Inspection on 14/11/05 for Smitham Downs Road (7)

This inspection was carried out on 14th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Smitham Downs Road (7) 23/05/06

Smitham Downs Road (7) 09/11/04

Smitham Downs Road (7) 06/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Smitham Downs Road (7) 7 Smitham Downs Road Purley Surrey CR8 4NH Lead Inspector Lee Willis Unannounced Inspection 14 November 2005 11:40 Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Smitham Downs Road (7) Address 7 Smitham Downs Road Purley Surrey CR8 4NH 020 8645 0873 020 8645 0873 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) Care Management Group Limited Mr Joseph Benedict Awolowo Kpebi Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: 7 Smitham Downs Road is owned, managed and staffed by the Care Management Group (CMG), a specialist provider of services for adults with learning disabilities and behaviours, which may challenge the service. The home is registered with the Commission for Social Care and Inspection (CSCI) to provide ‘personal support’ and accommodation for up to nine younger adults with mild to moderate learning disabilities. Joseph Kpebi, as the registered manager of the home, remains in operational day-to-day control. Joseph has been in charge of Smithham Downs for nearly two years. Situated in a quiet residential street in Purley, a large suburb to the South of Croydon, the home is well placed for accessing a wide variety of local shops, pubs and eating establishments. Smithham Downs is also on a bus route and very close to a local railway station, providing the service users with good public transport links to central Croydon, London and the surrounding areas. Since the building work on new extension was completed the home now comprises of nine single occupancy bedrooms, seven of which continue to be located in the main house. Three bedrooms, of which two are situated in the new extension, have there own ensuite facilities. Included on the ground floor of the main building are two lounges, one of which has recently been converted into a games/smoking room at the service users bequest, a separate dinning area, kitchen, office and laundry room. The new two bedroomed self-contained flat, which is attached to the side of the house, has its own kitchen facilities and front entrance. The garden at the rear of the property has a large sloping lawn, a wide variety of well-established trees and shrubs, and a patio area. There is amble space at the front of the building for parking vehicles. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 11.40 on the morning of Monday 14th November 2005. It took four and a half hours to complete. Since the homes last inspection the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the homes manager, a couple of the service users, although all nine were met at some stage during this visit, and three members of staff who on duty at the time. One of the homes immediate neighbours and the Regional Operations manager for Smitham Downs was also spoken with, albeit very briefly. The rest of this inspection was spent examining the homes records, touring the premises and playing pool with a couple of the service users and a member of staff. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although one vulnerable adult protection meeting has been convened by the Local Authority in this time. The allegation of abuse levied against a member of staff was upheld, following an internal investigation by CMG, and this particular individual has now been referred for possible inclusion on the Protection Of Vulnerable Adults (POVA) register. What the service does well: It was evident from the comments made by service users and the constant coming and going of people that the service users continue to enjoy very active social lives. Furthermore, despite this continually bustle the atmosphere in the home remained relatively relaxed with a number of service users choosing to relax in the main lounge and watch television or sit in the games room and have a cigarette. All the service users asked about the new pool table said it had been a great acquisition and was proofing very popular. It was also evident from comments made by service users spoken with at length, as well as staff practises observed, that the home continues to actively encourage and support individuals to maximise their independence and make as many ‘informed’ choices about their lives as possible. Most service users spoken with said they could choose, within reason, what they ate and did at the home. Finally, the service providers are commended for notifying all the relevant agencies without delay about an alleged incident of abuse at the home, and for the professional manner in which they dealt with the matter, a sentiment echoed by Croydon’s Vulnerable Adult Protection Team. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 The home ensures prospective new service users and their representatives are supplied with all the up to date information they need to know in order to make an informed decision about whether or not to move in. EVIDENCE: The homes Statement of purpose/service users guide was last updated in April 2005 to reflect all the changes that had occurred in the past twelve months. The manager was aware that this document needed to be kept under review and updated accordingly. The home remains fully occupied by the same group of service users who were residing there at the time of the homes last inspection. Having met one of the homes most recent admissions they said they liked living at Smithham Downs and felt they got on well with the other service users and most of the staff. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans are reviewed on a six monthly basis, and although most had been updated to accurately reflect changes in service users individual needs and personal goals, one had not, despite a review of their care plan taking place the previous month. Suitable arrangements are in place to ensure service users continue to have every opportunity to take ‘responsible’ risks as part of a structured programme to promote their independence and choice. EVIDENCE: Four care plans were inspected at random, including the plans for the homes two most recent admissions, who had now both completed their ‘trial’ period of residency. All four plans had been reviewed in the past six months and updated accordingly to reflect each service users changing needs and aspirations. One care plan reviewed in September indicated that the service user, their sister, a family friend, reviewing officer, and the homes manager had all been in attendance at this review meeting. Nevertheless, it was disappointing to note that despite the recent reviewing of one service users care plan it was evident that changes agreed at the meeting had not yet been incorporated into the individuals care plan. The review Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 10 meeting had taken place in November 2005, but the individuals care plan did not reflect any agreed changes and constantly referred to the persons previous placement, e.g. what social activities they liked to engage in whilst living at their previous address ect... Obviously it is good practice to gather as much information as possible about a new service user during the admissions process, but clearly following the individuals initial placement review, their new care plan must reflect all the changes that have occurred as a direct result of the move. Minutes of service user meetings revealed that three had been held since May 2005. These meetings had been well attended by the service users and two service users spoken with at length said they often used them to “get things of their chest”. Popular topics of conversation at these meetings include menu and social activity planning. It was positively noted that the manager had not only notified the Commission without delay about a significant incident that recently occurred in the home, but had also taken prompt action to establish a risk management strategy to minimise the likelihood of a similar incident reoccurring in the future. This risk assessment set out clearly the consequences of the identified hazard and the measures that were now in place to, so far as reasonably possible, minimise the likelihood of it reoccurring. The assessment is compatible with the homes underpinning philosophy of care which ensures service users continue to be supported to take ‘responsible’ risks as part of a structured programme to promote independent living and ‘informed choice’, whenever practicable. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 16 Social, leisure and employment opportunities for service users to engage in both inside the home and in the wider community are well managed, age appropriate, and provide the service users with daily variety and stimulation. EVIDENCE: One service user met said they liked to attend services at a local church every Sunday. During the course of this four and a half hour inspection it was evident by the continual coming and going of service users that everyone residing at Smitham Downs was being actively encouraged and supported to live very active and stimulating life’s. Having arrived at around lunchtime it was positively noted that the vast majority of the service users were out in the wider community attending various day centres and colleges, visiting relatives, or attending medical appointments. During the afternoon two service users went out shopping with staff. One service user spoken with at length said he it was his day to clean his bedroom, which he had agreed to do on a weekly basis. Another service met said he planned to go to the pub that evening. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 12 All the service users met said the acquisition of a new Pool/Snooker table for the second lounge had been a great idea and was clearly proofing very popular with the majority of the service users. The service user who said it had been his idea to buy a pool table said he particularly enjoyed playing against his keyworker and another service user who was equally as good as he was. Another service user spoken to at length said he had recently enrolled on a Law and English Literature course at a local college, which he enjoyed. Staff on duty at the time of this inspection are commended for calmly deescalating a potentially difficult situation by reassuring a service user, who had become rather agitated, that they were unable to go shopping that day because they were saving for a holiday but alternatively they would go for a walk with them. It was also evident from the minutes of care plan reviews that the home actively encourages service users families and friends to attend these meetings and to continue their involvement with their loved ones life’s. One service user spoken to at length said he continues to see his girlfriend on a regular basis and that she sometimes stays over at night. The manager said the home has a policy on sexual relations and it was clear from the individuals care plan that all the interested parties, including the service user, their representatives and other relevant professionals, had all been consulted and involved in drawing up appropriate guidelines. The same service user also said staff were always on hand to other him advice and support about sexual matters and personal relationships. As previously mentioned in this report it was clear from comments made by service users that they are actively encouraged to participate in the day-to-day running of the home and are ‘responsible’ for certain household chores, such as cleaning their bedrooms and doing their own laundry. One service user, who had arranged to go out early that evening, was observed being supported by a member of staff to prepare their evening meal. Two service users met said always knock on their bedroom doors to ask their permission before entering. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs are identified, planned for and met. Service users are also protected by the homes policies and arrangements for handling medicines, including its administration and storage. EVIDENCE: Several of the service user met all said they could choose what time they got up and went to bed. One of the homes most recent admissions said he liked living at Smitham Downs because they had a smoking room and he was able to go to the pub when he wanted. The homes accident book revealed that there had been one unplanned admission to casualty since the homes last inspection. Records revealed that staff on duty at the time appropriately dealt with the incident and that an assessment was carried out by the home in order to minimise the likelihood of a similar incident reoccurring in the future. A glucose form has now been introduced at the home to make it easier for staff to monitor blood sugar levels. Detailed records continue to be kept of all the service users health care appointments with community-based professionals, including GP’s, psychiatric nurses, and dieticians. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 14 Medication records sampled at random accurately reflected medication stocks currently held by the home at the time of this visit. No recording errors were noted on individual service users medication administration sheets. As recommended in the homes previous report it was positively noted that the manager in consultation with the homes dispensing pharmacist had rearranged the layout of the medication cabinet to increase its storage capacity. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Complaints are handled objectively and service users met were confident that any concerns they may have about the home are taken seriously and acted upon. The homes arrangements for dealing with suspected or alleged incidents of abuse are sufficiently robust to ensure the service users are protected, so far as reasonable practicable, from avoidable harm and/or abuse. EVIDENCE: The homes complaints procedure is conspicuously displayed on a notice board in the entrance hall and is available in a format that the majority of the service users are capable of understanding. One service user spoken with said staff were very approachable and always took his concerns seriously. The homes complaints record showed that two formal complaints had been made in the past six months. The first was concerned with service users smoking outside at the front of the house. The record detailed the action taken by the manager to address the problem and it was evident from comments made by service users that everybody now knew that smoking was only permitted in the games room, which had been fitted with an extractor fan, or on the patio in the back garden. A member of staff on a service users behalf, alleging that another service user had physically assaulted them in the kitchen, had recorded the second complaint. This is clearly an inappropriate use of the homes complaints log and the manager must remind his staff team that all allegations of abuse must be handled in accordance with CMG’s vulnerable adult protection protocols and recorded on the correct proforma. Furthermore, although the individuals care manager was notified about the incident, the home had failed to notify the Commission about the occurrence of this significant incident, contrary to the Care Homes Regulations. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 16 There has been one allegation of abuse made within the home in the past six months. The service providers, in accordance with vulnerable adult protection and multi-agency working protocols, notified all the relevant agencies without delay. Several case conference meetings were convened by the Local/host Authority to look into the matter and following a thorough investigation undertaken by CMG the accused member of staff was found guilty of abuse and immediately dismissed for gross misconduct. The former member of staff has also been referred to the Home Office for possible inclusion on their Protection Of Vulnerable Adults (POVA) register. CMG’s are commended for the professional manner in which they dealt with this case. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 27 Overall, the size and layout of the home, which is furnished and decorated to a good standard, ensures the service users have a homely, comfortable and safe environment in which to live. EVIDENCE: There have been no significant changes made to the homes physical environment in the past six months. Having tested the temperature of water running from the hot tap attached to the first floor bath it was found to be a safe 41 degrees Celsius at 15.35. As part of this inspection process one of the homes immediate neighbours were spoken with. The neighbour reported that overall they were satisfied with the arrangements that had been introduced by the home to minimise the previously identified risks/incidents reoccurring and that relations between themselves and the home were currently good. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 & 35 Overall, sufficient numbers of suitably experienced, qualified and competent staff are employed to meet the health and welfare needs of the service users. However, the homes arrangements for recruiting new members of staff are not sufficiently robust to, so far as reasonably practical, protect the service users from being harmed and/or abused by individuals who are ‘unfit’ to work with vulnerable adults. EVIDENCE: Several members of staff spoken to at the time of this inspection said they had been provided with the General Social Care Councils (GSCC’s) code of conduct. Staff training records revealed that two members of the homes current staff team had already achieved a National Vocational Qualification in Care Level 2 or above and that a further five were in the process of studying for theirs. The manager stated that at least 50 of his current staff team were well on the way to achieving this award by the end of 2005; in accordance with National Minimum training targets for care workers. Progress on this matter will be assessed at the homes next inspection. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 19 It was positively noted that in accordance with staffing levels previously agreed with Commission at least four members of staff, including the homes manager, were all on duty at the time of this inspection. The homes duty rosters for November accurately reflected this situation. Two members of staff were out supporting service users at the time of arrival. The manager is adamant that previously agreed minimum staffing levels remain adequate to meet the assessed needs of the service users, whose numbers have increased from seven to nine in the past twelve months. The home continues to experience relatively low levels of staff turnover and consequently only one new member of staff has been recruited in the past six months. The new member of staffs’ files was examined in some depth and found to contain a completed job application; the terms and conditions of their employment; proof of identity, which included a recent photograph; two written references, including one from their previous employer; a Home Office approved work visa/permit; and a Protection of Vulnerable Adults (POVA) First check. However, having cross referenced the date the individual commenced their employment at the home against the date their POVA first check was carried out it became immediately apparent that this particular individual had been working at the home for almost two months before a satisfactory POVA was obtained. Furthermore, the individuals Enhanced Criminal Records Bureau (CRB) check is still being processed. Having spoken to the homes Regional Operations Manager about this breach it would appear that there has been some sort of communication break down between the home and CMG’s Human Resources Department. The registered manager is reminded that he is ultimately responsible for ensuring CMG’s recruitment procedures are adhered to and that under no circumstances may new members of staff commence working at the home before a POVA first check has been completed. Furthermore, the manager and CMG are reminded that only in ‘exceptional’ circumstances may new members of staff commence working at a home while their CRB is still being processed, subject to certain conditions being met, i.e. New recruits may only start without a satisfactory CRB; providing their CRB has been applied for; a POVA First has been obtained, along with all the other documents specified in Schedule 2 of the Care Homes regulations (2001); they never work alone with service users and have a suitably qualified mentor to supervise them at all times; and the CSCI approves the appointment. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 20 The manager stated that a number of his staff team had recently attended refresher courses in CMG’s own British Institute of Learning Disabilities approved physical intervention training in April 2005. It was evident from dates highlighted in marker pen on the duty rosters that suitable cover had been arranged by the home to allow staff to attend these courses. However, three out of four of the staff files inspected at random did not contain any documentary evidence as proof of attendance of these refresher courses. Furthermore, despite each member of staff having a training and development assessment it was nevertheless difficult to ascertain how many members of staff had either achieved or needed further training in certain core areas of practice. Consequently, the manager is now required to undertaken a training needs assessment of his entire staff team as this has been recommended in the homes two previous inspection reports. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The homes health and safety arrangement are in the main sufficiently robust to protect the service users, their guests and staff from avoidable harm, although the homes emergency lighting needs to be tested on a more frequent basis. EVIDENCE: The manager has been in operational day-to-day control of the home for two years and is on course to have achieved his NVQ 4 in management and care by the beginning of 2006. The home is well maintained and overall ‘suitable’ arrangements are in place to promote and protect the health and safety of the service users, there guests and staff, although it was noted that the homes emergency lighting had not been tested by a suitable qualified person since 20/01/05. The manager is reminded that emergency lighting must be tested at least once every six months. The home has carried out a fire risk assessment of the building in the past twelve months in accordance with fire safety guidance. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 22 Up to date Certificates of worthiness were in place as evidence that a ‘suitably’ qualified professionals had checked the homes fire extinguishers, alarm system and portable electrical appliances, in the past twelve months. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Smitham Downs Road (7) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000025837.V258012.R01.S.doc Version 5.0 Page 24 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. 1 Standard YA6 Regulation 15(2)(c) (d) Requirement Care plans must be updated accordingly to accurately reflect any changes in an individual needs and/or personal goals agreed at review meetings. The homes complaints log must only contain detailed records of any complaint made about the homes operation and not include information about alleged incidents of abuse. No new members of staff must be permitted to commence their employment at the home before satisfactory Protection Of Vulnerable Adults checks have been completed in respect of that individual. Documentary evidence of any training undertaken by staff, which is relevant to the work they are expected to perform must be kept in the home and made available for inspection on request. A training and development assessment must be carried DS0000025837.V258012.R01.S.doc Timescale for action 01/01/06 2 YA22 17(2), Sch 4.11 15/12/05 3 YA34 13(6) 19(1) 2.5,2.7 15/12/05 4 YA35 19, Sch 2.4 01/01/06 5 YA35 18(1) 01/02/06 Smitham Downs Road (7) Version 5.0 Page 25 6 YA42 out by the manager in respect of his entire staff team and a plan established to address any identifed training needs. It was recommended for the manager consider undertaking such an assessment in the homes two previous inspection reports. 13(4)23(4)(c) A suitably qualified engineer must test the homes emergency lighting at least once every six months. 01/01/06 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 2 Refer to Standard YA32 YA37 Good Practice Recommendations 50 of care staff to have achieved an NVQ level 2 or above in Care by the end of 2005. The manager should have completed the managment component of his NVQ Level 4 training in management and care by 2005. Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Smitham Downs Road (7) DS0000025837.V258012.R01.S.doc Version 5.0 Page 27 - 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!