Inspection on 13/10/08 for Shila House

This inspection was carried out on 13th October 2008.

CSCI found this care home to be providing an Adequate service.

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

Shila House 17/09/07

Shila House 22/06/06

Shila House 16/02/06

Shila House 13/07/05

Shila House 08/11/04

Shila House 28/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOME ADULTS 18-65 Shila House 49-53 Main Avenue & 1 Poynter Road Enfield Middlesex EN1 1DS Lead Inspector Jackie Izzard Unannounced Inspection 13th October 2008 09:00 Shila House DS0000010620.V372218.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 Shila House DS0000010620.V372218.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. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shila House Address 49-53 Main Avenue & 1 Poynter Road Enfield Middlesex EN1 1DS 020 8367 8774 020 8350 5361 shilahouse@hotmail.co.uk 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) Simiks Care Limited Delroy George Watson Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 11 people with mental health needs of either gender at 49-53 Main Avenue and 3 people at 1 Poynter Road. 17th September 2007 Date of last inspection Brief Description of the Service: Shila House is a home registered to provide care to fourteen people with a mental disorder, excluding learning disability or dementia. The home is located at Main Avenue in Enfield and the annexe is across the road at Poynter Road. There are eleven places at Main Avenue and three at Poynter Road. The home is managed by Simiks Care Limited. Many of the residents have enduring mental health issues. The home was first registered in 1994. The main house was built partly above and behind a parade of shops. Poynter Road is a small end of terrace house. Next to the home are a range of local shops and public transport. There are other leisure amenities in the local area. The annexe at Poynter Road is a semi-independent service where residents do their own cooking and other domestic chores. All have their own bedrooms and at Shila House there is a wash basin in each room. Shila House has two communal lounges and dining room areas. There are also two kitchens, one of which is for the residents to cook their own food if they wish. The home does not have a garden but does have a yard at the back of the home where people can sit. The home has staff available 24 hours a day. Most of the residents spend their time doing domestic activities in the home or going out in the local area. At the time of this inspection, in October 2008, there were eleven people living at the home and three vacancies. Following Inspecting for Better Lives the registered provider must make information about the service, including inspection reports, available to the people living there and other stakeholders. Inspection reports can be obtained from the home on request. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We arrived unannounced on 13 October 2008 and spent eight hours in the home carrying out this inspection. The inspection consisted of a tour of both houses, talking to the manager and two staff members, meeting all residents and speaking individually with five residents. Four residents’ files, including their assessments, care plans and health records were inspected, along with three staff files containing information about their recruitment, training and supervision. The reason for this was to find out if residents care needs are known, recorded and met at this home. We also wanted to find out if staff were properly recruited, trained and supervised to work in the home. In addition, we observed interaction between staff and residents and looked at a selection of policies and procedures and health and safety records. Since the last inspection, a new provider has taken over Simiks Care Ltd. We had not been informed of this and so we requested to meet with a representative from the company as part of this inspection. This person attended the inspection and was helpful throughout. The requirements made at the last inspection were discussed with the manager and representatives from Simiks Care Ltd. What the service does well: Staff have formed good relationships with residents and there is a stable staff team. The lounges are made more homely by the provision of modern pictures, fish tanks, books and magazines. Staff are being provided with relevant training for their jobs which helps them to provide a better service for residents of the home. The majority of residents feel satisfied with the service they receive at the home. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 6 What has improved 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 Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether to move to this home. Their individual needs and aspirations are assessed before they are offered a place, to ensure the home can meet their needs. EVIDENCE: At the time of this inspection, a new resident was moving in during the day of the inspection. We had the opportunity to assess the admission process for this person and look at his/her assessments. It was evident that the resident had been given a copy of the updated Service User Guide informing him/her about Shila House. In addition the resident had been to visit and had stayed overnight to “test drive” the home and see if s/he wanted to move in. There were assessments in place showing that the manager had visited this person in his/her previous placement and carried out an assessment of his/her needs and aspirations before offering a place at Shila House. We also discussed the admission process for the home with a resident who had lived at the home for approximately 1 year. This person also said that the manager had visited him/her to carry out an assessment before offering a Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 10 place at the home. This person had also visited the home on a number of occasions to ensure s/he wanted to move there. Shila House DS0000010620.V372218.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are satisfied that their needs are known and recorded ina plan for their care and they are supported to make their own decisions where possible. Residents are at risk if they are responsible for their own cooking due to a lack of risk assessment and staff support in this area. EVIDENCE: We looked at the care plans for three residents. We carried out a case tracking exercise, where we looked at the assessments, care plans, risk assessment, daily records and other records relating to three residents and then discussed their care with them and/or the manager and staff to see if their needs were known and met. We selected one resident who lived at Poynter Road and was therefore assessed to be living more independently. We then selected one male and one female resident from the main house. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 12 We saw that each of the three residents had a care plan and that care plans were being reviewed regularly. There is a significant improvement since the last inspection where care plans were out of date and did not reflect residents current needs. Residents confirmed that they had been involved in reviewing their care plans and generally agreed with the content. Risk assessments were in place and up-to-date for two of the residents. This is also a significant improvement in the last year. The quality of risk assessment has also improved, giving clear detail of the risks relevant to that individual and the management plan for addressing these risks. The manager showed us a new care plan format which is to be introduced. The new formats will be an improvement on the current format as it addresses peoples holistic needs. The manager said that this new format will be implemented in the very near future and we concluded that this will benefit residents in that their holistic care needs will be identified through the new format. Residents meet their key worker regularly and records are kept of the meetings. Residents have the opportunity to make decisions about their lives and discuss these with staff. One person goes to a café with their key worker to discuss their needs and wishes. This person said they appreciated the support given by staff. We asked three residents if they are able to make their own decisions and all said they were encouraged to be as independent as possible. This was verified by looking at their progress records and discussing with the manager. Two people who were reluctant to go out of the home last year had been encouraged to make small steps to get out of the home and both had achieved a great deal and were able to go out locally independently. Both said that staff had supported and encouraged them to work on this area. One persons risk assessment was not satisfactory. Despite a requirement being made at the last inspection in 2007 to undertake urgent risk assessments regarding the risk of food poisoning for people living at Poynter road, this was only carried out for one of the two residents. One persons risk assessment did not include the risk of food poisoning. From discussion with this resident and inspection of the fridge in the home, it was clearly evident that this resident was at high risk of food poisoning. Therefore a requirement is made to urgently undertake a risk assessment and take action to reduce the risk of food poisoning for this resident. Shila House DS0000010620.V372218.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the lifestyle they lead in the home. They are encouraged to lead independent lifestyles. Residents engage in activities according to their abilities and interests. EVIDENCE: The majority of residents are able to go out alone and are encouraged to do so. Those who find this difficult are supported by staff to try and go out or to go out with staff. We spoke privately with five residents, four of whom were able to say that staff supported them to improve the quality of their life. One person said, “they have really helped me here. I have been stable for a long time here,” and “this is the best place I have stayed in”. Another said that staff were “quite” supportive. Residents have been encouraged to use a new local library and two told us that they were enjoying doing so. Most residents use local cafés and shops and others travel further using public transport. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 14 The home is improving the activities on offer to residents and trying to implement a more structured programme of activities for those who would like this. One resident said, “they play games here, Bingo and dominoes with me” and another said he enjoyed regular visits to a pub with staff and a small group of residents. Two people told us that they don’t like going out with staff but like to go out alone. The manager said he has given the responsibility for organising an activity programme to a member of staff and is expecting a programme to be implemented soon. One resident is supported to go out and buy food and undertake some culturally appropriate cooking once a week with staff which was recorded. Three people use a local mental health service and take part in leisure activities there and another attends art therapy. Residents are supported to maintain relationships with relatives and friends. Staff talk to relatives on the telephone and kept them up to date with residents’ wellbeing where a resident is not able to do this for themselves. Family contact is recorded in care plans where this is a support need. The menu has changed since the last inspection. Two residents discussed the menu with us and said they had been involved in a consultation about the food in the home and liked the improvements. A quality assurance audit showed that residents had not all been satisfied with the food previously . We asked six residents for their comments on the new menu; these were, “the food’s not bad,” “it’s alright,” “I like the food, “ “it’s better then it used to be and you get more for it, “ and “I like the puddings.” The menu is predominantly English food with a dessert every day. Three residents are diabetic and another is at risk of diabetes. The manager has advised them on appropriate diet. Residents are encouraged to take part in domestic duties and a rota of tasks was seen during the inspection. In the main house, residents have their own kitchen but there is no food stored there so if they want to prepare food they have to ask staff for the items they need. This was discussed with the deputy manager who explained that this restriction was due to the behaviours of a particular person. This matter was also discussed with the provider who agreed to reassess whether residents could have some food stored in their own kitchen to increase their autonomy. In Poynter Road, the two residents shop and cook for themselves. One resident is supported by staff and during the inspection we saw that this person went food shopping with a staff member. The other person shopped and cooked independently. From talking with this person and inspecting the kitchen it was evident that this person was at high risk of contracting food poisoning. There were eggs in the fridge which were over five weeks past their best before date, an open tin of food with inedible contents, frozen fish in the fridge and raw meat five weeks past its best before dare, stored touching other foods. The risk Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 15 assessments and care plan had no record of this risk and it was clear that no staff support nor training was being provided to this resident. A requirement is made in the previous section of this report to support this resident in this area without further delay. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported with their personal care, health and medication needs by staff. Records relating to health should be improved so that residents can feel assured staff know their health needs and that a record of their health appointments is being maintained on their behalf. EVIDENCE: The health needs of four residents were discussed with the manager and/or the resident at the inspection. In addition, diabetes was discussed as this is a current health concern for four residents. We looked at the files of four residents, two of whom had an identified medical condition either currently or in their history, for evidence of regular health care appointments with GP, consultants, dentist, etc. The standard of recording of health care appointments had improved recently but we had to look in a number of different places to see an overview of a resident’s health needs and appointments. These were recorded in their file, the homes diary and daily Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 17 records but none of these places held a complete record of an appointment, the reason for it and the outcome. A requirement is made to implement a clear system of recording health appointments for residents so that residents can feel confident that their health is being monitored properly. Medication was stored safely and securely and at a safe temperature. A sample of medication records for three residents were inspected. There were no concerns noted. Records had been completed properly. It was observed that some staff had administered medication in twos and both signed the record. Records of staff training showed that seven staff have completed medication training in 2007 (level 2 managing and safe handling of medicines) while the others need their training updated. The manager said he was in the process of booking this training. Two residents receive regular injections. One attends a local clinic for this and the other is visited at home by a community mental health nurse. A chiropodist visits every eight weeks for those who require this service. The manager has recently held a meeting for residents who are diabetic and provided information to them about diabetes and how to look after themselves better. He plans to provide this information to staff next as there are residents who are at risk from non compliance with their treatment and therefore staff need to be aware of symptoms that require medical attention. The manager said he has encouraged residents to support each other and remind each other to eat properly and not put their health at risk. This peer support may be of benefit to residents who do not respond well to staff telling them what to do so to look after their health. Personal care needs aware described in those care plans inspected so that staff know how to support each person with personal care. Some residents do not wish to have staff support in this area and their wishes are respected. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and they are protected by staff trained in safeguarding procedures. EVIDENCE: The complaints procedure has been updated as a result of a requirement made at the last inspection. Residents knew how to complain and we discussed complaints with three residents. Each said they had no reservations about making a complaint and knew how to do so. They said that staff listen and that they would talk to the deputy manager if they had any concerns as she was “good at listening and doing things for us.” We discussed with three residents whether they felt safe in the home. All three said they did. One said, “We are not bullied by staff.” We saw certificates of training showing that staff have now been provided with training on what do in the event of a resident being abused. We saw the course content and this covered following agreed safeguarding procedures. Staff said they were provided with a handbook do that they can read the procedures again to check their knowledge. There had been an incident reported to the Commission this year where a staff member was assaulted. Proper procedures had been followed for the protection of the staff member and a risk assessment had been completed to minimise the risk of further incidents. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 19 Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment which is homely and comfortable. EVIDENCE: Shila House is a building above and behind a row of shops. We inspected all the communal rooms and areas in both houses and a small sample of bedrooms in the main house. The residents are provided with comfortable sitting areas with televisions and fish tanks. In the main house a selection of books and magazines and board games are available which make the lounge area more homely. One resident said, “It’s alright here, they keep the place reasonably clean and there’s enough space for everyone.” Another said he liked having tropical fish to look at. There are two kitchens in the main house, one of which is designated as a residents’ kitchen. Both were cleaned to a satisfactory standard. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 21 The bedrooms seen were furnished and decorated but one was dirty with cigarette ends on the furniture and carpet which was not acceptable as somebody was due to move into that room on the day of the inspection. The manager said the room would be cleaned before the new resident arrived. The level of hygiene in the kitchen at Poynter Road could be improved for the benefit of the residents’ health and safety as there were areas which were dirty and sticky and the fridge was not being used safely. Outside the front door an overflow pipe was dripping. The provider said this has been reported and will be repaired shortly. A representative from the new company informed us that they intend to improve the outside environment for residents. Currently residents sit on a fire escape to smoke and do not have a pleasant environment to sit in so they would benefit from an improved outside environment. The standard of hygiene was satisfactory in Shila House. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a stable staff team who are safely recruited and provided with training to do the job. EVIDENCE: All of the four residents we asked thought current staffing levels were sufficient to meet their needs. One resident said,” they try to put me on the right road,”, another said, “ staff are alright. They tend to talk quietly to me and don’t interfere with me which I prefer,” and a third said, “ staff here are alright. They help you and listen to you and try to see you have everything you need.” All three praised the deputy manager whom , they said, always spoke respectfully to them, “treats us with respect not like patients” and spends time individually with residents. They also said they would go to her with any problem. There is only one staff member on duty at night in both houses but they have an intercom to communicate with each other if they need support and the manager told us that night staff have access to the phone at night if they need to call emergency services or the manager for advice. As a result of the last inspection, staff have been provided with basic mental health awareness Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 23 training. Nine of the thirteen staff employed attended this training in August 2008. Those who did not attend have already received training on mental health. Six of the staff team have completed or are undergoing NVQ level 3 training which is very positive as this training equips them with knowledge and skills to understand their job better. The other staff are doing NVQ level 2. We checked a sample of three staff files to see if proper checks had been taken out before they were employed. All had references, proof of their identity and a Criminal Records Bureau disclosure. This is evidence that Simiks Care Ltd have taken proper checks out to ensure residents are not put at risk of being cared for by unfit people. Supervision records for a sample of three staff were inspected to see if staff were being supervised regularly to ensure they are carrying out their duties properly. The frequency of supervision has improved as a result of a requirement made at the last inspection. The manager has chosen to delegate responsibility for supervising staff to other members of staff and he supervises those who supervise others. He said this new method is working well and that all staff still have the opportunity to meet with him if they wish to. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of this home has improved in recent months for the benefit of the residents. More formal monitoring of the service by Simiks Care Ltd and using the results of quality assurance audits to make plans for the home will result in further improvements. Residents consider that their views are listened to. EVIDENCE: A requirement made at the last inspection to ensure that the provider carries out monthly unannounced monitoring visits and produces a report on the conduct of the home (known as regulation 26 visits) has still not been met. A new provider has taken over Simiks Care Ltd a few months before this inspection. It was evident that this provider has been making regular visits to the home and has ensured that requirements made at the last CSCI inspection Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 25 have been acted on, however the monthly reports have not been carried out. A requirement is therefore made to do this and give a copy to the manager each month. The home has carried out a quality assurance audit in August 2008 where residents and their representatives were consulted for their views on Shila House. These questionnaires were seen during this inspection. A summary of this exercise and an annual development plan for the home, outlining all planned improvements for residents, now needs to be undertaken. A requirement is made to carry this out by 30 November. It was evident from looking at surveys and talking to residents, that the home has acted on residents’ views, for example by improving the quality of the food after residents raised concerns on this issue. This is positive and three residents told us that they felt listened to and thought staff would act on anything they raised. One said, “We have regular residents meetings and they do listen to our suggestions.” A sample of health and safety checks were inspected to see if the information provided on the home’s self assessment was accurate. The gas and electrical installations and appliances were up to date and the home was insured. Fire equipment was checked in February 2008 and staff test the fire alarm every week to ensure it is working properly. The last fire drill was three months ago. There were no health and safety concerns resulting from inspection of health and safety records. Staff have been provided with training in first aid and some have infection control training. The new provider which has taken over Simiks Care Ltd did not inform us that this had taken place. A requirement is made that the new provider write to our registration team and confirm that the home is properly registered without further delay. Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 2 X X 3 2 Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 27 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 YA9 Regulation 13(4)© Requirement The registered persons must ensure urgent risk assessments are undertaken for residents who are expected to shop and cook for themselves to address the risks of food poisoning from consuming out of date foods. The risk assessment must include a management plan which determines what action staff will take in this area. This requirement is restated. The registered persons must ensure that clear records of health appointments are made as evidence that health needs are being addressed. The registered persons must ensure the fridge freezer is kept in a safe and hygienic state for residents to use. This is to minimise the risk of people contracting food poisoning. DS0000010620.V372218.R01.S.doc Timescale for action 31/10/08 2. YA20 12(1)(2) 30/11/08 3. YA30 16(2)(j) 30/11/08 Shila House Version 5.2 Page 28 4. YA39 24(2) The registered persons must devise an annual development plan for the home, a copy of which must be sent to the CSCI. 30/11/08 5. YA43 26 The registered provider 30/11/08 must visit the home on an unannounced basis every month and inspect the home and prepare a written report, a copy of which must be sent to the home every month. A representative from Simiks Care Ltd must contact the CSCI registration team to confirm that the home is properly registered. 17/11/08 6. YA43 Care Standards Act RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shila House DS0000010620.V372218.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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