Inspection on 05/04/06 for Shalom Home

This inspection was carried out on 5th April 2006.

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

The inspector found 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 6 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 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 Unannounced Inspection 5th April 2006 10:00 Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 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.V287920.R01.S.doc Version 5.1 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.V287920.R01.S.doc Version 5.1 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 Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 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 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. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one Inspector over the course of a day. This was the Inspectors third visit to the home. The Inspector met with the Registered Manager, the Deputy Manager and spoke privately with one support worker. Service users personal files were inspected, as were staff personnel files and other relevant documentation. The Inspector also met privately with two service users and toured the homes premises. What the service does well: What has improved since the last inspection? The home has made good progress in addressing the requirements of the previous inspection. Service users meetings have been revamped and only supervision records relating to this home are available. Service users engaged in a range of community, occupational and leisure activities and are supported to maintain contact with their families. Service users are supported to maintain personal hygiene where a need is identified in their individual plan. Since the last inspection the home has implemented its complaints procedure and a log of all complaints received. Required policies and procedures have been revised and updated. The home quality assurance process has also been implemented. Records required by inspection were maintained and generally available. The homes communal areas and service users bedrooms have been refurbished and a current insurance certificate is displayed. The home offers a Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 6 hygienic, odour free environment and has also improved its health and safety practises regarding food hygiene and handling Core training for staff members has been identified and a number of these courses undertaken by staff since the last inspection. 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. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 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 Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 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 the following standard(s): 2 & 5. The home assesses the needs of prospective service users. EVIDENCE: There have been no new admissions to the home since the last inspection. The personal files for two service users were sampled and these evidenced that prior to their moving in the home had completed its own initial assessment and obtained relevant information from other agencies including Care Programme Approach documentation. The Inspector was shown copies of the homes contracts with service users, these were found to include details of the services offered and costs involved. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8, 9 & 10. The home assesses service users needs and develops individual plans and risk assessments to address these. Plans and risk assessments are regularly reviewed and service users are encouraged to participate in the day-to-day running of the home. EVIDENCE: The Inspector sampled the individual care plans for the three service users living at the home. The areas covered in the individual plan correspond with needs identified in the Care Programme Approach documentation. The plans address each service users personal, social and healthcare needs. All service users have an individual plan relating to their health care needs, social and community activities and maintaining the homes environment. Plans addressing particular service users needs such as support with personal hygiene and support with budgeting have also been developed and implemented. Each care plan has an attached evaluation sheet and this evidenced that the plans are reviewed at least six monthly, or in some instances more frequently if service users needs have changed. Support workers also complete a daily Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 10 record sheet for each individuals care plan, recording any issues or progress that have been made that day in implementing the plan. From sampling the evaluation sheets and daily record the Inspector was satisfied that individual plans are being comprehensively reviewed. Individual plans are signed by the service user to indicate their agreement and commitment to participate in the plan. Two service users receive support to manage their finances. Details of the support they receive are detailed in their individual plan. These service users have agreed to staff holding their monies in a lockable box in the staff office. Service users then request from staff in a small daily allowance. A record sheet signed by staff and service users details deposits and withdrawals. The Inspector sampled service users personal files to establish the homes current risk assessment tool and its implementation. Since the last inspection the home has restructured the tools it uses to assess and manage risk. Each service user now has a general risk assessment that addresses areas such as self-harm, self-neglect and dangerousness. A tick box system indicates whether there is a current or past history of behaviours. An indication that a service user has current risk behaviour leads to the completion of a detailed risk assessment for that particular behaviour. The Inspector was satisfied that this is a coherent system that had been properly implemented. Detailed risk assessments completed for individual service users included risk of absconding, non-compliance with medication and challenging behaviours. One service user who has developed mobility difficulties has been assessed for moving and handling. All of the detailed risk assessments viewed by the Inspector had been reviewed in March 2006. The Inspector asked to see the homes policy and procedure for unexplained absences by service users and was advised that the home does not currently have such a policy. The Inspector was advised that the home facilitates monthly service users meetings and that the aim of these is to include service users in the day-today running of the home. The Inspector sampled the minutes of these meetings and noted that since the last inspection the format of the meeting has been revised. A checklist for the meetings facilitator states that service users should be the focus of the discussion and that service users comments and suggestions should be properly discussed and recorded. The minutes of the actual meetings evidenced that recently service users have had a discussion regarding the homes smoking policy and agreed on smoking and non-smoking areas within the communal spaces. Service users have also used these meetings to make suggestions. The Inspector noted particularly that one service user who is very reticent to participate in any activities had suggested a visit to the pub and the activities log evidenced that this had been Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 11 organised by staff with a good take up from service users. The minutes of service users meetings are signed and dated. From sampling of a variety of records including service users personal files and staff supervision records the Inspector was satisfied that information relating to service users is accurate, secure and confidential. The Inspector also viewed the homes confidentiality policy and noted that this includes guidance to staff on the circumstances when confidentiality may need to be breached, for example an adult protection allegation. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. The home supports service users to develop independent living skills and to engage in appropriate community, leisure and occupational activities. EVIDENCE: Discussion with service users, support workers and sampling of individual plans evidenced that service users are supported and encouraged to develop independent living skills. One service user manages their finances independently and visits the bank weekly to manage their account. Another service user is supported to develop their cooking skills in a planned weekly practical session with a staff member. All service users have identified tasks to undertake in the communal areas and in their rooms to maintain the homes environment. The staff member on duty advised that the home obtains information about local activities through “Newham Magazine” and by direct contact with local resources such as the Theatre Royal. Information about local activities and events is discussed in the service users meetings and displayed on a notice board in the lounge area. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 13 Discussion with service users, sampling of the homes activities log and service users meeting minutes evidence that service users are engaged in a range of activities that they have identified as being of interest. All service users have participated in a regular weekly meal out and in a pub social evening. Some service users are supported to attend a local snooker hall and to participate in the homes weekly shop. Other service users have been supported to take a short holiday, attend church and visit local cafes. Service users have also been supported to attend local day services and community resources such as the cinema and theatre. Service users have been supported to obtain freedom bus passes and state that they are able to choose when to be alone or in company, and when to join in an activity. Within the home service users are able to access a stereo system with radio and satellite television. Several service users fedback to the Inspector that staffs select particular satellite channels to watch, and service users would prefer to have more choice in when the television is switched on and what is watched. Service users have the opportunity to make friends in the community through the range of activities they are now engaged in. Additionally all of the service users are supported to maintain appropriate relationships with their families. The Inspector sampled the record of meals offered in the home. This evidenced that a variety of nutritious meals had been offered to service users. Discussion of the meals to be included on the menu takes place at service users meetings. Service users fedback to the Inspector that they enjoyed the quality and variety of meals offered. Service users also stated that they found mealtimes to be relaxed and unrushed and flexible to suit service users activities and schedules. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users healthcare needs are met and personal care is provided in the way they prefer. However, the home must continue to develop and improve its medication administration and recording practises. EVIDENCE: The Inspector spoke with service users and sampled their individual plans. This evidenced that service users who require assistance with personal care receive sensitive support. One service user requires prompting to take a bath; another requires assistance with managing incontinence. Service users preferences for how they receive their care are included in the care plan and observed during practise. Service users choose their own clothes and their appearance reflects their personality. Each service user has an individual plan addressing their healthcare needs. A record of all healthcare appointments attended and the outcome of these are recorded on the attached daily record. All service users are registered with a local GP. Service users have also been supported to access specialist NHS services such as continence management. One service has diabetes that requires monitoring of their blood sugar levels. Correspondence on their personal file from the diabetic nurse outlines the arrangements for blood sugar monitoring including the frequency and actions Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 15 to be taken if blood sugar levels fall outside acceptable parameters. The daily record sheet evidences that these instructions have been followed and includes a record of all blood sugar levels taken. The Inspector viewed the homes medication policy and procedure. This was found to be appropriate for the current situation in the home. The policy does not include self-medication and at present none of the service users are ready to self medicate. The home should consider developing its policy to include self-medication. Since the last inspection the home have implemented a new recording system for the recording and administration of medicines. A medication file with a section for each service user includes a Medication Administration Record (MAR), a record of all medicines received and a list of any “as required (PRN)” medication. The new format provides an easy to access overview of service users medication. The majority of service users medications are administered via dossett boxes that are filled by the local pharmacist. When comparing the contents of the dossett box to the homes MAR, the medication available to service users did not correspond with that recorded on the MAR sheet. One medication loaded in the dossett box did not appear at all on the current or previous MAR sheet. For a second service user available PRN medication and a cream did not appear on the MAR. The Inspector was advised that these two medications had been discontinued. However, there was no record of this and the medications had not been disposed of. The homes medication administration and recording practises are subject to Enforcement Notices issued by the Commission for Social Care Inspection. The Commission accepts that some improvements have been made in this area, and shortfalls relating to the administration and recording of medication will therefore be dealt with by way of a requirement on this occasion. The home must continue to develop and improve its medication practise and this will be closely monitored over future inspections. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. The home has developed its practise in listening to service users and protecting them. EVIDENCE: The Inspector viewed the homes complaints policy. This includes guidance on how to make a complaint, the timescales within which the home plans to respond and contact details for the Commission for Social Care Inspection. The Inspector viewed the homes complaints log. Since the last inspection a service user had made one complaint. This related to an allegation of money being stolen from their room. Along with the complaint details of an investigation undertaken by the manager and the outcome were also recorded. An individual plan was subsequently developed with the service user to support them to safeguard their money. The Inspector also viewed the homes adult protection policy and procedure. This includes definition of different types of abuse and includes appropriate reference to the homes whistle blowing policy. The Inspector noted that in the event of an allegation being made against the manager, the policy state that a report should be made to the registered person. As the responsible individual and registered manager are the same person, the policy should be revised. Staff training addressing adult protection was held at the home in 2005. The Inspector spoke with a staff member on duty and was satisfied that they understood the types of abuse service users could be subjected to and were aware of the homes policy and procedure should they have any adult protection concerns. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30. The home has recently been refurbished and service users now benefit from a comfortable, hygienic environment that meets there identified needs. EVIDENCE: Since the last inspection the home has been redecorated throughout and new flooring installed in two service users bedrooms, the office and the stairway. A recent assessment of one service user needs highlighted increasing mobility difficulties. With their consent and involvement their bedroom has been relocated to the ground floor with the staff office and sleep in room being relocated to the first floor. Feedback from the service user indicates that the new arrangement is more suited to their mobility needs and they are happy with the new arrangement. The property comprises of an entrance porch, open plan communal lounge that incorporates stairs to the first floor, and a kitchen diner to the rear with a garden off. These communal spaces were comfortably furnished with a range of sofas, chairs, and a dining table. There is also a bathroom and one service users bedroom located on the ground floor. On the first floor there are a further two service users bedrooms and the staff office which doubles as the sleep in room. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 18 A current registration certificate and current insurance certificate were displayed in the homes hallway. Two service users showed the Inspector their bedrooms. These were noted to include sufficient and suitable furniture and fittings to meet their needs. Each service user has a choice of single or double bed, chest of draws, wardrobe and desk. One service users room has had its vanity basin removed in accordance with a risk assessment. Service users share a ground floor bathroom with shower over and WC. The premises were found to be clean, hygienic and free from odours on the day of inspection. All of the maintenance and repairs identified at the previous inspection have been completed. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Service users are protected by the homes recruitment practise and supported by competent staff. However the home must continue to develop its practise with regard to the supervision and appraisal of staff. EVIDENCE: The Inspector viewed the homes recruitment policy and procedure. This requires revision to include guidance on obtaining an enhanced Criminal Records Bureau check prior to taking up employment. The personnel files for three staff members appearing on the current rota were requested. One member of staff had yet to undertake their rostered shift, and the Inspector was advised that they are currently employed at the Registered Managers other home. The personnel records were requested but did not arrive on the day of the inspection. The Registered Manager stated that this member of staff would not work their rostered shift in the absence of information required by Schedule 2 of the Care Home Regulations. The Inspector sampled two staff personnel files and evidenced that both contained two satisfactory references, a current enhanced level Criminal Records Bureau (CRB) check obtained by Shalom Homes, appropriate proofs of identity and copies of relevant qualifications. Where appropriate, confirmation of overseas nationals entitlement to employment had been obtained. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 20 Both personnel files were found to contain a completed induction record. The Inspector noted however that a large proportion of support staff work across both Shalom Homes. The Inspector recommends that the familiarisation with environment section of the induction record be revised to reflect this. At present the home employs four support workers, a deputy manager and the Registered Manager. No new staff had been recruited since the last inspection. At present 3 staff are undertaking NVQ level 2 studies. One member of staff has completed NVQ level 2 and the deputy manager has completed NVQ level 3. The home has identified core training for all support staff, and this includes food hygiene, adult protection, medication, NVQ, first aid, fire training and continence management. Adult protection refresher training was given to staff in 2005. A programme of medication training over six sessions is currently being given to staff, and the deputy and registered manager are additionally undertaking continence management training. The Inspector was advised that the home is also hoping to offer health and safety refresher training to staff in the coming year. By sampling staff personnel files the Inspector evidenced that supervision records are maintained for each session, and that only records relating to this Shalom Home are available. The Commission for Social Care Inspection had recently issued Enforcement Notices requiring that staff receive a minimum of six supervisions sessions per year and a staff appraisal. The Registered Manager showed the Inspector a supervision schedule for the coming year. This plans for each staff member to receive a minimum of six supervisions. The Registered Manager also showed the Inspector a draft copy of an annual appraisal the home is aiming to introduce from June 2006. The Commission accepts that some improvements have been made in this area, and shortfalls relating to the supervision and appraisal of staff will therefore be dealt with by way of a requirement on this occasion. The home must continue to develop and improve its practise in this area and this will be closely monitored over future inspections. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 21 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. Service users are benefiting from improvements in the management and dayto-day running of the home. EVIDENCE: The Inspector was able to evidence much greater compliance with the management elements of National Minimum Standards during this inspection. The Inspector reviewed the homes attendance log and evidenced that the Registered Manager was recorded as having been on site for on a full time basis during the previous month. The Registered Manager has commenced NVQ level 4 studies. Since the last inspection the senior support worker has been promoted to deputy manager. The new management arrangements appear to be benefiting staff and service users by creating a clearer sense of direction and leadership. The Inspector sampled the homes own quality assurance tool and noted that this had been fully completed the Registered Manager advised that this tool would be revised on an annual basis. Since the last inspection the home have Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 22 sent out feedback surveys to service users families, other professionals involved in the care of service users and other stakeholders. Annual service users feedback questionnaires are due in May 2006. The Registered Manager advised that the outcomes from surveys would be published in the homes Service Users Guide from June 2006. The policies and procedures sampled by the Inspector were generally found to comply with legislation and were generally evidenced as being implemented in the homes practises. Exceptions to this are detailed in the requirements section of this report. With the exception of one personnel file, all records required by regulation were available for inspection on this occasion. The records sampled were found to be up to date and in good order. The Inspector viewed the homes petty cash records dating back to the previous inspection and found these to be in order. The records of fridge and freezer temperatures were also sampled and found to be within the limits recommended to the home during a recent environmental health inspection. Fire records evidence that weekly fire alarm tests are carried out and that no problems have been identified. A fire drill for service users and staff was carried out in March 2006 and evacuation times recorded. The Inspector viewed the contents of the homes fridge freezer. Started food items stored in the fridge were appropriately labelled. Two unlabelled packages were found in the freezer. The Inspector sampled the contents of the dried food cupboard and found their contents to be appropriately labelled and well within best before dates. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 3 2 3 Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 24 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 YA9 Regulation 17 & Sch 4 Requirement The homes must develop a procedure for staff to follow in the event of a service user becoming missing. The home must further develop its medication administration and recording practises. All current medication including PRN must be recorded on the MAR. Discontinued medications must be recorded as such and appropriately disposed of. 3. YA23 13(6) The homes adult protection policy and procedure requires further revision to include procedures if an allegation is made to staff against the manager. This is a restated requirement the previous target of the 28th Feb 2006 was not met. 4. YA34 19 The home must revise it recruitment policy to state that an enhanced CRB check must DS0000022875.V287920.R01.S.doc Timescale for action 31/07/06 2. YA20 13(2) 31/07/06 31/07/06 31/07/06 Shalom Home Version 5.1 Page 25 be obtained as part of the pre employment checks. 5. YA36 18(2) Staff must receive an annual 31/07/06 appraisal with their manager to review their performance. This is a restated requirement. The previous target of the 28/02/06 was not met. Staff must receive a minimum of six supervision sessions per year. 6. YA42 13(4) Foods stored in the homes freezer must be labelled with their contents and the date that they were frozen. 31/07/06 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 YA14 YA20 YA35 Good Practice Recommendations Service users should take the lead in choosing when the television will be switched on and what will be watched. The home should revise its medication policy to include guidance on self-medication. The home should review its induction record to reflect the homes practise of employing staff across both sites. Shalom Home DS0000022875.V287920.R01.S.doc Version 5.1 Page 26 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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