Inspection on 03/11/08 for Siloam Lodge

This inspection was carried out on 3rd November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Siloam Lodge 03/12/07

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Siloam Lodge 75 Bushgrove Road Dagenham Essex RM8 3SL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Pursotamraj Hirekar     Date: 0 3 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Siloam Lodge 75 Bushgrove Road Dagenham Essex RM8 3SL 02085923977 02085923977 siloamlodge@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Christine Owusu Type of registration: Number of places registered: Siloam Carehomes Ltd care home 2 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The Registered Person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 2 Date of last inspection Brief description of the care home Siloam Lodge is a small domestic style care home which provides accommodation and care for up to two people with mental health needs. The service is situated in Dagenham residential area. The home is semi terraced new build house. Off street parking is available for two vehicles at the front of the building. Public transport is near by. 2 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This is the report of the unannounced key inspection carried out on the 03/11/08 over 6 hours 45 minutes by Pursotamraj Hirekar. The registered manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff recruitment records, relevant care delivery documents, observation of administration of medication to people who use the service, partial tour of the premises, discussion with staff, registered manager and conversation with people at the home. In response to key inspection headline feedback session the documentation received from the manager, post this inspection is included for analysis and preparation of this report as well. Care Homes for Adults (18-65 years) Page 5 of 31 The quality rating for this services 1 star. This means the people whose this service experience good quality outcomes. What the care home does well: What has improved since the last inspection? What they could do better: The registered provider must ensure that the service users recommendations are implemented, if not reasons explained to the service user and recorded. The registered provider must ensure that hot water temperature checks are carried out at regularly intervals and recorded. The registered provider must carry out all the mandatory trainings for staff and provide evidence to verify the same. The registered provider should prepare and display staff rota to help service users know who is available at what time. The registered provider should evidence staff qualification with relevant documentation. The registered provider must ensure that the fire drills are carried out at regular intervals. The registered provider must ensure that the service users rooms are free from any harmful material and the room search records are maintained as part of the risk management strategy. The registered provider must notify us under regulation 37 with regard to any incident / accident that has potential harm to service user. The registered provider must provide written guidance for staff to ensure consistency and continuity of support for service users through individual working records setting Care Homes for Adults (18-65 years) Page 7 of 31 out the preferred routine, likes and dislikes. The registered provider must ensure that the service users are encouraged to administer their own medication on time as prescribed within a risk management framework. The registered provider must develop comprehensive care plans that reflect treatment and rehabilitation describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. The registered provider must carry out risk assessment for each individual service user in relation to his assessed needs and develop risk management strategies. The registered provider must carry out pre admission assessment for potential service user to demonstrate that the home could meet the assessed needs. The registered provider should complete a contract / terms and conditions for each individual service user detailing the nature of service provision, rights, responsibilities and fees as well. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The assessments carried out by the local social services are taken into account prior to the admission of service users. However, the home need to carry out pre admission assessment to demonstrate that it could meet the assessed needs. Evidence: There has been a new admission in September 2008 to the home since the last inspection. The potential service user had the opportunity to undertake trial visits to the home prior to the admission, the provider informed us. The home has completed a general information profile of the service user. The service user has complex mental health needs. The home has not carried out a pre - admission comprehensive assessment, to make an informed judgement on the suitability of the potential service user, taking into account the needs of the service user and capacity of the staff working at the home to demonstrate that the home could meet the assessed needs. The home had accepted the assessments carried out by the previous placement agency which was not comprehensive as well. This was brought to the attention of the manager as part of the inspection headline feedback, the manager has sent us a Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: revised care plan following a review, which included the assessment as well. However, there was further scope for improvements of the same, to cover all the complex nature of needs and risks in detail, that help understand the staff working at the home. The case files examined did contain the contract/terms and conditions for individual service users. However, these contracts were not comprehensive to cover various aspects of care assessments, care planning, care delivery, rights and responsibilities. This was brought to the attention of the manager during the inspection process. Care Homes for Adults (18-65 years) Page 11 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home did not provide detailed risk assessments and care plans that were reviewed and updated regularly to reflect the changing needs of the service users. Evidence: The home is registered for only 2 service users, care documents of 2 people using the service were seen which included risk assessments completed by previous agency for 1 service user and the care plan provided had information that included key objectives, time scale and comments. The information provided in the care pan was not comprehensive to take into account the complex needs of the service user, for example health and safety risk assessment form was left blank, CPA recommended for formal assessment of social cognition using standardised measure, this should include an observation tool completed by nursing staff as well as an individual assessment completed by the service user was not made available. An other example was the enhanced care plan prepared by south Essex partnership trust NHS stated that the xxx needs therapeutic support and promoting with daily living activities. xxx needs to Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: progressively engage in activities of interest. This has been not reflected in the care plan, how this was planned to be achieved. Also, when the service user accessed the community unsupervised, he was subjected to financial abuse by a person in the community and there was no risk assessment and a support plan to prevent such incidents. The support plans were not reviewed and updated, as and when the need arouse to reflect the changes in the support plan, for example a service user, following the incident in May 2008, the home office letter under restrictive order and recent review requires staff to frequently and routinely search yyy room from any inflammable material. There was neither an additional risk assessment carried out nor adequate staff guidance was provided in the care plan for staff to take appropriate action, despite the repeat incident of similar nature in the month of July 2008. The registered person / manger must undertake a complete review with the help of subject specialist and develop appropriate care plans. The information in the care plans was not holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and aspirations. The plans had not been written in sufficient detail including information that reflect their complex nature of needs to ensure that anyone working at the home could provide the necessary care. The information need to be written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks and accessing the community. The risk assessments and care plans need to be seen and signed by the staff working at the home. The people using the service can access social and community activities locally, which include their daily routines; going to their place of work or day centre. Observations made indicated that the relationship between people using the services and the staff was relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decision. In response to the inspection feedback session, the manager has sent us the revised care plan for both service user following a review. These care plans appeared to be of much improvised over those presented during the inspection. However, these care plans needed further improvements to include specific details of all the assessed needs, risks and appropriate interventions with clear guidelines for staff working at home with the service users. Care Homes for Adults (18-65 years) Page 13 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service experience and appeared to be enjoying a lifestyle that suits them, being part of the community and having meals of their choice. Evidence: Information about individual daily, social and community activities are presented, staff said people are supported to continue participating in daily social and community activities. The people using the services, confirmed during the discussion that they continued to participate in daily activities ranging from the day services to going out socially. People can choose how to spend the evening and weekends, ranging from seeing friends, family, watching television and going to church as well. Activities and daily routines were reflected in the records were consistent with the interests recorded in the individual support plans and have also matched with todays activity plan. However, when a service user unable to undertake the planned activity the reason Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: should be recorded in the activity register. The people who use the service indicated that they felt in control of their life at home and were not restricted in what they did. Except for 1 person who do not want to go to bed before 10.00.PM. People who use the service were spoken with, one person said this is like a home not like a hospital and another person said basically I am comfortable here. Staff demonstrated a good understanding of the people they work with, recognising if the person is anxious or unhappy, and how to approach them. People who use the service spoken to have said that they have the freedom to make choice of the meals and mealtime. Staff said they always encourage the people to choose the meals. It was noted that the people were neatly dressed and that they were treated as individuals. Throughout the inspection staff were seen talking to people and treating them with dignity; the people using the service had a good rapport with staff and the relationship between staff and the people appeared to be that of encouragement and supportive. one person said i have started going to day centre, I was not going before. An other person said Im learning to cook some dishes. Care Homes for Adults (18-65 years) Page 15 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The risk assessment and care plan were not comprehensive to ensure personal and health care needs of people, who use the service are met promoting their independence and quality of life. Evidence: The personal and health care needs of the people who use the service were not detailed in their individuals health care plans and care plans, which were not presented clearly with staff guidance in relation to the level of support required, if any. Risk assessments were not comprehensive to include information about personal care, personal hygiene, medication and day care activities. For example using shower, accessing community and fears. Staff appeared to have good working relationship with the people who use the service. This was supported through the observations made during the interactions, the people said; they are happy living at the home. However, there were no records provided to view, that suggest the people received personal support in the way they preferred and were encouraged to maximise their independence. Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: The people who use the service said they were not restricted to continue living their lifestyle of their choosing. The people who live at the home their privacy and dignity is respected. One service user was being supported to organise his birthday party and invitations were being arranged. Staff prompt service user for medication, however a service user who was scheduled to take his medication at 13.00 hours, until we prompted during this inspection at about 13.15 hours the manager and the staff member did not prompt the service user. The manager and the staff member said that they forgot to prompt. Self medication under staff supervision was observed for a service user. It was found that the service user had nomad system of medication and he was taking tablets from the container with his hand one after another and swallowing. He was not prompted to wash his hands prior to taking the medicine nor was he asked to use a bowl instead of using his hands. However, the staff member did remind him to keep a glass of water ready prior to taking the medicine. There was no assessment carried out on self medication nor any appropriate staff guidelines were written to follow. Both the service users medicine was stored in separate locked cupboard. The medicine stock reconciliation was carried out for 2 service users and found that the MAR sheet and the medicine available in the stock matched. The staff on duty need to demonstrate good understanding of the administration of medication, and the importance of having medication on time. People spoken to have said they receive medication on time. Care Homes for Adults (18-65 years) Page 17 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures to protect service users from financial abuse and self harm were not robust enough for staff to follow. Evidence: The people using the services indicated`that they were aware whom to complaint or express concerns about the provision of care provided to them. A person said, if Im not happy, I just speak to the staff member or the manager. The home had carried out an investigation on incident that occurred on the 23/10/08 involving a staff member, and concluded that none of the service user were subjected to any form of risk. This was further supported from the documentation that was made available during the inspection and the details recorded thereof. However, we were not notified about this incident, until we received a cover letter from the manager on the 03/11/08, which did not cover all the required information. The home had arranged for staff training on safeguarding. The manager appeared to be confident and was aware of the local protocol on adult safeguarding. However, there was inadequate evidence for staff to demonstrate adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. In the absence of comprehensive risk assessments, care plan and staff guidance, one service user were exposed to financial abuse while Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: accessing the community and the other person had self harming materials in his room (for details please refer to individual needs and choices outcome group of this report). None of these incidents have been notified to the commission. The people who use the service choose to manage their own money. Care Homes for Adults (18-65 years) Page 19 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in warm, clean and homely environment. However, further development work was needed to be complete fire drills, water temperature and room checks. Evidence: The home was maintained clean and tidy without any offencive odours. The home has had a regular premises maintenance programme in place. Individual bedrooms were personalised to suit the choice and taste of the people who use the service. The bedrooms are furnished with personal objects as well. The people appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. The hot water temperature checks for bath, shower, wash basins and fire drills need to be carried out and appropriate records maintained as well. There has been 2 incidents of a service user keeping self harming material in his room which prompted an home office restrictive order that require staff to carry out frequently and routinely search of the service user room. The staff guidance for Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: carrying out the search and suitable format for recording the search information was not made available. The registered manager need to develop comprehensive guidance for staff to follow and record the findings from the search. This was brought to the attention of the registered manager during the inspection feedback session, and the manager sent us post this inspection a structured format that has been developed for staff to record findings after the search of the service users room and the revised care plan covered information about the frequency of search. Care Homes for Adults (18-65 years) Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are protected by staff recruitment procedures, training and supervision. However, further development was needed to evidence relief staff pre-employment checks, training and supervision. Evidence: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The staff appeared to be aware of the needs of the people and their daily routines and how best to communicate with them. On a random sample, 3 staff recruitment records were seen and found that, staff appointed upon receipt of application, interview, satisfactory references, POVA and Criminal Records Bureau (CRB) check. Staff training records that were made available did not present a clear picture of staff trainings and qualification, the manager said that the staff training programme was under review. In response to the inspection headline feedback session, the manager has sent us the annual training brochure for the period August 2007 to August 2008 which detailed mandatory staff trainings and those relevant to the roles and Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: responsibilities of the staff. However, there was not enough evidence provided during the inspection that the staffs have received all the mandatory trainings. The home did not have the staff rota displayed that would help service user to know who is available at what time, and also, to have a clear picture staff deployment ratio based upon the needs of the people who use the service. Staff on duty confirmed they received regular supervision. However, this was not the case for all staff members. Care Homes for Adults (18-65 years) Page 23 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and the staff work as team, and have good working relationship with the people who use the service and with those external professionals who provide services to meet the needs of the people living at the home. Evidence: Discussion with the staff on duty and the people who live at the home, the manager appeared to have developed good working relations with the people who use the service and the staff as well. The various care documents seen on this inspection confirmed that the staff need to have clear roles and responsibilities in relation to the management of the home. Staff team meetings need to be held to discuss any concerns, areas of improvements and staff development as well, that are in the best interest of the people who use the service. As part of the quality assurance system and procedure the home had administered a Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: questionnaire with a service user and the recommendation has not been actioned so far and the reasons for not actioning have been not recorded. The home need to have in house quality monitoring mechanism in place and continuous improvement plan produced, to ensure that the people living at the home their quality of life goals both short term and long term, were reviewed and appropriate efforts were made to achieve them. The smoke alarms have been installed, the temperatures of fridge and freezer have been taken regularly to ensure food continues to be stored safely. Testing of portable electrical equipment was carried out. These checks help in identifying any concerns to the premises and to action them on time. Care Homes for Adults (18-65 years) Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 14 The registered provider must carry out pre admission assessment for potential service user to demonstrate that the home could meet the assessed needs. The home has not carried out pre admission assessment of a service user. 15/12/2008 2 6 15 The registered provider 15/12/2008 must develop comprehensive care plans that reflect treatment and rehabilitation describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. The care plan was not comprehensive with detail staff guidance. Care Homes for Adults (18-65 years) Page 27 of 31 3 9 13 The registered provider must carry out risk assessment for each individual service user in relation to his assessed needs and develop risk management strategies. The risk assessment provided were inadequate. 15/12/2008 4 18 12 The registered provider 15/12/2008 must provide written guidance for staff to ensure consistency and continuity of support for service users through individual working records setting out the preferred routine, likes and dislikes. The staff need adequate written guidance to work with service users with complex needs. 5 20 13 The registered provider 15/12/2008 must ensure that the service users are encouraged to administer their own medication on time as prescribed within a risk management framework. Service users need to administer their own medication within a risk management frame work. 6 23 13 The registered provider must notify us under regulation 37 with regard to any incident / accident that has potential harm to service user. 15/12/2008 Care Homes for Adults (18-65 years) Page 28 of 31 We were not notified under reg 37 regarding relevant incidents / accidents 7 24 16 The registered provider must ensure that the fire drills are carried out at regular intervals. The home need to have regular fire drills. 8 26 13 The registered provider 15/12/2008 must ensure that the service users rooms are free from any harmful material and the room search records are maintained as part of the risk management strategy. The service users room need to be free from any harmful material and search records maintained. 9 35 18 The registered provider 30/12/2008 must carry out all the mandatory trainings for staff and provide evidence to verify the same. The home did not adequate information to suggest that staff have received all the mandatory trainings. 10 39 24 The registered provider 15/12/2008 must ensure that the service users recommendations are implemented, if not reasons explained to the service user and recorded. Service user recommendation not implemented. 15/12/2008 Care Homes for Adults (18-65 years) Page 29 of 31 11 42 23 The registered provider must ensure that hot water temperature checks are carried out at regularly;ar intervals and recorded. Hot water temperature checks are not recorded. 15/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 5 The registered provider should complete a contract / terms and conditions for each individual service user detailing the nature of service provision, rights, responsibilities and fees as well. The registered provider should evidence staff qualification with relevant documentation. The registered provider should prepare and display staff rota to help service users know who is available at what time. 2 3 32 33 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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