Inspection on 09/05/07 for Shooters Hill Road, 156

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shooters Hill Road, 156 17/01/06

Shooters Hill Road, 156 16/03/05

Shooters Hill Road, 156 14/12/04

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

CARE HOME ADULTS 18-65 Shooters Hill Road, 156 156 Shooters Hill Road Blackheath London SE3 8RP Lead Inspector Keith Izzard Unannounced Inspection 9th May 2007 10:15 Shooters Hill Road, 156 DS0000006875.V329893.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 Shooters Hill Road, 156 DS0000006875.V329893.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. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shooters Hill Road, 156 Address 156 Shooters Hill Road Blackheath London SE3 8RP 020 8319 3939 020 8319 3939 mrshem2000@yahoo.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ahmad Mungul Mr Shemil Mungul Mr Shemil Mungul Mr Ahmad Mungul Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Shooters Hill residential Home provides 24-hour care for three adults of both sexes who have mental health problems, one of whom may be over the age of 65. The house is a large 4-bedroomed property on the main A2 close to Charlton village. It is domestic in style and not identified from the outside. There is a small parade of shops adjacent to the Home and the G.P. surgery is next door. Buses pass the front door towards Lewisham, Blackheath and Woolwich. Each service user has their own room, which is equipped with a bed, television, fridge, wash hand basin, easy chair and wardrobe. The rooms are well decorated and the house is maintained to a high standard throughout. Communal areas include a lounge, dining/meeting room, breakfast room and kitchen. The conservatory leading off the kitchen is the designated laundry area. There is a large secluded garden with shrubs, lawn and a vegetable plot that provides food for the table. Service users are encouraged to think of it as their home, and to live as independently as they can. Meals are provided but service users can prepare their own meals if they wish to do so. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over a period of 5.5 hours on 9/05/07. Three members of staff including the registered manager assisted the Inspector in a constructive and helpful manner. Four of the five residents currently accommodated were present and assisted the Inspector by providing information about themselves particularly in respect of the service provided to them by the home, all stated that the service was of good quality and that they were happy with both the home and the staff members. The inspection included a review of information received about the service, a tour of the premises, an examination of records that are required to be maintained, including care plans, talking to and observing residents’ interaction with members of the staff team. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: Residents at Shooters Hill Residential Home are very well cared for, and their physical and emotional needs are met with sensitivity and kindness. They consider themselves fortunate to be living there. The environment is comfortable, homely and maintained to a high standard. Records are accurate and well maintained, and staff and managers take pride in developing their expertise through training. Residents were involved in the day-to-day running of the home, they were also encouraged to speak up and to say what they wanted and said they did this at the regular residents’ meetings. The level of activities provided both internally and externally was appropriate to the needs of residents. Residents had received good health care and medication was safely dealt with. The home was comfortable and spacious and residents’ bedrooms were personalised with their own possessions. Residents who were interviewed said that staff treated them well and felt that the manager and staff were doing an excellent job. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 6 The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional and good attention was given to meeting residents’ individual needs. 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 contacting your local CSCI office. The summary of this inspection report can Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Shooters Hill Road, 156 DS0000006875.V329893.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 Shooters Hill Road, 156 DS0000006875.V329893.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed to ensure that their needs can be met. EVIDENCE: Standard 2 The personal care files of both new residents were examined and also for a resident who had resided at the home for a number of years. These included detailed referrals comprising assessments completed as part of the care management process and reports from professionals such as psychiatrists, and other therapists. All the files included a care plan and the provider stated that the care planning and risk assessment process starts before admission to the home and takes up to one month to fully complete. Residents had clearly been involved in the setting up of their care plans and had signed them. Goals for development had been clearly identified and the process by which care staff members would achieve them and reviews of care clearly scheduled with input from both Community Psychiatric Nurses and Care Managers. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the Home are treated as individuals, and their care plans reflect their individual needs and wishes. EVIDENCE: Standard 6 Each resident has a care plan, and this is reviewed and updated as required. In too cases examined the care plan was discussed in a meeting with the care manager and resident and both signed to say that they concurred with the plan. A planned review date was also recorded. However, in respect of CPA review forms, these were not always signed by residents, and the manager readily acknowledged that the mental health staff responsible for their completion should be formally persuaded to evidence that residents were in agreement with the care plan by obtaining their signature thereby promoting good practice and ensuring transparency. The manager agreed to expedite this as soon as possible. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 11 See Recommendation 1 Standard 7 Residents have opportunities to affect decision-making in the Home. There are regular monthly meetings and service users are encouraged to express their views. One resident spoken to said that he would feel able to tell the manager or any other staff member if he was unhappy about anything in the house. In addition the Home formally requests service users to complete questionnaires about their views on the quality of service provided, and copies of these were seen on the case files that were examined and recorded a high degree of satisfaction with the service provided for the home. Standard 9 Risk assessments were on file, and in individual cases had been updated to record where assessed risks may have reduced over time. Independence is promoted where possible. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of service users. Evidence was available from the service user’s records examined and from discussion with both service users interviewed that they are enabled to express choice in whatever they do. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents in the home enjoy a comfortable and stimulating lifestyle, where individual choice is respected and encouragement given to achieving life skills. EVIDENCE: Standard 12-16 None of the residents attend day centres as the three longer-term residents are placed outside of their placing authorities and local provision has been refused, but all are engaged in a programme of regular activities. The two new residents placed by the local authority have not been assessed as needing day centre placements. All residents had recently been included in trips to the Natural History Museum and Hastings and two residents regularly attend a local sports centre with the manager four times a week. This has not only developed fitness but also social Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 13 skills via meeting other people at this facility. Another resident used to attend college for gardening and obtained certificates for this and has put his skills to good use in developing the rear garden at the home for which he has been rewarded by receiving shopping and cinema trips provided by the home. Another residents is engaged in a local car cleaning service. The home has provided its own certificates for residents to reflect individual achievement in their different areas of activities, for example sports centre attendance, developing social skills, gardening and domestic activities. Three residents interviewed by the Inspector were evidently gratified with this initiative as they were all keen to show me them. Residents are free to come and go as they please. Some shop at the local shops and are known to the shopkeepers. One Resident goes to the church across the road for coffee mornings and worship, and says he is welcomed there whenever he goes; he has gained some spiritual comfort from this community link. The manager stated that residents are supported and encouraged to stay in touch with family and friends and their wishes are respected when they choose not to have contact. The manager stated that residents are made aware of advocacy facilities locally. Service users are enabled to conduct private telephone conversations and visitors are allowed in their rooms as long as this was pre arranged with staff members and this had been discussed within a service users meeting and individually with service users. Residents meetings were held on a regular basis, approximately monthly, and the manager confirmed that a copy of the minutes was provided for all, including those who chose not to attend. It was evident from the notes examined that agendas were comprehensive and that individuals in attendance freely aired their views. Standard 17 Menus were examined and showed that varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. One of the residents is of Afro/ Caribbean origin, but maintained that he only occasionally likes this food and that any requests to have it are positively responded to by staff members. Culturally appropriate diets could be catered for upon request, as could any other special diets and it was noted that a choice is always available. One resident is currently being assisted with attempts to lose weight, with his agreement, and recorded in his care plan. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive flexible personal support. The physical and mental healthcare needs of service users were met. The medication system for the home was well organised and recorded. EVIDENCE: Standard 18 The home is not registered to provide nursing care but residents are given assistance to maintain their own personal care, largely via prompting, where necessary in respect of their personal hygiene and to keep their clothes clean and their rooms tidy. One resident’s outdoor mobility is deteriorating and it was noted that he was assessed by an OT, for the provision of a wheelchair to facilitate trips outside of the home. Mobility within the home was not a cause for concern. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 15 Standard 19 Healthcare needs are given high importance at the Home. Residents are supported to take responsibility for their own healthcare, though are supported to attend appointments where necessary. Evidence of this was available on both the individual care files and the daily diary notes examined by the Inspector. One resident, who is overweight, has been weighed regularly and he is encouraged to eat healthily. There have been not been any incidents requiring notification under regulation 37, since the last inspection. Standard 20 The medication system was examined and was appropriately organised; medication was stored in a locked cabinet and quantities and dosage of medication tallied with the MAR sheets examined. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist and had a homely remedies procedure in place signed by the GP for the home. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. Residents express a high degree of satisfaction with the care in the Home, and the managers ensure that residents’ wishes are listened to and responded to. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. Several complaints were logged in the complaints log but on examination these were all found to be complaints relating to disagreements between a resident and his father and the resident had been supported to exercise his own choice, by staff members, regarding his dental treatment and whether or not he would visit his estranged mother. No complaints had been received directly by the Commission. All residents have the capacity to raise concerns and those spoken to by the Inspector both indicated that they were very happy within the home and actually had no complaints. The Inspector recommended that complaints should be separated in respect of their outcomes to reflect whether they were substantiated, or not, or partially substantiated. See Recommendation 2. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 17 Standard 23 The home had policies and procedures in relation to adult protection and as whistle blowing policy. No allegations of abuse had been made to the provider or the Commission since the last inspection. The home did not have a copy of the London Borough of Greenwich Adult Protection Procedures and it is recommended that this is obtained, be shown to staff members and to ensure that the homes policy matches the requirements within the local authority procedures. Those staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such an eventuality. See Recommendation 3 Shooters Hill Road, 156 DS0000006875.V329893.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Home is bright, spacious and welcoming. Bedrooms are personalised by the individual resident. The home was spotless and very well maintained. EVIDENCE: Standard 24 The home was clean, bright and comfortable. The Home is well suited to its purpose. There is a range of communal space including a large and comfortable lounge, a dining room suitable for meetings or reviews, a small breakfast room, and a large level garden mainly lawn with shrub borders with, a level patio and garden furniture nearer the house. Some new planting has been done in the garden, and one of the residents, who studied gardening at college, helped with this and was mowing the lawn at the time of the inspection. The garden looked very tidy and attractive. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 19 The four bedrooms seen by the Inspector were personalised by the individual residents, and there was evidence of their interests in videos on the shelf and pictures on the walls. One of the residents was encouraged to purchase a floor standing CD rack for his large collection, following a recommendation made at the previous inspection. Bedrooms were spacious and highly personalised, this is commendable, and there was ample communal space for service users. The Inspector was informed that the laundry area to the rear of the building was being developed and that in due course an conservatory would be attached to the side of this room to provide facilities for residents to practice independent living skliisdomest and a chalet type/ shed building was going to be erected at the bottom of the garden to provide a games room. Standard 30 This was an unannounced inspection of the service and the home was, as has been noted before, immaculate. The staff members maintain an extremely high standard of cleanliness and maintenance and in the light of the evidence from both this and previous inspections, the Standard is, again, exceeded. Shooters Hill Road, 156 DS0000006875.V329893.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practices were satisfactory. Staff training was comprehensive and a high level of staff members qualified above the minimum Standard requirement had been achieved. EVIDENCE: Standard 32 This is a family business and four of the six regular staff members are family members. The rota is the same week on week, so there is consistency for the residents. The proprietor’s wife has achieved her NVQ3 through practice assessed via a local nursing home. Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 21 From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite skills, attitudes and characteristics necessary to adequately support residents. Staff members were observed to be respectful and caring in the way they were relating to residents. It was equally evident that residents were content within their environment and responding positively to any staff interventions. Standard 34 There have been no changes to the staff employed since the previous inspections when this Standard was assessed and was met. The manager demonstrated a good awareness of recruitment practice whilst discussing the potential recruitment of two new members of staff. Standard 35 At this inspection the Inspector was informed that both of the care staff have achieved NVQ level 2 and that the other three staff are first level nurses this exceeds the National Minimum Standards. The manager provided evidence of a training plan for the year 2006-2007 and this was comprehensive. All staff members had received induction and foundation training and had, in place, an individual training and development plan. Shooters Hill Road, 156 DS0000006875.V329893.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was well run. Quality assurance mechanisms were developed and surveys of residents and were promoted on a regular basis. EVIDENCE: Standard 37 The Home’s manager, the proprietor and his wife are all well qualified and competent to run the Home. Certificates of registration, insurance and health inspections are displayed appropriately, records are in good order, and were immediately available for inspection. Policies and procedures had been updated and well maintained. Evidence was available that both managers are keen to Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 23 update their practice and to improve the service, for example they are planning to involve residents in the selection of new staff members planned in the near future and in being proactive in seeking new training opportunities for themselves. All residents in the home benefit individually from the way the Home is run, by the consistency and dedication of staff, and feedback suggests that the residents consider themselves fortunate to be living there. Standard 39 Feedback is evidently received from all residents in respect of the running of the home via monthly and recorded residents’ meetings. Opportunities are readily available for professionals to communicate their views, given the regularity of contact with residents, however the Inspector suggested that the manager introduces an annual survey, similarly, for involved professionals and any relatives or advocates involved with residents See Recommendation 4. Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. An Environmental health inspection had also been conducted in the recent past and no concerns were identified. A number of areas were picked at random and checked against the pre inspection questionnaire, in respect of routine health and safety checks such as fire drills and other areas requiring maintenance checks. This information provided, was accurately recorded and in accordance with that submitted by the manager to the CSCI. Shooters Hill Road, 156 DS0000006875.V329893.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 3 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 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 4 X Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 25 No 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The manager should ensure that community mental health staff responsible for CPA reviews are reminded to request residents signatures on their care plans to evidence their agreement, or otherwise, with their CPA care plans. The manager should ensure that complaints are recorded to indicate whether they are substantiated, partially substantiated, or not substantiated. The manager should obtain a copy of the London Borough of Greenwich Adult Protection Procedures and ensure compatibility with the homes procedures. Staff members should familiarise themselves with the contents of the procedures. Annual surveys of the views of professionals involved with residents and their relatives/ advocates should be introduced as a quality control mechanism. 2 3 YA22 YA23 4 YA39 Shooters Hill Road, 156 DS0000006875.V329893.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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