Inspection on 17/09/07 for Shila House

This inspection was carried out on 17th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shila House 13/10/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Shila House 49-53 Main Avenue & 1 Poynter Road Enfield Middlesex EN1 1DS Lead Inspector Jackie Izzard Key Unannounced Inspection 17th September 2007 09:30 Shila House DS0000010620.V337229.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.V337229.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.V337229.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 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.V337229.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. 22nd June 2006 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 over the road at Poynter Road. There are eleven places at Main Avenue and three at Poynter Road. Both homes are 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 homes 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 September 2007, there were twelve people living at the home and two vacancies. The current fees range from £450 to £750 per week. 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.V337229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced and spent eight hours in the home. The inspection consisted of a tour of both houses, talking to the manager and two staff members, meeting all residents and speaking individually with three 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. In addition, the inspector observed interaction between staff and residents and looked at a selection of policies and procedures and health and safety records. The requirements made at the last inspection were discussed with the manager and with one resident. What the service does well: What has improved since the last inspection? What they could do better: Nineteen requirements are listed at the back of this report. These are all actions that the registered provider, Simiks Care, and the manager Delroy Watson need to take in order to improve the service at this home. The requirements must be complied with in order to comply with the Care Homes Regulations 2001, the National Minimum Standards for Care Homes and to improve the quality of life for residents. The high number of requirements reflects the number of areas which do not meet the required standard. The registered persons need to concentrate on making these improvements for the Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 6 benefit of their residents. Improvements are needed in the areas of risk assessment, care planning, supervision of staff, staff training and health and safety issues. Further information on requirements can be found in the relevant sections of this report. 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. The summary of this inspection report can be made available in other formats on request. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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 Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,4 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed before being offered a place. The information they are given needs to be updated to ensure it is accurate. EVIDENCE: Since the last inspection two new residents have moved into Shila House. The inspector was able to meet one of these residents who confirmed that s/he was given information about the home and given the opportunity to visit before deciding to move here. The most recent resident was away at the time of this inspection. The manager said that this person had visited the home beforehand and that his/her needs were assessed by the manager who visited the resident in hospital. The inspector saw that assessments had been carried out for these two people and were present on their files. The home’s service user guide which informs people about the home was dated 2003 and needs to be updated to ensure the information is accurate. A requirement is made to do this. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to make decisions and their individual preferences are respected, however the standard of care planning and risk assessments is inadequate and so they cannot be assured that all their needs are known and will be met. EVIDENCE: To assess these standards, the inspector spoke privately with two residents and read the care plans, risk assessments and daily records for four residents then discussed these with the manager of the home. All four residents had a risk assessment but two were dated 2003 and there was no evidence that these had been reviewed regularly despite obvious changes to their care needs. One had been reviewed in 2005 and there was no record of the other being reviewed at all. One person’s risk assessment Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 10 contained insufficient detail regarding the identified risks of self harm , fire raising and assault and a requirement is made to address this. Care plans were not satisfactory. One resident had a CPA meeting on 6 August 2007 and care plan was discussed but this had still not been drawn up and an old care plan from a previous placement was in use. Another care plan was dated 2003 and had no record of being updated since then. Another had no date and the fourth had not been finalised. The plans were of a basic standard. The inspector discussed careplans with one resident who had no knowledge of their own care plan and had not signed it as evidence that they had seen and agreed to it. The standard of care plans does not reflect the work that staff are doing with residents and this needs to be improved. Residents said they are able to make decisions for themselves. People are allowed to go out independently and are able to use the residents’ kitchen to cook for themselves if they wish to and to make themselves drinks. Some residents do not wish to socialise with the others or to cooperate with staff. From discussion and observation, the inspector considered that their individual preferences were respected by staff who appeared to have a good knowledge of residents’ needs and wishes. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16, 17 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff support resident to go out into the community, although there are no organised activities. Residents’ rights and their relationships are supported. Residents at Poyner Road need more support with food safety to reduce the risk of food poisoning, meals in the main house are regarded as satisfactory. EVIDENCE: The majority of residents are able to go out in the local community and further afield using public transport. They are encouraged to retain their independence in this way. Staff offer to go out with those who need support or who would like company. On the day of the inspection a member of staff went out for lunch with three residents and residents said they are offered the change to go out to local pub and park when they wish to with staff. A group Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 12 had done this a few days prior to the inspection. Some residents do not feel able to leave the home and this is respected. There is very little use of local mental health services, either dayservices, adult education nor sheltered employment opportunities. This is an area the manager may wish to address with residents to ensure they are aware of what is on offer to them. None of the residents use any dayservices. One person attends an art therapy session and some use the library. There are no planned activities. The manager said that any activities are planned on a daily basis. One person was supported to go paintballing recently which was his choice. This summer eight residents and four staff went on holiday to Butlins. They contributed to the cost and the provider, Simiks Care, paid the balance and staff costs. This is positive. Within the home there is television, music, a pool table and games and magazines provided. The inspector saw the four week menu. No choice of meal is recorded on the menu but staff and residents said that they can request an alternative if they don’t like the meal on offer. Three residents were asked for their views on the food offered and all three said they had no complaints. In Poynter Road the two residents are encouraged to be more independent and to shop and cook for themselves. They had no risk assessments regarding this activity and it was evident that support was needed. There was cheese, bread products and meat in the fridge which were all out of date. The residents said they had not noticed this. A requirement is made to undertake risk assessments for these two residents to determine what support they need to minimise the risk of food poisoning and to inform staff of what support to provide in this area. Residents are encouraged to retain their relationships with friends and family outside the home and do so. One resident had gone to stay with relatives for a few days at the time of this inspection. Another told the inspector that his relatives visit him at the home and invite him to their home. There was a selection of food in Shila House including fresh fruit for residents to hep themselves to. Rights and responsibilities were discussed with two residents. Both felt that had been made aware of their rights and responsibilities. One said he felt that staff were not supporting his goals and was advised to discuss his concerns at his next review, which he had been given the date for. No records are kept of key worker meetings so the inspector was not able to look for any evidence as to whether this resident had raised his concerns before. The manager said he is shortly to introduce recorded key work meetings which is positive. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 People using the service experience adequate outcomes in this area. 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 and to medication need to 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 to of all the residents were discussed at the inspection. Three people have a dual diagnosis of learning disability and mental ill health while three others have physical health issues. The inspector 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 was poor. It was unclear why a resident had been to the doctor/ had a blood test, etc. There was one example where staff had accompanied a resident to the GP and a blood test Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 14 was undertaken where neither the resident nor staff knew what the test was for so no proper record could be made. Staff were also not aware of the current situation regarding a health issue recorded in the resident’s history. The manager was advised that clear records of medical appointments, the reason and the outcome are necessary in order to support people with their health needs. 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. One person had current health issues and the record keeping around this was inadequate. In addition this person’s risk assessment and care plans had not been updated to reflect the current health issues. A requirement is made to do this. From discussion it was apparent that staff were offering the resident support with his/her health issues but no records were made. A sample of medication records were inspected. Generally medication recording and was satisfactory but there there were some gaps in medication records where it wasn’t recorded that a resident had refused their medication. A requirement is made to ensure medication records are accurate at all times. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted on. All staff need to be trained on adult protection procedures in order to safeguard residents from risk of abuse. EVIDENCE: The inspector looked at the home’s complaints procedures, adult protection policy and procedures, training records relating to adult abuse and records of complaints and discussed these issues with the manager and deputy manager plus two residents. The complaints procedure displayed by the front door was over five years out of date and the inspector advised that it be removed. The manager said there was a more up to date procedure which he would display for residents and visitors’ use. There have been no complaints recorded since 2003. The manager said there had been one verbal complaint two years ago but it was not recorded as it was not regarded as a complaint. The manager said that there have been no safeguarding adult investigations relating to any of the residents at Shila House. A number of staff have attended training on the protection of vulnerable adults but 50 haven’t so a requirement is made that this training is attended, to Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 16 ensure all staff know what to do if they have a suspicion or disclosure of abuse. Two residents told the inspector they would complain to the manager or deputy if they were not happy and felt that they would be listened to. Both said they had no complaints at the time. One expressed some dissatisfaction with a domestic issue and the inspector observed that staff listened and addressed this concern straight away, offering a choice of actions to the resident, which was positive. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has been been made more homely by the addition of fish tanks and pictures in communal lounges. Residents at Poynter Road would benefit from greater regard for their privacy by the fitting of locks to their toilet and bathroom and removal of discarded items from their garden. EVIDENCE: The inspector looked at all communal rooms in both houses and a sample of bedrooms. The general standard of décor and cleanliness was satisfactory. There is a refurbishment programme but this is behind schedule. Bedrooms which have been refurbished are clean and furnished decorated to a good standard. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 18 Others need to be done. The lounges are homely with pictures on the walls and fish tanks. One has magazines for residents to look at. The kitchen facilities in the main house were adequate. The ceiling was dirty but the manager said this would be cleaned shortly. The kitchen in Poynter Road needed cleaning. There was food behind the fridge and between the kitchen cupboards which would attract rodents. There were pest control measures in place due to past rodent problems in the main kitchen. The garden at Poynter Road had discarded furniture including fridge freezers which need to be removed. At the main house there is a fire escape and small yard. Staff and residents use the fire escape to sit and smoke. No smoking is permitted within the house. There are laundry facilities in the home. Bath and shower facilities are available. At Poynter Road there was no lock on the toilet or bathroom and a requirement is made to provide a suitable lock to safeguard residents’ right to privacy and dignity. The inspector asked three people what they thought of the physical environment and they said, “it’s all right here, the staff keep it fairly clean,” “it’s like a home really,” and “it’s all right. I like my room, they tell me when to clean.” Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34, 35, 36 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who know them well. They would benefit from staff receiving regular supervision to ensure they understand the residents’ needs well. The provider must assess the risks associated with night time and provide staff with access to a telephone in order to promote health and safety of residents and staff at night. EVIDENCE: There were two members of staff on duty in the main house and one in Poynter Road plus the manager on the day of the inspection. Staffing levels at night have been reduced this year and two staff have expressed concerns about this reduction. There is one staff in the main house and one in Poynter Road at night. These staff do not have a telephone to contact each other in the event of an emergency. The manager said they are expected to use their mobile phones. This is unacceptable. Staff on duty only have access to a payphone as the provider has set up the phone to be used only if the caller knows a code. Staff are not informed of the code. The inspector was informed this was due to previous abuse of the phone. Advice was given that if staff abuse the phone, disciplinary procedures should be invoked but that staff Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 20 should have access to a telephone particularly at night to contact between the two houses. No risk assessment regarding reducing night staffing was available for inspection. A requirement is made on this matter. The inspector looked at three staff members’ files to see if they had been recruited properly, had been provided with relevant training for the job and were being supervised on a regular basis. In addition, these issues were discussed with the manager and the home’s policies regarding these topics were read. All three staff files seen contained evidence of a thorough vetting process, including references and Criminal records bureau check. The manager confirmed to the inspector that he is aware that Simiks Care have to take out a new Criminal Records Bureau check on any new staff employed. The last staff member employed was employed before the CRB was received but this was prior to the last inspection and there have been no further new staff. None of the staff had NVQ training but the manager said that three had enrolled on NVQ training, two on level 2 and one on level 3, last week. The last mental health awareness training was in 2004. Supervision was not meeting national minimum standards. The home’s policy was not being adhered to. Records of supervision showed that the three staff selected had not received regular supervision in the year between September 2006 and September 2007. The requirement is for at least six sessions a year. One staff member had only had two sessions within the past year, one had only one and the other had none. The interaction observed between staff and residents was positive and two residents told their inspector that they had a good relationship with the staff team and felt they knew them well. The deputy manager had a positive relationship with residents and was seen to be speaking to them respectfully. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered provider needs to monitor the conduct of the home more thoroughly in order to ensure that residents are given the best possible service. Health and safety of residents will be promoted by completion of outstanding health and safety checks. EVIDENCE: The manager is experienced at running this home and considers that he runs the home well. He is supported by a deputy manager who is also experienced and knows the residents very well. There was no quality assurance report for 2007 available for inspection. A requirement is made to send a copy of the next quality assurance exercise and Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 22 annual development plan for the home to the CSCI. There was no evidence that the registered provider has been carrying out the required monthly inspections of the home and writing reports on the home’s conduct as required by Regulation 26 of the Care Homes Regulations 2001. The last report available in the home was dated November 2006. These visits and reports are necessary for the provider to monitor that the home is meeting standards and accounts for why important work such as care plan reviews have not been monitored for so long. Requirement is made to carry out these monthly visits and send copies to the reports to the CSCI every month. The inspector checked a sample of health and safety records for both properties. The electrical appliances have been tested for safety this year and the gas appliances in the main house have been checked in August 2007. Gas appliances in Poynter Road are due to be tested this month. The electrical installation for the main house was undertaken in 2004 and is due to be repeated this year. The electrical installation in Poynter Road had not been retested since 2001 and a requirement is made to do this. The manager said he would arrange for this to take place the week after the inspection. Fire alarm system and fire fighting equipment has been serviced and appropriate contracts are in place for refuse and pest control. Fire tests and drills were not up to date. The home has not yet complied with all the recommendations made in the last environmental health officer report on the home and a requirement is made to do so. Shila House DS0000010620.V337229.R01.S.doc Version 5.2 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 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 2 2 2 3 X 1 X X 2 2 Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 5(1) Requirement Timescale for action 31/12/07 2 YA6 3 YA9 4 YA9 The registered persons must ensure the information in the service user guide given to prospective residents is reviewed and up to date. 15(2)(b)(c) The registered persons must ensure that all care plans are reviewed and updated with the resident to reflect residents’ current needs and goals. 13(4)(c) The registered persons must ensure that all residents’ risk assessments are reviewed and updated to address all current risks and to include risk management plans. 13(4)(c) The registered persons must ensure urgent risk assessments are undertaken for these 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. 31/10/07 31/10/07 31/10/07 Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 25 5 YA20 12(1)(2) 6 YA21 13(4)(c) 7 YA20 13(2) The registered persons must ensure that residents’ health needs are known by staff and recorded in their care plans. Proper records of health appointments must be made as evidence that health needs are being addressed. The registered persons must ensure that the risk assessment and care plan for the person whose health issues is reviewed and changed to reflect the resident’s changed needs. The registered persons must ensure that all medication records are completed accurately at all times. The registered persons must ensure that an up to date complaint procedure is made available to residents, visitors and placing authorities. The registered persons must ensure that all staff have attended training in safeguarding adults/protection of vulnerable adults. The registered persons must ensure discarded furniture and equipment are moved from the residents’ garden at Poynter Road. The registered persons must provide a suitable lock for the toilet and bathroom at Poynter Road to safeguard residents’ right to privacy and dignity. If necessary this may be a lock which can be opened from the outside in an emergency. The registered persons must provide basic mental health awareness training for all staff who have no previous training or experience in working with people with mental health issue. DS0000010620.V337229.R01.S.doc 07/11/07 31/10/07 31/10/07 8 YA22 22(7) 30/11/07 9 YA23 13(6) 31/12/07 10 YA24 23(2)(o) 31/10/07 11 YA27 12(4)(a) 30/11/07 12 YA35 18(1)(c)(i) 31/12/07 Shila House Version 5.2 Page 26 13 YA36 18(2) 14 YA33 18(1)(a) 13(4)(c) 15 YA39 24(2) 16 YA43 26 17 YA42 16(2) (j) The registered persons must ensure that staff receive recorded regular individual supervision in order to ensure they are doing their job properly and understand the residents’ needs. The registered provider must undertake a risk assessment regarding night time staffing and must provide staff with a means of communicating between the two houses at night and for phoning for assistance in the event of an emergency. Written confirmation that this has been provided must be sent to the CSCI. The registered persons must undertake a quality assurance exercise and provide an annual development plan for the home, a copy for which must be sent to the CSCI. The registered provider 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 CSCI every month. The registered persons must ensure that all matters raised in the environmental health officer’s (EHO) report are complied with. Written evidence of satisfactory compliance of the recommendations must be forwarded to the CSCI Inspector. This requirement is restated. Previous date of 21/08/07 not complied with. 31/12/07 31/10/07 31/12/07 31/10/07 30/11/07 Shila House DS0000010620.V337229.R01.S.doc Version 5.2 Page 27 18 YA42 13(4)(a) 19 YA42 23(4)(e) The registered persons must ensure that the electrical and gas checks for Poynter Road are carried out. F ire drills and tests must be completed regularly and records made of the outcome of tests. 31/10/07 31/10/07 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.V337229.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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.V337229.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!