Inspection on 16/10/06 for Sharon House

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sharon House 08/11/07

Sharon House 05/02/07

Sharon House 21/03/06

Sharon House 12/09/05

Sharon House 14/12/04

Sharon House 21/06/04

Similar services:

Cowden Road, 52 - 54

Norbury Crescent (30)

Chatsworth Care - Tudor Lodge

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

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

CARE HOME ADULTS 18-65 Sharon House 24 Sharon Road Enfield Middlesex EN3 5DQ Lead Inspector Jackie Izzard Key Unannounced Inspection 16 October 2006 09:30 Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sharon House Address 24 Sharon Road Enfield Middlesex EN3 5DQ 020 8804 5739 F/P 020 8804 5739 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 Chandra Jootun Mr Chandra Jootun Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two specified service users who are over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. 21st March 2006 Date of last inspection Brief Description of the Service: Sharon House is situated on a quiet residential road in Enfield, a short walk from Brimsdown train station. Residents can reach Enfield Town by bus or train. The home is registered for five adults aged between 18 and 65 years who have a learning disability. There is also a condition allowing the home to continue to care for two people who are now over the age of sixty five. The current residents are aged between 62 and 80 years. The home is owned and managed by Mr Chandra Jootun. The cost of placements was reported by the manager to be £570-680 per week. Following “Inspecting for Better Lives”, the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. THIS SUMMARY IS WRITTEN FOR THE PEOPLE WHO LIVE AT THE HOME The inspector arrived at the home at 9.30am on 16 October without telling anyone she was coming and stayed for about six hours. She met the five people who live at Sharon House and spoke with four of them. She spent from 9.30 until 10.45am with them. The inspector also talked to staff on duty, looked around the building, looked at the records and spent time with the owner/manager, Mr Jootun talking about the things he was asked to at the last inspection of the home on 21 March 2006 and seeing what progress had been made since then. What the service does well: What has improved since the last inspection? At the last inspection of Sharon House in March 2006, the inspector made 19 requirements. These were things that Mr Jootun must do to improve care of the people living in the home and to ensure the home meets the standards expected of all care homes in this country. 8 of the 19 requirements had been completed. • 2 care plans seen had been updated within 6 months. DS0000010653.V312879.R01.S.doc Version 5.2 Page 6 Sharon House • • • • • • • Regular meetings had been held with residents so that they can talk about what they think of the home one resident has been given a key to his bedroom medicines are stored in a large filing cabinet written guidance has been provided to tell staff what to do if a resident may have been abused copies of staff identity have been collected Mr Jootun has started meeting with staff individually to talk about how they do their job(this is called “supervision”) the electrical equipment has all been checked to make sure it is safe to use. 1 requirement could not be checked. This was to make sure anything staff agree to do at a resident’s review meeting is written into their care plan. Most residents have not had a review since the last inspection so this could not be checked but Mr Jootun said he will make sure that it is done. What they could do better: Mr Jootun was asked by the inspector to write and tell her which of the 19 requirements(things that Mr Jootun must do for the benefit of people living at the home) had been completed. He wrote to the inspector saying that all but 1 of the requirements had been done. But the inspector found that 11 requirements had not been fully completed. These have all been repeated in this report and Mr Jootun agreed that he would do all these things in a short time. These are: • • • • To write clear behaviour guidelines so that all staff are working with one resident in the most helpful way To write clear guidelines on how staff support a resident who has some difficulties with eating To keep clear records of what doctors are doing for a resident who is ill and write in their care plan what staff should do to help them To write guidelines for staff on when medicine should be given to a resident to help control behaviour. This is to make sure all staff know how best to help the person. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 7 • To arrange training for all staff on how to support people who have challenging behaviour and how to help them calm down if they are getting aggressive To ensure all staff have a CRB check. This is a check that Sharon House must arrange to see if staff have any criminal record and if they are suitable people to work in a care home. Three staff still did not have an up to date CRB check despite Mr Jootun being told that this must be done by 30 June 2006. He said that staff have applied for these CRB checks. He was asked to provide evidence of this to the inspector within one week. To make sure all staff have training in health and safety, including fire safety, first aid and food hygiene. All this training helps staff to know how to keep people safe in the home. To make sure each staff has an appraisal every year. This appraisal is a meeting to talk about how they are getting on with their job and what they might want or need to do in the future. To write a fire risk assessment which says all the things in the home which could cause a fire and what the home is doing to make sure this does not happen. To write a plan for the home for the next year • • • • • It is a concern that so many things have not yet been done. 2 requirements which were completed but need more work are: • Although Mr Jootun had updated care plans after six months, these had not been changed if a person’s needs changed before the six months. It is very important to change the care plan if somebody’s needs change so that all staff know how to care for that person properly. One person had been seriously ill and his/her needs had changed but the care plan was not changed. Mr Jootun’s meetings with staff on their own (supervision) did not meet the standard expected in care homes. The inspector showed him in the book of standards what he should talk to staff about. • New requirements have been made at this inspection. These are: • To find out what the medicines people are taking are for, so that staff can understand the reasons for the medicines, and help them know how to keep an eye on if medicine is working Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 8 • To make sure all staff write down every time a resident has seen a doctor, psychiatrist etc and what the result of the visit was. This is to help make sure that any health problems are sorted out as quickly as possible and also to make sure all staff know what the doctor said or did. To make sure staff are given clear guidance straightaway about any medication changes. To make sure that the Commission for Social Care Inspection (CSCI) is notified every time something important happens at Sharon House, for example, if a resident is seriously ill. • • Unmet requirements impact upon the health and safety of service users. Failure to comply with the timescales will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 9 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 Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 10 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): None of these standards were assessed at this inspection. EVIDENCE: No new service users have moved into the home since the last inspection so standard 2 was not inspected on this occasion. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is poor. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are consulted on decisions affecting their lives, but it is not possible to say that their changing needs are reflected in their care plan nor that they are receiving the appropriate and consistent support with more complex needs. EVIDENCE: The inspector looked at three of the five service users’ care plans in detail. Although these are reviewed six monthly, they did not necessarily reflect current needs. Since the last review, one service user’s care needs had changed due to serious illness and this was not mentioned in the care plan. The inspector advised the manger that care plans must be reviewed at least six monthly as a minimum but whenever care needs change. It was of concern to find that requirements to produce guidelines for managing one service user’s behaviour and another’s difficulties with eating had not been carried out. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 12 The manager showed the inspector a letter showing that the psychiatrist agreed with the home’s practice of threatening to withhold cigarettes from a service user, but the manager had not produced guidelines for staff on working with this person’s behaviour to ensure an appropriate and consistent approach. The service user said to the inspector that he was sent to his bedroom when he was naughty or bad. The requirement to produce guidelines for staff, agreed by care professionals involved in this person’s care, is repeated. The manager agreed to do this within a week for this inspection which is positive. The inspector also discussed the importance of written guidelines in the care plan for staff on how to support a service user who is reluctant to eat. This has become even more important since this person has been ill and weight records show a continued weight loss over recent months. From talking to one staff member and observing a mealtime, the inspector was satisfied that staff were doing their best to assist and support this person with eating. As well as the requirement for written guidelines on this issue, a recommendation is made to assess whether a daily record of food eaten by this service user would be of benefit and weekly rather than monthly weight records due to the marked weight loss during illness. Service users take part in regular meetings to say what their wishes are and make requests. Records of these were seen. Their finances were not inspected on this occasion. None of the service user manages their own money or medication. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 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): 12, 13,114, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are offered a healthy diet and like the meals. They have the opportunity to take part in some activities and go on annual holiday. EVIDENCE: The inspector discussed with the manager her observation that all the service users waited until 10am to have breakfast as a group and did not prepare their own breakfast or drinks. The manager said that service users are not able to use a kettle but one service user would sometimes make drinks for the group. He also said that some people could get their own cereal but chose not to. Service users are involved in daily chores such as setting the table for meals and tidying. One person’s activity programme stated that he made sandwiches and cakes with staff support on a regular basis which is positive. The inspector looked at the weekly activity programme for one service user then looked at daily records to see if the activities were taking place. These had not all taken place. The manager said that the programme is flexible depending on whether the service user wants to do the planned activity. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 14 He said that records of activities are sent to the service user’s care manager on a monthly basis so the suitability of the activity programme is assessed by her. This service user goes to college once a week and another goes to a day service. The other three are based at the home. During the inspection, two service users went to a local pub with a member of staff. Three service users said that they enjoyed regular outings to a local pub for a meal. Service users told the inspector about their last holiday where they went to a seaside resort for week and all three said they really enjoyed it and were going to the same place next year, one person showed the inspector photographs of this holiday. Service users said they liked music, television, reading (one service user) and games such as dominoes. The inspector saw a service user playing an organ, another reading and another watching television. Two took part in an art activity. The appropriateness of the art activity in the home was discussed with the manager. Two service users were asked about the food and both said they liked the food. They had fish for lunch on the day of the inspection. One person has lost weight for the benefit of his/her health since living at Sharon House and eating more healthily. In records of service user meetings it was noted that a service user had suggested activities he would like to do but had not yet done. A record should be kept as to whether a service user’s requests for activities have been met. The inspector spent over an hour talking to service users and two service users were able to tell the inspector of their personal interests and a discussion on past comedians was enjoyed. One said he enjoyed Christmas in the home and had not enjoyed this festival before living here. Service users get on well with each other. The inspector saw that service users could spend time together as a group or alone in their own room as they wish. Service users are visited by family and friends and the inspector observed a visit taking place in a service user’s bedroom so that the visit could take place in private. Another service user told the inspector that he goes to Southend with his aunt and sometimes goes with his aunt to stay with relatives in London and asked that this information be included in the inspection report. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 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 Quality in this outcome area is poor. This judgement has been made using evidence gathered both during and before the visit to this service. Although there was no evidence that service users’ health needs were not being met, record keeping regarding health appointments, medication changes and health needs need to contain more detail before service users can be assured that their health needs are being fully met. EVIDENCE: The inspector spoke with a relative of one service user who said that s/he was “100 satisfied” with the care provided at Sharon House, including how staff cared for the service user during a period of illness. Two service users who were asked by the inspector if they were happy at the home, said that they were and that staff looked after them well. At the last inspection of the home in March 2006 the inspector was concerned that the healthcare records for one service user did not contain enough detail about medical appointments, the purpose and outcome of the appointments and whether the home should be doing anything specific to assist the person who was unwell. At this inspection, some similar concerns were found. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 16 One service user’s care plan and health care records did not contain any guidance for staff on what support the person needed during and after a serious illness. Records also indicated that this service user had specific symptoms twenty days before s/he was taken to see the GP about the symptoms. Another GP appointment which may have been for these symptoms contained insufficient detail to show what the appointment had been for. Records showed that all service users saw a dentist, optician and chiropodist as needed and these records were clearly recorded. A requirement was made at the last inspection that written guidelines were developed for the use of PRN medication for one service user to ensure staff knew when to administer it. This had not taken place despite the medication being given for a further four months after that inspection. The manager told the inspector that this service user’s PRN medication had been discontinued recently but there was no record of the visit from the psychiatrist where this decision was made. Nor was there any record in the care plan , medication sheet or health record that the medicine had been discontinued. The manager said he was awaiting a letter of confirmation from the psychiatrist which is why he had not recorded the appointment. Staff had discontinued the medicine but four tablets were missing with no record on the medication sheet of these tablets. The inspector was informed that when the service user went to stay with a relative the tablets had been requested by the relative and one of the staff had given the medicine to the relative and had not said that it had been discontinued. The manager and staff did not know what certain medicines that two service users were taking were nor what they were prescribed for. A requirement is made that the manager find out this information from the pharmacist. Medication daily records were generally good with the exception of a tablet being signed for but not given on the morning of the inspection. The manager was asked to remind staff to sign for each tablet so they know they have given medication correctly. One service user had a serious illness in recent months and was being cared for by staff after an operation. District nurses were visiting regularly to provide nursing support. From discussion with a relative and a staff member, it was clear that staff were caring for the service user at the time of the inspection despite no information in the care plan detailing what his/her current health and personal care needs were. Staff on duty were caring towards service users and knew them well. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are protected by staff trained in adult protection issues but would benefit from staff being provided with training on how to appropriately deal with challenging behaviour. EVIDENCE: There have been no complaints about Sharon House to the home or to the CSCI since the last inspection of the home. After a requirement was made at the last inspection, the home now has an adult protection policy advising staff on how to deal with adult protection/abuse issues. This policy was very long and it was not clear if all staff were familiar with its content. The inspector advised the manager to write a simplified procedure which is easier for staff to follow. Staff have previously received training in adult protection issues. A requirement to provide all staff with training on challenging behaviour has not yet been met but the training has been booked to take place on 7 November. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Service users live in a comfortable homely environment which is kept clean and safe for them. EVIDENCE: The home is located in a quiet residential street but has easy access to buses and trains and has local shops within walking distance. The inspector looked at all the communal rooms which consisted of ; kitchen, lounge, shower room and bathroom, laundry room. These are all clean, safe and tidy. The shower was temporarily out of action. Staff said there was a crack in the shower tray and a new shower head was needed. The inspector was told that this was being addressed straightaway. Four of the residents are able to use the bath upstairs. One is currently washing in his/her bedroom for health reasons. The inspector looked at four of the five bedrooms in the home. These were all kept clean and safe for the person living in that room and contained personal items such as photographs or music systems. The inspector respected the preference of one resident that his/her room was not looked in. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 19 Health and safety matters are assessed under the Conduct and Management section of this report. None of the people living at Sharon House need any adaptations or special equipment at this time, although one person has swapped bedrooms to be on the ground floor for health and mobility reasons. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 Quality in this outcome area is poor. This judgement has been made using evidence gathered both during and before the visit to this service. Service users benefit from a stable staff team who know them well. Closer attention to professional staff supervision and appraisal may also benefit service users. EVIDENCE: Service users are obviously fond of staff and some know the rota so that they know who to expect each day. There has been no turnover of staff since the last inspection which is very positive. Staffing levels are satisfactory to meet service users’ current needs. There are two staff on duty during the day and one awake at night with a second person on call for any emergency. All staff files were inspected and it was seen that the manager had obtained evidence of their identity after this was required at the last inspection. Supervision records were up to date but the content of these sessions was minimal and did not meet the national minimum standard,, some contained only one or two sentences. The inspector advised the manager of the standard for staff supervision. Despite a requirement being made at the last inspection to ensure all staff had an annual appraisal, the inspector saw from records that some staff had not Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 21 had an appraisal in the last year. They had completed a self appraisal form in preparation for their appraisal with the manager. A requirement about staff training in health and safety topics is made in the Conduct and Management section of this report. The manager said that all but one staff has completed or is undertaking NVQ 2 or 3 as required. The staff team does not reflect the cultural or gender composition of the four male and one female white service users. However, service users benefit from the long relationship they have had with the staff team. At the last inspection a requirement was made that those staff who had worked at the home for several years but did not have a CRB taken out by Sharon House must have this in place by 30 June 2006. It was of serious concern that these were still not in place four months after the required date. The manager said that these had been applied for and both outstanding forms had been returned as they had not been completed properly which is why there had been such an unacceptable delay. He was unable to provide any evidence of when these applications had been made so an immediate requirement was issued to provide this evidence within one week of this inspection. It was reiterated that a CRB from a previous employer is not acceptable. The manager said he understood this and was fully aware that any new staff would need a new CRB taken out by Sharon House’s umbrella body before they could begin work. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Further action is needed to ensure health and safety of service users which includes ensuring all staff have up to date training in health and safety topics. EVIDENCE: The manager has the appropriate experience to manage this home. Although the manager saw some quality assurance questionnaires which had been completed, these had not been summarised and made available for people to see the results and there was no annual development plan for the home. The inspector advised the manager to include care managers/social workers in the consultation exercise when they visit the home and develop a plan for the home which incorporates all planned work over the coming year including annual holiday and any other positive plans for service users. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 23 A requirement made at the last inspection to ensure all staff have up to date training in health and safety topics has not been completed. A requirement is made to send the inspector a summary of staff training in health and safety topics. The fire equipment had been inspected in June 2006 and the fire alarm and emergency lighting had been assessed as fit for use. Portable electrical appliances had been overdue for inspection but were tested in September 2006 and found to be safe. Staff undertake a regular health and safety inspection of the premises which is quite comprehensive. The manager’s knowledge of fire regulations was not up to date. He had not produced a fire risk assessment despite this being a requirement at the last two CSCI inspections. He has now purchased a book telling him how to devise a fire risk assessment and he showed this to the inspector. A requirement is made for the third time to produce a fire risk assessment and send a copy to the CSCI. The owner/manager had not notified the CSCI as required of the serious illness of a service user who is currently receiving nursing care in the home from district nurses. The manager said he was not aware of the requirement under Regulation 37 of the Care Homes Regulations 2001 to report any serious illness to the CSCI. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 x 3 X 2 X X 2 x Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(2) Requirement Timescale for action 13/11/06 2. YA6 15(1) 3. YA6 13(6) The registered person must ensure that all the care plans are reviewed and updated at least every six months or sooner if care needs change. All care plans must reflect service users’ current needs. The registered person must 31/12/06 ensure that the actions agreed at the service users’ next review meetings are incorporated into the care plans. The registered person must 23/10/06 ensure that the service user who has his cigarette use restricted has clear behavioural guidelines agreed with the other care professionals involved in the service user’s care. Previous timescale of 30/04/06 not met. A copy must be sent to the CSCI. The registered person must 23/10/06 ensure that the service user who is reluctant to eat has clear guidelines for supporting him/her to eat, agreed with the other DS0000010653.V312879.R01.S.doc Version 5.2 Page 26 4. YA6 12(1) Sharon House care professionals involved in the service user’s care. Previous timescale of 30/04/06 not met. A copy must be sent to the CSCI. The registered person must 31/10/06 ensure that for service users who have healthcare issues there is a clear record of what action is being taken by the healthcare professionals. The service user’s care plan and risk assessments must include what the home needs to provide for the service user to meet his/her healthcare needs. Previous timescale of 30/04/06 not met. The registered person must ensure records are kept of every appointment a service user has with a health care professional and the outcome of the appointment. The registered person must ensure that any changes to medication by a doctor or psychiatrist are recorded so that all staff are aware of the changes. The registered person must ensure that written guidelines are in place for the service user who has PRN medication to help control his behaviour. Previous timescale of 30/04/06 not met. A copy must be sent to the CSCI. The registered person must ensure the staff have all been trained on how to positively DS0000010653.V312879.R01.S.doc 5. YA19 12(1) 6. YA19 12(1) 31/10/06 7. YA20 13(2) 23/10/06 8. YA20 13(2) 31/10/06 9. YA23 13(6) 30/11/06 Sharon House Version 5.2 Page 27 support the service users who have challenging behaviours. This training must include how to diffuse a potentially aggressive situation. Previous timescale of 30/06/06 not met. The registered person must inform the CSCI when this planned training has taken place for all staff. The registered person must ensure that all the staff have a CRB disclosure provided by Sharon House. Previous timescale of 30/06/06 not met. The registered person must supply written evidence that two outstanding CRB disclosures have been applied for to the CSCI. This is an immediate requirement. The registered person must ensure that all the staff have regular supervision, the content of which meets standard 36 of the National Minimum Standards for care homes for adults. The registered person must ensure that all the staff have an annual appraisal. Previous timescale of 30/04/06 not met. 14. YA39 24(1)-(3) The registered person must 31/12/06 undertake a quality assurance exercise seeking the views of the service users, relatives and other care professionals and once the views have been received this DS0000010653.V312879.R01.S.doc Version 5.2 Page 28 10. YA34 19(1)-(5) 30/11/06 11. YA34 19(1)-(5) 23/10/06 12. YA36 18(2) 30/11/06 13. YA36 18(2) 31/12/06 Sharon House must be collated into an action plan. Previous timescale of 31/07/06 not met. The registered person must prepare a fire safety risk assessment. Previous timescales of 31/10/05 and 30/04/06 not met) 16. YA42 18(1)(c) The registered person must ensure that all the staff have up to date health and safety training including fire safety, food hygiene and first aid. 30/01/07 15. YA42 23(4) 31/10/06 17. YA42 18(1)(c) 18. YA42 37 Previous timescale of 31/07/06 not met. The registered person must send 13/11/06 the inspector a written record of what health and safety training each staff member currently has. The registered person must 31/10/06 ensure all notifiable incidents as detailed in Regulation 37 of the Care Homes Regulations 2001 are reported to the CSCI without delay. Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 29 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 YA17 Good Practice Recommendations The registered person should assess whether there is a need for keeping records of the food eaten by a service 21/11/06user who has some difficulties with eating, and to keep weekly records of this person’s weight rather than current monthly records so that staff can respond promptly if s/he continues to lose weight. The registered person should simplify the adult protection procedure for the home so that all staff can easily understand it. 2. YA23 Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Sharon House DS0000010653.V312879.R01.S.doc Version 5.2 Page 31 - 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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