary period and service users should be involved in the probationary review. The home must ensure that its employment practises comply with legislation. (1) Where applicable, rights to employment must be clearly evidenced. (2) Adequate records of satisfactory police checks and the dates of these must be kept. (3) Comprehensive records of start dates and leaving dates must be kept for staff. (4) Permanent staff members who leave the home and then rejoin must be subject to recruitment policy and procedure. 27/10/05 27/10/05 27/10/05 27/10/05 Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 26 13. 36 18(2) 14. 37 24 15. 39 24(1) 16. 40 12(1)a & 12(1)b 17 17. 41 18. 42 13(4) 19. 43 25 The home must develop its supervision practise. (1) Staff supervision must occur at least six times per year. (2) Supervision sessions are recorded with copies being kept by both parties. 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. The Registered Person must ensure that there is a system for monitoring standards and whether the aims and objectives of the home are being met. This is a restated requirement. Previous timescales of 31/03/05 and 31/10/04 have not been met. The homes policies must comply with legislation and be implemented in the homes practises. Individual records and home records must be up to date and in good order in accordance with legislation. The Registered Person must ensure that all parts of the home and any activities that service users engage in at the home are assessed for health and safety risks and that the risk assessment process and the controls put in place are recorded and regularly reviewed. This is a restated requirement. Previous timescales of 31/10/04 and 31/03/05 were not met. The Registered Person must ensure that a business/development plan is available for inspection. This is a restated requirement. Previous 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 27 20. 9 12(1)(b) & 13(1)(b) 21. 23 15(1) & 15(2)(b) 22. 38 18 & 24(1) 23. 19 13(1)(a) 24. 23 25(1) timescales of 31/12/04 and 30/04/05 have not been met. The Manager must risk assess service users non compliance with medication and develop a strategy to manage this with mental health services. This is a restated requirement. The previous timescale of the 09/05/05 was not met. Risk assessments must be completed for service users who have difficulties in managing finances. This is a restated requirement. The previous timescale of the 31/05/05 has not been met. The Manager must ensure that he spends sufficent 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. The manager must review with the service user (travelling to E6) their preferred arrangements for accessing primary care services and arrange this with the health authority. This is a restated requirement. The previous timescale of 31/05/05 has not been met. Petty cash and the homes other monies must only be used to purchase appropriate items for the home or service users. The Manager must keep his own expenditures seperate from the businesses expenditures. This is a restated requirement. The previous timescale of the 13/04/05 has not been met. 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 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. 2. 3. Refer to Standard 23 9 Good Practice Recommendations The home should purchase a safe deposit box to safely keep service users monies in rather than keep them in an envelope in the service user file. Individual risk assessments should be reviewed and expanded to include absconsion from the placement. This is a restated recommendation. Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Gredley House 1-11 Broadway 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. Extracts may not be used or reproduced without the express permission of CSCI Shalom Home G57 G06 S22875 Shalom Home V241737 270705 Stage 4.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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